698 candida in the stool, and all of whom became completely symptom-free within 72 h of nystatin treatment and remained symptom-free without the benefit of a yeast-free diet. Georgetown University Hospital, 3800 Reservoir Road, N.W., Washington, D.C. 20007, U.S.A.
VINCENT F. GARAGUSI JANE H. CHRETIEN
Laboratory Sciences. This, together with the suggestion from the Department to the I.M.L.S. that only 25% of H.N.C. candidates should be encouraged to take fellowship, threatens the career prospects of junior staff in training, jeopardises effective staffing in pathology laboratories, and raises serious doubts about the provision of sufficiently trained staff in adequate numbers
to man
the emergency on-call service.
Group Pathology Laboratory, Princess Alice Hospital,
M. BASTABLE R. A. ELLISTON J. T. HARRISON D. M. MANNERS
Eastbourne, Sussex BN21 2AX
M. STONELAKE
LABORATORY TECHNICIANS
SIR,-The excellence of pathology services in the U.K.
depends the dedication and skill of laboratory technicians. The high standards which they attain in clinical chemistry are a result of the unfailing efforts of the Institute of Medical Laboratory Sciences. The Institute correctly appreciates that their members require substantial basic knowledge, as well as technical skill, if they are to adapt rapidly to advances in their subject. This on
knowledge is acquired during courses leading to fellowship of the Institute and the diploma in medical technology. I, therefore, share with Dr Davis and Mr MacTavish (March 13, p. 587) their concern at the far-reaching implications of an article in the Gazette of the Institute of Medical Laboratory Sciences (1976, 20, 49). This may be interpreted as meaning that the Department of Health and some of their advisers fail to appreciate the importance of post-H.N.C. qualification. This is certainly not the view of most of my colleagues in clinical chemistry. I believe I am also expressing the views of my colleagues in urging that fellowship of the Institute or the diploma in medical technology should be regarded as a basis from which the most talented technician can proceed to a PH.D., and that the Department grant recognition to the diploma as a qualification for biochemist posts. Department of Chemical Pathology, St. Bartholomew’s Hospital, London EC1A 7BE
J. LANDON
are quite right in queswhether of standards existing patient care could be tioning maintained, if fellowship of the Institute of Medical Laboratory Sciences was no longer to be required for promotion to the senior medical laboratory technician grade and above. An H.N.C. or a non-specialised science degree is not an adequate qualification for the substantial responsibilities which senior technical staff are now required to exercise. The modern medical laboratory needs staff who have a sound scientific knowledge coupled with a specialist qualification. It has been quite unrealistic for many years to think in terms of training "pairs of hands" to perform tasks of which they have no un-
SIR,-Dr Davis and Mr MacTavish
derstanding. One can imagine the reaction of the medical profession if we were told by administrators or by members of another profession that an M.B. or equivalent medical qualification was all that was necessary for the practice of pathology or of any other specialty and that steps would be taken to restrict the numbers pursuing further training. All of us, at one time or another, rely on the service provided by our medical laboratory colleagues, and I am sure that others will share my alarm at the threat to their profession and to the quality of the service. Rowhook Medical
Society, Chequers Inn, Rowhook, Horsham RH12 3PX
GEORGE DICK
