1020

blood-lipids, platelet aggregation, and on such other blood constituents as may plausibly be involved in the pathogenesis of atheroma. The results of this may then justify a randomised controlled trial of the preventive or therapeutic effects of moderate wine consumption on I.H.D. Such a study would, however, pose severe ethical and practical difficulties.

particular wine,

on

If wine is ever found to contain a constituent protective against I.H.D. then we consider it almost a sacrilege that this constituent should be isolated. The medicine is already in a highly palatable form (as every connoisseur will confirm). We can only regret that we are as yet unable to give information to our friends about the relative advantages of red, white or rose wine. Requests for reprints should be addressed

to

REFERENCES common.

81, 294. 11. Hennekens, C. H., Robner, B., Cole, D. Am J. Epidemiol 1978, 107, 196. 12. Yano, K., Rhoads, G. G., Kagan, A. New Engl. J. Med., 1977, 297, 405 13. Berecochea, J. E Report of "Health Consequences of Drinking Practices kind of beverage and subsequent mortality" prepared for the Wine Institute, California. Berkeley, 1978. 14. Stason, W. B., Neff, R. K., Miettmen, O. S., Jick, H. Am. J Epidemol

1976, 104, 603. Myrhed, M., Berglund, L., Bottiger, L. E. Acta med. scand. 1977, 202, 11 16. Castelli, W. P., Gordon, T., Hjortland, M. D., Kagan, A., Doyle, J. T, Hames, C. G., Hulley, S. B., Zukel, W. J. Lancet, 1977, ii, 153. 17. Paul, O., Lepper, M. H., Phelan, W. H., Dupertius, G. W., MacMillan, A, McKean, H., Park, H. Circulation, 1963, 28, 20. 18. Wilhelmsen, L., Wedel, H., Tibblin, G. Circulation, 1973, 43, 950. 15.

A.S.St.L.

1. Cochrane, A. L., St.Leger, A. S., Moore, F. J. Epidemiol. 1978, 32, 200

2. St.Leger, A S., Cochrane, A. L , Moore, F. Lancet, 1978, ii, 1153 3. Aubenque, M., Damiani, P., Deruffe, L. J. Soc. stat. Paris, 1978, 3, 1 4. Produktschap voor Gedistilleerde Dranken, Schiedam, Netherlands, 1975 5. Stamler, J, Stamler, R., Shekelle, R. B. in Ischæmic Heart-Disease edited by J. H. de Haas, H. C. Hemker, and H. A. Snellen); p 84, Leiden, 1970 6. Keys, A., Anderson, J. T., Grande, F. Lancet, 1957, ii, 959. 7. St.Leger, A. S., Sweetnam, P. M. Int. J. Epidemtol. (in the press). 8. Oliver, M. F., Heady, J. A., Morris, J. N., Cooper, J. Br. Heart J. 1978, 40, 1069. 9. Glueck, C. J., Mattson, F., Bierman, E. L. New Engl. J. Med. 1978, 298, 1471. 10. Klatsby, A. L., Friedman, G. D., Siegelaub, A. B. Ann. intern. Med, 1974,

Hlth,

Points of View

professor protects his interests by keeping his sub)ect unto itself. Setting up a school from scratch, is, naturally, a different matter. Razing the existing building and its incumbents was a solution occasionally discussed by the student committee, usually towards the end of the evening when beer was to the fore and ideals the an

IN SEARCH OF THE HOLY GRAIL PETER BARRITT Yeovil District Hospital, Yeovil, Somerset

THE publication of Sir George Pickering’s Quest for Excellence in Medical Education jogged a few memories because I met him on his fact-finding tour when I was a student representative at Birmingham. The memories are none too fond, I must confess. Hurried lunches, interminable meetings, polite silences, impolite silences, feelings of transparency ... all part of the regular life of a student representative on the curriculum review body of the day. My favourite senior physician used to say that if they changed the curriculum much more it would end up the same as when he

trained. The very existence of the student representatives was thorn in the flesh of the distinguished and erudite professors of the faculty who usually had a fairly shrewd idea of what was good for students. In true democratic style we aired our views and they were probably as unrepresentative of student interests as those of our elders and betters. Attempts at introducing democracy were made but they failed because, on the whole, the silent majority didn’t care a stuff about the curriculum as long as they passed through it uneventfully. a

Plans to break down established barriers between preclinical and clinical subjects are doomed to failure. There are two main reasons for this. Firstly, these two sections of the medical school have no idea what each teaches. Clinicians have an inherent interest in maintaining the status quo, since they can then hold forth on how little students seem to learn these days, and so on. Secondly, because funding and the political prestige of a department depend on the amount of teaching time,

island

somewhere behind.

Many of the problems of medical education stem from the enormous increase in the number of students being trained. Medicine, I believe, should be an apprenticeship and it seems sad that students can pass through a medical school without getting to know a few clinicians well. Groups of ten students lead to artificial relationships - the slothful undetected and the loud supreme.

review body’s new curriculum, I would have contained little pxdiatrics and remember, less obstetrics. The argument ran that these subjects were essentially postgraduate and would be learnt during vocational training. Only a teaching hospital could produce a theory like that; for anyone who has worked as a house officer in these specialties in peripheral hospitals would immediately recognise the fallacy of the argument. As an S.H.O. there you are immediately thrown into complex situations, sometimes with only a consultant above you. There is no time to start too much work and not enough learning basics then staff. In academic centres, where house officers are glonfied medical students with keen registrars breathing down their necks, there is no such problem. More important is that many profound medical advances have still not filtered through to some peripheral hospitals. In obstetrics, for example, the active management of labour, fetal monitoring, diabetic control in pregnant. resuscitation of the newborn, and the care of neonates may be mere pipe-dreams in smaller units. If one didn’t learn about these at the centre of excellence, one might never hear of them at all. The

faculty

...

