CORRESPONDENCE * All letters must be typed with double spacing and signed by all authors. * No letter should be more than 400 words. * For letters on scientific subjects we normally reserve our correspondence columns for those relating to issues discussed recently (within six weeks) in the BM7. * We do not routinely acknowledge letters. Please send a stamped addressed envelope ifyou would like an acknowledgment. * Because we receive many more letters than we can publish we may shorten those we do print, particularly when we receive several on the same subject.
Juniors' hours SIR,-The battle for reduction in junior doctors' hours would seem to have been fought and won much earlier in Denmark than in the countries mentioned in your overview.' After long and bitter industrial action by junior doctors in 1981 during which all work in Danish hospitals, including in casualty departments, was left to the consultants,junior doctors won the right to the same working hours as the rest of the population-namely, 40 hours a week. This has since been reduced to 37 hours. This reduction from the previous norm of about 80 hours required a massive increase in the number of junior doctors. Furthermore, all overtime was paid at a rate of about 150% of that paid for normal hours. The increase in the number of doctors and the increment in salary for extra hours means that doctors' salaries constitute one of the most expensive single items in the budget of the Danish hospital service and have been partly responsible for the severe cut backs in hospital services over the past 10 years. Many hospital departments and even entire hospitals have been closed. To limit the enormous burden of overtime payments strict rules have been introduced by hospital administrators that require junior doctors to take time off work in lieu of payment for overtime. This has, with few exceptions, met with little resistance from the junior doctors. The ruling has resulted in the team on duty changing at 0800 and 1600 every day and doctors being free after a night on duty; in many cases doctors may be free for as much as two weeks out of every five to obviate payment for extra hours. Junior doctors in Denmark have thus reached a solution for their need to sleep and a life outside medicine. Paradoxically, many of them use this free time to be locums elsewhere, often in neighbouring countries that have fewer doctors. They have achieved what their colleagues in other countries are only now striving for: but at what price? The cost to the hospital services has been mentioned. The cost to decent patient care and the junior doctors' own clinical training has been more subtle and far more damaging and is only now beginning to awaken concern. The system of staff changes two or more times a day, freedom after night duty, and compensation for overtime with free weeks, has led to a terrible situation, especially in surgical departments: one registrar admits a patient and makes a tentative diagnosis, which he or she will not be present to confirm. The next registrar might operate on the patient and never witness the postoperative course of the patient. Was my diagnosis correct? and How did the patient do after my operation? are two fundamental questions in registrars' learning processes to which they may never get answers. The detrimental effect on the clinical training of
BMJ
VOLUME
301
17 NOVEMBER 1990
registrars is obvious. Because registrars' normal working hours are restricted their exposure to clinical decision making, teaching by consultants, and elective operative procedures is severely limited. After six years of training a Danish surgical registrar may have performed only two to three cholecystectomies, a similar number of bowel anastomoses, and may never have done a gastrectomy. We are producing a whole generation of surgical trainees who are poorly equipped both clinically and technically. The effect on the doctor-patient relationship has also been disastrous. A patient rarely sees the same doctor twice and vice versa. It is not the same doctor who assesses the patient for work up or operation who carries out or assists at the operation. A third, fourth, fifth, or sixth doctor will see the patient on subsequent ward rounds or in the outpatient clinic. The concept that hours spent on clinical education might not be equated with actual work has not yet dawned on our junior doctors. Having decided on parity with all others in the labour market, the word professionalism risks being omitted from their vocabulary. We urge junior doctors in other countries to heed the experiences in Denmark and temper their struggle for shorter hours with a little more concern for their clinical training. Hours spent on clinical and technical education could be regarded as an investment in the future, which need not necessarily be measured in terms of money. JACK HOFFMANN ANDERS FISCHER
Horsholm Hospital, H0rsholm, Denmark 1 Various authors. Juniors' hours: international overview. BMJ 1990;301:830-2. (13 October.)
