Canadian medical education:50 years of innovation and leadership

W. Dale Dauphinee, MD, FRCPC

Over the past 50 years, many Canadian medical educators have pursued ideas andvisions, as individuals in the 1950s and 1960s and later in partnership with variousnational bodies. Relations between universities and national medical organizations havebeen productive in dealing with issues of postgraduate education and clinical assess-

ment, in particular. From 1970 to 1990, strong education offices and formally trainededucators led to many successes in the areas of research in cognition, continuingmedical education and clinical assessment. Canadian medical education has now

achieved international recognition for its work in all aspects of the continuum of thephysician's education through vision, initiative and cooperation.

Ces 50 dernieres annees, le Canada a compte un grand nombre d'educateurs medicauxcreatifs et visionnaires. Travaillant individuellement dans les annees 50 et 60, ils ontensuite forme des partenariats avec differents organismes nationaux. Les relations entreles universites et les divers organismes medicaux d'envergure nationale, ont eteparticulierement productifs dans les domaines de l'education postdoctorale et del'evaluation clinique. Les nombreux succes qui ont marque la periode de 1970 a 1990ont ete possibles grace a la mise en place de centres d'enseignement solides et a laformation de specialistes de l'enseignement medical, dans les domaines de la recherchecognitive, l'education medicale continue et l'evaluation clinique, domaines dont leCanada est devenu le chef de file mondial. Vision, initiative et cooperation, telles sontles qualites qui ont merite au Canada une renommee internationale pour ses realisationspedagogiques.

T he evolution of Canadian medical educationover 125 years has closely paralleled that ofthe American system. For example, the influ-

ence of Sir William Osler was felt in both countriesas he moved from McGill to Philadelphia, Baltimoreand later Oxford, and his impact on clinical educa-tion continued well into the first half of the 20thcentury.' Osler was the first Canadian to become amajor force in medical education.2 Abraham Flexn-er, whether innovator or merely clever observer ofwhat was already under way, caused changes on bothsides of the border with his report of 1910.3 As withOsler, Flexner's influence on medical education wasdominant for the next 50 years in both countries,especially in preclinical education.5 Given this com-mon heritage, it is not surprising that joint accredita-tion of medical schools has been shared over the past40 years.

More recently, the McMaster philosophy, withits problem-based learning, has had an influence atthe undergraduate level.6 Other major innovations inundergraduate education during the past 50 years areprimarily American in origin: the Hamm period atCase Western Reserve, the George Miller era atBuffalo and later Chicago, and the CoggenshallReport.6'7 Over the same period, Canadians havebeen widely recognized for their progress at thepostgraduate level: bringing postgraduate educationand continuing medical education (CME) underuniversity sponsorship, strengthening primary carepostgraduate education and, now, moving to a two-track licensure system.

The goal of this article is to familiarize readerswith a number of people and issues that have placedCanadian medical education at the forefront interna-tionally. The selected examples are from reports by

Dr. Dauphinee is a professor of medicine and chair ofthe Department ofMedicine, McGill University. He is also director ofMcGill'sCentre for Medical Education and physician-in-chiefat the Royal Victoria Hospital, Montreal.

Correspondence to: Dr. W. Dale Dauphinee, Centrefor Medical Education, McGill University, 1110 Pine Ave. W, Rm. 200, Montreal, PQH3A ]A3

1582 CAN MED ASSOC J 1993; 148 (9) This report has not been peer reviewed. LE ler MAI 1993

current leaders of medical schools and from pub-lished documents. They cover a period during whichCanada has become a major influence and hasproduced physicians of what may be unrivalledquality.8'9

Early innovators

To be creative is to be able to walk alone andwhere no one else has tread. In a century in whichchange for the sake of change is often the standard,one must differentiate between those who trulychallenged dogma and habit in medical educationand those who have engaged in the popular "aca-demic parlour game" of curriculum revision.'0 Forexample, in the late 1 950s, Stewart introducedcourses on the proper use of statistics in medicalliterature to first-year students and on chronic dis-ease epidemiology long before critical appraisal andclinical epidemiology became fashionable in the1970s.

