685
plea that the consultant The merit-award sysbe a replaced by specialist grade. grade tem should also go. The money released could be ploughed back into the general pool of renumeration, which, for the new specialist grade, could be on a sliding scale appropriate to experience but not necessarily to paper qualifications (of which there are too many already). These, although desirable, are often made the basis of false criteria of merit. They also lead to unhealthy comparisons as between one qualification and another. I support Professor Parkhouse’s
the Department of Government which bears the banner of health and issues booklets on prevention and health has hardly anything to say about nutrition. Nutrition has a major contribution to make to health, but it annot do so in the face of Departmental neglect and
professional ignorance. Shoulers End,
KENNETH BARLOW
Thornborough, Buckingham
Chairman, McCarrison Societ
RICHARD MACKARNESS
GEOFFREY TAYLOR
Chadwell Health Hospital, Romford, Essex RM6 4XH
I. M. LIBRACH
NATURAL FAMILY PLANNING
SIR,—Dr Billings (Sept. 11, p. 579) uses the term "true failure-rate" in relation to natural-family-planning surveys in away which differs from the generally accepted recommendations made by Tietze many years ago. Amongst a group of couples using a method of avoiding conception, some will conceive whilst failing to follow the instructions, others whilst scrupulously adhering to them (for no method is infallible). The true failure-rate is the sum of the two because that is in fact what happened; that is the truth of the situation. On this basis the true failure-rate of the Tongan trial’ of the ovulation method was 25%, as I stated (Aug. 7, p. 282). This failure-rate can then be broken down into the rate among those who followed instructions (method failure) and the rate among those who did not (user failure). If method failure is low in relation to user failure, it may be because users were badly instructed or because the method is too difficult for whatever reason for them to follow; if the latter, then this is a limitation of the method. These criteria are obvious and straightforward, and it is essential they be applied to the evaluation of natural methods of family planning as they are to other methods. One cannot ignore people who become pregnant after stopping the oral contraceptive because of side-effects. Equally one cannot ignore people who conceive whilst failing to observe the period of abstinence required with a natural method. Both tell us something about the methods concerned. University Department National Hospital,
of Clinical
TAKING A PSYCHIATRIC HISTORY
SIR,—The two papers by Dr Maguire and Dr Rutter (Sept. 11) are very interesting, but in our opinion misguided. A psychiatric interview is not designed to screw the maximum amount of information from patients in the minimum of time. To inquire about intimate personal issues within 15 min of meeting a total stranger (unless such matters are volunteered) we would regard as bad clinical practice. Department of Psychiatry, University of Leeds, Leeds LS2 9LT
JOHN
.
MARSHALL
MEDICAL MANPOWER
SIR,—I was pleased to read Professor Parkhouse’s sensible contribution to the vexed question of medical manpower as it affects hospitals (Sept. 11, p. 466). It would seem that he considers the consultant grade to be the major bar to a rational approach to the problem. I agree. The term "consultant" is a hangover from pre-N.H.S. days. It represents a prejudice which was largely directed against those working in the municipal hospital service at that time, especially in fevers and tuberculosis. It was, therefore, no accident that when the N.H.S. was introduced, those who worked in these hospitals suffered most under a so-called grading system that was more appropriate to apples than to doctors. The apparent confusion between grading the individual and grading the post has led to a bitterness and frustration lasting until the present day and aggravated by repeated arguments about a so-called sub-consultant grade. Another major factor has been the merit-award system, which is, in effect, a continuation of the grading system, but :hlS time confined to consultants alone. It gives the lie to the dea that all consultants are equal. Merit has to be earned. It cannot be awarded. One of the reprehensible features of h: system is that it was originally introduced in part to compensate for the loss of private earnings, thus equating ability .
,
with financial
acumen.
