Médecins Sans Frontières (Doctors without Borders)

Bringing medical aid and international recognition to the vulnerable populations around the globe

Lilia Malkin, MSc
Contributing Author,
Geriatrics & Aging

In today's turbulent economic and political climate, it is often easy to focus on the headlines and statistics, and to neglect the individual human faces behind the facts and maps. Surrounded by seemingly, never-ending references to violence and disaster in news reports, and in popular culture, our society often appears virtually desensitized to the masses who are suffering around the globe. Fortunately, we are also frequently reminded that there are thousands of individuals who are committed to the humanitarian goals of helping those in dire need of assistance. One such reminder came in the fall of 1999, when Médecins Sans Frontières (MSF) received worldwide acclaim and recognition by being awarded the Nobel Peace Prize for their thirty-year effort to aid the planet's populations in distress.^1,2 For the past three decades, the volunteers of MSF (known to the English-speaking world as 'Doctors Without Borders') have been at the sites of natural- and human-made disasters, making a valiant attempt to help the wounded and the vulnerable.

Elderly Patients Excluded from Clinical Trials

Tawfic Nessim Abu-Zahra, BSc, MSc

Elderly people (i.e. those over 65 years of age) tend to be excluded from clinical research trials in areas such as cancer and heart disease.^1-4 Physicians wishing to make evidence-based treatment decisions for elderly patients may have to extrapolate clinical data from studies that have been conducted in a younger population. However, given that there are age-related changes that occur even in healthy elderly people, any such extrapolation may not be scientifically sound.^1-3 Changes in physiological parameters that occur with increasing age, such as decreases in renal and cardiovascular function, blood flow and hepatic volume, make the disposition of drugs more variable in the elderly and predispose them to drug toxicities and adverse drug reactions.³ The result is that geriatric patients may not receive the newest therapies or may receive a treatment whose efficacy and safety in the elderly is not known.^1-3

In a study published in the New England Journal of Medicine, Hutchins and colleagues5 determined the enrollment rate of cancer patients aged 65 years or older in clinical trials, and compared this with the corresponding rate of elderly cancer patients in the general population. Overall, the authors reported that the elderly were significantly underrepresented in all cancer trials and in 14 of the 15 types of cancer that were individually investigated.

Putting Life Back in Your Years

Understanding the Science of Human Aging

Christine Oyugi, BSc
Managing Editor,
Geriatrics & Aging 

"…. it's not the years in your life that counts. It's the life in your years"
Abraham Lincoln

With this in mind, researchers gathered in Toronto on January 16th at The Inaugural Symposium of the Anne and Max Tanenbaum Chair Program in Biomedical Research. The one day symposium provided a good summary of biogerontology and geriatric medicine and a glimpse of our current understanding of the mechanisms of aging.

The field of aging research, biogerontology, is often not distinguished from geriatric medicine--research on age-associated disease. According to Dr Leonard Hayflick, advances in aging research rely on the distinction between these two fields. As people do not actually die from aging, there is a tendency to focus on diseases that afflict the growing elderly population. However, if we do find a resolution to the leading causes of death such as cancer, stroke and cardiovascular diseases, how much will this tell us about the fundamental biology that is involved in aging? The loss of physiological capacity in cells of vital organs is the hallmark of aging and understanding the mechanisms involved could advance our fundamental knowledge of aging and age-associated disease.

There exists abundant evidence linking telomerase to the aging process. Telomerase is a ribonucleoprotein enzyme that extends telomeres by adding hexameric nucleotide repeats to the ends of chromosomes. Without the activity of telomerase, telomeres continue to shrink during cellular division, thereby losing genes that are important for cell function. Telomerase expression is exceptionally high in a variety of animals that appear to age at a negligible rate; these animals include tortoises, lobster, rainbow trout, and sharks. Further research will involve examining the action of telomerase in cells of such animals.

It has been shown that the life span of cultured cells, normally limited to around 50 cell doublings--the so-called Hayflick limit--can be more than doubled by the addition of telomerase. Research shows that the maintenance of telomere length by telomerase is critical to the proliferative ability of some immortalized mammalian cells in culture and in vivo. The catalytic core of telomerase is made up of a reverse transcriptase component (TERT) and RNA component. "It appears that TERT is sufficient for maintenance of telomere-length," says Dr. Lea Harrington from the Department of Medical Biophysics at the University of Toronto.