Those who challenged the conventional wisdomin academic life and broke ground in the reorganiza-tion of medicine before and just after World War IIfrequently did walk alone, often in the face of majoropposition. One of the first people to focus myinterest in education was H.B. Atlee from Dalhousie.Upon returning from postgraduate training in Lon-don, this native Nova Scotian had great difficultyseparating the specialty of obstetrics and gynecologyfrom the domain of the general surgeon." Black-balled for several years, Atlee wrote short stories tosupplement his meagre income. However, he went*on to become the dominant force in his specialty inAtlantic Canada for the next 40 years. A fiery manwho did not always practise what he preached abouthuman relations, Atlee was an outspoken critic ofcontemporary education in general as well as medi-cal education.

Two educational initiatives undertaken in thelate 1920s and later in the 40s can only be describedas remarkable, considering the time at which theyoccurred. Atlee advocated effective CME and aban-doning undergraduate lectures. Manning and DeBakey'2 state that the first medical college CMEprogram was at the University of Michigan in 1927;however, Atlee was instrumental in starting the firstuniversity-based refresher courses at Dalhousie in1923.'3 According to the course descriptions, Atlee'ssessions were conducted as "clinics" and were not inlecture format. In the early 1950s, Atlee convincedDalhousie to arrange community hospital-basedCME conferences with the participation of universi-ty teachers. While he was chair, lectures were nevergiven in his department, and this practice continuedin the 1 960s after his retirement. Patients werealways presented and their problems discussed, even

in introductory sessions in second- and third-yearcourses. In 1957, Atlee wrote a colourful text thatreplaced the lecture as the medical student's intro-duction to obstetrics, stating, as justification, thatstudents record things in lectures that he would notsay, drunk or sober.'4

At the age of 74, Atlee's complained that therewere two things wrong with education: what theyteach and how they teach it. To paraphrase hisbiographer, Benge Atlee pushed Canadian medicineand, some would say, medical education into the20th century. His views on education, as well aswomen's rights, natural childbirth and excess sur-gery, were probably 30 years ahead of his time."

Equally able to walk the lonely path of dissentwas a completely different personality, WendellMacLeod. A native of Quebec and a McGill gradu-ate, MacLeod's education was greatly influenced bythe environment of the 1930s, which made him anavowed socialist. After serving as chief medicalofflcer at the Halifax Naval Hospital during WorldWar II, MacLeod moved west and joined the Winni-peg clinic. In 1951, when the University of Saskatch-ewan moved to a full-fledged medical course, Mac-Leod became the first dean. Seizing the opportunitygiven only to new faculties and first-time deans,MacLeod and his associates broke ground in severalareas. They were the first faculty to establish incomepooling. With this innovation, Saskatchewan wasable to recruit a number of distinguished, full-timeclinical teachers, not a common phenomenon at thetime; among them were Nason, Feindel, Baxter,Horlick and Badgley.'6 Among MacLeod's contribu-tions were the development of the Department ofSocial and Preventive Medicine, which included thefirst medical sociologist on a medical faculty inCanada (Badgley), and the first steps toward a familymedicine practice unit in an academic department.

The late 1 960s was a time of ferment, inmedical education as well as society. Four newmedical schools were established in Canada, andmany creative ideas in education were generated atthe established schools. William Cochrane movedfrom Dalhousie to be the first dean in Calgary, andJohn Evans, William Spaulding and Fraser Mustardmoved from Toronto to help found the innovativefaculty at McMaster. These men took full advantageof new schools to implement long-cherished ideaswithout hindrance.'7

Within the "old" schools, where change wasmore difficult, many innovative and interestingideas took root in the 1960s. A general interest ineducation also encouraged many young Canadians toenter the field of medical education. Giles Cormierwas the first Canadian physician and faculty mem-ber to receive a PhD in education. He returned toLaval and became a pioneer in developing a Bureau

CAN MED ASSOC J 1993; 148 (9) 1583MAY 1, 1993

de Pedagogie. Cormier also developed a Centred'Evaluation en sciences de la sante at Laval(CESSL) under Jean Jacques Ferland. CESSL wasinstrumental in developing a province-wide exami-nation for graduating students (1'examen de syn-these) and later a provincial objective-structuredclinical examination (OSCE) for those completing aresidency in family medicine (P. Potvin: personalcommunication, 1992).

Another interesting development of that periodwas carried out by Alex Bryans in conjunction withLeslie Valberg and George Southall at Queen's. Theycreated the clinical learning centre, "the house downthe street," as it was known.'8 Beginning in 1972,they introduced students to the patient and the moresensitive aspects of the physical examination and theinterview. The centre, which is still in operation, hasbeen one of the most effective and enduring educa-tional innovations in Canadian medicine.