1 Weissmann, M.
ii, 813
C., Foliaki, L., Billings, E. L., Billings, J. J. Lancet, 1972,
W. MCC. ANDERSON
CLINICAL IMMUNOLOGY
Neurology,
London WC1N 3BG
MAX HAMILTON
SIR,—Dr Reeves (Aug. 28, p. 459) lists five areas in which clinical immunologists need to be intimately familiar. He does not include infection, which remains the most important target for our immune systems. What would we all die of if we lost our immunity? What do millions of children die of each year before they develop immunity? Not lymphoproliferative diseases, autoimmune diseases, or diseases treatable by plasmapheresis or immunotherapy. This lack of interest in infectious disease is also apparent in the second part of the British Society of Immunology Working Party’s report on clinical immunology, none of whose authors is an infectious-disease physician or microbiologist. This is surprising, now that evidence is building up for a possible role of microbes in the aetiology of autoimmune diseases such as systemic lupus erythematosus, multiple sclerosis, and rheumatoid arthritis. And in some nfectious diseases the damage is done entirely or largely by the immune response—subacute sclerosing panencephalitis and lymphocytic choriomeningitis, for example, or such mundane diseases as measles (deaths 40% of paediatric deaths in South America), leprosy (20 million sufferers), or tuberculosis. Chemotherapy has not put an end to infectious disease, and immunologists have much to offer still in the production of vaccines (e.g., malaria, gonorrhoea), the understanding of pathology (e.g., trypanosomiasis, Crohn’s disease), diagnosis (e.g., meningitis, septicaemia), and the management of patients
(e.g., endotoxæmia, leprosy). The gap which is appearing in Britain between immunology and the study of infectious disease makes immunologists seem narrow-minded, which they are not, and will do neither specialty any good. It will also set a bad example to those developing countries who are keenly watching the emergence of clinical immunology. Dr Reeves’ five areas offer little of interest to them. In the past twenty years the study of infectious diseases in the U.S.A. has blossomed. This is largely because of cooperation between infectious-disease physicians (many of whom also have laboratory training and responsibilities), immunologists, and microbiologists, to the benefit of all three specialties and of patients, as a glance at any issue of the Journal of Infectious Diseases will confirm. There is no equivalent journal in Britain: one has only to attend a meeting of the British Society of Immunology one week and the British Society for the Study of Infection the next to see why, for membership hardly overlaps at all.
plea that the consultant The merit-award sysbe a replaced by specialist grade. grade tem should also go. The money released could be ploughed back into the general pool of renumeration, which, for the new specialist grade, could be on a sliding scale appropriate to experience but not necessarily to paper qualifications (of which there are too many already). These, although desirable, are often made the basis of false criteria of merit. They also lead to unhealthy comparisons as between one qualification and another. I support Professor Parkhouse’s
the Department of Government which bears the banner of health and issues booklets on prevention and health has hardly anything to say about nutrition. Nutrition has a major contribution to make to health, but it annot do so in the face of Departmental neglect and
professional ignorance. Shoulers End,
KENNETH BARLOW
Thornborough, Buckingham
Chairman, McCarrison Societ
RICHARD MACKARNESS
GEOFFREY TAYLOR
Chadwell Health Hospital, Romford, Essex RM6 4XH
I. M. LIBRACH
NATURAL FAMILY PLANNING
SIR,—Dr Billings (Sept. 11, p. 579) uses the term "true failure-rate" in relation to natural-family-planning surveys in away which differs from the generally accepted recommendations made by Tietze many years ago. Amongst a group of couples using a method of avoiding conception, some will conceive whilst failing to follow the instructions, others whilst scrupulously adhering to them (for no method is infallible). The true failure-rate is the sum of the two because that is in fact what happened; that is the truth of the situation. On this basis the true failure-rate of the Tongan trial’ of the ovulation method was 25%, as I stated (Aug. 7, p. 282). This failure-rate can then be broken down into the rate among those who followed instructions (method failure) and the rate among those who did not (user failure). If method failure is low in relation to user failure, it may be because users were badly instructed or because the method is too difficult for whatever reason for them to follow; if the latter, then this is a limitation of the method. These criteria are obvious and straightforward, and it is essential they be applied to the evaluation of natural methods of family planning as they are to other methods. One cannot ignore people who become pregnant after stopping the oral contraceptive because of side-effects. Equally one cannot ignore people who conceive whilst failing to observe the period of abstinence required with a natural method. Both tell us something about the methods concerned. University Department National Hospital,
of Clinical
TAKING A PSYCHIATRIC HISTORY
SIR,—The two papers by Dr Maguire and Dr Rutter (Sept. 11) are very interesting, but in our opinion misguided. A psychiatric interview is not designed to screw the maximum amount of information from patients in the minimum of time. To inquire about intimate personal issues within 15 min of meeting a total stranger (unless such matters are volunteered) we would regard as bad clinical practice. Department of Psychiatry, University of Leeds, Leeds LS2 9LT
JOHN
.
