1029 Health
decide whether
must
they
wish the activities of
medically qualified anatomists, as set out above, to continue by ensuring a reasonable financial return, possibly derived in part from University and partly from N.H.S., or whether the rearguard action of British anatomists to maintain a medical presence must finally end and the departments become staffed by non-medical individuals who quite reasonably put science first and second, and vocational training a poor third; a balanced staff provides a balanced course. Both Vice-Chancellors and the U.G.C. have been aware of the deteriorating situation for the past The seven years, but have chosen to remain inactive. crisis in staffing is now, and with the current exodus of career anatomists overseas and into general practice, the new schools, and even some long established schools, may fail to meet their teaching commitments during the next 12 months. Virtually all the older establishments will be past the point of no-return so far as medical staff is concerned within 5 years. Department of Human Morphology, University Park, Nottingham NG7 2RD.
lower or not in an Open University medical course. Possibly not, but we would have to try the experiment on a small scale to find out. What is likely, however, is that his estimate of 2 years’ preclinical and 22 years’ clinical period is too short. It is frightening to expect even mature students to learn " anatomy, physiology, biochemistry, pharmacology, behavioural sciences, general pathology and microbiology, medical statistics and epidemiology, and
genetics",
as
suggested by Professor Acheson,
R. E. COUPLAND.
138
MEDICAL COURSE AT THE OPEN UNIVERSITY
SiR,—Iam an admirer of the Open University and I am full of praise for its achievements in developing new techniques in education and in enabling 10,000 of our citizens to achieve its degrees since its start only a few years ago. However, I do not accept the case made by the Dean of the Medical Faculty at Southampton University, Prof. Donald Acheson, for an undergraduate medical course for the Open University (April 26, p. 965). The chief reason for developing the idea must be the need for more doctors in the United Kingdom. No sound case has been made for this in spite of the fact that the Governments, U.G.C., and our medical schools are planning to double the annual intake of medical schools to over 4000 (compared with 1970 intakes). Even allowing for a 2-3% annual increase I believe that we need approximately 2600 new medical students each year to meet our own requirements. I believe that we may be creating medical unemployment within 10-15 years if we go ahead with present projections.l There is therefore no good reason for accepting that we need a new Open University Medical School to take in 600 students annually in order to produce 300, as Professor Acheson suggests. Professor Acheson seeks to show that the Open University course would be cheaper than setting up a traditional medical school for 100 students. Surely it is wrong to make such comparisons. It would be crazy for us to build such a It would be much fairer if he had comof increasing the intake of existing medical schools by 100 each year with those of an Open University course. We must realise also that each new medical student who graduates will be responsible for a national capital expenditure of up to Elmillion in his or her professional lifetime.1 Another reason given by Professor Acheson is that it would make it easier for mature students to gain entry to a medical school. If there is a strong case for taking in more mature students into medicine, then why do not Professor Acheson and his fellow deans agree to allocate a higher proportion of places in their existing medical schools for this purpose and convince the Treasury and the Department of Education of the need to support such students with
school
pared the
part-time
University. Croydon Road. Beckenham,
JOHN FRY.
Kent BR3 4DG.
new
as
home students. In spite of my uncertainty of the need for an undergraduate medical course I am certain that there is much that the Open University can contribute to postgraduate medical education. There are great opportunities for Open University involvement and cooperation in specialist training and continuing education. The methods and techniques of teaching and learning that it has developed would add greatly to the current programmes. It is in the postgraduate medical field that I see the greatest scope for the Open
now.
