1322
BRITISH MEDICAL JOURNAL
27 NOVEMBER 1976
"experienced" GPs turned, with each "modu- significant difference between antibody res- personal satisfaction results from the fragponses to vaccine given by the subcutaneous mented services one will be able to offer on a
lation" of the Nuffield "circus," into an exercise in educational methods-fishbowls, role-play, self-assessment, peer assessment, interminable MCQs, MEQs, etc, etc. Each session became an educational exercise in itself-"it's not what you teach-it's the way that you teach it." Surely, training's missed the point if it's not primarily aimed at consumer satisfaction. Not enough is written of what the trainee has learnt or wants to learn and far too much of educational principles, objective evaluation, etc. Methinks, Nuffield supporters, you protest too much. MARGARET THOMSON Luton, Beds
Reactions to current influenza vaccine SIR,-I write to confirm the increased incidence of reactions to influenza vaccine containing the new A/New Jersey/76 strain referred to in Dr T W Hoskins's letter (6 November, p 1131). I am medical officer to two schools in North Devon. After having vaccinated 284 children at one school I noted an overall incidence of mild systemic reactions of approximately 24°0o; however, looking at these figures more closely revealed that the majority occurred in the 104 boys aged 13 or less: in fact, the reaction rate among these was 4800, while the reaction rate among the older pupils was only 11°'. In view of these unexpectedly high reaction rates, especially in the younger pupils, it was decided to reduce the dose for children aged 13 and under at the second school to half the recommended adult dose. At this school 100 children (all aged 13 or under) were vaccinated and mild reactions were observed in 20 (20%). Although these rates are high, the reactions were very mild; the commonest complaint was headache often associated with malaise. No pupil was unwell for more than 24 h. At the first school only 13 out of the 104 younger children rested on their beds; none of those receiving the reduced dose at the second school were unwell enough to require bed rest. There appears, therefore, to be a direct quantitative relationship between the dose and the incidence of reactions. This finding is slightly at variance with Dr Hoskins's observations. On this evidence it might be justifiable to give children of 13 years or less a dose of 0-25 ml of the influenza vaccine. Whether or not this dose gives an acceptable protection rate has yet to be determined, but the two populations will be kept under observation. I would agree with Dr Hoskins that this unexpectedly high reaction rate requires a reassessment of vaccination policy.
MICHAEL HALL Exeter Postgraduate Medical
Centre,
Exeter
SIR,-In October 1976 a communication was received from the Medical Officers of Schools Association stating that there had been an unusually high reaction rate, particularly in the younger child, to the present influenza vaccine containing A/New Jersey/76. Dr T W Hoskins confirms this in his letter (16 November, p 1131). The findings in autumn 19731 showed no
part-time basis in clinical work. Present-day medical and social requirements versus numbers of patients make very difficult indeed at any level-whether primary or secondary health care-this type of professional fulfilment for which, maybe, social case work is the answer. I do not feel qualified to offer anything but thought rather than suggestions. Community medicine does deal with individuals but does it indirectly. Community physicians can help, can be heard, can even be "respected" provided they know whom they serve and have the ability to convince their peers to that end or apply the stamina clinicians show for the interests of their patients. For the less co-ordination-advisorymanagerial-role-minded community doctor I can think of hardly any brand of present-day medicine with such ample opportunities for research. And if going back to the grass-roots "so that we know what we are talking about" is the only way community physicians can get themselves accepted I would happily opt for clinical sabbaticals every so many years in one's own particular interests from the past. By this I mean whole-time one thing or another. I am afraid the time has come when Medical we should accept with self-confidence and dignity that we cannot have it both ways.
route and the intradermal route using the Porton jet injector. Therefore it was arranged, in conjunction with the various school medical officers, for Schuco's Porton jet injector team to give all the boarding-school children in Malvern and district a 0 1-ml intradermal dose of Admune vaccine, the injector being suitably calibrated. Over 2000 children, including some 400 under 13 years old, received the vaccine. The reactions were minimal, there being only 12 children with recognised raised temperatures within the first 24-h period. In order to ascertain the effectiveness of the vaccine by the intradermal method on this occasion antibody titres are being analysed in approximately 30 volunteers. Until the blood results are available it would seem to be expedient to employ the intradermal technique as a worthwhile alternative to a method which is causing such unpleasant and unwanted side effects. A further benefit in these days of the diminishing pound is the great reduction in cost. D K PAYLER Medical Centre,
Malvern College, Malvern, Worcs
Payler, D K, and Skirrow, M B, British Journal, 1974, 2, 727.
KYVELIE PAPAS
Is there a future for community medicine? SIR,-The respect I have for Dr D H Stone (30 October, p 1086) has prompted this answer, a rather unusual emergence from the state of peaceful scepticism to which international, national, and professional problems -including those related to community medicine-have converted me for some time now.
