259
least ensures that all can obtain service at a the country that is less than in any other comparable population. We certainly have rationing by queuing and we certainly pay our health professionals less than do most of the Western European countries. Those are matters that will have to be put right, but not at the expense of some other needed service. Health in England does not get its full share of the social budget, which also has to meet the cost of education, social security, social welfare, and assisted housing. Those services, with health, consume 53% of our national budget, including local-government expenditure; the health share of that total is less than a fifth, and only about half what is spent on social security, in England. Wales has 6% more than England to spend per head on health, while Scotland has an extra 25%. It is small wonder that Scotland has nearly 40% more consultants per 100 000 of the population than does England. But both Scotland and Wales, like England, have failed to balance the senior and junior hospital staff. The problem is not simply one of lack of money; it is in-built in our professional organisation. Specialisation is a necessary condition of progress in medical science and in efficient service to people. It requires planned preparation for aspirants to the specialty and an ongoing educational opportunity throughout a professional career. Naturally it requires technical support, with appropriate equipment and buildings and the assistance of other relevant scientists and technologists. It requires planned deployment so that most services are available within a district for the population of the district, and the rest within the region of which the district is a part. All this will be most economically achieved if two factors are satisfied-that effective primary care outside hospital ensures economic use of the specialties, and that the hospitals are organised on a district basis, as in Britain or Scandinavia, and in one ownership. The other systems are likely to have at least as high a level of competence in some centres, but they are less likely to guarantee as effectively that all services are equally accessible to those who need them.
which
at
cost to
Medical Education IF I WERE A DEAN
TIMOTHY L. CHAMBERS* of the suicide of somebody who years before had refused a contract to the Beatles in their early days. That any dean of medicine will be driven to such extreme measures is unlikely because the academic and financial rewards of medical practice accumulate at a more leisurely pace than those of the popular music industry, and whoever was responsible for the occasional genius or villain is usually retired and unremembered. But what gives a dean job-satisfaction? Choosing and grooming the most eminent research-worker of a lifetime, or a medical politician who negotiates benefits for the whole profession, or a generation of respected and sympathetic hospital and family doctors? A fluent author ; a talented actor; a poised beauty queen? Both Glaser’ and Rhodes,2 when describing the work of a LEGEND tells
us
*Consultant Pædiatrician, Derbyshire Children’s DE1 3BA. 1. Glaser, R. J. J. Med. Educ. 1969, 44, 1115. 2. Rhodes, P. Br. med. J. 1977, i, 953.
Hospital, Derby
dean, bemoan their many difficult tasks but neither comments on cesses or
medical-student selection--still less their sucgaffes. Is this aspect less important or intri-
than finance or politics or do they have no more idea how to choose doctors than the rest of us? Why should a paediatrician claim particular insight? Most importantly, our specialty has close relationships with the three main branches of the profession-hospital and academic medicine, community medicine, and general practice. A paediatrician undergraduate dean (currently there is none in the U.K.) should know the skills and instincts required in these different disciplines and plan suitably representative teaching. Hospital and community paediatricians recognise the particular needs of children-who comprise a quarter of the patients in other specialties, particularly surgical-and, through personal example and curricular emphasis, a paediatrician dean might improve professional attitudes towards children. It is surprising that two recent publications on the future of child health (Pcediatrics in the Seventies; Fit for the Future) concentrate almost exclusively on postgraduate education. A clear statement about the choice and the scope of the undergraduate course would have been welcome. What qualities are sought in applicants, and how can they be spotted in a stereotyped application form? Intelligence, patience, humanity, and sound health (when will cigarette and alcohol consumption be assessed?) are important. Ability to "get on with children" is too superficial an expression of the sensitivity required for a successful child practice. The knack is to know when to start investigations or treatment and, more especially, when to stop: discernment is valuable but hard-learned. It is important to accept a third party, usually parents, in the doctor-patient relationship. Adults may not wish to discuss their illness but parents always want to know about their child’s. Undergraduates are