The ability of organisms to respond to oxygen and oxidative stress is also connected to aging and life span. Back in the 1950's Denham Harman described the 'free-radical theory' of aging, which states that reactive oxygen species (ROS) cause cellular damage. This cellular damage accumulates with age, eventually leading to disease. Later, the identification of superoxide dismutase (SOD) gave support to this finding. The function of SOD is to promote the conversion of oxygen radicals into the less toxic form, hydrogen peroxide. Studies with SOD knockout Drosophila (Fruit fly) show that flies that lack the gene encoding the SOD 1 protein show signs of neurodegeneration and aging. Furthermore, expressing SOD1 transgene in the motor neurons of knockout flies "rescues " adult lifespan in a dose dependant manner, and the flies live up to 40% longer. The researchers also found that the extension of life span in transgenic SOD flies was not due to lower metabolic rate.

Are there cellular targets for oxidative damage? Evidence gained from studying human degenerative diseases point to the nervous system. Some cases of Alzheimer's disease and Lou Gehrig's disease are linked to mutations involving the SOD protein. Injecting SOD into the motorneurons of knockout mice extends life span; a finding that is not seen when SOD is injected into the muscle or a ubiquitous promoter. "This suggest that the nervous system is a primary target of the aging process," said Dr. Boulianne, professor of molecular and medical genetics at the University of Toronto. She went on to say that future research should determine if there are other cells that may be targets for aging and identify additional genes which may extend lifespan.

A number of human genes have been identified in which mutations can lead to the accelerated emergence of features associated with aging. These cause diseases such as those labeled segmental progerias (e.g. Werner's syndrome) and Alzheimer's disease. Research on these genes and their protein products may lead to a clearer understanding of the aging process and to ways in which aging might be delayed.

Is the goal of aging research to increase the lifespan? Is it likely that we can extend maximum lifespan significantly beyond where it currently stands? There are a number of societal implications of increasing the life-span. For instance, the length of time spent in retirement would increase, perhaps leading to people 'out-living' their old age pensions. Furthermore, it would mean that one would perhaps spend a greater number of years in physical weakness and dependency. The question then becomes one of whether we can improve quality of life, as well as increasing lifespan. At least in part, the development of breakthrough therapies for the treatment of the chronic disease of old age may rely on improvements in our understanding of the fundamental mechanism of human aging.

Suggested Reading

1. Hayflick L.The illusion of cell immortality British Journal of Cancer, Vol. 83, No. 7, Oct 2000, pp. 841-846.
2. Hayflick L. The future of ageing. Nature 2000 Nov 9;408(6809):267-9.
3. Hayflick L. New approaches to old age. Nature 2000 Jan 27;403(6768):365.
4. Harman, D. The aging process. Proc. Natl Acad. Sci. USA 78, 7124&endash;7128 (1981).
5. Kaeberlein, M., McVey, M. & Guarente, L. The SIR2/3/4 complex and SIR2 alone promote longevity in Saccharomyces cerevisiae by two different mechanisms. Genes Dev. 13, 2570&endash;2580 (1999).
6. Liu Y, Snow BE, Hande MP ,Yeung D , Erdmann NJ, Wakeham A, et al. The telomerase reverse transcriptase is limiting and necessary for telomerase function in vivo Current Biology 2000, 10:1459-1462.
7. Martin GM, Turker MS Model systems for the genetic analysis of mechanisms of aging. J Gerontol 1988 Mar;43(2):B33-9.
8. Parkes, T., Elia, A.E., Dickinson, D., Hilliker, A.J., Phillips, J.P. & Boulianne, G.L. (1998). Extension of Drosophila lifespan by overexpression of human SOD in motorneurons. Nature Genetics 19:171-174.

Vintage Advice

Both the British Medical Journal and the Journal of the American Medical Association (JAMA) participate in the charming and instructive activity of reprinting short sections from their pages of 100 years ago. These pieces are often quaint, always entertaining and frequently outdated--but not always.

Many a time, and oft, in fact, they still speak to the heart of our clinical practice, even from over a century in which both the practice and face of medicine have changed so dramatically. For example, published in a recent issue of JAMA (Volume 182(17):1606i), and penned over a century ago by Dr. J.W. Bell in his prime as Professor of Physical Diagnosis and Clinical Medicine at the University of Minnesota, was an impassioned "Plea for the Aged".

It should be pointed out that, in 1899, geriatrics did not yet formally exist as a specialty and that Ignatz Naccher's seminal work, "Geriatrics: The Diseases of Old Age and their Treatment" would not come out in print for another 14 years. Marjorie Warren, considered the founder of modern hospital geriatrics in the UK for work in the 1940's, was then barely three years old.