Dr Stone's article attempts to offer solutions. Sadly it ends by adding more confusion to the existing one, particularly for the so-called prospective recruits. What stands out is the strongly expressed conflict between old concepts of medicine and present realities. It is widely known that young enthusiasts or devotees enter medicine with preconceived ideas of stereotyped outcomes: status, prestige, authority, recognition, and glamour for some and, thankfully, an honest desire to be of help to a lot of others. Dr Stone seems almost obsessed with the idea that achieving some or all of the above requires unconditionally the clinical component. Even more, and in spite of his mentioning it faintly, he fails to stress the concept that groups and populations are in fact individuals put together. With regard to the impact the community physician has among his peers, one should see in the same light, for example, the chemical pathologist, the diagnostic radiologist, or the morbid anatomist. However, the high standards medicine has achieved in the UK owe, may I say, more to the excellence of such nonclinical specialties than to the collection of some hundreds of clinical geniuses. For the lack of academic credentials, on the other hand, part-time clinical work is a very poor substitute. None of the specialties mentioned (for example, developmental paediatrics, psychiatry, geriatrics, or family planning) can, given "part-time attention," act as a status propeller. And coming to the most traumatic point of all of the one-to-one relationship, no
Lewisham Health District Officer, Lewisham Hospital, London SE13
SIR,-The proposal that part-time clinical practice might help rid community medicine of its problems is not unfamiliar. Before further developing this theme its proponents, such as Dr David Stone (30 October, p 1086), might usefully examine situations in which specialists in community medicine already obtain job satisfaction and do not experience "real difficulties of identification and communication, particularly with clinicians" or "difficulties in relating the medical, as opposed to the administrative, functions . . . to the reality of their work." They might find that the growing number of such people have a great deal in common with specialist clinicians, particularly in their use of professional skills (rather than "grey book" fiat) to determine the priorities of their work in the light of problems presenting but also in the sufficiency of their information for making precise diagnoses and in their recognition that their special mastery of diagnostic skills in the field is an essential prerequisite to gaining acceptance by fellow clinicians of the treatments they prescribe. They might. even conclude, as I do, that the specialty cannot help but languish until it can call upon sufficiently developed health information systems to provide adequate diagnostic support for its prescriptions. It is thus unreasonable to judge the contribution of the specialty and propose significant changes until health information systems are widely in operation so that community medicine at least has the potential to make the contribution it was restructured to provide. Therefore the least useful development which could occur now would be the wholesale abandonment of that specialist endeavour in favour of part-time work divided between clinical practice and health service administration, presumably at subspecialist level, since
BRITISH MEDICAL JOURNAL
27 NOVEMBER 1976
"experienced" GPs turned, with each "modu- significant difference between antibody res- personal satisfaction results from the fragponses to vaccine given by the subcutaneous mented services one will be able to offer on a
lation" of the Nuffield "circus," into an exercise in educational methods-fishbowls, role-play, self-assessment, peer assessment, interminable MCQs, MEQs, etc, etc. Each session became an educational exercise in itself-"it's not what you teach-it's the way that you teach it." Surely, training's missed the point if it's not primarily aimed at consumer satisfaction. Not enough is written of what the trainee has learnt or wants to learn and far too much of educational principles, objective evaluation, etc. Methinks, Nuffield supporters, you protest too much. MARGARET THOMSON Luton, Beds
Reactions to current influenza vaccine SIR,-I write to confirm the increased incidence of reactions to influenza vaccine containing the new A/New Jersey/76 strain referred to in Dr T W Hoskins's letter (6 November, p 1131). I am medical officer to two schools in North Devon. After having vaccinated 284 children at one school I noted an overall incidence of mild systemic reactions of approximately 24°0o; however, looking at these figures more closely revealed that the majority occurred in the 104 boys aged 13 or less: in fact, the reaction rate among these was 4800, while the reaction rate among the older pupils was only 11°'. In view of these unexpectedly high reaction rates, especially in the younger pupils, it was decided to reduce the dose for children aged 13 and under at the second school to half the recommended adult dose. At this school 100 children (all aged 13 or under) were vaccinated and mild reactions were observed in 20 (20%). Although these rates are high, the reactions were very mild; the commonest complaint was headache often associated with malaise. No pupil was unwell for more than 24 h. At the first school only 13 out of the 104 younger children rested on their beds; none of those receiving the reduced dose at the second school were unwell enough to require bed rest. There appears, therefore, to be a direct quantitative relationship between the dose and the incidence of reactions. This finding is slightly at variance with Dr Hoskins's observations. On this evidence it might be justifiable to give children of 13 years or less a dose of 0-25 ml of the influenza vaccine. Whether or not this dose gives an acceptable protection rate has yet to be determined, but the two populations will be kept under observation. I would agree with Dr Hoskins that this unexpectedly high reaction rate requires a reassessment of vaccination policy.
