1238 TWO UNIVERSAL NEEDS IN U.K. MEDICAL SCHOOLS Committee will descend on the groves of academe and take the pulse and temperature of university medicine. There are two areas which merit diligent inquiry by the U.G.C. The first is the wide gap between clinical and preclinical disciplines, a gap which is cemented by the harsh reality of a savage salary differential. The surgeon seeks parity with N.H.S. colleagues by virtue of his scalpel, the physician by his stethoscope, the bacteriologist by his culture-laden loops of platinum, and the pathologist by the use of the microscope. But let none of these forget they owe their very existence to their teachers of basic science. Basicscience workers make their contribution to the N.H.S. by producing the medically qualified graduate, and this alone merits a reversal of contemporary trends in salary. In this country we regard ourselves with much satisfaction and are reluctant to examine the better points of foreign centres of learning. In Berne I believe there exists a basic medicalschool salary, and consequently it is not unheard of for medical graduates to seek a career in one of the basic sciences. Furthermore, over the past 15 years there has been a growth of experimental laboratories, staffed by persons trained in preclinical science, within clinical departments. Expansion and extension of this pattern might lead to further sequestration of the academic preclinical

SIR,-Shortly

the

University Grants

departments. The second point deals with the increasing importance of non-medical staff in the day-to-day affairs of a medical school. The role of the science graduate in both teaching and service is steadily increasing, and rightly so. But what is done by medical schools to encourage our scientists in understanding the medical milieu ? Surely there is a need for short courses which will cover the nature of disease, the functions of specialties, and the outlines of health administration ? This might be done by just one medical school as an educational experiment. 27 Inverleith

Terrace, Edinburgh 3.

WOMEN

A. E. STUART.

DOCTORS’ RETAINER SCHEME

SIR,-Your correspondents (April 26, p. 974) highlight the problems of all women doctors accepting parttime work either as clinical medical officers or as clinical assistants in hospitals. These women will shortly find themselves out on a limb, junior to their contemporaries and to many less well-qualified, less experienced doctors. The time spent in their posts will not qualify them for any of the higher medical echelons. Clinical medicine in community health is not part of a community physician’s training, neither is it recognised training for any specialty; even senior clinical medical officers remain junior to all community physicians. Clinical assistant is not a hospital grade, neither is it recognised as a training post for specialist registration; but if the community clinical services were to be integrated with the hospital service then doctors working part-time in this field could be graded s.H.o., registrar, hospital practitioner, &c. ; and part-time work could be counted pro rata for specialist qualification. There are overriding reasons for the integration of family planning and cytology services in this way: all major complications and problems arising in these areas are dealt with in obstetric and gynxcological departments; familyplanning experience is a compulsory part of junior staff training and for trainee general practitioners; it is a requirement for the D.OBST. and is part of the nursing curriculum. The Royal College of Obstetricians and Gynaecologists

(in conjunction with the Royal College of General Practitioners) has already made itself responsible for medical standards in this field. How can it determine that standards will be maintained unless these services and the doctors providing them are included in obstetric and gynxcological departments ? The doctors would then become an integral part of the department with the opportunity for further specialist training. If the B.M.A. and the Royal Colleges wait until the Court Committee reports at the end of 1975, it will be very difficult to unscramble the system. The Warren, Elenors Grove,

Quarr,

near

Ryde,

DIANA EDWARDS.

Isle of Wight.