costs
BIOLOGY, ABORTION,
AND ETHICS
SIR,-As one who, like Dr Potts (April 19, p. 913), is interested in the relationship between the natural law and resistance to disease, I believe that biological evidence favours the natural law. For example, there is evidence that oestriol plays a significant anticarcinogenic role in the human female, accounting for the reduced expectancy of mammary cancer in women with multiple pregnancies in their early childbearing years.l It has also been suggested that pregnancy at a young age is associated with the formation of favourable cestrogen ratios and decreased breast-cancer risk later.2 On the other hand, there is an association between changes in adrenocortical function and mental disturbances.3 It has been found that excretion of urinary ketosteroid levels and levels of circulating lymphocytes may be modified by emotional stress.44 It has been affirmed that emotional stress results in increased adrenocortical activity.5 There is also much evidence to suggest that depressed emotional states decrease resistance to tuberculosis, rheumatoid arthritis, and cancer, diseases to which immunity is cell-mediated. It is well known that plasmaoestrogen levels are increased in pregnancy. Should not the exponents of a liberal policy towards abortion be asked to quote objective evidence of urinary and plasma steroid assays in support of their contention that terminations are justified on account of psychological stress ? Plymouth Road, Buckfastleigh, Devon TQ110DH.
72
MICHAEL WILKINSON.
MEDICAL AUDIT
.
government
grants ?
It is difficult 1.
to
theorise whether standards would be
Fry, J. Update (in the press).
SIR,-It is apparent that a myth called Medical Audit is being promoted in Great Britain. Having wasted countless hours during the past twenty years on meetings of the so-called medical audit and tissue committee, I feel obliged to sound an alarm. The myth of medical audit was invented by the Council ,
1. 2. 3. 4.
5.
Lemon, H. M. Cancer, 1970, 25, 423. Cole, P., McMahon, B. Lancet, 1969, i, 604. Beck, J. C., McGarry, E. E. Br. med. Bull. 1962, 18, 134. Hill, S. R., Goetz, F. C., Fox, H. M., Murawski, B. J., Krakauer, L. J., Reifenstein, R. W., Gray, S. J., Reddy, W. J., Hadberg, S. E., St. Marc, J. R., Thorn, G. W. Archs intern. Med. 1956, 97, Greenwood, F. C., Landon, J. Nature, 1966, 210, 540.
no.
3.
1030
Hospital Accreditation (a peculiarly North American institution) presumably to measure and improve the quality of medical care. However it either did not realise or was incapable of understanding that, in order to measure anything, a fairly precise set of standards was an absolute uecessity. Without such a set, serious evaluation of the mode of investigation and treatment of a disease entity is a slow, involved, and expensive process amounting in fact to the writing of a paper. If it is neither measurement against a on
set
of standards nor an effort to write a paper, the whole is a waste of time. All the Commission on Hospital
thing
Accreditation seem to care about are the minutes of audit committee meetings. Recently the American College of Surgeons (not the Commission) came up with a set of reasonable standards for about a dozen surgical entities. But then, do we know what we should audit-the process of care or its outcome ? The mythologists themselves are still at
loggerheads. Does our experience allow us to say that a better kind of medicine is practised on the North American continent than in Britain, the Scandinavian countries, &c., without making ourselves look like a bunch of fools ? Certainly not. Has anybody compared the extent of medical care improvement here and in the above countries over the past twenty years ? I can assure you that no one ever thought about it. I think I can say without too many reservations that the audit is as useful as a plague. It would be indeed advisable for Britain and other countries where this myth is not endemic to try to quarantine those who show clinical evidence of infection as well as its carriers. Department of Pathology, North Bay Civic and St. Joseph’s Hospitals, North Bay, Ontario, Canada.
