199
Careful lifelong follow-up is essential in these patients and should include physical examination and chest X-rays, liver-function tests, and tumour markers (C.E.A.) (fig. 2). The aim of follow-up is not only to detect metastatic disease but to identify early any new primary mass population screening has not as had been hoped in cancer detecsuccessful proved tion, it is ideally suited for early diagnosis of new
tumours.
Though
as
tumours.
well as managing family members with cancer, must inform and screen other members of cancer families. Krush18 found that only 7 of 32 members of a cancer family had regular medical examinations. Only 2 of 6 who had had cancer attended for check-ups. Fear of discovering cancer was the most common emotional response, followed by apathy and denial. Only 8% of the physicians answering Krush’s questionnaire sent written reminders to their patients for routine physical examination. Family members should be educated in methods of cancer detection and the undoubted benefits of early diagnosis in some tumours. They should also be encour-’ aged to assume some responsibility for their own health and that of their immediate family. Screening for malignancy in members of a cancer family should concentrate on early diagnosis of the common uterine and colon cancers, because early diagnosis of these cancers improves survival. Cervical cytology and colposcopy should be used routinely, though they are less sensitive in the diagnosis of uterine cancer than cervical cancer. Screening techniques for colorectal cancer, which are less clearly defined and are in some cases more cumbersome, have not so far been useful in mass screening programmes,19 but they may be useful in patients from cancer-families, who should have regular physical examinations. Testing for occult blood is simple and effective, since most colorectal tumours bleed. The ’Hxmoccult’ technique is the most accurate and can be used at home by patients, provided they comply with the necessary dietary restrictions. Winawer and Sherlock2O found good patient compliance with this method and detected 119 colon cancers beyond the reach of a sigmoidoscope with only 1 false negative. 85% of these tumours were localised to the bowel wall. Whether or not occult-blood testing is positive, all cancer-family members should have periodic proctosigmoidoscopic examinations; although its use is limited in population screening, 55% of all colon cancers can be identified by a standard 25 cm sigmoidoscope. Although some authors21 do not recommend a barium enema as a mass screening procedure, an air-contrast barium study should be done in patients with stools positive for occult blood. Colonoscopy has revolutionised the surgeon’s diagnostic capabilities, but it is far too cumbersome and
Physicians,
expensive
C. W. is
as
to use
in routine
screening. However,
it may
be indicated in patients who are occult-blood positive. Pulsatile rectocolonic lavage is particularly useful in patients with premalignant changes .20 Unfortunately, there are no biological markers specific for colorectal
Carcinoembryonic antigen is not specific enough ’22,21 though it is undoubtedly useful in following the progress of colon-cancer patients when the level is initially elevated. Until more specific tumour markers are available, they should probably not be used to screen family members. cancer.
At follow-up full physical examination, including breast examination, chest X-ray, and blood-chemistry tests, should be done to exclude other cancers. By selection of appropriate initial treatment, careful follow-up of patients with cancer, and a screening programme for symptom-free members of "cancer families", it is hoped that the death-rate from cancer in these families can be materially reduced.
supported by the
Cancer Research
Campaign.
REFERENCES H. T. (editor) in Recent Results in Cancer Research; vol. XII, p. 186. New York, 1967. 2. Lynch, H. T., Krush, A. J. Gastroenterology, 1967, 53, 517. 3. Lynch, H. T., Krush, A. J. Sth. med. J., Nashville, 1971, 64, suppl. 1, 26. 4. Lynch, H. T., Shaw, M. W., Magnuson, C. W., Larsen, A. L., Krush, A. J. Archs intern. Med. 1966, 117, 206. 5. Dukes, C. E. Ann. Eugen. 1953, 17, 1. 6. Li, F. P., Fraumeni, J. F. Jr. Ann. intern. Med. 1969, 71, 747. 7. Lynch, H. T., Krush, A. J. Surgery Gynec. Obstet. 1971, 133, 644. 8. Lovett, E. Proc. R. Soc. Med. 1974, 67, 751. 9. Lynch, H. T., Swartz, M., Lynch, M., Krush, A. J. Surgery Gynec. Obstet.
