320
lution, being in the lee of the foundry when the prevailing south-westerlies were blowing. Why were there not more deaths from respiratory cancer there? The houses in area F were built in the 1960s and were occupied by families from rural areas. Hence these residents had probably been less exposed to polluted air than the inhabitants of the long-established area E. Alternatively, the carcinogenicity of the polluted environment in area F may have resulted in the mortality from "other cancer" there being the highest in the town. Area F also contained the largest proportion (35%) of cancers of the upper digestive tract (cesophagus, stomach, pancreas) 8 among the "other cancers".* Radial clustering analysis-based on the theory of
random
flights-was used to evaluate the geographical disposition of the deaths from respiratory cancer.8 The foundry was shown to be the focus of the clustering. In a study of respiratory cancer in a neighbouring town a geographical cluster of deaths was demonstrated similarly in an air-polluted and long-established housing area directly to the east of (and hence downwind from) a foundry where some technological processes were similar to those used in the foundry in town V.8 Two of the constituents of the smoke-iron (as ferric oxide) and nickel-have been associated with occupational respiratory cancer.3,9-11 The causality of this association has been supported by experimental evidence.12 It is possible, therefore, that metallurgical processes, introduced into town V’s foundry during the 1960s or earlier, changed the foundry’s fumes qualitatively or quantitatively, thereby stimulating respiratory2 carcinogenesis in the susceptible population nearby.2 But in the present study, it would be premature to link causally the clusters of respiratory cancer with either ferric oxide, until the chemical and biological composition of the polluted air has been analysed further. A shortage of various resources imposed limitations on aspects of this study. However, the findings demonstrate the need for epidemiology and preventive medicine to be promoted systematically as a service commitment." airborne nickel
or
This study was undertaken when the author was in receipt of a fellowship in community medicine at the Lothian Health Board. Technical assistance was provided by Mr T. Gillanders, Mr R. Thornton, Mr M. Inskip, and Mrs C. Grant. I am grateful to Dr Roger Barclay, Dr I. D. Campbell, Dr J. L. Gil-
loran, and Prof. A. Mair for administrative support.
REFERENCES 1. Royal College of Physicians. Smoking and Health Now. London, 1971. 2. Stocks, P. Br. J. Cancer, 1966, 20, 595. 3. Doll, R. Br. J. ind. Med. 1959, 16, 181. 4. Bohlig, H., Hain, E. Int. Agency Res. Cancer sci. Publ. 1973, 8, 212. 5. Milham, S., Strong, T. Envir. Res. 1974, 7, 176. 6. Schuenman, J. J., High, M. D., Bye, W. E. Air Pollution Aspects of the Iron and Steel Industry. Publ. Hlth Serv. Publs, Wash. no. 999-AI -1, U.S. Dept of Health, Education and Welfare, Public Health Service, Cincinatti, 1963. 7. Goodman, G. T., Smith, S., Inskip, M. J. Report of a Collaborative Study on Certain Elements in Air, Soil, Plants, Animals & Humans in the Swansea-Neath-Port Talbot Area; chaps 7, 8. Welsh Office Report, 1975. 8. Lloyd, O. L1. Thesis submitted for M.D., Edinburgh University, 1977. 9. Faulds, J. S., Stewart, M. J. J. Path Bact. 1956, 72, 353. 10. Doll, R., Morgan, L. G., Speizer, F. E. Br. J. Cancer, 1970, 24, 623. 11. I.A.R.C. Monographs on the Evaluation of Carcinogenic Risk of Chemicals to Man, vol. 1, W.H.O. Lyon, 1972. 12. Sellakumar, A. R., Montesano, R., Saffiotti, U., Kaufman, D. G. J. natn. Cancer Inst. 1973, 50, 507. 13. Doll, R. Prevention of Cancer: Pointers from Epidemiology. Rock Carling Fellowship, Nuffield Provincial Hospitals Trust. London, 1967.
Medical Education IF I WERE A DEAN ...