SIR,-Dr Stephen Hunter discusses the need for the active support of junior doctors in the struggle to reduce their working hours. ' We have examined another problem encountered by juniors-namely, obtaining time off and funding for study leave. Everyone attending a final fellowship revision course for a surgical specialty was asked to reply to a questionnaire, which asked about employing authority, length of appointment, study leave already taken in present year of appointment and the preceding year, whether study leave had been granted for the course, and what proportion of course fees, travelling expenses, and subsistence would be refunded. Of 35 doctors attending the course, 29 completed questionnaires. Five were excluded because they were unemployed or employed abroad, leaving 24 respondents. Nineteen had appointments of 18-36 months and five appointments of one year or
less. None had received more than 10 days' study leave in their appointment. Seven doctors had been refused some part of their full allowance of study leave, fees, or expenses. Of these seven, three were granted study leave for only some of the course but were allowed to attend the full course by taking the remainder as annual leave. These three were refunded a pro rata amount of course fees, travel, and subsistence expenses. Four of the seven were granted study leave and some or all of the course fees but were refused all subsistence. Two who lived in the city where the course was held did not receive travel expenses despite incurring greater costs than in their normal journey to work. Six of the seven were from health authorities in or south of London. The BMA reports Whitley Council recommendations as follows2: "Study leave" . is particularly appropriate for the training grades.... It is a privilege, but ... it is not in the long term interest of the Service to subordinate the educational needs of Junior Staff . . to immediate service requirements. [Senior house officers or registrars are entitled to] either, day release with pay and expenses ... of one day a week during University term; or leave with pay and expenses of up to 30 days in a year . .. counted from 1 October [for] an examination ... except where ... contrary to the interests of the individual or the service. [Study leave] may accumulate over ... the appointment provided that the total amount . .. is not taken until one year ... has been served. Authorities should accept the natural consequences of granting study leave so that all reasonable expenses associated with a period of study leave are paid [at] rates of travel and subsistence set by the General Whitley Council. The reasons for refusing full study leave or expenses for attending the course seem to be financial. Denial of these entitlements is too common and may lower staff morale and quality of
service; this should be considered when allocating resources. The authors' employing authority met all expenses. P A BLOOM D A H LAIDLAW
Bristol Eye Hospital, Bristol BSI 2LX 1 Hunter S. Juniors' hours: measuring the strength of feeling.
BMJ 1990;301:1008. (3 November.) 2 British Medical Association. Handbook for junior doctors. London: BMA, 1990:34-6.
Long term reduction in sodium balance SIR, - Dr Joe B Pevahouse and colleagues observed sodium retention in eight patients with essential
1159
hypertension who were switched from nifedipine to placebo.' They note that the size of this acute sodium retention was similar to the extent of initial natriuresis that had been reported when nifedipine was introduced and then infer that nifedipine induces a long term reduction in sodium balance and that this is a "possible additional mechanism whereby nifedipine lowers blood pressure." They mention anecdotal reports that oedema of the legs induced by nifedipine is unresponsive to diuretics. They imply, but do not state, that no other drugs were given during the overall course of their study. This should be made clear. Dr Pevahouse and colleagues did not perform any long term measurements, and their conclusions are speculative. Curiously, they do not quote some studies that examined the problem directly, the results of which do not support their inferences. Marone et aP found that treatment with nifedipine 10 to 20 mg three times daily for six to eight weeks in 10 patients increased the total exchangeable sodium concentration by an average of 27% compared with the concentration in patients taking placebo. The subsequent addition of chlorthalidone 25 to 50 mg daily for six to eight weeks corrected the sodium retention and led to significant further reduction in several measures of arterial pressure. The introduction of chlorthalidone also corrected leg oedema in the two patients who had developed it while taking nifedipine. In another study no significant change in mean body sodium concentration was found in 16 patients with essential hypertension taking nicardipine 30 mg three times daily for 12 weeks compared with those taking placebo; individual values fell slightly in nine patients, rose slightly in six, and were unaltered in one.' Dr Pevahouse and colleagues make extensive extrapolations from their data concerning the effects of class II calcium antagonists in general, and nifedipine in particular, in essential hypertension. In view of the above comments a more cautious approach might be more appropriate. J I S ROBERTSON Janssen Research Foundation, B-2340 Beerse, Belgium I Pevahouse JB, Markandu ND, Cappuccio FP, Buckley MG, Sagnella GA, MacGregor GA. Long term reduction in sodium balance: possible additional mechanism whereby nifedipine lowers blood pressure. BMJ 1990;301:580-4. (22 September.) 2 Marone C, Luisoli S, Bomio F, Beretta-Piccoli C, Bianchetti MG, Weidmann P. Body sodium-blood volume state, aldosterone, and cardiovascular responsiveness after calcium entry blockade with nifedipine. Kidney Int 1985;28:658-65. 3 Murray TS, East BW, Robertson JIS. Nicardipine versus propranolol in the treatment of essential hypertension: effect on total body elemental composition. Br 7 Clin Pharnacol
1986;22(suppl 3):249-66.