1.
Lynch,
1972, 134, 781. 10. Warthin, A. S. Archs intern. Med. 1913, 12, 546. 11. Lynch, H. T., Krush, A. J. Cancer, N.Y. 1971, 27, 1505. 12. Lynch, H. T., Thomas, R. J., et al. ibid. 1975, 36, 1315. 13. Macklin, M. T. J. natn. Cancer Inst. 1960, 24, 551. 14. Kluge, T. Acta chir. scand. 1964, 127, 392. 15. Peltokallio, P., Peltokallio, V. Dis. Colon Rectum, 1966, 9, 367. 16. MacDougall, I. P. M. Lancet, 1964, ii, 655. 17. Moertel, C. G., Hill, J. R., Adson, M. A. Archs Surg., Chicago. 1970, 100, 521. 18. Krush, A. J., Lynch, H. T., Magnuson, C. Am. J. med. Sci. 1965, 249, 432. 19. Moertel, G. B. in Cancer Medicine (edited by J. Holland and E. Frei, III);
p. 1597. Philadelphia, 1973. 20. 21. 22. 23.
Winawer, S. J., Sherlock, P. Hosp. Pract. 1977, 12, 49. Copeland, M. M. J. surg. Oncol. 1976, 8, 555. Zamchek, N., Pusztaszeri, G. CA, 1975, 25, 204. Zamchek, N. Adv. intern. Med. 1974, 19, 413.
Medical Education IF I WERE A DEAN
J. W. PAULLEY* ONE has great sympathy for deans and their committees in their difficult task of selection, and having heard them speak on the matter at meetings of the Association for the Study of Medical Education, I was initially somewhat reluctant to contribute to this series. I should make it plain therefore that I write only from the standpoint of an employer of the "product" for 35 years, and as an occasional "consumer". As A.S.M.E. and Commonwealth Fund of New York travelling fellow in 1966 I had the opportunity to com-
pare North American interns and residents with their British equivalents. A striking difference was that the Americans seemed to be "self-propelled" after graduation whereas our graduates remained relatively incurious and apathetic to the acquisition of new knowledge. This no doubt was partly because our students were 18 months to 2 years younger, a suspicion reinforced by the
stimulating experience of teaching ex-combatants aged 23 or more in the immediate post-war years. However, American education from junior high school up is less didactic than ours, encourages more questioning, and specialises later than we do. British students while still little more than children are confined to the very narrow A-level entry requirement of our medical schools. A dis*Consultant
physician, Ipswich Hospitals,
Suffolk.
200 that is surely not immutable. Gilmourl says "there are many who question whether ... emphasis upon academic prowess is wise ... when medicine offers such a wide range of careers", and expresses something of that groundswell of dissatisfaction popularised by Illich and which if not heeded by medical educators will result in further isolation of scientific medicine from what may still be best described as the "art" of medicine. As a psychosomatist seeing the integral causative role that inadequate emotional coping-mechanisms play in perhaps 90% of illness in Western societies, I welcome the current renewal of interest by the young in the art of medicine, suitably honed from its intuitive past to the, near precision instrument it can and must become. However, I do not agree with those rather vociferous "feeling" doctors who rejoice in scientific ignorance and preach contempt for scientific medicine, any more than I agree that medical scientists should continue to spend the whole of their professional lives with a permanent hemianopia for the psyche. Medicine is difficult enough without the unnecessary handicap of having one hand tied behind the back. The price of failure if doctors do not equip themselves on both planes is heavy and will first be paid by the patient, but as heavily, if a little later, by the whole profession in loss of job satisfaction, self-regard, and public esteem. The solution is therefore not one of "either or" as some people on both sides of the divide are suggesting. So how would this affect student selection? My conclusion is that while it is not possible for y or p- intellects to acquire a sufficiency of scientific expertise to render them safe with patients, it is quite possible to equip (x and p+ intellects with sufficient psychotherapeutic skills, or at least an understanding of them, to render them relatively immune from the disastrous consequences of manipulation by their patients, which are daily before us, and which account for much of the current tide of criticism of our