clearly influenced by paediatrics-it is a popular career choice, especially for women. A knighthood surely awaits the dean who can not only choose women who can combine family life with work but also persuade his colleagues and the D.H.S.S. to provide flexible postgraduate training and employment. Doubtless the dean can send his admissions tutor on courses that advise on medical-student selection. One of the obvious points is to identify the student who does not know what he is undertaking. Medicine, in common with law and theology, is not taught in schools as a distinct subject, as are mathematics or history. The applicant’s only acquaintance with the biological sciences may be through the mechanistic school examination courses, so it is crucial to identify the true motivation. Zeal, intellect, tradition, and lucre (not necessarily in that order) are some incentives and it is difficult but important to select the correct mixture since accepted students usually complete the course. The small drop-out rate in the U.K. is curious: does it reflect accurate selection, poor discrimination later, or the insatiable requirements of the N.H.S.? The only stipulated entrance hurdle is A-level attainment. Minimum standards exceed those for pure science, and mathematics appears to be an acceptable alternative to biology and zoology. Although some entrants need more than one attempt to achieve the stipulated grades, perhaps their enthusiasm is sufficient for medical practice and the year retaking examinations could be spent more imaginatively. The profession faces the hypothetical danger that narrow scientific ability might be confused with learnedness, to
guing
260
the detriment of clinical practice (though scientific rigour is surely an asset in academic life). This is unprovable because of the difficulty in assessing the quality of doctoring and we must not draw hasty conclusions-after all, candidates may be brighter or examinations easier than when we attempted them. And how do we choose from the larger number of eligible applicants if the A-level criteria are relaxed? The objectivity of school reports is questionable and a recommendation from the candidate’s family doctor may give more insight. The personal interview is now used by only half the medical schools to select students but it is the usual method of selecting medical teachers. Does this demean student selection or is it because a bad teacher will haunt a school longer and be a worse influence than a bad student? Presumably the occasional psychopath (where would medicine be without them?) can be spotted at interview and this will be important for the dean who will be required to vouch for the sanity of his graduates. Perhaps the interview could be extended to a residential assessment similar to that for military officers. Less conventional techniques, such as a tutorial, have been used but not compared with the traditional interview or examination results. In Hippocrates’ time a medical background was desirable, but not today. Remember the response to an advertisement placed in the B.M J. by a surgeon seeking a medical-school place for his son with low A-level grades.
Points of View METABOLIC EPIDEMIOLOGY CLASSICAL retrospective and prospective epidemiological inhave led to important discoveries about the factors involved in various chronic diseases. Relationships such as those between lung cancer and smoking, oral-cavity cancer and alcohol usage, cervical cancer and marital factors, and coronaryartery disease and diet illustrate the contributions of epidemiological techniques to the improved understanding of chronic diseases. As we become more aware of the multifactorial influences on chronic disease, however, traditional techniques such as time-trend analysis, population studies, and the investigation of the influences of various socioeconomic factors on disease incidence will be of decreasing value in efforts to gain further understanding about the aetiology and induction of dis-
quiries
ease.
Moreover, experimental animal studies
are
of limited value
understanding of human disease because it is difficult to extrapolate results from one species to another. New research techniques are clearly necessary if we are to surmount the growing impasses. Metabolic epidemiology seems to be such an innovative approach, for it examines biochemical and metabolic factors as possible markers, symptoms, or consein the
quences of disease, and compares them within and across population groups. This expansion of epidemiology has already proved to be a powerful means of linking a number of important variables. For example, metabolic epidemiology was instrumental in determining the relationship of blood-lipids to cardiovascular diseases. Investigation of metabolites in urine has advanced knowledge of the aetiology of hormone-related cancers, as has more recent work on plasma constituents and on breast secretions. The understanding of colon cancer has been furthered not only by comparing fsecal constituents of populations at high and low risk but also by comparing colon-cancer patients with controls and with individuals at high risk for colon cancer, such as those with familial polyposis and ulcerative colitis.
