Journal of the Royal Society of Medicine Volume 84 November 1991
Medical malpractice crisis Dr McQuade's paper (July 1991 JRSM, p 408) is well supported by references to the literature with the exception of references to studies on the perceptions of physicians and surgeons who are exposed to the real or imagined threats of litigation. One of the earliest post-Second World War investigations into 'job satisfaction' in relation to malpractice was carried out by Mawardil as part of a longitudinal follow-up study of graduates from the innovative medical undergraduate course at Case Western Reserve University in Cleveland, Ohio. The author was able to demonstrate a growing level of dissatisfaction among progressively older cohorts of graduates. The most recent survey of perceived satisfaction in clinical practice was carried out on behalf of the Alumni Council of Harvard Medical School. The paper2'A Career in Medicine: A Promise Fulfilled?' refers to angst, fear of malpractice lawsuits, and alienation from the practice of medicine in summarizing the 1990 survey of a stratified random sample of 1514 Harvard Medical School graduates. Responses to a questionnaire on professional activities, problems, feelings and opinions were received from 1096 graduates of whom 448 practised in primary care, 310 in non-surgical specialties, and 269 in surgical specialties. A great deal of concern and (some concern) about malpractice adversely affecting medical care was expressed by 42(49)% in primary care, 53(41)To in non-surgical specialties, and 55(37)% in surgical specialties. A related question: ifthe right to sue physicians were limited and replaced by a no-fault system, would medical care be better/about the same? produced the following responses: primary care 83/11%, non-surgical specialties 77/13%, and surgical specialties 76/14%. C E ENGEL
Centre for Higher Education Studies, University of London, 55/59 Gordon Square, London WC1H ONT
References 1 Marwardi BH. Physicians and their careers. New York: University Microfilms International, 1972 2 Massagli MP, Fowler, FJ. A career fulfilled? Harvard Medical Alumni Bull 1991;64(4):50-5
Anal cancer: the case for earlier diagnosis I read with interest the article by Edwards et al. on the case for earlier diagnosis in anal cancer (July 1991 JRSM, p 395). Two principal points are raised in this paper, firstly the necessity for early diagnosis and referral of patients with anal cancer and secondly the importance of choosing the most efficacious treatment. Pain, discharge and bleeding are the commonest presenting symptoms in most anal cancer series but approximately 25% of patients are asymptomatic and their anal cancers are an incidental finding. It is vital that general practitioners examine rectally all patients presenting with even trivial anorectal symptoms and that local facilities exist for prompt assessment of these patients in a rectal clinic. The ICRF colorectal cancer unit at St Mark's has over the last 3 years developed and refined the technique of microanoscopy for the potentially premalignant anal intraepithelial neoplasia'. This technique in conjunction with anal smear may provide a useful screening tool in groups identified as being at high risk of developing anal cancer2.