S. L. BARLEY* IN his original brief the Editor did not supply me with the three full stops but, added to the title, they supply the correct measure of doubt, astonishment, and disbelief that would assuredly follow my appointment. It would be nice to pretend that any medical school eccentric enough to choose a general practitioner as dean would also have chosen one of golden oratorical skills and quicksilver speed of mind in committee; and that is therefore what, in this most conditional of imaginary exercises, I should need if I were to persuade my reluc-
faculty to make the changes suggested here. Like the number of cough medicines on the pharmacist’s shelf, the multiplicity of methods used to select medical students surely indicates that none of them is overwhelmingly superior, even supposing the selection committees have a very clear idea of what kind of doctor they are aiming to produce. I agree with those who argue that, for the sake of fairness, and because selection by interview is costly and time-consuming, it is best to set an educational standard to be achieved in the usual three A-level science subjects and then choose names entirely at random. The argument is much the same as that advanced in favour of randomised controlled trials in clinical medicine. If there is genuinely nothing to choose between the present methods, then it is more ethical to randomise. There will of course always be those opinionated people who say something like "Ah, but I myself can always pick out by my own judgment those with the kind of depression which will always respond to E.C.T." Similarly, there will always be those experienced selection-committee members who say "Ah, but I have always prided myself on being able to pick the sort of students who do well at St Julian’s." Both arguments have about as much force as a damp biscuit. Having selected my students-but not quite all of them, as I will explain later-I would subject them to a proving test, rather like the labours of Hercules. Admittedly I would not ask them to bring back golden apples, poverty-stricken though my institution might be, but would aim, by no more subtle or certain, a process than the passage of time, to increase their maturity. Already many medical schools openly admit that they could select their entire student intake from those who are mature, in the sense that they have done other work first; I merely suggest making this wish reality. Let them all go off and earn their living for 2 years. Let them make bicycle axles in a factory, like Sillitoe’s Arthur Seaton, let them carry luggage on Waterloo station, let them guide itinerants round ancient Greek temples, or let them simply lead a roving life like John Steinbeck, "becoming in turn ranch hand, carpenter’s mate, painter’s apprentice, chemist, labourer, newspaperman and caretaker of an estate (snow-bound for eight months of the year)". If certain kinds of work, travel, and extant
*
General practitioner, 30 Endcliffe Crescent, Sheffield S10 3ED.
1. 2.
Sheldrake, P. Br. J. med. Educ. 1975, 9, 91. Steinbeck, J. Quoted in Of Mice and Men (Penguin worth, 1957.
edition).
Harmonds-
321
maturity, so much the better, and better still if anyone finds, so early on, that medicine
perience induce
a
greater
is the wrong career. Above all, let students see life and become acquainted with the business of independent living and with those jobs and positions in society from which for the rest of their lives they will be distanced. It cannot seriously be held against this 2-year break that the academic urge will be lost, because for over 20 years many students postponed their university course to spend two years on national service. Indeed it is often said that the generation of older students which arrived in 1945 after years of war service was the best ever to enter medicine. Where would this leave today’s mature students, the ones who decide later than the age of 18 that they want to do medicine? Already Charing Cross Hospital, London, recognises that these mature students "have a leavening effect on the student body as a whole,"3 and I would certainly wish to capture a sizeable minority, perhaps 20%, to work this "process of fermentation," as the Oxford dictionary calls it, on the dough of my warmedup majority. If necessary the premedical or 1st M.B. course would be enlarged and strengthened so that it could teach in one year the traditional sciences to approximately A-level standard. The intake to this year would be delightful to choose because I would cast my net as widely as possible, looking for anyone who seriously wanted to practise medicine, could pass a suitable intelligence test, and who had already shown high achievement in any field, whether it was sailing round the world single-handed or being a successful discjockey. After all, if this is the kind of thing some of the most interesting doctors have done after qualification, why not reverse the process? I believe, however, that it is not just for traditional reasons that medical schools do not do more to encourage students to mature themselves; it is the custom to begin a university course at 18, but why should medicine automatically do the same? Already the London Hospital allows half its entrants to delay their course by a year,4 so why not all of them and for 2 years? It cannot be fortuitous that many doctors are unable to deal easily with their patients on an adult level, preferring more or less openly to cast them into the role of the child. These doctors tend to treat students in the same way, and perhaps feel much safer teaching fresh-faced young things straight from school. Mature students will be much more threatening to these insecure teachers. They will ask uncomfortable questions. They will see through hollow pretence. They may even realise how unwise it is to have the most undifferentiated level of medicine taught by the most highly differentiated kind of doctor.S But does all this really matter? Is the process of selection the most important factor in deciding what kind of a doctor the student becomes? I think not. Many analysts of the performance of medical students have tried to see what factors are discriminating, and most have been able to say only that motivation overrides all else.6 The mistake the analysts then make is to seek to measure motivation in the students: they should instead be seeking its obverse-inspiration-in the teachers. Few 3. General Medical Council. Basic Medical Education 238.London 1977. 4.ibid.p. 270. 5.Byrne, P. S. JlR.Coll. gen. Practnrs, 1975, 25, 785. 6.Rhoads, J. M., Gallemore, J. L., Gianturco, D. T.,
Educ. 1974, 49, 1119.