How to save lives SIR,-Mr Peter K Plunkett wrote in his review' of Dr P J F Baskett's resuscitation handbook2 that "a central venous monitor as the sole indicator of the volume and pump state of the patient is virtually antediluvian," and he denigrates Baskett's suggestion that pulmonary artery flotation catheters are rarely useful in the early stages of resuscitation. Though many old treatments are of no value or have been superseded, the fact that a treatment is old is not in itself a measure of lack of value: foxglove, admittedly in a somewhat more secure formulation, is still the correct treatment for fast, established atrial fibrillation.' And not everyone would share Mr Plunkett's enthusiasm for SwanGanz catheters, which were described by Robin and Morin as accounting for "almost 1% (0 75%) of all personal health care costs in the United States in 1983! This for a test of unestablished benefit and with major risks!"4 Commenting on the debate, Winterbauer writes of the false sense of scientific
1160
elitism that follows the adoption of certain treatments and patterns of practice.4 One practice we must beware of in this time of limited resources coupled with availability of expensive equipment is the substitution of clinical measurement for clinical management. NEVILLE W GOODMAN
2 Home Office. Report of the working party on forensic pathology. London: HMSO, 1989. 3 House of Commons Home Affairs Committee. The forensic science service. London: HMSO, 1989. 4 Crowzn Court advance notice of expert evidence rules. London: HMSO, 1987. 5 Knight B, McKim Thompson I. The teaching of legal medicine in British medical schools. Med Educ 1986;20:246-58.
Southmead Hospital, Bristol BS10 5NB 1 Plunkett PK. How to save lives. BMJ 1990;301:675. (29
September.) 2 Baskett PJF. Resuscitation handbook. Philadelphia: Lippincott/ London: Gower Medical, 1989. 3 British Medical Association and Royal Pharmaceutical Society of Great Britain. British national fortnulary. No 20. London: Pharmaceutical Press, September 1990:52. 4 Matthay MA, Robin ED, Morin M, Winterbauer RH. A pulmonary artery catheter should be used in patients with respiratory failure. In: Gitnick G, Barnes HV, Duffy TP, Winterbauer RH, eds. Debates in medicine. Vol 2. Chicago: Year Book Publishers, 1989.