Despite a lack of formal training in medicaleducation, many other people may be described asinnovators in the 1960s and 1970s. Richard Rossall19at the University of Alberta was nationally respectedas a bedside teacher of cardiology. In 1968, heintroduced computer-assisted instruction into theteaching of clinical medicine. In Alberta, WilliamTaylor created the first computer-based examinationquestions for the Royal College of Physicians andSurgeons of Canada (RCPSC).20

Others focused on curriculum issues. In the late1960s, Lewis, Scriver and MacDonald2' at McGillcreated an integrated behaviour, growth and devel-opment course for first- and second-year students.The developers also saw the course as a way tointroduce the patient earlier in the curriculum and tofocus more on the interactional and behaviouralaspects of the medical encounter. Their course, alongwith Hugh Scott's 4-week, introductory course onphysical diagnosis with patient actors and videofeedback, changed the experience of McGill studentsforever.

In the late 1960s and 70s, the presentation ofbasic science material in an integrated course orsystems format began at many schools; new schoolslike Calgary, Sherbrooke and Memorial, as well assuch established schools as Laval, Dalhousie, Otta-wa, Toronto and Montreal used this approach. Adifferent approach was taken at McGill and Western,where basic science teaching was curtailed in thefirst and second year and "a return" to the sciencesrelated to medicine was added in the senior year(B.P. Squires: personal communication, 1992).22

One of the most unusual innovations in Canadi-an medical education took place in the 1950s and1960s, when Joe Doupe, professor of physiology atthe University of Manitoba, introduced an optionaljournal club and research program for second-year

students that extended through the summer betweensecond and third years. In addition to critiquingabout 100 journal articles, the 10 to 12 students inthe program had to undertake a formal researchproject; upon successful completion, they received aBMed degree along with their MD.23 It must havebeen an effective introduction to research, becausethose who experienced it still sing its praises morethan 30 years later. Manitoba graduates of that erabecame some of Canada's most distinguished aca-demics: Henry Friesen, John Dirks, Norman,Charles and Martin Hollenberg, Barry Posner, Har-vey Guyda, Aubie Angel, Len Moroz, Allen Ronald,Clarence Guenther, Ashley Thompson, Kirk Oster-lund, Lionel Isreals, Keith McCannell, Morley Sut-ter, Garth Bray, Chuck Roland and Arnold Naimark.Doupe also taught students the importance of scepti-cism. He provided an ironic example by seldommonitoring his own diabetic condition because"there was no evidence" that it made a difference;he suffered major diabetic complications near theend of his life.23

Canada's leadership in clinical assessment

In the 1970s, a different theme emerged fromCanadian medical education: clinical assessment. Inthe mid 1960s, Donald Wilson24 and a group ofacademic colleagues at the University of Albertaworked tirelessly to establish the McLaughlin Re-search and Examination Centre for the RCPSC inEdmonton. Under Wilson's leadership, standardswere indeed raised, but other impacts were alsoapparent as Wilson sought to collaborate with otherbodies and universities. The development of aMcLaughlin francophone centre at Laval promotedCormier's work and Ferland's evaluation group.With Wilson's help, the Medical Council of Canada(MCC) moved its examination contracts from theNational Board to the McLaughlin Centre. Theseevents, in combination with the return of a host ofyoung educational specialists from the United States,stimulated an interest in assessment. Wilson and hissuccessor, Sam Kling, involved many of the retur-nees in an unofficial scientific advisory panel.

The curriculum changes of the 1960s and 70sspawned a general interest in evaluation. McMasterneeded new methods of assessment to evaluate itsinnovative programs. Changes at McGill, Western,Laval and Toronto had to be evaluated for accredita-tion purposes. The new schools at Calgary andSherbrooke emphasized better assessment. Offices ofeducation appeared to assess both the programs andthe products of those programs. Toronto was thefirst Canadian medical school to designate an educa-tion resource person when John Flowers from theOntario Institute of Education Studies was appoint-

1584 CAN MEDASSOCJ 1993; 148(9) LE ler MAI 1993

ed in 1967. In 1968, Arthur Rothman was recruitedas a full-time educator by Jan Steiner at Toronto,and Laurie Fisher was appointed soon afterward atCalgary. Schools became committed to providingsalary support and infrastructure, and a criticalapproach to education assessment became institu-tionalized at most schools.