in
the British
Isles;
p.
Osterhout, S. J. med.
students applying to read medicine lack motivation; one build a fair system of random selection on that assumption. Talk to the students in their first year and it is very rare to find them, unless they have doctor parents, expressing the cynicism and obsession with status that their. teachers will manage to instill into them in such a sadly short time. A. N. Whitehead, describing the stages of learning, called the first one the stage of romance.’ The supreme achievement of far too many medical schools is to cripple this romance, to weaken it, and to overlay it by a sour desire to do nothing better than pass examinations. But above all, in our selection, let us have nothing to do with stated policy of St. George’s Hospital, London, which is said in the G.M.C.’s report (p. 299) not to be looking specifically in its candidates for "the human qualities which will make a good general practitioner". One can only assume that they are still hoping to select some of those notably inhuman creatures who for generations-at St George’s and every medical school-have been making the lives of patients and students a misery. We. should instead be trying, with the wonderfully talented young people pressing to enter our medical schools, to produce just the opposite kind of doctor. To paraphrase the family planners’ phrase, let us say "Every doctor a human doctor". Let them all learn the meaning of Carl Rogers’ triad: accurate empathy, non-possessive warmth, and genuineness. If instruction in medicine can become true medical education, we shall have doctors who will be interested in caring, not just can
curing. 7.
Whitehead, A. N. The Aims of Education and other
essays.
London, 1962.
Round the World Australia
(FAMILIARLY KNOWN AS MARK II) In Australia, health insurance is compulsory, so everyone has either to join a private fund or become a member of the MEDIBANK
Federal Medibank Standard Health Scheme, which operates 2-5% levy on taxable income up to a maximum of$150 for a single person or$300 for a family. Anyone who wishes to choose his own doctor when in hospital, or who decides not to enter a public ward, must join one of the more expensive private schemes, which include Medibank Private, a fund also run by the Federal Health Department. One of the ’77 electioneering promises of the Fraser Government was that the Medibank Standard Health Care levy and maximum charge would remain unchanged for six monthsthat is,until the end of the financial year. This promise will be kept in spite of two increases in doctors’ fees (one during 1977 and the other on Jan. 1), higher nursing-home benefits, and greater use of medical services during 1977. The private schemes, unable to absorb escalating costs, are about to seek and will undoubtedly gain approval for an increase in subscriptions of about 25% by applying to the Administrative Appeals Tribune, a body which can overrule ministerial decisions. As a consequence, there could be a dramatic move of members away from the private funds to Medibank Standard. During the year, attempts have been made by the Health Department to find an alternative to Medibank Standard, because the scheme is held to have failed in so far as control of costs and overuse of facilities are concerned. The new plan, while shielding people from the worry and financial strain of having to pay heavy medical and hospital bills, will, it is hoped, reduce running costs by giving inducements to those on a