Forensic pathology SIR,-The negative tenor of Dr J D J Havard's editorial is difficult to comprehend,' in particular because nowhere does he state what he considers to be "the main problems" or "inevitable and radical reorganisation," which the report fails either to tackle or to propose. We believe that attention should be drawn to apparent errors and interpretations that render several of the implied or overt criticisms inappropriate or invalid. The Home Office forensic science service (itself the subject of a different report) may undertake work for parties other than the police,3 although, admittedly, the reluctance of other parties to use the service may be related to the fact that evidence has to be submitted by the police and that the results of analysis are made available to the prosecution. Such a practice, however, is not contrary to the spirit of current Crown Court rules4 and, therefore, should not constitute an unfair advantage. Although undergraduate training in forensic medicine was not within the remit of the working party, it is difficult to see how funding of new senior lectureships in university departments can have other than a beneficial effect on this neglected part of the medical curriculum.5 Such criticism would be better directed at the General Medical Council. Comparison with European medicolegal institutes is invalid. The legal basis of the investigation of deaths within the community differ between countries-in one country, at least, the decision on whether to perform a necropsy rests solely with the police. Experience with the bodies of British nationals repatriated from several European countries does not allow wholehearted confidence in their medicolegal systems. When, as a consequence of the deliberations of the working party, the provision of forensic pathological services for the police in London has not been free for several months and now stands on firmer foundation than ever before, pessimism seems unwarranted. The revitalisation of university departments outside London makes other practising forensic pathologists optimistic that they can build on these foundations. If there are any hard data on which the confident prediction of Dr Havard's final sentence is based perhaps we should be told. S LEADBEATTER B HULEWICZ Wales Institute of Forensic Medicine, Cardiff CF12 lSZ P VANEZIS
Charing Cross and Westminster Hospital School, London W6 8RF 1 Havard JDJ. Forensic pathology: a blinkered report. BMJ 1990;301:943-4. (27 October.)
SIR,-We were disappointed by Dr J D J Havard's editorial on the report of the working party on forensic pathology.' He attacks the report for not advocating the setting up in Britain of medicolegal institutes similar to those in Germany, which deal not only with forensic pathology but with forensic science and most aspects of forensic medicine, including, examining the victims of assault, industrial injuries, and diseases. In most of the English speaking world these disciplines have grown apart. There is now little connection between the scientific aspects of forensic pathology and the techniques of forensic science. We see little justification for setting up multidisciplinary medicolegal institutes, although we do welcome the increasingly close links with clinical forensic medicine and academic departments of law and public health. The aim of the medical members of the working party, of which we were two, was to strengthen university departments of forensic pathology and to ensure the continuing availability of pathologists with a special interest in forensic work in those subjects in which a university service is impracticable. In our view this is the most sensible way to provide a forensic pathology service and is not merely an interim solution. Given the government's financial restraints and political views, we believe that the working party's package is as much as could be expected and will substantially help solve the difficulties of forensic pathology in this country. The working party believes that its proposals will result in a considerable improvement in forensic pathology services to. London, and there are already signs that this is taking place. Financial negotiations between the University of London and the police authorities concerned have recently been satisfactorily concluded. Similar expansion of the university departments in Sheffield and Cardiff is also well under way. There are other aspects of the editorial that we are inclined to criticise, but we might be accused of nit picking. It was clearly written by a bystander rather than a player, and we hope that it will not be generally regarded as representing the profession's view. We must draw attention, however, to a seriously misleading misprint. The Home Office is setting up a policy advisory board, not a police advisory board. M A GREEN
Department of Forensic Pathology, Sheffield A C HUNT
Derriford Hospital,
Plymouth 1 Havard JDJ. Forensic pathology: a blinkered report. BMJ
1990;301:943-4. (27 October.)
SIR, -Dr J D J Havard's criticisms of the working party prompt me, not being a member, to write in the working party's defence. Advocating the development of medicolegal institutes in this country, similar to those found on the Continent, raises two important and distinct questions: the future of forensic medicine and the future of forensic science. Forensic science was not in the remit of the working party. There has been much disquiet about the forensic science service over the past decade. The Home Affairs Committee's latest report in 1989 lists 10 other reports since 1981.2 In common with
BMJ
VOLUME
301
17
NOVEMBER
1990