SIR,-We strongly deprecate the refusal of the Department of Health to extend the training provisions of STM 47/70 to enable medical laboratory scientists to engage in full day-release courses for the fellowship of the Institute of Medical
K. M. HARRISON D. A. LONG S. J. SURTEES D. C. TAYLOR
Consultant Chief technicians pathologists and 32 other medical laboratory scientists
IATROGENIC DISEASE
SIR,-Now that the medical profession has ceased to smart from the cutting blows of Ivan Illichl regarding its role as a creator of disease and perpetrator of a morbid society, surely the time has come to take stock and see if there is any truth in Illich’s heresies. SartwelP lists some of the known "epidemic situations" of iatrogenic disease ; many were quickly discovered (e.g., thalidomide), while others came to light much more slowly (e.g., leukaemia in early radiologists). An "epidemic situation" implies that the incidence of a disease in a population has increased beyond normal expectation.3 In the many less determinate forms of iatrogenic disease, I doubt if thereis enough knowledge of the amount of disease in the community for any disease frequency to be termed epidemic. The essential nature of iatrogenic disease has become our scured because many medical professionals regard it froma very limited viewpoint-i.e., as an entity which is very easily perceived, such as a reaction to a drug. This, almost certainly, is not a broad enough concept. Watson4provides a much more comprehensive definition: "any deterioration in the patient’s condition which comes from seeking medical advice and which cannot be attributed to the natural history of his disease", Using this definition of iatrogenic disease, which depends on patient experience and medical knowledge, an attempt should be made to assess epidemiologically the veracity or fallacy of Illich’s words, replacing intellectualism by objectivity. This is a difficult and complex task, but Illich’s accusation could function as a timely stimulus. 17 Kelvin
Kilsyth, Glasgow
Estate,
DAVID R. BROWN
G65 0TD
LOGICAL DISEASES seems that we are nowadays afflicted by a spate "logical" diseases. Neurological diseases seem to have totally displaced the neural ones. Gynaecic diseases do not occur, but there is no shortage of the gynaecological variety Immunological diseases seem to have multiplied rapidly in the past few years, although autoantibodies do not yet appear to have produced any cases of autoimmunological disease. Likewise, I have not yet seen any reports of cardiological or dermatological diseases, but perhaps I have missed them. Should not editors be taking steps to eradicate these logical diseases?
SIR,-It
of
Ministry of Agriculture, Fisheries and Food, Veterinary Investigation Centre, Madingley Road, Cambridge
SHERWIN A. HALL
1. Illich, I. Lancet, 1974, i, 918. Sartwell, P. E. Intl, J Hlth Serv. 1974, 4, 89-93. MacMahon, B., Pugh, T. F., Ipsen, J. Epidemiologic Methods, Boston, 1980 4. Watson, W. C. Hlth Bull., Edin. 1969, 27, no. 24.
2. 3.
VINCENT F. GARAGUSI JANE H. CHRETIEN
Laboratory Sciences. This, together with the suggestion from the Department to the I.M.L.S. that only 25% of H.N.C. candidates should be encouraged to take fellowship, threatens the career prospects of junior staff in training, jeopardises effective staffing in pathology laboratories, and raises serious doubts about the provision of sufficiently trained staff in adequate numbers
to man
the emergency on-call service.
Group Pathology Laboratory, Princess Alice Hospital,
M. BASTABLE R. A. ELLISTON J. T. HARRISON D. M. MANNERS
Eastbourne, Sussex BN21 2AX
M. STONELAKE
LABORATORY TECHNICIANS
SIR,-The excellence of pathology services in the U.K.