lution, being in the lee of the foundry when the prevailing south-westerlies were blowing. Why were there not more deaths from respiratory cancer there? The houses in area F were built in the 1960s and were occupied by families from rural areas. Hence these residents had probably been less exposed to polluted air than the inhabitants of the long-established area E. Alternatively, the carcinogenicity of the polluted environment in area F may have resulted in the mortality from "other cancer" there being the highest in the town. Area F also contained the largest proportion (35%) of cancers of the upper digestive tract (cesophagus, stomach, pancreas) 8 among the "other cancers".* Radial clustering analysis-based on the theory of
random
flights-was used to evaluate the geographical disposition of the deaths from respiratory cancer.8 The foundry was shown to be the focus of the clustering. In a study of respiratory cancer in a neighbouring town a geographical cluster of deaths was demonstrated similarly in an air-polluted and long-established housing area directly to the east of (and hence downwind from) a foundry where some technological processes were similar to those used in the foundry in town V.8 Two of the constituents of the smoke-iron (as ferric oxide) and nickel-have been associated with occupational respiratory cancer.3,9-11 The causality of this association has been supported by experimental evidence.12 It is possible, therefore, that metallurgical processes, introduced into town V’s foundry during the 1960s or earlier, changed the foundry’s fumes qualitatively or quantitatively, thereby stimulating respiratory2 carcinogenesis in the susceptible population nearby.2 But in the present study, it would be premature to link causally the clusters of respiratory cancer with either ferric oxide, until the chemical and biological composition of the polluted air has been analysed further. A shortage of various resources imposed limitations on aspects of this study. However, the findings demonstrate the need for epidemiology and preventive medicine to be promoted systematically as a service commitment." airborne nickel
or
This study was undertaken when the author was in receipt of a fellowship in community medicine at the Lothian Health Board. Technical assistance was provided by Mr T. Gillanders, Mr R. Thornton, Mr M. Inskip, and Mrs C. Grant. I am grateful to Dr Roger Barclay, Dr I. D. Campbell, Dr J. L. Gil-
loran, and Prof. A. Mair for administrative support.
REFERENCES 1. Royal College of Physicians. Smoking and Health Now. London, 1971. 2. Stocks, P. Br. J. Cancer, 1966, 20, 595. 3. Doll, R. Br. J. ind. Med. 1959, 16, 181. 4. Bohlig, H., Hain, E. Int. Agency Res. Cancer sci. Publ. 1973, 8, 212. 5. Milham, S., Strong, T. Envir. Res. 1974, 7, 176. 6. Schuenman, J. J., High, M. D., Bye, W. E. Air Pollution Aspects of the Iron and Steel Industry. Publ. Hlth Serv. Publs, Wash. no. 999-AI -1, U.S. Dept of Health, Education and Welfare, Public Health Service, Cincinatti, 1963. 7. Goodman, G. T., Smith, S., Inskip, M. J. Report of a Collaborative Study on Certain Elements in Air, Soil, Plants, Animals & Humans in the Swansea-Neath-Port Talbot Area; chaps 7, 8. Welsh Office Report, 1975. 8. Lloyd, O. L1. Thesis submitted for M.D., Edinburgh University, 1977. 9. Faulds, J. S., Stewart, M. J. J. Path Bact. 1956, 72, 353. 10. Doll, R., Morgan, L. G., Speizer, F. E. Br. J. Cancer, 1970, 24, 623. 11. I.A.R.C. Monographs on the Evaluation of Carcinogenic Risk of Chemicals to Man, vol. 1, W.H.O. Lyon, 1972. 12. Sellakumar, A. R., Montesano, R., Saffiotti, U., Kaufman, D. G. J. natn. Cancer Inst. 1973, 50, 507. 13. Doll, R. Prevention of Cancer: Pointers from Epidemiology. Rock Carling Fellowship, Nuffield Provincial Hospitals Trust. London, 1967.
Medical Education IF I WERE A DEAN ...