profession. I refer to the appalling misuse of the pharmacopoeia and the way patients "split" their doctors, surgeons, and other therapists.2,3 I am, therefore, unrepentant about the need to insist on the highest possible intellectual requirements for entry to the medical profession, with the following provisos. Firstly, it should be recognised that high A-level passes in chemistry, physics, and biology are a better test of a retentive memory and application than of ability to think constructively or divergently. Not all doctors need the latter facility, but most do. If interviews are out-and I do not see why they should be for a final selection from a short list-then might not a paper set on the lines of Oxford and Cambridge entrance be a helpful guide? My second proviso is that there should be greater opportunity for students, including mature students from disciplines such as classics, mathematics, pure biology, and P.P.E. to switch at a late stage to medicine. Closure of one after another of the premedical schools has virtually shut this door. I think the policy should be reversed. As I conclude I hear our contemporary flat-earthers sharpening their quills in defence of mediocrity. "Why train doctors to be competent medical scientists if they
advantage
1. Gilmour, A. Lancet, 1977, ii, 985. 2. Winnicott, D. W. Int. J. Psycho-Analysis, 1966, 47, 510. 3. Winnicott, D. W. ibid. 1958, 39, 298.
become frustrated because they think they their skill?" If some general practitioners at present feel frustrated in this way, and some do, it is not, I suggest, because they have been too highly trained, or because the job is insufficient to tax their ability; it is because of the disincentives of general practice as at present structured in this country, which fail to reward excellence and penalise indolence, fail to permit sufficient time for interview and examination, and fail to provide training for the other essential skill, the art of medicine. For thirty years or more the art of medicine has been used as a term of ridicule by medical scientists ("Anecdotal my dear chap"-screams of laughter, collapse of stout party). Provide incentives, competent nurse assistants and thereby time, and general practice can become again, as many perceive it shouldbe, and once was, one of the most challenging careers in medicine. To be a competent generalist is more difficult than to become a competent specialist. The requirements for a career in industrial medicine, epidemiology, tropical medicine, and medical journalism should be no less; but when it comes to medical administration, rehabilitation, or administrative geriatrics a demanding scientific education is inappropriate and unnecessary except for a few top-flight personnel. Much of such work is already being better done by people trained in disciplines such as management, hospital administration, nursing, physiotherapy or the social services. I suggest medicine should reduce its claim on these areas with benefit to its own job satisfaction and its public image. The only alternative is to train two kinds of doctor from the start, one a medical scientist and the other a kind of Westernised barefoot doctor. As a potential patient the idea terrifies me, because the medical scientists would then be encouraged to retreat even further from their patients into laboratories, or behind a smokescreen of monitors and technological wizardry, while the barefoot doctors would remain forever blissfully ignorant of their own ignorance and constitute a menace to life and limb. No, when a patient consults a doctor he expects, and is entitled to expect, total comprehension of his problem at all levels. To aim at anything less will not do.
subsequently cannot use
Occupational
Health
REDUCTION OF MERCURY VAPOUR IN A DENTAL SURGERY
JOHN WILSON* General Dental Practitioner
A restricted survey in one dental practice has shown that a considerable reduction in contamination by mercury vapour can be achieved by the use of a fume cupboard. Failure to employ this added protection may have legal implications.
Summary
INTRODUCTION
intoxication after accidental review the handling of mercury. The aims were to reduce atmospheric levels of contamination and to prevent spillage. A
reportl on mercury spillage stimulated me to
*
Address: Pennine
hamshire, England.