Bell acknowledged that, despite the paucity of current American literature on the subject of the elderly, the French (Charcot, Pine) and British (Day, McLachlan) authorities had helped "to furnish the nucleus of our present knowledge of senile pathology". However, despite the interest of these eminent authorities, Dr. Bell offered a criticism that unfortunately is still quite relevant today: "The want of interest, as indicated by the scanty and fragmentary character of the literature on the subject, is largely responsible for the apathy existing today in our medical schools".

As we enter the new millenium, it must be acknowledged that there has been a modest improvement in the number of Canadian medical schools offering a course in geriatrics. Still, the growth is not at all proportional to the increase in the numbers of elderly. In 1899, less than 5% of the continent's population was over the age of 65. Today, that percentage has almost tripled and life expectancy has increased significantly throughout the developed world.

Despite his critique of the system, Bell understood the circular wars of the medical schools that still rage today. He offers that "It would seem criminal to even suggest that addition of another distinct course to the already overcrowded college [medical] cirriculum (sic)…." But he does offer two suggestions, the first of which still makes sense: "That the chairs of anatomy and physiology impart to the student the necessary primary instruction…". To the contemporary reader, his second suggestion may seem a bit quaint but it was obviously born out of desperation and the faint hope that colleagues might heed his plea. Here, Bell suggests that the "The chair of practice [Internal Medicine], or if deemed best, in order to contrast disease, the chair of pediatrics enlarge its scope and furnish the necessary…instruction…"

Were Dr. Bell to survey the situation today, he would also still have much room and justification for complaint. Despite improvements in our field, his words from one hundred years ago ring true today: "[the medical student] scarcely recalls reference by one of his teachers to old age, unless suggested in mitigation of the failure of some brilliantly planned but misjudged operation or equally ill-timed drug treatment".

JAMA's recent '100 Years Ago' column has helped us to realize that despite some improvement, at least in the field of treating the elderly, 'plus ça change; plus c'est le meme chose".

Dr. A. Mark Clarfield is the Chief of Academic Affairs at the Herzog Hospital in Jerusalem and on staff in the Division of Geriatric Medicine, Sir Mortimer B. Davis-Jewish General Hospital, McGill University, Montreal.

Hypodermoclysis is a Valuable Method for Management of Dehydration in the Long-Term Care Setting

Sudeep Gill, MD and
Paula A. Rochon, MD MPH FRCPC
Baycrest Centre for Geriatric Care.

One of the goals of long-term care is to provide the patient with an appropriate level of care without unnecessarily disrupting his or her comfort and living situation. Older long-term care residents often suffer from acute intercurrent illnesses for which fluid replacement is an important component of treatment. If intravenous (IV) fluid replacement is not possible in these frail seniors, either because of regulations or due to staffing issues in the long-term care facility, it is often necessary to transfer them to an acute-care hospital setting.

In the institutionalized older patient, hypodermoclysis, which is the subcutaneous infusion of fluids, is an attractive alternative to the use of intravenous therapy for fluid replacement. It is a method that has been used since near the turn of the century. Although it has been employed with success for years at the Baycrest Centre for Geriatric Care, and a few other institutions, it remains under-recognized and underutilized as a valuable method for the management of mild to moderate dehydration in the long-term care setting.

Physician Heal Thyself

Geriatrics & Aging Presents a Debate on Doctors Treating Their Near and Dear

C.J. Olson, BA, MD

The essay: " On Not Doctoring the Family" by A. Mark Clarfield, MD in your July/August issue iterates time honoured sentiments that I have seen occasionally over the years, but I can't recall any attempt to question them. It is time to throw down the gauntlet and challenge some of the comments made in the essay. En garde, Dr. Clarfield.

The first issue is his reference to the statement of the American Medical Association, a hundred years ago, that a family member's illness "tends to obscure judgment." He adds that: "Attitudes have not changed much since then." The key word is "attitude" and I think we should all realize it is no more than that. Also, longevity is not a supportive argument for such a theory. When we consider the changes that have occurred in all aspects of Medicine in the past century, we should simply view this as a rock in the midst of the river, immobile and unchanging, because it has never been seriously challenged.