The myth that abdominoperineal resection (APER) of the anorectum provides the best and only treatment for locally advanced anal cancer is not supported by the available data that shows no overall difference in survival between patients treated with surgery or radiotherapy (DXT) although a randomized prospective trial has still to be undertaken. The results of the UKCCCR anal cancer trial3 comparing radiotherapy alone with chemoradiotherapy are eagerly awaited. Until the results of the trial are available a simple protocol for the treatment of patients whom surgeons choose not to enter into the trial would be that Ti tumours are managed by local excision, larger tumours are managed by radiotherapy, APER should be reserved for those with a poor response to DXT and cases where treatment has produced incontinence or radionecrosis. ICRF Colorectal Cancer Unit P CARTER St Mark's Hospital, London EC1V 2PS
References 1 Scholefield JH, Sonnex C, Talbot IC, Palmer JG, Whatrup C, Mindel A, Northover JMA. Anal and cervical intraepithelial neoplasia: possible parallel. Lancet 1989;ii:765-9 2 Carter PS, de Ruiter A, Mindel A, Northover JMA. Anal intraepithelial neoplasia in HIV seropositive men. Br J Surg 1991;78:744 3 UKCCCR Anal Cancer trial CRC Clinical Trials Centre, Rayne Institute, 123 Coldharbour Lane, London SE5 9NU
Superior oblique palsy following ethmoidal surgery I read with interest the article by Dawidek et aL (June 1991 JRSM, p 369). Both transient and persistent diplopia due to disturbance of superior oblique function is a recognized complication following external fronto-ethmoidectomy. In a prospective study conducted with Moorfields Eye Hospital seven out of 22 patients undergoing external fronto-ethmoidectomy had some degree of persistent superior oblique underaction without an acquired Brown's syndrome'. This was in contradistinction to the transient exacerbation of diplopia experienced due to decompression of a fronto-ethmoidal mucocoele. During a modified Lynch-Howarth external fronto-ethmoidectomy the trochlea is usually detached from the frontal bone2. It is assumed that if the periosteum is not breached, damage to the tendon of the superior oblique muscle in the trochlea is negligible and reattachment occurs. The absence of an acquired Brown's syndrome supports the contention that there is no tethering of the superior oblique tendon but suggests that reattachment does not occur in the correct anatomical position. It seems likely that posterior displacement ofthe trochlea may result if no specific attempt is made to surgically reattach it to orbital periosteum and this mechanism would also account for the cases reported by Dawidek et al.. Careful repositioning of the trochlea has subsequently overcome this problem in all recent patients undergoing external frontoethmoidal surgery. V J LUND
Senior Lecturer in Rhinology, Institute of Laryngology & Otology, 330 Gray's Inn Road,
London WClX 8DA
References 1 Lund VJ, Rolfe ME. Ophthalmic considerations in frontoethmoidal mucocoeles. J Laryngol Otol 1989;103:667-9 2 Harrison DFN. The ENT surgeon looks at the orbit. J Laryngol Otol 1980;suppl 3:1-43
695
Medical malpractice crisis Dr McQuade's paper (July 1991 JRSM, p 408) is well supported by references to the literature with the exception of references to studies on the perceptions of physicians and surgeons who are exposed to the real or imagined threats of litigation. One of the earliest post-Second World War investigations into 'job satisfaction' in relation to malpractice was carried out by Mawardil as part of a longitudinal follow-up study of graduates from the innovative medical undergraduate course at Case Western Reserve University in Cleveland, Ohio. The author was able to demonstrate a growing level of dissatisfaction among progressively older cohorts of graduates. The most recent survey of perceived satisfaction in clinical practice was carried out on behalf of the Alumni Council of Harvard Medical School. The paper2'A Career in Medicine: A Promise Fulfilled?' refers to angst, fear of malpractice lawsuits, and alienation from the practice of medicine in summarizing the 1990 survey of a stratified random sample of 1514 Harvard Medical School graduates. Responses to a questionnaire on professional activities, problems, feelings and opinions were received from 1096 graduates of whom 448 practised in primary care, 310 in non-surgical specialties, and 269 in surgical specialties. A great deal of concern and (some concern) about malpractice adversely affecting medical care was expressed by 42(49)% in primary care, 53(41)To in non-surgical specialties, and 55(37)% in surgical specialties. A related question: ifthe right to sue physicians were limited and replaced by a no-fault system, would medical care be better/about the same? produced the following responses: primary care 83/11%, non-surgical specialties 77/13%, and surgical specialties 76/14%. C E ENGEL
Centre for Higher Education Studies, University of London, 55/59 Gordon Square, London WC1H ONT
References 1 Marwardi BH. Physicians and their careers. New York: University Microfilms International, 1972 2 Massagli MP, Fowler, FJ. A career fulfilled? Harvard Medical Alumni Bull 1991;64(4):50-5
Anal cancer: the case for earlier diagnosis I read with interest the article by Edwards et al. on the case for earlier diagnosis in anal cancer (July 1991 JRSM, p 395). Two principal points are raised in this paper, firstly the necessity for early diagnosis and referral of patients with anal cancer and secondly the importance of choosing the most efficacious treatment. Pain, discharge and bleeding are the commonest presenting symptoms in most anal cancer series but approximately 25% of patients are asymptomatic and their anal cancers are an incidental finding. It is vital that general practitioners examine rectally all patients presenting with even trivial anorectal symptoms and that local facilities exist for prompt assessment of these patients in a rectal clinic. The ICRF colorectal cancer unit at St Mark's has over the last 3 years developed and refined the technique of microanoscopy for the potentially premalignant anal intraepithelial neoplasia'. This technique in conjunction with anal smear may provide a useful screening tool in groups identified as being at high risk of developing anal cancer2.