The third building block was the evolution ofthe MCC from a follower to an innovator in clinicalassessment. The MCC's consultants during the1970s, Don Wilson and Charles Schumacher, helpeda great deal in this change, but equally importantwas the emergence of delegates from the licensurebodies and the medical schools, who had expertise ora personal interest in education and measurement.Dean Tim Cameron from Alberta, as Presidentworking with Registrar John Barr, overhauled theMCC and created a research and development(R&D) committee. Dauphinee, Des Marchais, Cam-eron, Snidal, Baumber, Boggie and later Harley,Jean, LeClerc, Lescop and Bowmer were key mem-bers of the R&D group.

The MCC and its leaders were able to establisheffective collaboration with the universities and, inso doing, created an evaluation system that served asthe model for guidelines on clinical assessment.25 In1985, under the guidance of Registrar Michel Berardand President Gordon Cameron, the MCC askedDan Snidal of Manitoba to head a group to createexamination objectives; the job was completed in1992 by John Baumber and others at Calgary. LouisLevasseur and his colleagues at Laval developed amatrix system to classify evaluation items againstthe objectives. The "key features" project undertak-en by Georges Bordage of Laval and Gordon Page ofthe University of British Columbia (UBC) with helpfrom Peter Harosym from Calgary, allowed the MCCto replace the discredited portion of its examinationon patient management problems.26'27 The problemof reference standards was also tackled by the MCC;Tom Maguire, Ernie Skakun and Charles Harley ofthe University of Alberta were able to convert theMCC examinations to ones based on referencecriteria as standards, possibly the first such systemadopted by a national licensing body.28

More recently, the MCC has created an OSCE.Richard Resnick and colleagues29 created the firstnational licensing examination using this method.The Toronto group had already developed the OSCEas an effective part of a comprehensive assessmentof foreign graduates for Ontario.30 A similar exami-nation had been used in Quebec under the directionof Joelle Lescop, Paul Grand'maison and CarlosBrailovsky.3' Danny Klass from Manitoba was im-plementing the same examination format in theUnited States for the National Board of MedicalExaminers.

The catalyst in the emergence of the assessmenttheme was the involvement of Canadians in interna-tional "think tanks" like the Cambridge conferences,the Ottawa conferences on clinical assessment, andthe research in medical education portion of theannual meeting of the Association of AmericanMedical Colleges. They provided Canadians with thearenas and confidence to show their wares.

The Ottawa conference on clinical assessmentbegan with the collaboration of Ian Hart of Ottawaand Ron Harden of Dundee. Hart and Harden hadbeen classmates at Glasgow and research fellows inthyroid disease at the Royal Victoria Hospital in thelate 1960s. Harden returned to Scotland and, mov-ing into educational technology, rapidly became aworld leader in medical education. He developed theconcept of the OSCE in the 1970s.32 About that time,Hart, who had a long-standing interest in education,took leave to work with Harden for a year. WhenHart returned to Ottawa, he "sold" the OSCE toNorth America.

Hart's promotion of the OSCE as an undergrad-uate assessment tool had an earlier parallel inCanada. Howard Barrows, who came to McMasterfrom the University of Southern California with theidea of simulated patients, further developed theidea of the standardized patient with Robyn Tam-blyn.33 Although Barrows, Stillman and others usedthe technology innovatively in the United States,Tamblyn,34 in the late 1 980s at Manitoba (withDanny Klass) and later at McGill was the first toassess many of the measurement issues and qualitiesof the standardized patient during multiple-site ad-ministration.

Other emerging fields of leadership

A consequence of the development of education-al units in the medical schools was the emergence ofa research theme around cognitive aspects of medi-cal decision making and medical expertise. In the1 970s at McMaster, Neufeld, Feightner and Normanworked with Barrows on studies of medical problemsolving.35 When Barrows returned to the UnitedStates, Norman, an exphysicist who had done gradu-ate work in medical education, continued work ondefining the nature of medical expertise. Norman'sobservations were based on real-life situations ratherthan on the so-called high-fidelity simulations usedin earlier studies. His work was not limited to thenature of expertise; his research into methods ofevaluation was substantial, earning him the JohnHubbard Award of the National Board of MedicalExaminers in 1990.

