1033 HOW MANY SPECIALISTS?
SIR,-Dr Davies (March 31, p. 729) refers to "Jennett’s plan for radiology", and claims that "Jennett disapproves of radiology for being an ’inclusive’ specialty...". My paper (March 17, p. 594) was about hospital medicine as a whole, and all references to radiology were to the recent writings of radiologists about their own specialty. These provided good examples of the problems which specialties must face as medicine evolves, and of the willingness of some specialists to question traditional attitudes and roles in response to changing needs and circumstances. These statements stimulated vigorous comments from fellow radiologists when they were published, which indicates how controversial proposals touching on the organisation of the work of doctors can be. It was not my intention to rekindle that controversy, but rather to draw the attention of a wider readership to some questions of principle which many different specialties may find it necessary to consider in the future.
medical officers firmly as clinical links with community medicine.
doctors, albeit with important
Royal College of Physicians of London
DOUGLAS BLACK
Royal College of Physicians of Edinburgh
R. F. ROBERTSON
President
R. F. ROBERTSON President
Royal College of Physicians and Surgeons of Glasgow
GAVIN B. SHAW
British Pædiatric Association
GEORGE KOMROWER
President
President
President
Department of Child Health, University of Edinburgh, Edinburgh EH9 1UW
J. O. FORFAR J.
O. FORFAR
Chairman, Joint Pædiatric Committee of the Royal
Colleges of Physicians and the British Pædiatric Association
-
Department of Neurosurgery, Institute of Neurological Sciences, Southern General Hospital, 4TF
Glasgow G51
BRYAN
FUTURE OF MENTAL-SUBNORMALITY HOSPITALS
JENNETT p. 918) has devoted much of his life to the care of the mentally handicapped, and has made a valuable contribution to their welfare. It seems a pity, therefore, that his thinking stops where it does in his article. It is impossible at the moment to close down all large subnormality hospitals, but the evidence indicates that the care of human beings by other human beings in large units is doomed to failure. The ten solutions which Bavin offers might well improve the position but they represent no more than tinkering with a doomed machine. We do not, as he suggests, have a stark choice between shifting resources towards the mentally handicapped or a continuation of social euthenasia. The solution is. to create a variety of facilities within the community into which most mentally handicapped people could in due course be absorbed. I think it is a great pity that Bavin should castigate the Jay Committee, and suggest that by replacing nurses with residential care staff trained under a Central Council for Education and Training there would be a return to bedlam. Whilst nurses can contribute a great deal, what is required is another form of care. So much controversy has raged in this field. Is it too late for those of us who have been deeply committed to meet to try to work out new approaches for the 1980s rather than to take over the debris of old battlefields?
SIR,-Dr Bavin (April 28,
working HOW TO TRAIN DOCTORS one who has recently moved from a traditional medical school to the medical school at McMaster university University in Hamilton, Ontario, I found your editorial of April 7 (p. 761) most interesting. I agree that there is an urgent need to change the subject-based learning systems in traditional medical schools to something more in keeping with today’s needs in medicine. You did not mention the problembased system which has been evolved at McMaster. When I came here in January of this year, I was, I must admit, sceptical of the methods being used to teach students. I could not see how a system where the teacher acted as a mere facilitator of the student’s learning and where the student as a member of a small group would self-direct his own studies, could possibly work. I now have come to realise not only that the system does work but also that it works well. The McMaster system has much of interest for those interested in medical education, not least of which is the fact that it has proved able to produce a doctor within three years-and a competent one at that. Just as the followers of Mohammed the Prophet make at least one pilgrimage in their life to Mecca, so should those responsible for medical curricula pay at least one visit to McMaster. Perhaps those who come to scorn may stay to pray.
SIR,-As
Department of Medicine, McMaster University Medical Centre, Hamilton, Ontario L8S 4J9, Canada
Spastics Society, 12 Park Crescent, London W1N 4EQ
JAMES LORING Director
W. WATSON BUCHANAN
LOIN PAIN/HÆMATURIA SYNDROME CLINICAL MEDICAL OFFICERS
SIR,-The problem of clinical medical officers, the large are employed in child health, is of great concern to the Joint Pxdiatric Committee of the three Royal Colleges of Physicians in the United Kingdom and the British Pxdiatric Association. We feel strongly that their natural affiliation lies not with community medicine but with clinical
majority of whom
pædiatrics. There are, of course, many important matters to be looked at in relation to their training, qualifications, and career structure and in relation to the status of existing clinical medical officers. BX’e intend to consider these in detail in the near future. The decision of the British Pxdiatric Association to establish a grade of associate membership in this context is welcomed. The urgent necessity for the present is to establish clinical
SIR,-As a rider to the interesting paper by Dr Burden and colleagues (April 28, p. 897) I would point out that selective renal-artery catheterisation and injection of contrast medium alone can produce ischxmic changes on the angiogram. Such startling but transient patches of renal cortical ischaemia are rare but they have been published;’ they are not seen on good initial aortograms or on repeat selective studies. They probably represent spasm. I have seen patients like those of Burden et al. with undoubted structural ischsemic lesions, but I have seen two others in whom temporary changes were induced by the selective arteriogram. Both women had the usual severe loin symptoms, together with neurotic traits as mentioned by Burden et al. By contrast a female with an unrelated congeni1.
Tadavarthy, S. M., Castaneda, W., Amplatz,
I.