brisk correspondence from medical students outraged the idea of such patronage: I wonder if the writers are as unbending now-and what happened to the surgeon’s son? It has been suggested that some working-class applicants be favoured so that medical standards are improved in deprived areas-an assumption founded more on misplaced idealism than the facts of life. Is nothing being learned from the Bakke case? If you find this discussion jading, read again Richard Gordon’s account of his interview for St. Swithin’s; decadent, surely, but it has grace and style—qualities lacking in a pile of U.C.C.A. forms. If I were a dean I would select amiable students by individual interview with me or a colleague in another specialty (including general practice), and offer places conditional either on 3 high science A-levels or on lower grades in 4 subjects, 1 being non-scientific. This arbitrary method reflects my view that who you select and how you choose matter less than how and what you teach them. I would weed out unmercifully during the course as the consequences are more easily managed than later professional disenchantment. Teaching ability would be as important a criterion in choosing lecturers as their research ambitions and, because I believe that examiners need to be satisfied more than computers, proficiency at writing English would be rewarded in the final examination. Finally, I would encourage The Lancet to solicit from me an article entitled If I were a Postgraduate Dean. There
was a
at
,
To be most effective, metabolic studies should continue to make comparisons between persons at the extremes of risk for disease. Many examples of such studies exist today. For instance, analysis of the constituents of -cigarette smoke in smoker’s plasma, urine, and pancreatic fluid should increase understanding of the role played by these factors in the development of heart-disease and bladder and pancreatic cancer. Determination of the possible effects of alcohol consumption and physical activity on lipoprotein density requires metabolic epidemiological techniques, as does research on the aetiology of psychiatric disorders, endocrine dysfunctions, and diseases such as multiple sclerosis. Many more diseases could be cited for which metabolic epidemiological inquiries could offer
explanations. Investigations
such as these have been neglected partly because many institutions find it impossible to organise the necessary interdisciplinary effort which demands a great deal of cooperation between different specialties and the establishment of a team of epidemiologists, clinicians, chemists, biologists, pathologists, and other health professionals. Another requisite is the cooperation of patients or volunteers to provide biological material, such as urine, faeces, plasma, tissues, and body fluids. A comprehensive epidemiological research centre should not consist merely of epidemiologists and statisticians: it must maintain a working relationship with clinical and experimental science departments to foster an effective programme in metabolic epidemiology. Epidemiological units in public-health institutes, in clinical centres, and in research institutions should be enlarged to include metabolic epidemiology and thereby integrate clinical and experimental specialties. Just as descriptive epidemiology and animal laboratory studises have recognised limitations, metabolic epidemiology too is faced with problems. Nevertheless, the development of metabolic epidemiology may be the step which will overcome some of the research obstacles we are now experiencing with many chronic diseases. Division of Epidemiology, Naylor Dana Institute, American Health Foundation, New York, N.Y. 10019, U.S.A.
ERNST L. WYNDER
least ensures that all can obtain service at a the country that is less than in any other comparable population. We certainly have rationing by queuing and we certainly pay our health professionals less than do most of the Western European countries. Those are matters that will have to be put right, but not at the expense of some other needed service. Health in England does not get its full share of the social budget, which also has to meet the cost of education, social security, social welfare, and assisted housing. Those services, with health, consume 53% of our national budget, including local-government expenditure; the health share of that total is less than a fifth, and only about half what is spent on social security, in England. Wales has 6% more than England to spend per head on health, while Scotland has an extra 25%. It is small wonder that Scotland has nearly 40% more consultants per 100 000 of the population than does England. But both Scotland and Wales, like England, have failed to balance the senior and junior hospital staff. The problem is not simply one of lack of money; it is in-built in our professional organisation. Specialisation is a necessary condition of progress in medical science and in efficient service to people. It requires planned preparation for aspirants to the specialty and an ongoing educational opportunity throughout a professional career. Naturally it requires technical support, with appropriate equipment and buildings and the assistance of other relevant scientists and technologists. It requires planned deployment so that most services are available within a district for the population of the district, and the rest within the region of which the district is a part. All this will be most economically achieved if two factors are satisfied-that effective primary care outside hospital ensures economic use of the specialties, and that the hospitals are organised on a district basis, as in Britain or Scandinavia, and in one ownership. The other systems are likely to have at least as high a level of competence in some centres, but they are less likely to guarantee as effectively that all services are equally accessible to those who need them.
which
at
cost to
Medical Education IF I WERE A DEAN
TIMOTHY L. CHAMBERS* of the suicide of somebody who years before had refused a contract to the Beatles in their early days. That any dean of medicine will be driven to such extreme measures is unlikely because the academic and financial rewards of medical practice accumulate at a more leisurely pace than those of the popular music industry, and whoever was responsible for the occasional genius or villain is usually retired and unremembered. But what gives a dean job-satisfaction? Choosing and grooming the most eminent research-worker of a lifetime, or a medical politician who negotiates benefits for the whole profession, or a generation of respected and sympathetic hospital and family doctors? A fluent author ; a talented actor; a poised beauty queen? Both Glaser’ and Rhodes,2 when describing the work of a LEGEND tells
us
*Consultant Pædiatrician, Derbyshire Children’s DE1 3BA. 1. Glaser, R. J. J. Med. Educ. 1969, 44, 1115. 2. Rhodes, P. Br. med. J. 1977, i, 953.