The medical training of the average student consists of his medical education and subsequent experience in non-teaching hospitals. The impact of the vocationalh trained has yet to be felt in general practice, but it will

1021 one. Whether general practice in hold this country will enough challenge remains to be seen. Meanwhile the passage of trainees through hospitals has boosted morale in some areas of the country where applicants had been previously hard to find. If the Quest for Excellence is to be successful, teaching hospitals will have to show more interest in their non-teaching counterparts. Postgraduate education is still rudimentary in many parts of the country. The various diplomas may hold special problems for those who have had no opportunity to encounter the very rare disorders common in large referral centres. Rotation of teaching registrars should be encouraged and their

surely

be

a

beneficial

tutorials could easilv be transmitted on slide shows, which the representatives of drug firms are only too keen to help with. In this way the academic chestnuts can be collected and a roasting at Queen Square can be forestalled. Life as a student representative was tedious. One moment of compensation came a few months ago when I read an article full of outlandish views by one of our most erudite professors. It was all about how students were taught too much at medical school. I can clearly remember him looking through me when I made that suggestion a few years ago, wrinkling up his nose as though I had just broken wind.

Medicine and the Law

All Reasonable

Requirements

I DO not know how many health-service authorities closed wards or hospitals, or restricted admissions, during recent industrial action by National Health Service staff. However, it may be that they, and any that might contemplate taking such action in the future, should take heed of remarks made by Lord Denning, Master of the Rolls, in the Court of Appeal on March 13. Lord Denning’s comments could serve as a warning to any public authority which fails in its statutory duty to provide a service because it does not wish to take action which the unions would construe as provocative. The context was not a health one. A group of Haringey parents sought to take Haringey Council to court for closing its schools when caretakers went on strike. Lord Denning and the two judges sitting with him agreed that the parents could take the council to court and ask for a declaration that the council had acted unlawfully. Whatever the outcome of any such action which these parents may take, Lord Denning’s remarks are still highly significant. He said, according to the report in The Guardi*an:l "On the evidence as it stands before us, it appears that the trade unions were the dominating influence in requiring the schools to be closed-and not re-opened: and the borough council also closed them at the behest of the trade unions or in agreement with them. In so doing the borough council was breaking its statutory duty: and the trade unions’ leaders were inducing them to break it. Such conduct was in my view unlawful, and the trade unions’ leaders have no immunity in respect of it." He went on to say that it appeared the council and the trade unions had agreed to do an unlawful act, or to use unlawful means. "Such an action, if it results in damage to anyone, is an actionable conspiracy." Now the

importance of Lord Denning’s

remarks for health-service administrators is that there is a clear parallel between the action of Haringey Borough Council in closing the schools, and the closure of a hospital, or 1 Guardian, March 13, 1979.

wards or departments of a hospital, in response to similar trade-union pressure. There is always the possibility in law that the precise circumstances of each case may quite properly induce judges to take a different view in two instances which may appear to a layman to be exactly similar. Furthermore, the Haringey parents have yet to take their case to full trial and the outcome when they do so can not be predicted in advance of the evidence that will be presented and the legal arguments that may be put forward at such a trial. Nonetheless, Lord Denning’s view was that Haringey council should have kept the schools open, and risked the consequences, or should have sought an injunction to restrain the trade-unions from interfering with the opening of the schools. It is at least possible that he would take a similar view in the case of a hospital and a health authority. The same issue of The Guardian also referred to an application for legal aid by a Northampton man to enable him to sue a National Union of Public Employees (NUPE) shop-steward who is alleged to have been responsible for the closure of an operating-theatre at Northampton General Hospital. The man’s wife was awaiting an exploratory operation for possible cancer. If this action is brought it will not unfortunately test the question of whether or not the health authority was in breach of its statutory duty in closing the operating-theatre. As far as I am aware such a point has not yet been put to the test. However, earlier this year four patients on the waiting-list for admission to Good Hope Hospital, Sutton Coldfield, sought in the High Court an order to compel the Secretary of State for Social Services, the ",X’est Midlands R.H.A., and the Birmingham A.H.A.(T) to perform their duty under the 1977 National Health Service Act. The patients claimed that although in pain from arthritic disease they were having to wait two years or more for necessary operations. The Secretary of State was failing to provide the comprehensive health service it was his duty to provide. They lost their case. Mr Justice Wien sympathised, but said: "I have come to the conclusion that it is impossible to pinpoint anywhere a breach of statutory duty on the part of the Secretary of State ... It all turns on the question of financial resources. If the monev is not there then the services cannot be met in one particular place." With all respect to the judge, that is an astonishing stateOn the face of it he seems to have been saying that the Secretarv of State had a statutory duty, he had failed to fulfil his statutory duty, but he was to be excused because Parliament had not made available to him sufficient monev to ment.

2

ibid, Jan 25, 1979

In search of the Holy Grail.

1020 blood-lipids, platelet aggregation, and on such other blood constituents as may plausibly be involved in the pathogenesis of atheroma. The resul...
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