Radiology, 1977, 122,
343.
SIR,-Dr Davies (March 31, p. 729) refers to "Jennett’s plan for radiology", and claims that "Jennett disapproves of radiology for being an ’inclusive’ specialty...". My paper (March 17, p. 594) was about hospital medicine as a whole, and all references to radiology were to the recent writings of radiologists about their own specialty. These provided good examples of the problems which specialties must face as medicine evolves, and of the willingness of some specialists to question traditional attitudes and roles in response to changing needs and circumstances. These statements stimulated vigorous comments from fellow radiologists when they were published, which indicates how controversial proposals touching on the organisation of the work of doctors can be. It was not my intention to rekindle that controversy, but rather to draw the attention of a wider readership to some questions of principle which many different specialties may find it necessary to consider in the future.
medical officers firmly as clinical links with community medicine.
doctors, albeit with important
Royal College of Physicians of London
DOUGLAS BLACK
Royal College of Physicians of Edinburgh
R. F. ROBERTSON
President
R. F. ROBERTSON President
Royal College of Physicians and Surgeons of Glasgow
GAVIN B. SHAW
British Pædiatric Association
GEORGE KOMROWER
President
President
President
Department of Child Health, University of Edinburgh, Edinburgh EH9 1UW
J. O. FORFAR J.
O. FORFAR
Chairman, Joint Pædiatric Committee of the Royal
Colleges of Physicians and the British Pædiatric Association
-
Department of Neurosurgery, Institute of Neurological Sciences, Southern General Hospital, 4TF
Glasgow G51
BRYAN
FUTURE OF MENTAL-SUBNORMALITY HOSPITALS
JENNETT p. 918) has devoted much of his life to the care of the mentally handicapped, and has made a valuable contribution to their welfare. It seems a pity, therefore, that his thinking stops where it does in his article. It is impossible at the moment to close down all large subnormality hospitals, but the evidence indicates that the care of human beings by other human beings in large units is doomed to failure. The ten solutions which Bavin offers might well improve the position but they represent no more than tinkering with a doomed machine. We do not, as he suggests, have a stark choice between shifting resources towards the mentally handicapped or a continuation of social euthenasia. The solution is. to create a variety of facilities within the community into which most mentally handicapped people could in due course be absorbed. I think it is a great pity that Bavin should castigate the Jay Committee, and suggest that by replacing nurses with residential care staff trained under a Central Council for Education and Training there would be a return to bedlam. Whilst nurses can contribute a great deal, what is required is another form of care. So much controversy has raged in this field. Is it too late for those of us who have been deeply committed to meet to try to work out new approaches for the 1980s rather than to take over the debris of old battlefields?
SIR,-Dr Bavin (April 28,
working HOW TO TRAIN DOCTORS one who has recently moved from a traditional medical school to the medical school at McMaster university University in Hamilton, Ontario, I found your editorial of April 7 (p. 761) most interesting. I agree that there is an urgent need to change the subject-based learning systems in traditional medical schools to something more in keeping with today’s needs in medicine. You did not mention the problembased system which has been evolved at McMaster. When I came here in January of this year, I was, I must admit, sceptical of the methods being used to teach students. I could not see how a system where the teacher acted as a mere facilitator of the student’s learning and where the student as a member of a small group would self-direct his own studies, could possibly work. I now have come to realise not only that the system does work but also that it works well. The McMaster system has much of interest for those interested in medical education, not least of which is the fact that it has proved able to produce a doctor within three years-and a competent one at that. Just as the followers of Mohammed the Prophet make at least one pilgrimage in their life to Mecca, so should those responsible for medical curricula pay at least one visit to McMaster. Perhaps those who come to scorn may stay to pray.
SIR,-As
Department of Medicine, McMaster University Medical Centre, Hamilton, Ontario L8S 4J9, Canada
Spastics Society, 12 Park Crescent, London W1N 4EQ
JAMES LORING Director
W. WATSON BUCHANAN
LOIN PAIN/HÆMATURIA SYNDROME CLINICAL MEDICAL OFFICERS
SIR,-The problem of clinical medical officers, the large are employed in child health, is of great concern to the Joint Pxdiatric Committee of the three Royal Colleges of Physicians in the United Kingdom and the British Pxdiatric Association. We feel strongly that their natural affiliation lies not with community medicine but with clinical
majority of whom
pædiatrics. There are, of course, many important matters to be looked at in relation to their training, qualifications, and career structure and in relation to the status of existing clinical medical officers. BX’e intend to consider these in detail in the near future. The decision of the British Pxdiatric Association to establish a grade of associate membership in this context is welcomed. The urgent necessity for the present is to establish clinical
SIR,-As a rider to the interesting paper by Dr Burden and colleagues (April 28, p. 897) I would point out that selective renal-artery catheterisation and injection of contrast medium alone can produce ischxmic changes on the angiogram. Such startling but transient patches of renal cortical ischaemia are rare but they have been published;’ they are not seen on good initial aortograms or on repeat selective studies. They probably represent spasm. I have seen patients like those of Burden et al. with undoubted structural ischsemic lesions, but I have seen two others in whom temporary changes were induced by the selective arteriogram. Both women had the usual severe loin symptoms, together with neurotic traits as mentioned by Burden et al. By contrast a female with an unrelated congeni1.
Tadavarthy, S. M., Castaneda, W., Amplatz,
I.
Radiology, 1977, 122,
343.