Hospital, Derby
dean, bemoan their many difficult tasks but neither comments on cesses or
medical-student selection--still less their sucgaffes. Is this aspect less important or intri-
than finance or politics or do they have no more idea how to choose doctors than the rest of us? Why should a paediatrician claim particular insight? Most importantly, our specialty has close relationships with the three main branches of the profession-hospital and academic medicine, community medicine, and general practice. A paediatrician undergraduate dean (currently there is none in the U.K.) should know the skills and instincts required in these different disciplines and plan suitably representative teaching. Hospital and community paediatricians recognise the particular needs of children-who comprise a quarter of the patients in other specialties, particularly surgical-and, through personal example and curricular emphasis, a paediatrician dean might improve professional attitudes towards children. It is surprising that two recent publications on the future of child health (Pcediatrics in the Seventies; Fit for the Future) concentrate almost exclusively on postgraduate education. A clear statement about the choice and the scope of the undergraduate course would have been welcome. What qualities are sought in applicants, and how can they be spotted in a stereotyped application form? Intelligence, patience, humanity, and sound health (when will cigarette and alcohol consumption be assessed?) are important. Ability to "get on with children" is too superficial an expression of the sensitivity required for a successful child practice. The knack is to know when to start investigations or treatment and, more especially, when to stop: discernment is valuable but hard-learned. It is important to accept a third party, usually parents, in the doctor-patient relationship. Adults may not wish to discuss their illness but parents always want to know about their child’s. Undergraduates are clearly influenced by paediatrics-it is a popular career choice, especially for women. A knighthood surely awaits the dean who can not only choose women who can combine family life with work but also persuade his colleagues and the D.H.S.S. to provide flexible postgraduate training and employment. Doubtless the dean can send his admissions tutor on courses that advise on medical-student selection. One of the obvious points is to identify the student who does not know what he is undertaking. Medicine, in common with law and theology, is not taught in schools as a distinct subject, as are mathematics or history. The applicant’s only acquaintance with the biological sciences may be through the mechanistic school examination courses, so it is crucial to identify the true motivation. Zeal, intellect, tradition, and lucre (not necessarily in that order) are some incentives and it is difficult but important to select the correct mixture since accepted students usually complete the course. The small drop-out rate in the U.K. is curious: does it reflect accurate selection, poor discrimination later, or the insatiable requirements of the N.H.S.? The only stipulated entrance hurdle is A-level attainment. Minimum standards exceed those for pure science, and mathematics appears to be an acceptable alternative to biology and zoology. Although some entrants need more than one attempt to achieve the stipulated grades, perhaps their enthusiasm is sufficient for medical practice and the year retaking examinations could be spent more imaginatively. The profession faces the hypothetical danger that narrow scientific ability might be confused with learnedness, to
guing
260
the detriment of clinical practice (though scientific rigour is surely an asset in academic life). This is unprovable because of the difficulty in assessing the quality of doctoring and we must not draw hasty conclusions-after all, candidates may be brighter or examinations easier than when we attempted them. And how do we choose from the larger number of eligible applicants if the A-level criteria are relaxed? The objectivity of school reports is questionable and a recommendation from the candidate’s family doctor may give more insight. The personal interview is now used by only half the medical schools to select students but it is the usual method of selecting medical teachers. Does this demean student selection or is it because a bad teacher will haunt a school longer and be a worse influence than a bad student? Presumably the occasional psychopath (where would medicine be without them?) can be spotted at interview and this will be important for the dean who will be required to vouch for the sanity of his graduates. Perhaps the interview could be extended to a residential assessment similar to that for military officers. Less conventional techniques, such as a tutorial, have been used but not compared with the traditional interview or examination results. In Hippocrates’ time a medical background was desirable, but not today. Remember the response to an advertisement placed in the B.M J. by a surgeon seeking a medical-school place for his son with low A-level grades.
