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Designing a doctor SIR,-Since the conception of the National Health Service the chiefs have worried about the design of the indians.1 The recent Lancet series Designing a Doctor shows that doctors, students, and patients bum with a desire for change to more efficient training. Simply filling students with more facts has not affected the problem-indeed selecting students capable of memorising facts, by virtue of their lacking other skills and graces, may have made matters worse.

Dr Godfrey suggests that the perfect medical graduate would be "even more enthusiastic to learn about medicine than at the first day of medical school" and that "art is best learnt by apprenticeship", yet he concedes that the "dominant sense in these unhappy young people tends to be one of disillusionment". As Dr McManus says "One certainly should not underestimate the obstacles within the conservative world of medical education in which short-term interests prevent structural change. But change is both possible and inevitable". He too admits that students are force-fed ("... 80% of today’s factual knowledge is unnecessary and rapidly forgotten"). Professor Abrahamson writes of a Renaissance man (or woman) being necessary to fulfil the role of the average faculty member charged with teaching, administration, research, and clinical duties. And other contributors show that radical change is possible. Does change need to be so radical? Here in Britain are we not already a long way on the road to the more rational system your series has pressed for? I have argued2 that the roles of qualified nurse and houseman have in certain areas become indistinguishable. A ("stem doctor"), an amalgam of staff nurse and house doctor, could be integrated into virtually any health-care system.3 He or she could, like stem cells, differentiate into any specialty depending on intellectual ability, competitiveness, and social pressures. The training would include a core curriculum, be versatile, and, in McManus’ words, include "something resembling a sandwich or layer cake with alternating basic science and clinical medicine each reinforcing the other". A blueprint has therefore already been written. Can it be implemented? I would argue that economic and moral pressures have already ensured that, in Britain at least, this blueprint is well on the way to being implemented. Newly trained doctors and nurses are rapidly approaching my generic stem doctor. Nurses train longer, need higher academic entrance hurdles, and, on qualifying, are given support from "nursing care assistants". The Royal College of Nursing presses for even more specialist training for those who opt to work in operating-theatres, intensive care, dialysis units, and so on. The profession also argues its right to prescribe.’ Most published work on physician assistants is based on the very wise premise that since most disease is self-limiting or out of control of modern medicine, commonsense and judgment are the only features necessary in those doing the treatment. The UK Government’s December, 1990, agreement on junior hospital doctors acknowledged that a competent staff nurse is all that is required to clerk and (probably) examine a patient, thus inferring that a "doctor" should do something more important. That "something more important" is beginning to boil down to legal prescribing and certification of death. After five or six years training via medical schools this is often all that separates the junior hospital doctors from senior nurses. As your series writers note, the core knowledge of junior doctors is minimal (and probably equalled by graduate nurses). An MB, BS is not a prerequisite for putting up drips, external cardiac massage, or passage of catheters. Most important judgments by hospital doctors during their first few months are vetted by more experienced clinicians. In essence, the house-jobs put right the defects in undergraduate medical training. By contrast, nurses, following Godfrey’s apprenticeship principle, have been doing the correct things from day one. Nurses have a well-developed system of ward tutors, who unlike today’s medical academics, do nothing but teach. In summary, therefore, we have all the building blocks but no courage to take the next step. We have highly trained degree nurses capable of all the core curricular activities of most house-doctors but unable to prescribe or certify death and, we have overtrained housemen capable of prescribing but overworked and often disillusioned. A shift to a stem doctor system would require little

an agreement between Royal Colleges and the Government to licence such individuals for work under supervision until they reach full specialist qualification.

change other than

Department of Vascular Surgery, Southampton University Hospitals, Southampton SO9 4PE, UK

A. D. B. CHANT

1. Chant ADB, Lord Horder and the new white paper. J Roy Soc Med 1990; 83: 283-84, 2. Chant ADB. "The stem doctor" melting pot. Health Soc Serv J 1982 (Dec 9): 1462-64. 3. Chant ADB. The stem doctor. Privately published, 1989 (ISBN 0-951532502). 4. Fawcett-Henesy A. Tools of the trade. Commun Outlook 1988 (Feb): 12-13.

Research

human embryos, cryopreservation, and the HFEA on

SiR,—The number of research projects on human embryos from infertile couples undergoing in-vitro fertilisation (IVF) treatment has been increasing-both non-invasive (eg, looking at optimum metabolic requirements) and invasive (such as the detection of gender and chromosome anomalies on removed blastomeres). The new Human Fertilisation and Embryo Authority (HFEA) consent form rightly ensures that infertile couples indicate their choice about the use of their embryos, including those left over from IVF or gamete intrafallopian transfer (GIFT) treatment. Three principal choices are mentioned in the consent form: use for own treatment; use for treating others; and use for research. But do infertile couples really have a complete choice? ’I’hey might not be aware that embryos can be preserved for future use. We therefore asked 953 couples whether they would wish their left-over oocytes or embryos to be made available: for their own future use after freezing; for research purposes only; or donated for the use of other infertile couples. When given this choice only 48 couples (5 %) wished the embryos to be used for research, 191 (20%) wished to donate them to other infertile couples, and 667 (70%) requested that they be used for their own future benefit.’ The remaining 5% did not makea specific recommendation. Indeed, 791 (83%) couples believed that research should be done only on embryos donated specifically for this—eg, from those volunteering at the time of other elective procedures such as sterilisation. Cryopreservation is acknowledged to increase the cumulative pregnancy rate from a single IVF or GIFT attempt, and pregnancies resulting from the transfer of thawed embryos have taken place for many years. Is it therfore correct to deny infertile couples future children by failing to provide a cryopreservation service and thereby limiting their choice? The new HFEA should consider the ethics of not pointing out to couples that they have this choice and should emphasise the need that embryo cryopreservation is available for all couples undergoing IVF and GIFT treatment. Ideally, any essential research might best be done on embryos generated specifically for that purpose.

London Fertility Centre and Medicraft Services, Cozens House, 112A Harley Street, London W1N 1AF, UK

IAN CRAFT DAVID SHAPLAND ELLY FINCHAM TALHA AL-SHAWAF

E, Brinsden P, Craft I. Patients’ response to a questionnaire on assisted reproduction treatment. Ethic Prob Reprod Med 1989; 1: 25-27.

1. Fincham

Paediatrics or child health SIR,-In your issue of Aug 24, you publish as an editorial what is essentially a book review of a volume based on a conference organised by members of the Academic Board of the British Paediatric Association under the title Paediatric Specialty Practice for the 1990s. As a book review the editorial is critical, and to that one has no objection. However, the editorial distorts the clearly expressed intention of the volume by implying that paediatrics is a "disease oriented specialty with a lesser interest in health, in primary care and in the needs of children". The book’s preface notes that: "Specialisation of paediatrics into sub-specialty areas mainly in referral centres" has been a feature of

Designing a doctor.

888 Designing a doctor SIR,-Since the conception of the National Health Service the chiefs have worried about the design of the indians.1 The recent...
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