Cottage,
15 Britwell Road, Burnham,
Bucking-
Careful lifelong follow-up is essential in these patients and should include physical examination and chest X-rays, liver-function tests, and tumour markers (C.E.A.) (fig. 2). The aim of follow-up is not only to detect metastatic disease but to identify early any new primary mass population screening has not as had been hoped in cancer detecsuccessful proved tion, it is ideally suited for early diagnosis of new
tumours.
Though
as
tumours.
well as managing family members with cancer, must inform and screen other members of cancer families. Krush18 found that only 7 of 32 members of a cancer family had regular medical examinations. Only 2 of 6 who had had cancer attended for check-ups. Fear of discovering cancer was the most common emotional response, followed by apathy and denial. Only 8% of the physicians answering Krush’s questionnaire sent written reminders to their patients for routine physical examination. Family members should be educated in methods of cancer detection and the undoubted benefits of early diagnosis in some tumours. They should also be encour-’ aged to assume some responsibility for their own health and that of their immediate family. Screening for malignancy in members of a cancer family should concentrate on early diagnosis of the common uterine and colon cancers, because early diagnosis of these cancers improves survival. Cervical cytology and colposcopy should be used routinely, though they are less sensitive in the diagnosis of uterine cancer than cervical cancer. Screening techniques for colorectal cancer, which are less clearly defined and are in some cases more cumbersome, have not so far been useful in mass screening programmes,19 but they may be useful in patients from cancer-families, who should have regular physical examinations. Testing for occult blood is simple and effective, since most colorectal tumours bleed. The ’Hxmoccult’ technique is the most accurate and can be used at home by patients, provided they comply with the necessary dietary restrictions. Winawer and Sherlock2O found good patient compliance with this method and detected 119 colon cancers beyond the reach of a sigmoidoscope with only 1 false negative. 85% of these tumours were localised to the bowel wall. Whether or not occult-blood testing is positive, all cancer-family members should have periodic proctosigmoidoscopic examinations; although its use is limited in population screening, 55% of all colon cancers can be identified by a standard 25 cm sigmoidoscope. Although some authors21 do not recommend a barium enema as a mass screening procedure, an air-contrast barium study should be done in patients with stools positive for occult blood. Colonoscopy has revolutionised the surgeon’s diagnostic capabilities, but it is far too cumbersome and
Physicians,
expensive
C. W. is
as
to use
in routine
screening. However,
it may
be indicated in patients who are occult-blood positive. Pulsatile rectocolonic lavage is particularly useful in patients with premalignant changes .20 Unfortunately, there are no biological markers specific for colorectal
Carcinoembryonic antigen is not specific enough ’22,21 though it is undoubtedly useful in following the progress of colon-cancer patients when the level is initially elevated. Until more specific tumour markers are available, they should probably not be used to screen family members. cancer.
At follow-up full physical examination, including breast examination, chest X-ray, and blood-chemistry tests, should be done to exclude other cancers. By selection of appropriate initial treatment, careful follow-up of patients with cancer, and a screening programme for symptom-free members of "cancer families", it is hoped that the death-rate from cancer in these families can be materially reduced.
supported by the
Cancer Research
Campaign.
REFERENCES H. T. (editor) in Recent Results in Cancer Research; vol. XII, p. 186. New York, 1967. 2. Lynch, H. T., Krush, A. J. Gastroenterology, 1967, 53, 517. 3. Lynch, H. T., Krush, A. J. Sth. med. J., Nashville, 1971, 64, suppl. 1, 26. 4. Lynch, H. T., Shaw, M. W., Magnuson, C. W., Larsen, A. L., Krush, A. J. Archs intern. Med. 1966, 117, 206. 5. Dukes, C. E. Ann. Eugen. 1953, 17, 1. 6. Li, F. P., Fraumeni, J. F. Jr. Ann. intern. Med. 1969, 71, 747. 7. Lynch, H. T., Krush, A. J. Surgery Gynec. Obstet. 1971, 133, 644. 8. Lovett, E. Proc. R. Soc. Med. 1974, 67, 751. 9. Lynch, H. T., Swartz, M., Lynch, M., Krush, A. J. Surgery Gynec. Obstet.