MICHAEL HALL Exeter Postgraduate Medical
Centre,
Exeter
SIR,-In October 1976 a communication was received from the Medical Officers of Schools Association stating that there had been an unusually high reaction rate, particularly in the younger child, to the present influenza vaccine containing A/New Jersey/76. Dr T W Hoskins confirms this in his letter (16 November, p 1131). The findings in autumn 19731 showed no
part-time basis in clinical work. Present-day medical and social requirements versus numbers of patients make very difficult indeed at any level-whether primary or secondary health care-this type of professional fulfilment for which, maybe, social case work is the answer. I do not feel qualified to offer anything but thought rather than suggestions. Community medicine does deal with individuals but does it indirectly. Community physicians can help, can be heard, can even be "respected" provided they know whom they serve and have the ability to convince their peers to that end or apply the stamina clinicians show for the interests of their patients. For the less co-ordination-advisorymanagerial-role-minded community doctor I can think of hardly any brand of present-day medicine with such ample opportunities for research. And if going back to the grass-roots "so that we know what we are talking about" is the only way community physicians can get themselves accepted I would happily opt for clinical sabbaticals every so many years in one's own particular interests from the past. By this I mean whole-time one thing or another. I am afraid the time has come when Medical we should accept with self-confidence and dignity that we cannot have it both ways.
route and the intradermal route using the Porton jet injector. Therefore it was arranged, in conjunction with the various school medical officers, for Schuco's Porton jet injector team to give all the boarding-school children in Malvern and district a 0 1-ml intradermal dose of Admune vaccine, the injector being suitably calibrated. Over 2000 children, including some 400 under 13 years old, received the vaccine. The reactions were minimal, there being only 12 children with recognised raised temperatures within the first 24-h period. In order to ascertain the effectiveness of the vaccine by the intradermal method on this occasion antibody titres are being analysed in approximately 30 volunteers. Until the blood results are available it would seem to be expedient to employ the intradermal technique as a worthwhile alternative to a method which is causing such unpleasant and unwanted side effects. A further benefit in these days of the diminishing pound is the great reduction in cost. D K PAYLER Medical Centre,
Malvern College, Malvern, Worcs
Payler, D K, and Skirrow, M B, British Journal, 1974, 2, 727.
KYVELIE PAPAS
Is there a future for community medicine? SIR,-The respect I have for Dr D H Stone (30 October, p 1086) has prompted this answer, a rather unusual emergence from the state of peaceful scepticism to which international, national, and professional problems -including those related to community medicine-have converted me for some time now.
Dr Stone's article attempts to offer solutions. Sadly it ends by adding more confusion to the existing one, particularly for the so-called prospective recruits. What stands out is the strongly expressed conflict between old concepts of medicine and present realities. It is widely known that young enthusiasts or devotees enter medicine with preconceived ideas of stereotyped outcomes: status, prestige, authority, recognition, and glamour for some and, thankfully, an honest desire to be of help to a lot of others. Dr Stone seems almost obsessed with the idea that achieving some or all of the above requires unconditionally the clinical component. Even more, and in spite of his mentioning it faintly, he fails to stress the concept that groups and populations are in fact individuals put together. With regard to the impact the community physician has among his peers, one should see in the same light, for example, the chemical pathologist, the diagnostic radiologist, or the morbid anatomist. However, the high standards medicine has achieved in the UK owe, may I say, more to the excellence of such nonclinical specialties than to the collection of some hundreds of clinical geniuses. For the lack of academic credentials, on the other hand, part-time clinical work is a very poor substitute. None of the specialties mentioned (for example, developmental paediatrics, psychiatry, geriatrics, or family planning) can, given "part-time attention," act as a status propeller. And coming to the most traumatic point of all of the one-to-one relationship, no
Lewisham Health District Officer, Lewisham Hospital, London SE13
SIR,-The proposal that part-time clinical practice might help rid community medicine of its problems is not unfamiliar. Before further developing this theme its proponents, such as Dr David Stone (30 October, p 1086), might usefully examine situations in which specialists in community medicine already obtain job satisfaction and do not experience "real difficulties of identification and communication, particularly with clinicians" or "difficulties in relating the medical, as opposed to the administrative, functions . . . to the reality of their work." They might find that the growing number of such people have a great deal in common with specialist clinicians, particularly in their use of professional skills (rather than "grey book" fiat) to determine the priorities of their work in the light of problems presenting but also in the sufficiency of their information for making precise diagnoses and in their recognition that their special mastery of diagnostic skills in the field is an essential prerequisite to gaining acceptance by fellow clinicians of the treatments they prescribe. They might. even conclude, as I do, that the specialty cannot help but languish until it can call upon sufficiently developed health information systems to provide adequate diagnostic support for its prescriptions. It is thus unreasonable to judge the contribution of the specialty and propose significant changes until health information systems are widely in operation so that community medicine at least has the potential to make the contribution it was restructured to provide. Therefore the least useful development which could occur now would be the wholesale abandonment of that specialist endeavour in favour of part-time work divided between clinical practice and health service administration, presumably at subspecialist level, since