COOPERATION BETWEEN SOCIAL WORKERS AND GENERAL PRACTITIONERS JIlt,-At

a recent

ot social workers and

general decided that there is a need for a group whose special function is to foster cooperation between social work and general practice. It was thought that professional organisations involved in promoting cooperation were too remote to be able to monitor adequately the problems in the field. It was also pointed out that the professional organisations most intimately concerned, the British Association of Social Workers and the Royal College of General Practitioners, were limited to dealing with their own members when they tried to promote cooperation. The meeting therefore decided to constitute itself formally, and the title chosen for the group was General Practitioner and Social Worker Workshop. We have drawn up a constitution, and have appointed officers for the forthcoming year. It is unfortunately necessary for us to charge a subscription to cover the costs of postage, stationery, &c,, and some small-scale research projects that we envisage being undertaken. We would stress that we see ourselves not as a rival organisation to other professional bodies but rather as a body which has constituted itself to perform a special task. Should we find that the need for our existence no longer exists we would dissolve ourselves. Our experience so far, however, during 2t years of informal meeting, is that there is a need for a group which can act as a focal point for those interested in general practice/social work meetmg

practitionersin Manchester it

was

cooperation. If anyone is interested in joining the group, details of constitution and aims can be obtained by sending a reply-paid envelope to the Honorary Secretary.

our

G. KEELE, Darbishire House Health Centre, Upper Brook Street, Manchester M13 0FW.

Hon. Secretary, General Practitioner and Social Worker Workshop.

MEDICAL AUDIT

SIR,-Dr Garber (May 10, p. 1086) quite rightly points the fact that a major medical priority is to establish " what more surely, quickly, and cheaply improves the quality of medical care ", but contrary to his line of argument the only means at his disposal is bound to be some

to

form of " output " audit. His claim that the quality of surgical care in the best U.S. centres compares favourably with the best in Britain may well be true but can only be validated by assessment of results in comparable centres according to appropriate " criteria-i.e., an output audit. " The input recommendations he quotes in relation to improving care in general practice seem laudable but are "

"

1239

meaningless unless the anticipated improvement is measured by audit of performance before and after implementation of the proposals. Indeed the recommendations themselves imply the need for " output " audit in " promotion of examination by the Royal College of General Practitioners " (though the appropriateness of audit by formal examination is

questionable). No system (medical, military, clerical,

HYPONATRÆMIA AND DIURETICS

SiR,—Hyponatrasmia is, as Dr Roe (May 17, p. 1146) reported, not uncommon in ill patients, particularly if they are elderly, and regardless of whether they have been taking diuretics. Perhaps I might comment that his stateIf the ’sick cell ’ hypothesis is correct then it might ment be expected that many of the observed electrolyte disturbances would be corrected simply by treating the underlying disease " could with equally impeccable logic (and arguably more truth) be rephrased " If inappropriate "

"

legal) can planning improve efficiently progress rationally its new " inputs " on the basis. of previous, adequately measured, " outputs ": the basic tenet of cybernetics. or

or

without

secretion of A.D.H. were a common concomitant of any illness... " St. George’s Hospital Medical School, PETER RICHARDS. London SW1. -

severe

Department of Therapeutics, Ninewells Hospital and Medical

School, Dundee DD2 1UB.

"

T. J. WILKIN.

THE FUTURE OF PSYCHIATRY

SIR,-In your editorial (April 26, p. 963) on my pamphlet, The Future of Psychiatry, there appear some very curious phrases which are "not at all in line with reality. It is said, no candidate is likely to pass a higher for instance, that qualification in psychiatry without a passing knowledge of the therapeutic applications of learning theory ". Having run the psychology course for the D.P.M. and other higher qualifications in psychiatry at the Maudsley for some 30 years, and having acted as examiner for the latter for almost the same length of time, I feel I can speak with some is just wishful thinkingauthority in stating that this unless passing knowledge " is interpreted as synonymous with " having a nodding acquaintance with ". Candidates certainly have only a very elementary knowledge of learning theory; indeed, as this is a very complex and difficult see how the position could be different. field, it is hard to I also doubt if " the statement that psychiatrists have no adequate knowledge of behaviour therapy is open to dispute". In making the statement I was obviously referring to psychiatrists having received the usual psychiatric training; there are some psychiatrists who have studied psychology before taking up medicine, and there are others (including those cited in your editorial, whose work in behaviour therapy is praised).who explicitly studied learning theory in an academic psychology department for a lengthy period. These people have learned psychology and learning theory properly, and not as part of their usual psychiatric training; they are irrelevant to the argument. The piece ends by stating that " psychiatrists, despite Eysenck’s disparaging remarks about their general level of ability, are quite capable of using behavioural techniques wisely and appropriately". Having never made disparaging remarks (or any other kind of remark) about psychiatrists’ general level of ability, I am at a loss to understand the meaning of this phrase. My point was that the lengthy medical training of psychiatrists was irrelevant to the use of behavioural techniques, and that the proper use of these techniques required a background training which psychiatrists in the nature of the case could not possess (except in isolated and very unusual cases, as described above). Provided that they receive the appropriate training, which would add perhaps another year or two to their already overlong period of study, I have no doubt that many of them could advance to the stage of using these methods " wisely and appropriately ". That they can do so without the requisite knowledge and training is equivalent to saying that a psychologist, having received a 30-hour course of introduction into medical treatment, could apply these methods wisely and appropriately. I beg to disagree. "