Juniors' hours SIR,-The battle for reduction in junior doctors' hours would seem to have been fought and won much earlier in Denmark than in the countries mentioned in your overview.' After long and bitter industrial action by junior doctors in 1981 during which all work in Danish hospitals, including in casualty departments, was left to the consultants,junior doctors won the right to the same working hours as the rest of the population-namely, 40 hours a week. This has since been reduced to 37 hours. This reduction from the previous norm of about 80 hours required a massive increase in the number of junior doctors. Furthermore, all overtime was paid at a rate of about 150% of that paid for normal hours. The increase in the number of doctors and the increment in salary for extra hours means that doctors' salaries constitute one of the most expensive single items in the budget of the Danish hospital service and have been partly responsible for the severe cut backs in hospital services over the past 10 years. Many hospital departments and even entire hospitals have been closed. To limit the enormous burden of overtime payments strict rules have been introduced by hospital administrators that require junior doctors to take time off work in lieu of payment for overtime. This has, with few exceptions, met with little resistance from the junior doctors. The ruling has resulted in the team on duty changing at 0800 and 1600 every day and doctors being free after a night on duty; in many cases doctors may be free for as much as two weeks out of every five to obviate payment for extra hours. Junior doctors in Denmark have thus reached a solution for their need to sleep and a life outside medicine. Paradoxically, many of them use this free time to be locums elsewhere, often in neighbouring countries that have fewer doctors. They have achieved what their colleagues in other countries are only now striving for: but at what price? The cost to the hospital services has been mentioned. The cost to decent patient care and the junior doctors' own clinical training has been more subtle and far more damaging and is only now beginning to awaken concern. The system of staff changes two or more times a day, freedom after night duty, and compensation for overtime with free weeks, has led to a terrible situation, especially in surgical departments: one registrar admits a patient and makes a tentative diagnosis, which he or she will not be present to confirm. The next registrar might operate on the patient and never witness the postoperative course of the patient. Was my diagnosis correct? and How did the patient do after my operation? are two fundamental questions in registrars' learning processes to which they may never get answers. The detrimental effect on the clinical training of
BMJ
VOLUME
301
17 NOVEMBER 1990
registrars is obvious. Because registrars' normal working hours are restricted their exposure to clinical decision making, teaching by consultants, and elective operative procedures is severely limited. After six years of training a Danish surgical registrar may have performed only two to three cholecystectomies, a similar number of bowel anastomoses, and may never have done a gastrectomy. We are producing a whole generation of surgical trainees who are poorly equipped both clinically and technically. The effect on the doctor-patient relationship has also been disastrous. A patient rarely sees the same doctor twice and vice versa. It is not the same doctor who assesses the patient for work up or operation who carries out or assists at the operation. A third, fourth, fifth, or sixth doctor will see the patient on subsequent ward rounds or in the outpatient clinic. The concept that hours spent on clinical education might not be equated with actual work has not yet dawned on our junior doctors. Having decided on parity with all others in the labour market, the word professionalism risks being omitted from their vocabulary. We urge junior doctors in other countries to heed the experiences in Denmark and temper their struggle for shorter hours with a little more concern for their clinical training. Hours spent on clinical and technical education could be regarded as an investment in the future, which need not necessarily be measured in terms of money. JACK HOFFMANN ANDERS FISCHER
Horsholm Hospital, H0rsholm, Denmark 1 Various authors. Juniors' hours: international overview. BMJ 1990;301:830-2. (13 October.)
SIR,-Dr Stephen Hunter discusses the need for the active support of junior doctors in the struggle to reduce their working hours. ' We have examined another problem encountered by juniors-namely, obtaining time off and funding for study leave. Everyone attending a final fellowship revision course for a surgical specialty was asked to reply to a questionnaire, which asked about employing authority, length of appointment, study leave already taken in present year of appointment and the preceding year, whether study leave had been granted for the course, and what proportion of course fees, travelling expenses, and subsistence would be refunded. Of 35 doctors attending the course, 29 completed questionnaires. Five were excluded because they were unemployed or employed abroad, leaving 24 respondents. Nineteen had appointments of 18-36 months and five appointments of one year or
less. None had received more than 10 days' study leave in their appointment. Seven doctors had been refused some part of their full allowance of study leave, fees, or expenses. Of these seven, three were granted study leave for only some of the course but were allowed to attend the full course by taking the remainder as annual leave. These three were refunded a pro rata amount of course fees, travel, and subsistence expenses. Four of the seven were granted study leave and some or all of the course fees but were refused all subsistence. Two who lived in the city where the course was held did not receive travel expenses despite incurring greater costs than in their normal journey to work. Six of the seven were from health authorities in or south of London. The BMA reports Whitley Council recommendations as follows2: "Study leave" . is particularly appropriate for the training grades.... It is a privilege, but ... it is not in the long term interest of the Service to subordinate the educational needs of Junior Staff . . to immediate service requirements. [Senior house officers or registrars are entitled to] either, day release with pay and expenses ... of one day a week during University term; or leave with pay and expenses of up to 30 days in a year . .. counted from 1 October [for] an examination ... except where ... contrary to the interests of the individual or the service. [Study leave] may accumulate over ... the appointment provided that the total amount . .. is not taken until one year ... has been served. Authorities should accept the natural consequences of granting study leave so that all reasonable expenses associated with a period of study leave are paid [at] rates of travel and subsistence set by the General Whitley Council. The reasons for refusing full study leave or expenses for attending the course seem to be financial. Denial of these entitlements is too common and may lower staff morale and quality of
service; this should be considered when allocating resources. The authors' employing authority met all expenses. P A BLOOM D A H LAIDLAW
Bristol Eye Hospital, Bristol BSI 2LX 1 Hunter S. Juniors' hours: measuring the strength of feeling.