The second point is trying to decide just where Dr. Clarfield wants to draw the line between what is acceptable and what is not. On the one hand, he feels it appropriate to examine, diagnose, prescribe medication and advise on surgical procedures for family members--procedures which may not be as innocuous as he thinks. I was uncertain whether he does these because he feels they are acceptable, or that he feels they are acceptable because he does them. At the other end of the spectrum, he feels that performing (major) surgery on family members is inappropriate. In between is a large grey area--such things as minor surgery, spontaneous vaginal deliveries and assisting in the operating rooms are examples--in which he does not take a stand. This seems to be sort of 'no man's land' into which no one wants to venture for fear of stirring up controversy.

One problem that bothers Dr. Clarfield is the Heimlich manoeuvre and measures related to CPR. He quotes Dr. Howard Bergman, who feels these are acceptable because they are a knee jerk or 'reflex' response. This is simply not true. Some of us take a one evening course in CPR every year or two, but I think we are in the minority. The procedures are filed away, because we rarely get a chance to practice them. When the occasion does arise, the response is certainly not a reflex one; it "gives furiously to think," trying to remember all the details of something we have rarely had to do in a real life situation. Only emergency Physicians and Paramedics, who do these things regularly could be considered as doing them "by reflex", but even this is doubtful. Why Dr. Clarfield felt it necessary to justify these measures in the first place puzzles me. It is proper for anyone, under any circumstance, to perform such procedures whether or not he or she is a physician, just as long as they know what to do. I can't see why we should justify it amongst ourselves.

My greatest concern is that Dr. Clarfield is convinced that, faced with such a crisis in the family, physicians turn to jelly, become irrational and cease to function as intelligent beings. There is no evidence for this at all. What he does not realize is that the real stress comes when dealing with relatives of a colleague. There, one has the feeling that everything one does is under both a spotlight and a microscope, and stress is truly great. One problem is that a specialist, having such a case referred to him, may feel obligated to "do" something, and I have seen quite a few unfortunate results in consequence. Within my own family I have had, believe it or not, seven occasions when I have been asked by family members to intervene when things have not gone well, and can state without equivocation that the result has in every case been good. I wish there were space here to elaborate; it would give the reader pause to think.

Where is all this leading? Quite simply to the suggestion that we should stop parroting the myths and fables that are passed down from one generation to the next, and take an in depth look at them to see if they are valid.

We must first be aware that Medical Theory differs very much from theories in sciences which depend entirely on the scientific approach. There, hypotheses are proposed, subjected to experiment and research, argued (sometimes bitterly) and publicly debated. General acceptance is slow--witness the history of Atomic theory, and the Theories of Evolution and Relativity.

Medical Theory, by contrast, is based upon the Galenic approach. One of our number somehow gains recognition as an authority on a subject, states a Theory based on his attitudes, belief and experiences, and expounds on it at length. It appears, like Athena on Mount Olympus, full blown and fully armed. It is bolstered by such arguments as "It stands to reason that…" or "It is obvious that…" when in fact it is not at all obvious, and has never been seriously challenged by reason. Others pick up the concept, adding their support and soon there us a consensus and extensive literature to back it up. Some may disagree, but few--faced with this formidable array of talent and support--are willing to speak out. The worrisome thing is that if the first person who said it was wrong, then the whole thing is a house of cards. Such theories therefore rely on consensus, silencing any opposition, and discouraging any attempt at experimentation or research.

What we should do is rephrase our Theories as hypotheses; offer them as ideas to be investigated (without a lot of rhetoric) and try to find out whether they are valid or not. A good example would be the study mentioned by Dr. Clarfield, which was done by Dr. John La Puma and colleagues. The frequency with which various procedures was done by physicians was recorded, and Dr. Clarfield has stated in his opinion whether these were "acceptable" or "weird", but these are purely subjective impressions. What I cannot understand is why no attempt was made to determine whether the outcome was good or bad. This would have been a simple and much more instructive approach. Surely someone must have thought of this when setting up the questionnaire! Was it because no one wants to know? Let's face it--we need to know.

Dr. Clarfield takes up the Gauntlet…

In response to Dr. Olson's chivalrous en garde, I take up the gauntlet with verve and answer as follows. First, I would like to thank him for taking the time and energy to read my piece and for reacting so emphatically. The worst fate for any writer, of course, is to have his words ignored.

Let us begin where Dr. Olson and I are indeed in violent agreement. It is true that much, if not most, of what I had to say was subjective--as were all of Dr. Olson's claims as well. And that was the whole point of my article: indeed it is difficult for most of us to be objective with those patients to whom we are related.