MECHANICAL FACTORS IN ATHEROSCLEROSIS SIR,-It is certainly healthy that medical dogma be examined periodically, and to the extent that there may exist in some circles a dogmatic view that lipids are the sole xtiological factor in atherosclerosis, then Dr Stehbens’ articlemay have performed a useful service. However Dr Stehbens seems rather to be beating a straw man. Nobody has suggested that the lipid hypothesis explains everything, so it is gratuitous on Dr Stehbens’ part to attribute such a narrow posture to his colleagues. Among a wide acquaintanceship with scientists who have worked on lipids in relation to atherosclerosis, I do not know a single one who is oblivious to the highly probable role of mechanical factors. I doubt that I have ever been to an atherosclerosis meeting which omitted acknowledgment of mechanical factors, and I have never heard or read a denial that they exist and are relevant. In referring at random to one published " symposium " on atherosclerosis, I find not only that it includes a paper on hypertension and atherosclerosis,2 but also that two research groups who have devoted most of their own effort to studies of lipids make specific reference to haemodynamic factors and arterial

injury.3. 4 It is certainly true that there has been more lipid research than hasmodynamic research in regard to atherogenesis-with the very important exception of a large body of research on hypertension as an astiological factor. The emphasis on lipids can scarcely be the result of a conspiracy within funding agencies, for the phenomenon seems to be international. More likely these agencies are receiving relatively few proposals for research on haEmodynamic factors, or at least relatively few high-calibre proposals. Possibly the time is not yet technologically ripe for further exploration of these problems. Perhaps the time is ripe but the field has not attracted enough scientists with appropriate backgrounds. In any event Dr Stehbens seems to have misstated the issue in alleging there is a long-neglected tissue factor influencing, if not governing, the accumulation of lipid in the blood-vessel wall " (italics mine). While agreeing in a sense with Dr Stehbens’ remark that " large-scale dietary intervention trials for the prevention of coronary heart-disease have been disappointing ", I would emphasise that the disappointment is not so much in the results of these trials, which have been quite encouraging indeed, but rather in the very small number and limited size of well-controlled primary prevention studies.ó,6s "

Institute of Psychiatry,

1. 2. 3. 4. 5.

De Crespigny Park, Denmark Hill,

Stehbens, W. E. Lancet, March 29, 1975, p. 724. Freis, E. D. 4tM. . Med. 1969, 735. Getz, G. S. ibid. p. 657. Frantz, 1. D. ibid. p. 684. Dayton, S., Pearce, M. L., Hashimoto, S., Dixon, W. J., Tomiyasu,

6.

Miettinen, M., Karvonen, M. J., Turpeinen, 0., Elosuo, R., Paavilainen, E. Lancet, 1972, ii, 835.

London SE5 8AF.

U. American Heart Association

H. J. EYSENCK.

Monograph

no.

25. 1969.

Letter: Medical audit.

1238 TWO UNIVERSAL NEEDS IN U.K. MEDICAL SCHOOLS Committee will descend on the groves of academe and take the pulse and temperature of university medi...
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