In the early 1980s, Vimla Patel completed aPhD at McGill in educational evaluation but beganto study the techniques of discourse analysis devel-

CAN MED ASSOC J 1993; 148 (9) 1585MAY 1, 1993

oped by Carl Frederiksen of the Faculty of Educa-tion at McGill. In collaboration with the late GuyGroen, Patel used the technique as an analytical toolto define the nature of expertise. Groen, an educa-tion psychologist who had worked with Nobel laure-ate, Herbert Simons, was a key partner for Patel, andtheir productivity over the ensuing decade wasexceptional. They were acknowledged internationallyas the leading authorities on the subject.3637

The third focus for cognitive studies was atLaval, where Georges Bordage, a physician who hadcompleted studies for a PhD degree with ArthurElstein at Michigan State, approached the issue ofmedical diagnostic thinking by the use of semiotics.37

As mentioned above, the first CME course wasoffered at Dalhousie in 1923, followed closely byToronto and McGill in the mid-1920s (L.C. Steeves:personal communication, 1992). In 1950, Toronto,under Ian Macdonald, was the first to offer amultifaceted program of CME and, during the1980s, Fred Fallis and Colin Wolfe promoted tele-conferencing and developed new approaches to theassessment of CME needs.3839 Dalhousie (1951) andUBC (1961) also developed multifaceted CME pro-grams.40 In the 1960s, Lea Steeves and later PaulCudmore at Dalhousie built on Atlee's idea of takingCME into the community hospitals by using needsassessments and other contemporary methods ofadult learning. In 1968, after his appointment asCME director at Saskatchewan, Ollie Laxdall devel-oped ready-access telephone programs for physiciansneeding diagnostic or therapeutic advice.4' With theopening of Memorial's Faculty of Medicine, MaxHouse, an established neurologist was given the jobof overseeing CME. He responded by developing aprogram to serve even the most remote areas ofNewfoundland and Labrador using distance trans-mission techniques, including satellite technology.42Once installed, the system not only served Atlanticregions, but also allowed communication with proj-ect personnel funded by the Canadian InternationalDevelopment Agency in Africa and the Caribbean.43

Today the official voice of academic CME inNorth America, the Society of Medical CollegeDirectors of CME, has been heavily influenced byCanadians. For example, John Parboosingh andJocelyn Lochlear of Calgary, Wayne Putnam, LynnCurry and Karen Mann from Dalhousie, and DaveDavis from McMaster were recognized for develop-ing productive research programs in CME. Putnam,Lochlear, Parboosingh and Davis were leaders in amilestone inquiry that established the key influencesmotivating changes in practices.44

Today's movers

The exciting developments of the 1970s and

especially the 1980s were prompted by a new breedof medical educator, formally trained but workingwith interested faculty and supported by education-al resource or research units. Spurred by the needto assist, support and evaluate the many new ideasof the 1970s, almost all schools recruited educa-tion experts and sent individuals away to acquireexpertise.

Although the output of that generation wasimpressive, new problems, new opportunities andbright, new people are appearing on the scene: forexample, the Education of the Future Physicians ofOntario project at the five Ontario medical schoolsunder the guidance of Victor Neufeld, David Hol-lomby, Jeffrey Turnbull, Bob Maudsley and BeverleyWalter. The established level of research will contin-ue to be produced by Vimla Patel at McGill andGeoffrey Norman at McMaster, working on cogni-tive aspects of medical decision making; PennyJennett and Peter Harosym at Calgary; Gordon Pageat UBC; Ernie Skakun at Edmonton; Robyn Tam-blyn and her group of Linda Snell, Leora Berksonand Peter McLeod at McGill; and Arthur Rothman,Bob Cohen, Peeter Poldre, Richard Resnick and thenew generation of young investigators emerging atToronto. They will continue to report exciting workat international meetings, far out of proportion toCanada's collective size. Equally encouraging is thefact that the cohort of the 1970s and 1980s is nowattracting young faculty recruits to the field andtraining them in Canada in large numbers.

The successes at Laval, McGill, Toronto andMcMaster are notable, and more are certain tocome. An excellent example is the development ofthe 1-year course for faculty in pedagogy underPierre Jean and Pierre Delorme at Universite deMontreal.45 These people have now achieved thestatus and influence to encourage other facultymembers to be involved in effective change andimprovements. Perhaps one of the most dramatichas been Jacques Des Marchais' role46 in establishinga problem-based curriculum at Sherbrooke. Othershave changed their curricula to deal with new needs:for example, June Penny's approach to teaching amore humane medicine at Dalhousie and PennyHansen's teaching innovations in the basic sciencesat Memorial.47'48 As we have seen, interest in educa-tion had never been higher in Canadian medicalschools as expert educators and traditional academ-ics work side by side to improve programs andcurricula.