If Dr. Olson and his ilk are steely enough to look after wife and child--especially when things get critical--more power to them. I do know that in such a situation, in comparison to what occurs with the patient with whom I am not involved emotionally, I turn to jelly. And I believe that most physicians are more like me than Dr. Olson. However, I do agree with him that the topic deserves more study.

And as a card-carrying member of the evidence-based mafia, I once again see eye to eye with Dr. Olson in his plea for appropriate, methodologically sound research into these hypotheses. My piece in Geriatrics & Aging, with all of the pride that I can muster for my work, was clearly not meant as a research paper but as a thought-provoking opinion piece. That it elicited a reaction from Dr. Olson is clear.

With respect to the Heimlich manoeuvre and CPR, once again I am at one with Dr. Olson that it is preferable that these techniques should be studied, learned and practiced as much as possible. My point was that in a true emergency any doctor would, and should, do whatever was necessary to save a life--regardless of how he felt about the patient: love, hate or indifference. But when one has the choice, by dint of the situation being less than life threatening, I think that most practitioners would, and should, prefer to let someone who is more objective look after the patient.

Regarding caring for the family members of colleagues, once again I concur with Dr. Olson's point of view. This is indeed a difficult issue and in a way is tangentially related to the point I have made. In both cases, but for different reasons, the physician is struggling because of a loss of objectivity. I agree that looking after a colleague's family is not easy, but I never found it as difficult as looking after family--perhaps because, despite the lack of complete objectivity, appropriate emotional distance can still be kept to enable sound judgement to prevail.

I too look forward to more research into this important field. But, when my family turns to me for medical help--except in cases of medical trivia or dire emergency--I will refer loved ones on to my friends. Let them sweat it out!

Yours Sincerely,
A. Mark Clarfield, MD

The Merck Manual of Geriatrics, 3rd Edition

Reviewed by: Barry Goldlist

The Merck Manual of Geriatrics, 3rd Edition
Published by Merck Research Laboratories
Whitehouse Station, NJ 2000

Almost a decade ago, I received a copy of the first edition of the Merck Manual of Geriatrics for review, and decided to take it on ward rounds with my residents. Rather than my answering their patient related questions, we looked things up in the manual and were all favourably impressed by the results. It was easy to use, and provided rapid access to succinct and helpful information. Needless to say, my review of the volume was very favourable. I was still able to give my residents good evaluations because they said they still preferred my answers. Smart residents.

The third edition of the manual is much larger, and significantly heavier than was that original volume. It has gone from 1267 pages in length to 1507 pages, and the pages are larger. It would not accompany anybody on ward rounds. However, with the added weight comes more information. It is still very easy to extract information in order to answer specific clinical questions because of the excellent index, and the usual Merck technique of making the chapter headings visible via 'thumb holes'. Not only does it provide excellent information on specific geriatric issues such as falls, incontinence, and interdisciplinary teams, it also provides good coverage of important issues in general internal medicine that relate to the elderly.

Unlike standard textbooks of geriatric medicine, the geriatric giants (incontinence, falls, etc.) are not grouped together, but rather are addressed in the appropriate system section. However, this method of indexing does not cause any problems. As in previous editions, many charts are used to transmit information in a very efficient manner.

Who should buy this textbook? It is not intended to be a comprehensive textbook of geriatrics, and the lack of references probably makes it inappropriate for purchase by those who specialize in geriatrics. However, the ease of use, and the wide variety of useful information it contains, would make it a useful text for family physicians or internists who treat elderly patients in their practices. It would also be a useful textbook for trainees in those disciplines. I highly recommend it.

Apocalyptic Demography: The Impact of the Baby Boomers on our Health Care System

Dr. Michael J. Taylor

"Apocalyptic demography", "bankruptcy hypothesis of aging", "population aging crisis scenario"--these are only three of the many catch phrases currently being used to describe the impact that an aging population will have on our limited health care resources as we enter the first decade of the new millennium. Almost daily the news media reports stories of emergency departments filled to capacity, lengthy waiting lists for elective surgery and diagnostic imaging, and nation-wide shortages of long-term care beds. Public opinion polls consistently reveal that concerns about the future of health care are uppermost for many Canadians. Whether and how our national health care system, apparently already faltering, will survive the increase in demand that an aging population will impose is already the subject of intense national debate. Some form of health care reform over the upcoming years seems inevitable, but instituting reforms that will ensure the survival of our universally accessible health care system, the pride of many Canadians since its inception in the 1960s, will no doubt prove to be a great challenge to policy makers. This article will attempt to shed light on the complex issue of just how an aging population will affect our health care system; it will also present various perspectives regarding the directions that health care reform could take.