depends the dedication and skill of laboratory technicians. The high standards which they attain in clinical chemistry are a result of the unfailing efforts of the Institute of Medical Laboratory Sciences. The Institute correctly appreciates that their members require substantial basic knowledge, as well as technical skill, if they are to adapt rapidly to advances in their subject. This on
knowledge is acquired during courses leading to fellowship of the Institute and the diploma in medical technology. I, therefore, share with Dr Davis and Mr MacTavish (March 13, p. 587) their concern at the far-reaching implications of an article in the Gazette of the Institute of Medical Laboratory Sciences (1976, 20, 49). This may be interpreted as meaning that the Department of Health and some of their advisers fail to appreciate the importance of post-H.N.C. qualification. This is certainly not the view of most of my colleagues in clinical chemistry. I believe I am also expressing the views of my colleagues in urging that fellowship of the Institute or the diploma in medical technology should be regarded as a basis from which the most talented technician can proceed to a PH.D., and that the Department grant recognition to the diploma as a qualification for biochemist posts. Department of Chemical Pathology, St. Bartholomew’s Hospital, London EC1A 7BE
J. LANDON
are quite right in queswhether of standards existing patient care could be tioning maintained, if fellowship of the Institute of Medical Laboratory Sciences was no longer to be required for promotion to the senior medical laboratory technician grade and above. An H.N.C. or a non-specialised science degree is not an adequate qualification for the substantial responsibilities which senior technical staff are now required to exercise. The modern medical laboratory needs staff who have a sound scientific knowledge coupled with a specialist qualification. It has been quite unrealistic for many years to think in terms of training "pairs of hands" to perform tasks of which they have no un-
SIR,-Dr Davis and Mr MacTavish
derstanding. One can imagine the reaction of the medical profession if we were told by administrators or by members of another profession that an M.B. or equivalent medical qualification was all that was necessary for the practice of pathology or of any other specialty and that steps would be taken to restrict the numbers pursuing further training. All of us, at one time or another, rely on the service provided by our medical laboratory colleagues, and I am sure that others will share my alarm at the threat to their profession and to the quality of the service. Rowhook Medical
Society, Chequers Inn, Rowhook, Horsham RH12 3PX
GEORGE DICK
SIR,-We strongly deprecate the refusal of the Department of Health to extend the training provisions of STM 47/70 to enable medical laboratory scientists to engage in full day-release courses for the fellowship of the Institute of Medical
K. M. HARRISON D. A. LONG S. J. SURTEES D. C. TAYLOR
Consultant Chief technicians pathologists and 32 other medical laboratory scientists
IATROGENIC DISEASE
SIR,-Now that the medical profession has ceased to smart from the cutting blows of Ivan Illichl regarding its role as a creator of disease and perpetrator of a morbid society, surely the time has come to take stock and see if there is any truth in Illich’s heresies. SartwelP lists some of the known "epidemic situations" of iatrogenic disease ; many were quickly discovered (e.g., thalidomide), while others came to light much more slowly (e.g., leukaemia in early radiologists). An "epidemic situation" implies that the incidence of a disease in a population has increased beyond normal expectation.3 In the many less determinate forms of iatrogenic disease, I doubt if thereis enough knowledge of the amount of disease in the community for any disease frequency to be termed epidemic. The essential nature of iatrogenic disease has become our scured because many medical professionals regard it froma very limited viewpoint-i.e., as an entity which is very easily perceived, such as a reaction to a drug. This, almost certainly, is not a broad enough concept. Watson4provides a much more comprehensive definition: "any deterioration in the patient’s condition which comes from seeking medical advice and which cannot be attributed to the natural history of his disease", Using this definition of iatrogenic disease, which depends on patient experience and medical knowledge, an attempt should be made to assess epidemiologically the veracity or fallacy of Illich’s words, replacing intellectualism by objectivity. This is a difficult and complex task, but Illich’s accusation could function as a timely stimulus. 17 Kelvin
Kilsyth, Glasgow
Estate,
DAVID R. BROWN
G65 0TD
LOGICAL DISEASES seems that we are nowadays afflicted by a spate "logical" diseases. Neurological diseases seem to have totally displaced the neural ones. Gynaecic diseases do not occur, but there is no shortage of the gynaecological variety Immunological diseases seem to have multiplied rapidly in the past few years, although autoantibodies do not yet appear to have produced any cases of autoimmunological disease. Likewise, I have not yet seen any reports of cardiological or dermatological diseases, but perhaps I have missed them. Should not editors be taking steps to eradicate these logical diseases?
SIR,-It
of
Ministry of Agriculture, Fisheries and Food, Veterinary Investigation Centre, Madingley Road, Cambridge
SHERWIN A. HALL
1. Illich, I. Lancet, 1974, i, 918. Sartwell, P. E. Intl, J Hlth Serv. 1974, 4, 89-93. MacMahon, B., Pugh, T. F., Ipsen, J. Epidemiologic Methods, Boston, 1980 4. Watson, W. C. Hlth Bull., Edin. 1969, 27, no. 24.
2. 3.