P. N. KARNAUCHOW.
SCREENING FOR BREAST CANCER
SIR,-Dr Wright (April 26, p. 983), writing from the B.U.P.A. Medical Centre, says " we continue to use and expand the activities of nurses-our three breast-screening units, one of which is mobile, are entirely operated by them ". Did it escape his notice that in the recent series in The Lancet on screening for disease the process of screening for breast cancer was not very highly regarded by the relevant experts ? Professor Hollandsummed it up with: " In Britain the Health Department have lately been advised not to introduce mass screening for breast cancer; all the same this area will probably repay further efforts " (i.e., research). Dr Irwig2 stated: " On present evidence it would seem wise to await these further developments before considering the introduction of mass screening for breast cancer." Why then the expansion to which Dr Wright refers ? In reporting his experience of the Kaiser Permanente system in California, Dr Wright writes that " the future, for the imaginative’development of this type of (paramedical) help, including the dilution of the nursing care of the sick with intelligent’tender loving care ’, &c., is limitless ". How does nursing care of the sick differ from intelligent " tender loving care " ? In just what sense does the one " dilute " the other ? In his immediately succeeding paragraph Dr Wright highly commends history-taking by computer. May I ask just how he reconciles the use of what is certainly a non-human and might be thought to be an alienating mechanism for history-taking with intelligent, tender, 1. 2.
Holland, W. W. Lancet, 1974, ii, Irwig, L. M. ibid. p. 1307.
1494.
loving care ? Or has the computer been programmed supply some of this commodity too ? Garraway House, How Caple, Hereford.
to
JOHN S. BRADSHAW.
SCREENING FOR SICKLING SIR,-As topic of screening for disease is so relevant to present-day practice, perhaps further comments may still be made on your recent series. Sooner or later, the economically less developed sickle belts of the world may contemplate setting up mass the
screening programmes for sickling. Judging by previous experience,l it seems almost certain that, on the African scene also, misconceptions about the sickle-cell trait would arise, and hitherto unexplained deaths might soon be popularly attributed to the " new disease " of sickle-cell trait. Another important considerarion is that genetic counselling is unlikely to find a place for some time among the people of the sickle-endemic countries of the Third,World, not only because they have children for different reasons, but also because their family pattern, traditional customs, and beliefs are entirely different from those in advanced countries. There has been less emphasis recently on mass screening programmes. Despite the scepticism that has been expressed on the overall values, some form of screening will always be required to detect sickling in certain well-defined groups of patients and individuals, in order to establish the diagnosis of a sickling syndrome, or to identify trait carriers amongst potential sicklers2 fot the special circumstances of general anaesthesia and high-altitude flying. Outside the defined groups, screening for sickle-cell trait per se now seems unjustified,3except for genetic counselling purposes, which, as many would now agree, should be undertaken only at the specific request of high-risk individuals who are able to grasp the implications. However, even judiciously conducted screening and genetic counselling may still produce psychosocial side-effects,4which are yet to be fully assessed. Department of Clinical Pathology, General Hospital,
Ilorin, Nigeria.
I. MAMMAN.
BLOOD-BRAIN BARRIER IN THE HUMAN FETUS SIR,-We should like to make a short addendum to the
interesting paper by Dr Thorley and his collaborators (March 22, p. 651) on the presence of maternal diphtheria and tetanus antitoxins in the cerebrospinal fluid (c.s.F.) of infants from 1 to 6 days old. In the course of an investigation on the origin of oc-fetoprotein (A.F.P.) in the amniotic fluid of fetuses with neural-tube defects, we have estimated the levels of this protein in the C.S.F. of six " normal"" fetuses. The amount of A.F.P. in C.s.F. was found to decrease from 1220 jjg. per ml. in a 16!-week-old fetus to 52-70 tg. per ml. in three fetuses 25 weeks old, while the levels of albumin increased with age. Maternal IgG was detected in all c.s.F. tested, with values ranging from 60 to 117 jg. per ml. These findings, which are to be published in detail elsewhere,5 and preliminary results in laboratory animals using 1251-labelled plasma-proteins (Adinolfi and Petrakis, N. L. Lancet, 1974, ii, 1368. Oduro, K. A., Searle, J. F. Br. med. J. 1972, iv, 596. Motulsky, A. G. in Genetic Polymorphisms and Diseases in Man (edited by B. Ramot et al.); p. 215. New York, 1974. 4. Whitten, C. F., Fischhoff, J. Archs intern. Med. 1974, 133, 681. 5. Seller, M. J., Adinolfi, M. Archs Dis. Childh. (in the press).
1. 2. 3.