S. L. BARLEY* IN his original brief the Editor did not supply me with the three full stops but, added to the title, they supply the correct measure of doubt, astonishment, and disbelief that would assuredly follow my appointment. It would be nice to pretend that any medical school eccentric enough to choose a general practitioner as dean would also have chosen one of golden oratorical skills and quicksilver speed of mind in committee; and that is therefore what, in this most conditional of imaginary exercises, I should need if I were to persuade my reluc-
faculty to make the changes suggested here. Like the number of cough medicines on the pharmacist’s shelf, the multiplicity of methods used to select medical students surely indicates that none of them is overwhelmingly superior, even supposing the selection committees have a very clear idea of what kind of doctor they are aiming to produce. I agree with those who argue that, for the sake of fairness, and because selection by interview is costly and time-consuming, it is best to set an educational standard to be achieved in the usual three A-level science subjects and then choose names entirely at random. The argument is much the same as that advanced in favour of randomised controlled trials in clinical medicine. If there is genuinely nothing to choose between the present methods, then it is more ethical to randomise. There will of course always be those opinionated people who say something like "Ah, but I myself can always pick out by my own judgment those with the kind of depression which will always respond to E.C.T." Similarly, there will always be those experienced selection-committee members who say "Ah, but I have always prided myself on being able to pick the sort of students who do well at St Julian’s." Both arguments have about as much force as a damp biscuit. Having selected my students-but not quite all of them, as I will explain later-I would subject them to a proving test, rather like the labours of Hercules. Admittedly I would not ask them to bring back golden apples, poverty-stricken though my institution might be, but would aim, by no more subtle or certain, a process than the passage of time, to increase their maturity. Already many medical schools openly admit that they could select their entire student intake from those who are mature, in the sense that they have done other work first; I merely suggest making this wish reality. Let them all go off and earn their living for 2 years. Let them make bicycle axles in a factory, like Sillitoe’s Arthur Seaton, let them carry luggage on Waterloo station, let them guide itinerants round ancient Greek temples, or let them simply lead a roving life like John Steinbeck, "becoming in turn ranch hand, carpenter’s mate, painter’s apprentice, chemist, labourer, newspaperman and caretaker of an estate (snow-bound for eight months of the year)". If certain kinds of work, travel, and extant
*
General practitioner, 30 Endcliffe Crescent, Sheffield S10 3ED.
1. 2.
Sheldrake, P. Br. J. med. Educ. 1975, 9, 91. Steinbeck, J. Quoted in Of Mice and Men (Penguin worth, 1957.
edition).
Harmonds-
321
maturity, so much the better, and better still if anyone finds, so early on, that medicine
perience induce
a
greater
is the wrong career. Above all, let students see life and become acquainted with the business of independent living and with those jobs and positions in society from which for the rest of their lives they will be distanced. It cannot seriously be held against this 2-year break that the academic urge will be lost, because for over 20 years many students postponed their university course to spend two years on national service. Indeed it is often said that the generation of older students which arrived in 1945 after years of war service was the best ever to enter medicine. Where would this leave today’s mature students, the ones who decide later than the age of 18 that they want to do medicine? Already Charing Cross Hospital, London, recognises that these mature students "have a leavening effect on the student body as a whole,"3 and I would certainly wish to capture a sizeable minority, perhaps 20%, to work this "process of fermentation," as the Oxford dictionary calls it, on the dough of my warmedup majority. If necessary the premedical or 1st M.B. course would be enlarged and strengthened so that it could teach in one year the traditional sciences to approximately A-level standard. The intake to this year would be delightful to choose because I would cast my net as widely as possible, looking for anyone who seriously wanted to practise medicine, could pass a suitable intelligence test, and who had already shown high achievement in any field, whether it was sailing round the world single-handed or being a successful discjockey. After all, if this is the kind of thing some of the most interesting doctors have done after qualification, why not reverse the process? I believe, however, that it is not just for traditional reasons that medical schools do not do more to encourage students to mature themselves; it is the custom to begin a university course at 18, but why should medicine automatically do the same? Already the London Hospital allows half its entrants to delay their course by a year,4 so why not all of them and for 2 years? It cannot be fortuitous that many doctors are unable to deal easily with their patients on an adult level, preferring more or less openly to cast them into the role of the child. These doctors tend to treat students in the same way, and perhaps feel much safer teaching fresh-faced young things straight from school. Mature students will be much more threatening to these insecure teachers. They will ask uncomfortable questions. They will see through hollow pretence. They may even realise how unwise it is to have the most undifferentiated level of medicine taught by the most highly differentiated kind of doctor.S But does all this really matter? Is the process of selection the most important factor in deciding what kind of a doctor the student becomes? I think not. Many analysts of the performance of medical students have tried to see what factors are discriminating, and most have been able to say only that motivation overrides all else.6 The mistake the analysts then make is to seek to measure motivation in the students: they should instead be seeking its obverse-inspiration-in the teachers. Few 3. General Medical Council. Basic Medical Education 238.London 1977. 4.ibid.p. 270. 5.Byrne, P. S. JlR.Coll. gen. Practnrs, 1975, 25, 785. 6.Rhoads, J. M., Gallemore, J. L., Gianturco, D. T.,
Educ. 1974, 49, 1119.
