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Letters to the Editor

Round the World Yugoslavia

THE DOCTOR IN THE HOSPITAL

LABORATORY VISITORS FROM THE STATES

The Orient Express still stops in Zagreb, though Monsieur Poirot is no longer aboard. The station remains a monument: a large and sombre summer-house which no-one could find room for at Schonbrunn. The solid structures of the former Empire crowd around; and an B-type Jaguar sweeps along the Proleterskih Brigada. Neon lights recommend Swissair and Omega; the tower blocks loom in the new city; the taxis congregate; and the folk are all very friendly-though they are puzzled by inquiries about the result in the final of the World Cup (cricket). George Segal and Glenda Jackson are in town, adding an extra Touch of Class to the Kino Central.

Also in town last month from the United States were Dr Thomas McCarthy, of the Health Resources Administration, Department of Health, Education and Welfare, and some equally vigorous colleagues, who set out before the 19th International Hospital Congress the approach of their country to the " control of health-care cost in an uncontrolled environment". As a Canadian friend put it at the end of the meeting, it may be that the perpetual energy sources which set U.S. man so early on the moon will now be directed towards the better allocation of health At all events, Dr McCarthy acknowledged the care. grounds well of impatience " about inequities in the States; and the Federal Government could not go it alone. The U.S. was unlikely to adopt a unified system, with 50 States and 3000 counties, all with some power to raise their own revenue. Demands for deprived groups were mounting; and rising costs called for a redistribution of dollar flow in the face of potentially unrestricted calls for aid throughout the social services. "

From Dr McCarthy’s team came a powerful array of U.S. domestic arguments which must have dazed some of the visitors to Zagreb-and those who lived just round the block. The U.S. had, in 1966-71, continued to conduct a very expensive foreign war; and a left-of-centre administration had striven to introduce new social legislation. To aggravate this money-spending situation, few people had realised that health insurance was not neutral; and costs had soared because services had expanded to meet insurance-backed demand. The curbs of rate regulation of prices and charges and " utilisation control " of those who used the hospitals had not come as much of an answer. It had been easier to justify the cost than to evaluate it. Regulation was not enough: hospitals must make the right decisions themselves. Dr Stuart Altman, Deputy Assistant Secretary (Departof Health, Education and Welfare) for Health Planning and Analysis, cheerfully recognised that things were more (" hopefully better ") planned elsewhere than in the U.S. The new comprehensive Act, the National Health Planning and Resources Development Act 1974, still left the real power with the State Governments (" a whole new system of health-care planning without the capacity to do anything about your plans "). Experiments would, however, progress (" we’re really a developing One of the most remarkable country in this area "). points (though what they thought of it in Belgrade was never revealed) came from Dr Gerald Rosenthal, director of the National Center for Health Services Research: a health system that did everything for 50% of the people got high marks; a system that achieved 800", of the possible for everybody got low marks. Work that one out! ment

Sm,—Your editorial (June 14, p. 1327) on the future, lack of it, for chemical pathologists is one aspect of the dilemma facing the future of pathology itself. This is

or

the direct result of the way in which the discipline is dividing and subdividing. It has now become almost axiomatic that one person cannot be knowledgeable in or practise more than one of certain arbitrary specialties within pathology. This proposition needs to be examined in the light of the require-" ments of the National Health Service. Are the " ologists which we proliferate the best way of meeting these needs ? The practice of medicine provides countless examples of patients who obstinately refuse to drop into our predesigned specialties. Who should make the diagnosis of

myelomatosis ? Obviously medicine has become so complex that certain skills and knowledge demand the exclusive devotion of their practitioners. This pattern is desirable and already well established in our large postgraduate centres, but the question needs to be asked urgently whether it should be imposed on the district general hospital centres where most of the sick of the country are treated, because even in these situations the ordinary four subspecialties of pathology are insufficient. Thus, the clinical pathologist who wishes to refer a patient with a bleeding disorder will often wish to send him to a coagulationist ", rather than a run-of-themill hoematologist. Unfortunately, the examination structure of the Royal College of Pathologists may have fossilised career patterns that are already outdated. The proposed specialist register could be the final death knell. Your editorial questions the role of the doctor in the laboratory. It is often argued that the " link man " is no longer required because of the number of high-powered specialists in medicine, who do not need his interpretative function. However, it is precisely because of increased specialisation that he is needed in the general hospital setting in providing a diagnostic service to a wide variety of specialists and general practitioners. It would be presumption on the part of a pathologist to interpret his thyroid-function tests to the endocrinologist, but the general surgeon might well not be averse to a little help "

from such a source. Many of the pathologist’s functions cannot be taken over by the non-medical. In our zeal to avoid a charge of elitism, we have become almost masochistic in the way we denigrate the significance of a medical qualification and overestimate the clinical understanding of the non-medical. The final insult is the contemplated crash-course of " " medicine-made-easy for the non-medical. A day in the life of one of the country’s few remaining general pathologists can include dealing with a hospital outbreak of salmonellosis; reporting a batch of histology; performing a post-mortem examination; investigating hxmatological disease-and knowing when and where to seek further help. It need not be a sign of conceit for a pathologist to regard these functions as within his competence by virtue of his medical-school training, clinical experience, and long postgraduate practice. While he performs these duties, senior technical staff are more than able to supervise the provision of quantitative results which can vie with any that even a chemical pathologist might submit to a National Quality Control Scheme. It is ironic that when we are told that general pathology is too much for mortal men (and will not that always be so ?) subspecialty practitioners should seek to preserve their

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viability by taking on the most onerous and time-consuming task of all-namely, the clinical charge and care of inpatients -sometimes by men who have not served their clinical apprenticeship. Pathology used to attract those intrigued by its emphasis on diagnosis and laboratory-based investiThis approach bridges subspecialty barriers, not least in its use of apparatus. No matter how this argument develops, the realities of the situation may hopefully induce some reappraisal. Should not two or three consultant pathologists (each one with special interests) be sufficient for an average district general hospital ? The insistence on rigid restriction to one specialty by men who cannot cover another would entail at least eight, and for these there are neither the men, the money, nor sufficient genuine work-load. Another relevant point is that the desirability and efficiency of district hospitals over 700 beds is being questioned. At a time when the general practitioner has to a large degree redefined his role, it would be good if the generalist in the hospital laboratory were also to find his. The late S. C. Dyke and his colleagues had a vision of the contribution of clinical pathology to the welfare of the patient. This produced men who matched themselves to the immense opportunities afforded by the advances in scientific medicine. I submit the time for a similar reappraisal has arrived once more.

gation.