’
decide whether
must
they
wish the activities of
medically qualified anatomists, as set out above, to continue by ensuring a reasonable financial return, possibly derived in part from University and partly from N.H.S., or whether the rearguard action of British anatomists to maintain a medical presence must finally end and the departments become staffed by non-medical individuals who quite reasonably put science first and second, and vocational training a poor third; a balanced staff provides a balanced course. Both Vice-Chancellors and the U.G.C. have been aware of the deteriorating situation for the past The seven years, but have chosen to remain inactive. crisis in staffing is now, and with the current exodus of career anatomists overseas and into general practice, the new schools, and even some long established schools, may fail to meet their teaching commitments during the next 12 months. Virtually all the older establishments will be past the point of no-return so far as medical staff is concerned within 5 years. Department of Human Morphology, University Park, Nottingham NG7 2RD.
lower or not in an Open University medical course. Possibly not, but we would have to try the experiment on a small scale to find out. What is likely, however, is that his estimate of 2 years’ preclinical and 22 years’ clinical period is too short. It is frightening to expect even mature students to learn " anatomy, physiology, biochemistry, pharmacology, behavioural sciences, general pathology and microbiology, medical statistics and epidemiology, and
genetics",
as
suggested by Professor Acheson,
R. E. COUPLAND.
138
MEDICAL COURSE AT THE OPEN UNIVERSITY
SiR,—Iam an admirer of the Open University and I am full of praise for its achievements in developing new techniques in education and in enabling 10,000 of our citizens to achieve its degrees since its start only a few years ago. However, I do not accept the case made by the Dean of the Medical Faculty at Southampton University, Prof. Donald Acheson, for an undergraduate medical course for the Open University (April 26, p. 965). The chief reason for developing the idea must be the need for more doctors in the United Kingdom. No sound case has been made for this in spite of the fact that the Governments, U.G.C., and our medical schools are planning to double the annual intake of medical schools to over 4000 (compared with 1970 intakes). Even allowing for a 2-3% annual increase I believe that we need approximately 2600 new medical students each year to meet our own requirements. I believe that we may be creating medical unemployment within 10-15 years if we go ahead with present projections.l There is therefore no good reason for accepting that we need a new Open University Medical School to take in 600 students annually in order to produce 300, as Professor Acheson suggests. Professor Acheson seeks to show that the Open University course would be cheaper than setting up a traditional medical school for 100 students. Surely it is wrong to make such comparisons. It would be crazy for us to build such a It would be much fairer if he had comof increasing the intake of existing medical schools by 100 each year with those of an Open University course. We must realise also that each new medical student who graduates will be responsible for a national capital expenditure of up to Elmillion in his or her professional lifetime.1 Another reason given by Professor Acheson is that it would make it easier for mature students to gain entry to a medical school. If there is a strong case for taking in more mature students into medicine, then why do not Professor Acheson and his fellow deans agree to allocate a higher proportion of places in their existing medical schools for this purpose and convince the Treasury and the Department of Education of the need to support such students with
school
pared the
part-time
University. Croydon Road. Beckenham,
JOHN FRY.
Kent BR3 4DG.
new
as
home students. In spite of my uncertainty of the need for an undergraduate medical course I am certain that there is much that the Open University can contribute to postgraduate medical education. There are great opportunities for Open University involvement and cooperation in specialist training and continuing education. The methods and techniques of teaching and learning that it has developed would add greatly to the current programmes. It is in the postgraduate medical field that I see the greatest scope for the Open
now.