MARSHALL
MEDICAL MANPOWER
SIR,—I was pleased to read Professor Parkhouse’s sensible contribution to the vexed question of medical manpower as it affects hospitals (Sept. 11, p. 466). It would seem that he considers the consultant grade to be the major bar to a rational approach to the problem. I agree. The term "consultant" is a hangover from pre-N.H.S. days. It represents a prejudice which was largely directed against those working in the municipal hospital service at that time, especially in fevers and tuberculosis. It was, therefore, no accident that when the N.H.S. was introduced, those who worked in these hospitals suffered most under a so-called grading system that was more appropriate to apples than to doctors. The apparent confusion between grading the individual and grading the post has led to a bitterness and frustration lasting until the present day and aggravated by repeated arguments about a so-called sub-consultant grade. Another major factor has been the merit-award system, which is, in effect, a continuation of the grading system, but :hlS time confined to consultants alone. It gives the lie to the dea that all consultants are equal. Merit has to be earned. It cannot be awarded. One of the reprehensible features of h: system is that it was originally introduced in part to compensate for the loss of private earnings, thus equating ability .
,
with financial
acumen.
1 Weissmann, M.
ii, 813
C., Foliaki, L., Billings, E. L., Billings, J. J. Lancet, 1972,
W. MCC. ANDERSON
CLINICAL IMMUNOLOGY
Neurology,
London WC1N 3BG
MAX HAMILTON
SIR,—Dr Reeves (Aug. 28, p. 459) lists five areas in which clinical immunologists need to be intimately familiar. He does not include infection, which remains the most important target for our immune systems. What would we all die of if we lost our immunity? What do millions of children die of each year before they develop immunity? Not lymphoproliferative diseases, autoimmune diseases, or diseases treatable by plasmapheresis or immunotherapy. This lack of interest in infectious disease is also apparent in the second part of the British Society of Immunology Working Party’s report on clinical immunology, none of whose authors is an infectious-disease physician or microbiologist. This is surprising, now that evidence is building up for a possible role of microbes in the aetiology of autoimmune diseases such as systemic lupus erythematosus, multiple sclerosis, and rheumatoid arthritis. And in some nfectious diseases the damage is done entirely or largely by the immune response—subacute sclerosing panencephalitis and lymphocytic choriomeningitis, for example, or such mundane diseases as measles (deaths 40% of paediatric deaths in South America), leprosy (20 million sufferers), or tuberculosis. Chemotherapy has not put an end to infectious disease, and immunologists have much to offer still in the production of vaccines (e.g., malaria, gonorrhoea), the understanding of pathology (e.g., trypanosomiasis, Crohn’s disease), diagnosis (e.g., meningitis, septicaemia), and the management of patients
(e.g., endotoxæmia, leprosy). The gap which is appearing in Britain between immunology and the study of infectious disease makes immunologists seem narrow-minded, which they are not, and will do neither specialty any good. It will also set a bad example to those developing countries who are keenly watching the emergence of clinical immunology. Dr Reeves’ five areas offer little of interest to them. In the past twenty years the study of infectious diseases in the U.S.A. has blossomed. This is largely because of cooperation between infectious-disease physicians (many of whom also have laboratory training and responsibilities), immunologists, and microbiologists, to the benefit of all three specialties and of patients, as a glance at any issue of the Journal of Infectious Diseases will confirm. There is no equivalent journal in Britain: one has only to attend a meeting of the British Society of Immunology one week and the British Society for the Study of Infection the next to see why, for membership hardly overlaps at all.