in
the British
Isles;
p.
Osterhout, S. J. med.
students applying to read medicine lack motivation; one build a fair system of random selection on that assumption. Talk to the students in their first year and it is very rare to find them, unless they have doctor parents, expressing the cynicism and obsession with status that their. teachers will manage to instill into them in such a sadly short time. A. N. Whitehead, describing the stages of learning, called the first one the stage of romance.’ The supreme achievement of far too many medical schools is to cripple this romance, to weaken it, and to overlay it by a sour desire to do nothing better than pass examinations. But above all, in our selection, let us have nothing to do with stated policy of St. George’s Hospital, London, which is said in the G.M.C.’s report (p. 299) not to be looking specifically in its candidates for "the human qualities which will make a good general practitioner". One can only assume that they are still hoping to select some of those notably inhuman creatures who for generations-at St George’s and every medical school-have been making the lives of patients and students a misery. We. should instead be trying, with the wonderfully talented young people pressing to enter our medical schools, to produce just the opposite kind of doctor. To paraphrase the family planners’ phrase, let us say "Every doctor a human doctor". Let them all learn the meaning of Carl Rogers’ triad: accurate empathy, non-possessive warmth, and genuineness. If instruction in medicine can become true medical education, we shall have doctors who will be interested in caring, not just can
curing. 7.
Whitehead, A. N. The Aims of Education and other
essays.
London, 1962.
Round the World Australia
(FAMILIARLY KNOWN AS MARK II) In Australia, health insurance is compulsory, so everyone has either to join a private fund or become a member of the MEDIBANK
Federal Medibank Standard Health Scheme, which operates 2-5% levy on taxable income up to a maximum of$150 for a single person or$300 for a family. Anyone who wishes to choose his own doctor when in hospital, or who decides not to enter a public ward, must join one of the more expensive private schemes, which include Medibank Private, a fund also run by the Federal Health Department. One of the ’77 electioneering promises of the Fraser Government was that the Medibank Standard Health Care levy and maximum charge would remain unchanged for six monthsthat is,until the end of the financial year. This promise will be kept in spite of two increases in doctors’ fees (one during 1977 and the other on Jan. 1), higher nursing-home benefits, and greater use of medical services during 1977. The private schemes, unable to absorb escalating costs, are about to seek and will undoubtedly gain approval for an increase in subscriptions of about 25% by applying to the Administrative Appeals Tribune, a body which can overrule ministerial decisions. As a consequence, there could be a dramatic move of members away from the private funds to Medibank Standard. During the year, attempts have been made by the Health Department to find an alternative to Medibank Standard, because the scheme is held to have failed in so far as control of costs and overuse of facilities are concerned. The new plan, while shielding people from the worry and financial strain of having to pay heavy medical and hospital bills, will, it is hoped, reduce running costs by giving inducements to those on a