costs
BIOLOGY, ABORTION,
AND ETHICS
SIR,-As one who, like Dr Potts (April 19, p. 913), is interested in the relationship between the natural law and resistance to disease, I believe that biological evidence favours the natural law. For example, there is evidence that oestriol plays a significant anticarcinogenic role in the human female, accounting for the reduced expectancy of mammary cancer in women with multiple pregnancies in their early childbearing years.l It has also been suggested that pregnancy at a young age is associated with the formation of favourable cestrogen ratios and decreased breast-cancer risk later.2 On the other hand, there is an association between changes in adrenocortical function and mental disturbances.3 It has been found that excretion of urinary ketosteroid levels and levels of circulating lymphocytes may be modified by emotional stress.44 It has been affirmed that emotional stress results in increased adrenocortical activity.5 There is also much evidence to suggest that depressed emotional states decrease resistance to tuberculosis, rheumatoid arthritis, and cancer, diseases to which immunity is cell-mediated. It is well known that plasmaoestrogen levels are increased in pregnancy. Should not the exponents of a liberal policy towards abortion be asked to quote objective evidence of urinary and plasma steroid assays in support of their contention that terminations are justified on account of psychological stress ? Plymouth Road, Buckfastleigh, Devon TQ110DH.
72
MICHAEL WILKINSON.
MEDICAL AUDIT
.
government
grants ?
It is difficult 1.
to
theorise whether standards would be
Fry, J. Update (in the press).
SIR,-It is apparent that a myth called Medical Audit is being promoted in Great Britain. Having wasted countless hours during the past twenty years on meetings of the so-called medical audit and tissue committee, I feel obliged to sound an alarm. The myth of medical audit was invented by the Council ,
1. 2. 3. 4.
5.
Lemon, H. M. Cancer, 1970, 25, 423. Cole, P., McMahon, B. Lancet, 1969, i, 604. Beck, J. C., McGarry, E. E. Br. med. Bull. 1962, 18, 134. Hill, S. R., Goetz, F. C., Fox, H. M., Murawski, B. J., Krakauer, L. J., Reifenstein, R. W., Gray, S. J., Reddy, W. J., Hadberg, S. E., St. Marc, J. R., Thorn, G. W. Archs intern. Med. 1956, 97, Greenwood, F. C., Landon, J. Nature, 1966, 210, 540.
no.
3.
1030
Hospital Accreditation (a peculiarly North American institution) presumably to measure and improve the quality of medical care. However it either did not realise or was incapable of understanding that, in order to measure anything, a fairly precise set of standards was an absolute uecessity. Without such a set, serious evaluation of the mode of investigation and treatment of a disease entity is a slow, involved, and expensive process amounting in fact to the writing of a paper. If it is neither measurement against a on
set
of standards nor an effort to write a paper, the whole is a waste of time. All the Commission on Hospital
thing
Accreditation seem to care about are the minutes of audit committee meetings. Recently the American College of Surgeons (not the Commission) came up with a set of reasonable standards for about a dozen surgical entities. But then, do we know what we should audit-the process of care or its outcome ? The mythologists themselves are still at
loggerheads. Does our experience allow us to say that a better kind of medicine is practised on the North American continent than in Britain, the Scandinavian countries, &c., without making ourselves look like a bunch of fools ? Certainly not. Has anybody compared the extent of medical care improvement here and in the above countries over the past twenty years ? I can assure you that no one ever thought about it. I think I can say without too many reservations that the audit is as useful as a plague. It would be indeed advisable for Britain and other countries where this myth is not endemic to try to quarantine those who show clinical evidence of infection as well as its carriers. Department of Pathology, North Bay Civic and St. Joseph’s Hospitals, North Bay, Ontario, Canada.
