Highlights of this issue
========================


## The physical rigours of fellowship training

![Figure1](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/170/6/923/F1.medium.gif)

[Figure1](http://www.cmaj.ca/content/170/6/923/F1)

Figure. Photo by: Eric Field

It is well known that physician trainees work long hours while on call. A study by Parshuram and colleagues, involving senior fellows in a pediatric critical care unit, provides objective evidence of the physical demands associated with being on call. The authors found that, on average, fellows worked 69 hours per week and, per shift, received 41 pages, walked 6.3 km and slept 1.9 hours. Ketonuria (a marker of dehydration) was detected in participants in 21% of the 33 shifts during which it was measured, and in some fellows Holter monitoring revealed significant cardiac ectopy. Although the fellows were adhering to current regulations for workload set by their provincial resident organization, the authors conclude that trainees are unlikely to be performing optimally while under such physiologic stress.

In a related commentary, Howard and Gaba discuss whether the current limitations on residents' hours of work are sufficient to ensure physician and patient safety.

See pages [965](http://www.cmaj.ca/lookup/volpage/170/965?iss=6) and [975](http://www.cmaj.ca/lookup/volpage/170/975?iss=6)

## Interventions to promote breast-feeding

![Figure2](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/170/6/923/F2.medium.gif)

[Figure2](http://www.cmaj.ca/content/170/6/923/F2)

Figure. Photo by: Health Canada Media Photo Gallery

The Canadian Task Force on Preventive Health Care has updated its earlier recommendations on interventions to improve the initiation and duration of breast-feeding. On the basis of the evidence available, the task force concludes that effective interventions include antepartum and postpartum education provided by lactation specialists or nurses, and peer counselling. The evidence showed that written materials are not helpful and that commercial discharge packages decrease the rates of breast-feeding. There was insufficient evidence to show that counselling by primary care physicians makes any difference.

See page [976](http://www.cmaj.ca/lookup/volpage/170/976?iss=6)

## Guidelines for the management of locally advanced breast cancer

In this latest guideline from Health Canada's Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer, the authors review the evidence for the management of locally advanced breast cancer (LABC). Although it occurs infrequently, LABC is difficult to manage. It is defined as large breast tumours (> 5 cm in diameter) associated with either skin or chest-wall involvement or with fixed (matted) axillary lymph nodes or with disease spread to the ipsilateral internal mammary or supraclavicular nodes. Recommendations for treatment involving surgery, chemotherapy, radiotherapy and hormone therapy are provided, as is an information sheet for patients with LABC.

See page [983](http://www.cmaj.ca/lookup/volpage/170/983?iss=6)

## Time-management tips for family physicians

![Figure3](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/170/6/923/F3.medium.gif)

[Figure3](http://www.cmaj.ca/content/170/6/923/F3)

Figure. 

Physicians often feel stretched by the many demands on their time in a busy clinical practice. Crosby provides a list of tips for family physicians to help them improve efficiency in their office. Meeting with staff to discuss problems, making schedules, charting, and handling paperwork are a few of the topics covered. Crosby points out that, although inefficiencies can occur in any aspect of a medical office, it is the physician who has the most to contribute to fixing the problem.

See page [949](http://www.cmaj.ca/lookup/volpage/170/949?iss=6)