Closing comments

As we celebrate the first 50 years of the Associa-tion of Canadian Medical Colleges, it is useful totrace the history of events to understand why

1586 CAN MED ASSOC J 1993; 148 (9) LE 1ler MAI I1993

changes flourish in some locales and not in others. Inthe case of medical education, we can trace Canada'srecent successes to several factors: individuals withideas and vision and, equally important, a spirit ofcooperation and purpose among national bodies anduniversities that has allowed the ideas and visions todevelop. The association has served as a forum tofocus those developments and has been both animportant catalyst and a beneficiary of educationalprogress. Although the examples cited here are selec-tive, they are representative of the successful effortsin Canada. One can only hope that the nationalmood of cooperation and purpose will continue andthat the next five decades will be equally fruitful.

I thank the many people responding to the questionnaireson behalf of their faculties who provided key informationused in this manuscript. Review of the manuscript byDean Richard Cruess and Dr. Stuart MacLeod, and theprocessing of several drafts by Ms. Celine Pereira, isgratefully acknowledged.

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Conferencescontinuedfrom page 1553

Oct. 15, 1993: Nursing Clinic DayNorth York, Ont.Sybil Gilinsky, Continuing Education Department,

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Oct. 20, 1993: A Day in GeriatricsTorontoCindy Stolarchuk, conference coordinator, Sunnybrook

Health Science Centre, 2075 Bayview Ave., North York,ON M4N 3M5; tel (416) 480-5904

Oct. 20-22, 1993: Hygiene and Health Management in theWorking Environment - 3rd International Symposium

Antwerp, BelgiumOfficial language: English3rd International Symposium, "Hygiene and HealthManagement in the Working Environment," c/o Ms.Rita Peys, TI-K VIV, Desguinlei 214, B-2018Antwerpen, Belgium; tel 011-32-3-216-09-96,fax 011-32-3-216-06-89

Oct. 20-22, 1993: Tobacco-Free Canada - 1st NationalConference on Tobacco or Health; organized around thegoals and the seven strategic directions of the NationalStrategy to Reduce Tobacco Use in Canada. Memberorganizations on the planning committee are: AlbertaHealth, Canadian Cancer Society, Canadian Council onSmoking and Health, Health and Welfare Canada, Hearland Stroke Foundation of Canada, Nova ScotiaDepartment of Health and Ontario Ministry of Health

OttawaTobacco-Free Canada: 1st National Conference onTobacco or Health, conference organizer, Taylor &Associates, PO Box 46066, 2339 Ogilvie Rd.,Gloucester, ON KIJ 9M7; tel (613) 747-0262,fax (613) 745-1846

Oct. 27-29, 1993: 1st North American RegionalConference of Rehabilitation International - Partners

for Independence: Models that Work (cohosted by theCanadian Rehabilitation Council for the Disabled andthe United States Council for InternationalRehabilitation)

AtlantaProgram coordinator, North American Congress of

Rehabilitation International, 801-45 Sheppard Ave. EnToronto, ON M2N 5W9; tel (416) 250-7490,fax (416) 229-1371

Oct. 28-31, 1993: What is Aging? - Canadian Associationon Gerontology Annual Conference

MontrealCanadian Association on Gerontology, 500-1306

Wellington St., Ottawa, ON K1Y 3B2;tel (613) 728-9347

Nov. 1-3, 1993: Medical and Scientific Writing DynamicsTorontoMcLuhan and Davies Communications, Inc., 167 Carlton

St., Toronto, ON M5A 2K3; tel (416) 967-7481,fax (416) 967-0646

Nov. 4-7, 1993: Philosophic Foundations of Bioethics -International Perspectives

WashingtonDr. Eric M. Meslin, Centre for Bioethics, University ofToronto, Tanz Neuroscience Bldg., 6 Queen's ParkCres. W, Toronto, ON M8V 1X4; tel (416) 978-2709,fax (416) 978-1911

Nov. 5, 1993: Social Work Clinic DayNorth York, Ont.Sybil Gilinsky, Continuing Education Department,

Baycrest Centre for Geriatric Care, 3560 Bathurst St.,North York, ON M6A 2E1; tel (416) 789-5131,ext. 2365

Nov. 26, 1993: Practitioners DayNorth York, Ont.Sybil Gilinsky, Continuing Education Department,

Baycrest Centre for Geriatric Care, 3560 Bathurst St.,North York, ON M6A 2E1; tel (416) 789-5131,ext. 2365

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1588 CAN MED ASSOC J 1993; 148 (9) LE Ier MAI 1993