1.
Lynch,
1972, 134, 781. 10. Warthin, A. S. Archs intern. Med. 1913, 12, 546. 11. Lynch, H. T., Krush, A. J. Cancer, N.Y. 1971, 27, 1505. 12. Lynch, H. T., Thomas, R. J., et al. ibid. 1975, 36, 1315. 13. Macklin, M. T. J. natn. Cancer Inst. 1960, 24, 551. 14. Kluge, T. Acta chir. scand. 1964, 127, 392. 15. Peltokallio, P., Peltokallio, V. Dis. Colon Rectum, 1966, 9, 367. 16. MacDougall, I. P. M. Lancet, 1964, ii, 655. 17. Moertel, C. G., Hill, J. R., Adson, M. A. Archs Surg., Chicago. 1970, 100, 521. 18. Krush, A. J., Lynch, H. T., Magnuson, C. Am. J. med. Sci. 1965, 249, 432. 19. Moertel, G. B. in Cancer Medicine (edited by J. Holland and E. Frei, III);
p. 1597. Philadelphia, 1973. 20. 21. 22. 23.
Winawer, S. J., Sherlock, P. Hosp. Pract. 1977, 12, 49. Copeland, M. M. J. surg. Oncol. 1976, 8, 555. Zamchek, N., Pusztaszeri, G. CA, 1975, 25, 204. Zamchek, N. Adv. intern. Med. 1974, 19, 413.
Medical Education IF I WERE A DEAN
J. W. PAULLEY* ONE has great sympathy for deans and their committees in their difficult task of selection, and having heard them speak on the matter at meetings of the Association for the Study of Medical Education, I was initially somewhat reluctant to contribute to this series. I should make it plain therefore that I write only from the standpoint of an employer of the "product" for 35 years, and as an occasional "consumer". As A.S.M.E. and Commonwealth Fund of New York travelling fellow in 1966 I had the opportunity to com-
pare North American interns and residents with their British equivalents. A striking difference was that the Americans seemed to be "self-propelled" after graduation whereas our graduates remained relatively incurious and apathetic to the acquisition of new knowledge. This no doubt was partly because our students were 18 months to 2 years younger, a suspicion reinforced by the
stimulating experience of teaching ex-combatants aged 23 or more in the immediate post-war years. However, American education from junior high school up is less didactic than ours, encourages more questioning, and specialises later than we do. British students while still little more than children are confined to the very narrow A-level entry requirement of our medical schools. A dis*Consultant
physician, Ipswich Hospitals,
Suffolk.
200 that is surely not immutable. Gilmourl says "there are many who question whether ... emphasis upon academic prowess is wise ... when medicine offers such a wide range of careers", and expresses something of that groundswell of dissatisfaction popularised by Illich and which if not heeded by medical educators will result in further isolation of scientific medicine from what may still be best described as the "art" of medicine. As a psychosomatist seeing the integral causative role that inadequate emotional coping-mechanisms play in perhaps 90% of illness in Western societies, I welcome the current renewal of interest by the young in the art of medicine, suitably honed from its intuitive past to the, near precision instrument it can and must become. However, I do not agree with those rather vociferous "feeling" doctors who rejoice in scientific ignorance and preach contempt for scientific medicine, any more than I agree that medical scientists should continue to spend the whole of their professional lives with a permanent hemianopia for the psyche. Medicine is difficult enough without the unnecessary handicap of having one hand tied behind the back. The price of failure if doctors do not equip themselves on both planes is heavy and will first be paid by the patient, but as heavily, if a little later, by the whole profession in loss of job satisfaction, self-regard, and public esteem. The solution is therefore not one of "either or" as some people on both sides of the divide are suggesting. So how would this affect student selection? My conclusion is that while it is not possible for y or p- intellects to acquire a sufficiency of scientific expertise to render them safe with patients, it is quite possible to equip (x and p+ intellects with sufficient psychotherapeutic skills, or at least an understanding of them, to render them relatively immune from the disastrous consequences of manipulation by their patients, which are daily before us, and which account for much of the current tide of criticism of our profession. I refer to the