Bridgend General Hospital, Bridgend, Glamorgan.

D. E. B. POWELL.

laboratory management..." any more attractive to the good non-medical scientist than the medical scientist ? If clinicians with specialised laboratories take over all the biochemical work, where will people good ensure proper standards for the day-to-day routine be found ? The time may be ripe for a change of direction, but is the production of a man who is neither a fully fledged physician nor a fully fledged medical scientist the right one ? Letters must be even shorter than editorials. Therefore the questions are posed, but no answers given. Who will take up the challenge ?

interesting enough to

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Department of Biochemical Medicine, University of Dundee,

P. D. GRIFFITHS.

Dundee. of Biochemical

Department Medicine, Ninewells Hospital and Medical School,

P. E. G. MITCHELL.

Dundee DD2 1UD.

SIR,-Having worked in hospitals with and without chemical pathologists well trained in clinical medicine and relevant laboratory expertise, I am convinced that this specialty should not disappear. In my opinion the future of chemical pathology lies in the direct care or combined bedside care of patients with special problems on the same or similar lines as in hmmatology. 1-4 University Department of Hæmatology, Royal Infirmary,

service. I believe that physicians are keen to discuss their chemical problems and with someone whose training leads them to speak in the same language. The examinations conducted by the Royal College of Pathologists all have a clinical bias and the practical work involved uses only basic equipment. Yet at a time when the equipment installed in laboratories is increasingly complex and sophisticated, regional and hospital authorities still seek to appoint staff who can combine the technical expertise required to understand and operate this equipment with the clinical skill needed to interpret the data. The balance is continually being shifted in favour of the technologist, hence the threat to the clinically oriented pathologist. Is it not time that authorities recognised that technical and clinical skills are complementary but separate functions and appointed their staff accordingly ? Department of Pathology, Royal Hampshire County Hospital,

R. BUCHANAN.

Winchester.

E. K. BLACKBURN.

Sheffield S6 3DA.

SIR,-While sharing the concern expressed in your editorial, I suggest that the problem lies not in any lack of communication between physicians and pathologists, but rather in the failure of the employing authorities to adapt their staffing to meet the demands of a modern pathology

ANGIOSARCOMA OF THE LIVER AS THE CERTIFIED CAUSE OF DEATH 1963-73

SIR,-In early 1974, cases of angiosarcoma of the liver amongst American workers exposed to vinyl-chloride monomer (v.c.M.) in the manufacture of polyvinyl chloride (P.v.c.) were first reported. Other countries which made P.v.c. were alerted, and at least forty workers known to have worked with v.c.M. have been reported as dying from this liver cancer. Two of these deaths were in the United Kingdom, one in 1972 and the other in 1974. To evaluate the rarity of this tumour and to observe any trend in its incidence, the Employment Medical Advisory Service (E.M.A.S.) asked the Office of Population Censuses and Surveys (covering England and Wales) and the Registrar General for Scotland to search their records for death certificates of cases dying between the years 1963 to 1973. This communication reports the results in England and Wales; the search in Scotland continues. All certificates with an underlying cause of death of certain benign or malignant liver tumours (I.C.D. nos. 155-0, 1551, 197-7, 197-8, 211-5, 237-X, 230-5) were a diagnosis of angiosarcoma, malignant

scrutinised for

SIR,-Brevity carries with it the risk of superficiality. Your editorial (June 14, p. 1327) has perhaps fallen into this trap. " Chemical Pathology seems heavily pre" most of the published occupied with methodology ... work seems to come from physicians and full-time research workers ". Did you ask why ? The major part played by the non-medical in the United States is mentioned-did you ask why the difference from the U.K.? Did you ponder why Scandinavia, where the practice of chemical pathology is among the best in the world, attracts and maintains significant numbers of first class M.n.s ? Is "collaborating" in clinical, biochemical, and metabolic investigations going to give greater job satisfaction ? Are " the tedious years now spent in methodology, "

haemangioendothelioma, or Kupffer cell sarcoma. Copies of these death certificates, along with liver-cancer death certificates mentioning " haem ", angio ", or sarcoma ", The cases reported were sent to E.M.A.S. for review. here are those bearing the diagnoses angiosarcoma or malignant haemangioendothelioma. "

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There were twenty-one adult male and eleven adult female cases. In addition, two cases in children were observed, one aged 2 weeks and one aged 3 months. The 1. 2. 3. 4.

Training of Medical Graduates in Pathology. Royal College of Pathologists, 1972. First Report of the Joint Committee on Higher Medical Training of the Royal Colleges of Physicians, 1972. Recommendations on Training: Hæmatology. Joint Committee on Higher Medical Training of the Royal Colleges of Physicians, 1973. J. clin. Path. 1973, 26, 881.

Letter: The doctor in the hospital laboratory.

26 Letters to the Editor Round the World Yugoslavia THE DOCTOR IN THE HOSPITAL LABORATORY VISITORS FROM THE STATES The Orient Express still stops...
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