P. N. KARNAUCHOW.
SCREENING FOR BREAST CANCER
SIR,-Dr Wright (April 26, p. 983), writing from the B.U.P.A. Medical Centre, says " we continue to use and expand the activities of nurses-our three breast-screening units, one of which is mobile, are entirely operated by them ". Did it escape his notice that in the recent series in The Lancet on screening for disease the process of screening for breast cancer was not very highly regarded by the relevant experts ? Professor Hollandsummed it up with: " In Britain the Health Department have lately been advised not to introduce mass screening for breast cancer; all the same this area will probably repay further efforts " (i.e., research). Dr Irwig2 stated: " On present evidence it would seem wise to await these further developments before considering the introduction of mass screening for breast cancer." Why then the expansion to which Dr Wright refers ? In reporting his experience of the Kaiser Permanente system in California, Dr Wright writes that " the future, for the imaginative’development of this type of (paramedical) help, including the dilution of the nursing care of the sick with intelligent’tender loving care ’, &c., is limitless ". How does nursing care of the sick differ from intelligent " tender loving care " ? In just what sense does the one " dilute " the other ? In his immediately succeeding paragraph Dr Wright highly commends history-taking by computer. May I ask just how he reconciles the use of what is certainly a non-human and might be thought to be an alienating mechanism for history-taking with intelligent, tender, 1. 2.
Holland, W. W. Lancet, 1974, ii, Irwig, L. M. ibid. p. 1307.
1494.
loving care ? Or has the computer been programmed supply some of this commodity too ? Garraway House, How Caple, Hereford.
to
JOHN S. BRADSHAW.
SCREENING FOR SICKLING SIR,-As topic of screening for disease is so relevant to present-day practice, perhaps further comments may still be made on your recent series. Sooner or later, the economically less developed sickle belts of the world may contemplate setting up mass the
screening programmes for sickling. Judging by previous experience,l it seems almost certain that, on the African scene also, misconceptions about the sickle-cell trait would arise, and hitherto unexplained deaths might soon be popularly attributed to the " new disease " of sickle-cell trait. Another important considerarion is that genetic counselling is unlikely to find a place for some time among the people of the sickle-endemic countries of the Third,World, not only because they have children for different reasons, but also because their family pattern, traditional customs, and beliefs are entirely different from those in advanced countries. There has been less emphasis recently on mass screening programmes. Despite the scepticism that has been expressed on the overall values, some form of screening will always be required to detect sickling in certain well-defined groups of patients and individuals, in order to establish the diagnosis of a sickling syndrome, or to identify trait carriers amongst potential sicklers2 fot the special circumstances of general anaesthesia and high-altitude flying. Outside the defined groups, screening for sickle-cell trait per se now seems unjustified,3except for genetic counselling purposes, which, as many would now agree, should be undertaken only at the specific request of high-risk individuals who are able to grasp the implications. However, even judiciously conducted screening and genetic counselling may still produce psychosocial side-effects,4which are yet to be fully assessed. Department of Clinical Pathology, General Hospital,
Ilorin, Nigeria.
I. MAMMAN.
BLOOD-BRAIN BARRIER IN THE HUMAN FETUS SIR,-We should like to make a short addendum to the
interesting paper by Dr Thorley and his collaborators (March 22, p. 651) on the presence of maternal diphtheria and tetanus antitoxins in the cerebrospinal fluid (c.s.F.) of infants from 1 to 6 days old. In the course of an investigation on the origin of oc-fetoprotein (A.F.P.) in the amniotic fluid of fetuses with neural-tube defects, we have estimated the levels of this protein in the C.S.F. of six " normal"" fetuses. The amount of A.F.P. in C.s.F. was found to decrease from 1220 jjg. per ml. in a 16!-week-old fetus to 52-70 tg. per ml. in three fetuses 25 weeks old, while the levels of albumin increased with age. Maternal IgG was detected in all c.s.F. tested, with values ranging from 60 to 117 jg. per ml. These findings, which are to be published in detail elsewhere,5 and preliminary results in laboratory animals using 1251-labelled plasma-proteins (Adinolfi and Petrakis, N. L. Lancet, 1974, ii, 1368. Oduro, K. A., Searle, J. F. Br. med. J. 1972, iv, 596. Motulsky, A. G. in Genetic Polymorphisms and Diseases in Man (edited by B. Ramot et al.); p. 215. New York, 1974. 4. Whitten, C. F., Fischhoff, J. Archs intern. Med. 1974, 133, 681. 5. Seller, M. J., Adinolfi, M. Archs Dis. Childh. (in the press).
1. 2. 3.
’