Points of View METABOLIC EPIDEMIOLOGY CLASSICAL retrospective and prospective epidemiological inhave led to important discoveries about the factors involved in various chronic diseases. Relationships such as those between lung cancer and smoking, oral-cavity cancer and alcohol usage, cervical cancer and marital factors, and coronaryartery disease and diet illustrate the contributions of epidemiological techniques to the improved understanding of chronic diseases. As we become more aware of the multifactorial influences on chronic disease, however, traditional techniques such as time-trend analysis, population studies, and the investigation of the influences of various socioeconomic factors on disease incidence will be of decreasing value in efforts to gain further understanding about the aetiology and induction of dis-
quiries
ease.
Moreover, experimental animal studies
are
of limited value
understanding of human disease because it is difficult to extrapolate results from one species to another. New research techniques are clearly necessary if we are to surmount the growing impasses. Metabolic epidemiology seems to be such an innovative approach, for it examines biochemical and metabolic factors as possible markers, symptoms, or consein the
quences of disease, and compares them within and across population groups. This expansion of epidemiology has already proved to be a powerful means of linking a number of important variables. For example, metabolic epidemiology was instrumental in determining the relationship of blood-lipids to cardiovascular diseases. Investigation of metabolites in urine has advanced knowledge of the aetiology of hormone-related cancers, as has more recent work on plasma constituents and on breast secretions. The understanding of colon cancer has been furthered not only by comparing fsecal constituents of populations at high and low risk but also by comparing colon-cancer patients with controls and with individuals at high risk for colon cancer, such as those with familial polyposis and ulcerative colitis.
brisk correspondence from medical students outraged the idea of such patronage: I wonder if the writers are as unbending now-and what happened to the surgeon’s son? It has been suggested that some working-class applicants be favoured so that medical standards are improved in deprived areas-an assumption founded more on misplaced idealism than the facts of life. Is nothing being learned from the Bakke case? If you find this discussion jading, read again Richard Gordon’s account of his interview for St. Swithin’s; decadent, surely, but it has grace and style—qualities lacking in a pile of U.C.C.A. forms. If I were a dean I would select amiable students by individual interview with me or a colleague in another specialty (including general practice), and offer places conditional either on 3 high science A-levels or on lower grades in 4 subjects, 1 being non-scientific. This arbitrary method reflects my view that who you select and how you choose matter less than how and what you teach them. I would weed out unmercifully during the course as the consequences are more easily managed than later professional disenchantment. Teaching ability would be as important a criterion in choosing lecturers as their research ambitions and, because I believe that examiners need to be satisfied more than computers, proficiency at writing English would be rewarded in the final examination. Finally, I would encourage The Lancet to solicit from me an article entitled If I were a Postgraduate Dean. There
was a
at
,
To be most effective, metabolic studies should continue to make comparisons between persons at the extremes of risk for disease. Many examples of such studies exist today. For instance, analysis of the constituents of -cigarette smoke in smoker’s plasma, urine, and pancreatic fluid should increase understanding of the role played by these factors in the development of heart-disease and bladder and pancreatic cancer. Determination of the possible effects of alcohol consumption and physical activity on lipoprotein density requires metabolic epidemiological techniques, as does research on the aetiology of psychiatric disorders, endocrine dysfunctions, and diseases such as multiple sclerosis. Many more diseases could be cited for which metabolic epidemiological inquiries could offer
explanations. Investigations
such as these have been neglected partly because many institutions find it impossible to organise the necessary interdisciplinary effort which demands a great deal of cooperation between different specialties and the establishment of a team of epidemiologists, clinicians, chemists, biologists, pathologists, and other health professionals. Another requisite is the cooperation of patients or volunteers to provide biological material, such as urine, faeces, plasma, tissues, and body fluids. A comprehensive epidemiological research centre should not consist merely of epidemiologists and statisticians: it must maintain a working relationship with clinical and experimental science departments to foster an effective programme in metabolic epidemiology. Epidemiological units in public-health institutes, in clinical centres, and in research institutions should be enlarged to include metabolic epidemiology and thereby integrate clinical and experimental specialties. Just as descriptive epidemiology and animal laboratory studises have recognised limitations, metabolic epidemiology too is faced with problems. Nevertheless, the development of metabolic epidemiology may be the step which will overcome some of the research obstacles we are now experiencing with many chronic diseases. Division of Epidemiology, Naylor Dana Institute, American Health Foundation, New York, N.Y. 10019, U.S.A.
ERNST L. WYNDER