The myth that abdominoperineal resection (APER) of the anorectum provides the best and only treatment for locally advanced anal cancer is not supported by the available data that shows no overall difference in survival between patients treated with surgery or radiotherapy (DXT) although a randomized prospective trial has still to be undertaken. The results of the UKCCCR anal cancer trial3 comparing radiotherapy alone with chemoradiotherapy are eagerly awaited. Until the results of the trial are available a simple protocol for the treatment of patients whom surgeons choose not to enter into the trial would be that Ti tumours are managed by local excision, larger tumours are managed by radiotherapy, APER should be reserved for those with a poor response to DXT and cases where treatment has produced incontinence or radionecrosis. ICRF Colorectal Cancer Unit P CARTER St Mark's Hospital, London EC1V 2PS
References 1 Scholefield JH, Sonnex C, Talbot IC, Palmer JG, Whatrup C, Mindel A, Northover JMA. Anal and cervical intraepithelial neoplasia: possible parallel. Lancet 1989;ii:765-9 2 Carter PS, de Ruiter A, Mindel A, Northover JMA. Anal intraepithelial neoplasia in HIV seropositive men. Br J Surg 1991;78:744 3 UKCCCR Anal Cancer trial CRC Clinical Trials Centre, Rayne Institute, 123 Coldharbour Lane, London SE5 9NU
Superior oblique palsy following ethmoidal surgery I read with interest the article by Dawidek et aL (June 1991 JRSM, p 369). Both transient and persistent diplopia due to disturbance of superior oblique function is a recognized complication following external fronto-ethmoidectomy. In a prospective study conducted with Moorfields Eye Hospital seven out of 22 patients undergoing external fronto-ethmoidectomy had some degree of persistent superior oblique underaction without an acquired Brown's syndrome'. This was in contradistinction to the transient exacerbation of diplopia experienced due to decompression of a fronto-ethmoidal mucocoele. During a modified Lynch-Howarth external fronto-ethmoidectomy the trochlea is usually detached from the frontal bone2. It is assumed that if the periosteum is not breached, damage to the tendon of the superior oblique muscle in the trochlea is negligible and reattachment occurs. The absence of an acquired Brown's syndrome supports the contention that there is no tethering of the superior oblique tendon but suggests that reattachment does not occur in the correct anatomical position. It seems likely that posterior displacement ofthe trochlea may result if no specific attempt is made to surgically reattach it to orbital periosteum and this mechanism would also account for the cases reported by Dawidek et al.. Careful repositioning of the trochlea has subsequently overcome this problem in all recent patients undergoing external frontoethmoidal surgery. V J LUND
Senior Lecturer in Rhinology, Institute of Laryngology & Otology, 330 Gray's Inn Road,
London WClX 8DA
References 1 Lund VJ, Rolfe ME. Ophthalmic considerations in frontoethmoidal mucocoeles. J Laryngol Otol 1989;103:667-9 2 Harrison DFN. The ENT surgeon looks at the orbit. J Laryngol Otol 1980;suppl 3:1-43
695