Pierre Elliott Trudeau: 1919-2000

He said 'Just watch me', and we did. From his rise to power in the late 60's through almost 16 years of his tenure as Prime Minister, we were all witnesses to his triumphs and his downfalls. On September 28, the Right Honourable Pierre Trudeau passed away from complications associated with prostate cancer and Parkinson's disease.

Trudeau was known as a man of surpassing intellect, acerbic wit, and an absolute single-mindedness when he had a goal in sight. He was born October 18, 1919, to father Charles Emile Trudeau, and mother Grace Elliott, a family whose wealth afforded him the opportunity to obtain an international education and to travel the globe. He attended the Jesuit College Jean de Brebeuf, Universite de Montreal, Harvard University, Ecole des sciences politique (Paris) and the London School of Economics.

It is difficult to pinpoint exactly which of his actions will stand out most clearly in our memory. For some it will be when he invoked the War Measures Act, making it a criminal offence to be a member of the FLQ and suspending habeas corpus. For others, it will be his drive to patriate the Canadian Constitution and amend it with the Charter of Rights and Freedoms. For many Canadians he was, and is, a hero. In Quebec and Western Canada, his legacy may be viewed differently. It can be said that the patriation of the Constitution, which has still to be signed by Trudeau's home province, increased the feelings of estrangement of francophone Quebec from the Federal Government, and possibly from the rest of Canada. His introduction of the National Energy Program in 1980 also resulted in a fuelling of separatism in the Western Provinces.

In 1984, he retired from politics and returned to practicing law with the Montreal firm of Heenan and Blaikie. However, to the chagrin of those who governed after him, he kept returning from his private life to defend his much beloved Constitution. Despite his preference for a private life, he stepped back into the national limelight to express his view on the national unity debate and on constitutional issues, harpooning both the Meech Lake and the Charlottetown Accords.

His private life seems to have been almost as tumultuous as his political one. In 1971 he stunned the nation when at the age of 51, in a secret ceremony, he married the 22 year-old flower child, Margaret Sinclair. The two had three sons, Justin, Sacha and Michel before they decided on a trial separation in 1977, which ended in divorce in 1983. Trudeau gained custody of all three of the children and part of his decision to leave politics was to enable him to dedicate more of his time to their care. In the early 1990s, Trudeau again surprised us all when he had an affair with constitutional law expert Deborah Coyne, and on May 1991, the two had a daughter, Sarah. Probably the most devastating event of Trudeau's personal life came years after his departure from politics, with the death of his youngest son Michel, who died in an avalanche in Kokanee Lake, BC, in 1998. Several of Trudeau's closest personal friends attribute his health problems to grief over Michel's death.

For several days in October, Trudeau united us again as a nation. People gathered from across Canada to view his coffin at Parliament Hill, or to stop and salute his funeral train as it made its way from Ottawa to Quebec. Foreign dignitaries including former US President, Jimmy Carter, and Cuban leader, Fidel Castro, attended the funeral along with his family and his friends. They all gathered to say a final farewell to the man who reminded us that "we Canadians are standing on a mountaintop of human wealth, freedom and privilege".

The Good, The Bad, and the Indifferent

How to Deliver a Riveting Lecture

As I write these lines, I am sitting through a long, exceedingly dry, and from my own perspective, mostly irrelevant, medical lecture. If this were a rare event, or one that only occurred when I was in the audience, there would be no reason to continue with this piece. In fact, just as I began to pen the end of the previous sentence, the chin belonging to the person seated next to me dropped precipitously to his chest.

There is much evidence (albeit anecdotal) to suggest that this process, oft repeated around the world, is one of the greatest wastes of time known to professional people.

One must first consider the origin and history of "the lecture", to fully comprehend how such a profligate dissipation of professional person-hours has been allowed. Before Herr Guthenberg's timely invention, books were both exceedingly rare and restrictively expensive; as a result, they were not available to the majority of the populace, which in any case, was mostly illiterate.

In medieval universities, the art of teaching involved a professor reading aloud to his students from the one available book. (Thus the word lecture: through Middle English, via Middle French, originating from Latin: lectura, from lectus [past participle of legere: to gather, select, read.])

Books, and the knowledge that lies therein, have always represented power.