appalling misuse of the pharmacopoeia and the way patients "split" their doctors, surgeons, and other therapists.2,3 I am, therefore, unrepentant about the need to insist on the highest possible intellectual requirements for entry to the medical profession, with the following provisos. Firstly, it should be recognised that high A-level passes in chemistry, physics, and biology are a better test of a retentive memory and application than of ability to think constructively or divergently. Not all doctors need the latter facility, but most do. If interviews are out-and I do not see why they should be for a final selection from a short list-then might not a paper set on the lines of Oxford and Cambridge entrance be a helpful guide? My second proviso is that there should be greater opportunity for students, including mature students from disciplines such as classics, mathematics, pure biology, and P.P.E. to switch at a late stage to medicine. Closure of one after another of the premedical schools has virtually shut this door. I think the policy should be reversed. As I conclude I hear our contemporary flat-earthers sharpening their quills in defence of mediocrity. "Why train doctors to be competent medical scientists if they
advantage
1. Gilmour, A. Lancet, 1977, ii, 985. 2. Winnicott, D. W. Int. J. Psycho-Analysis, 1966, 47, 510. 3. Winnicott, D. W. ibid. 1958, 39, 298.
become frustrated because they think they their skill?" If some general practitioners at present feel frustrated in this way, and some do, it is not, I suggest, because they have been too highly trained, or because the job is insufficient to tax their ability; it is because of the disincentives of general practice as at present structured in this country, which fail to reward excellence and penalise indolence, fail to permit sufficient time for interview and examination, and fail to provide training for the other essential skill, the art of medicine. For thirty years or more the art of medicine has been used as a term of ridicule by medical scientists ("Anecdotal my dear chap"-screams of laughter, collapse of stout party). Provide incentives, competent nurse assistants and thereby time, and general practice can become again, as many perceive it shouldbe, and once was, one of the most challenging careers in medicine. To be a competent generalist is more difficult than to become a competent specialist. The requirements for a career in industrial medicine, epidemiology, tropical medicine, and medical journalism should be no less; but when it comes to medical administration, rehabilitation, or administrative geriatrics a demanding scientific education is inappropriate and unnecessary except for a few top-flight personnel. Much of such work is already being better done by people trained in disciplines such as management, hospital administration, nursing, physiotherapy or the social services. I suggest medicine should reduce its claim on these areas with benefit to its own job satisfaction and its public image. The only alternative is to train two kinds of doctor from the start, one a medical scientist and the other a kind of Westernised barefoot doctor. As a potential patient the idea terrifies me, because the medical scientists would then be encouraged to retreat even further from their patients into laboratories, or behind a smokescreen of monitors and technological wizardry, while the barefoot doctors would remain forever blissfully ignorant of their own ignorance and constitute a menace to life and limb. No, when a patient consults a doctor he expects, and is entitled to expect, total comprehension of his problem at all levels. To aim at anything less will not do.
subsequently cannot use
Occupational
Health
REDUCTION OF MERCURY VAPOUR IN A DENTAL SURGERY
JOHN WILSON* General Dental Practitioner
A restricted survey in one dental practice has shown that a considerable reduction in contamination by mercury vapour can be achieved by the use of a fume cupboard. Failure to employ this added protection may have legal implications.
Summary
INTRODUCTION
intoxication after accidental review the handling of mercury. The aims were to reduce atmospheric levels of contamination and to prevent spillage. A
reportl on mercury spillage stimulated me to
*
Address: Pennine
hamshire, England.
Cottage,
15 Britwell Road, Burnham,
Bucking-