BMJ 1990;301:1008. (3 November.) 2 British Medical Association. Handbook for junior doctors. London: BMA, 1990:34-6.
Long term reduction in sodium balance SIR, - Dr Joe B Pevahouse and colleagues observed sodium retention in eight patients with essential
1159
hypertension who were switched from nifedipine to placebo.' They note that the size of this acute sodium retention was similar to the extent of initial natriuresis that had been reported when nifedipine was introduced and then infer that nifedipine induces a long term reduction in sodium balance and that this is a "possible additional mechanism whereby nifedipine lowers blood pressure." They mention anecdotal reports that oedema of the legs induced by nifedipine is unresponsive to diuretics. They imply, but do not state, that no other drugs were given during the overall course of their study. This should be made clear. Dr Pevahouse and colleagues did not perform any long term measurements, and their conclusions are speculative. Curiously, they do not quote some studies that examined the problem directly, the results of which do not support their inferences. Marone et aP found that treatment with nifedipine 10 to 20 mg three times daily for six to eight weeks in 10 patients increased the total exchangeable sodium concentration by an average of 27% compared with the concentration in patients taking placebo. The subsequent addition of chlorthalidone 25 to 50 mg daily for six to eight weeks corrected the sodium retention and led to significant further reduction in several measures of arterial pressure. The introduction of chlorthalidone also corrected leg oedema in the two patients who had developed it while taking nifedipine. In another study no significant change in mean body sodium concentration was found in 16 patients with essential hypertension taking nicardipine 30 mg three times daily for 12 weeks compared with those taking placebo; individual values fell slightly in nine patients, rose slightly in six, and were unaltered in one.' Dr Pevahouse and colleagues make extensive extrapolations from their data concerning the effects of class II calcium antagonists in general, and nifedipine in particular, in essential hypertension. In view of the above comments a more cautious approach might be more appropriate. J I S ROBERTSON Janssen Research Foundation, B-2340 Beerse, Belgium I Pevahouse JB, Markandu ND, Cappuccio FP, Buckley MG, Sagnella GA, MacGregor GA. Long term reduction in sodium balance: possible additional mechanism whereby nifedipine lowers blood pressure. BMJ 1990;301:580-4. (22 September.) 2 Marone C, Luisoli S, Bomio F, Beretta-Piccoli C, Bianchetti MG, Weidmann P. Body sodium-blood volume state, aldosterone, and cardiovascular responsiveness after calcium entry blockade with nifedipine. Kidney Int 1985;28:658-65. 3 Murray TS, East BW, Robertson JIS. Nicardipine versus propranolol in the treatment of essential hypertension: effect on total body elemental composition. Br 7 Clin Pharnacol
1986;22(suppl 3):249-66.
How to save lives SIR,-Mr Peter K Plunkett wrote in his review' of Dr P J F Baskett's resuscitation handbook2 that "a central venous monitor as the sole indicator of the volume and pump state of the patient is virtually antediluvian," and he denigrates Baskett's suggestion that pulmonary artery flotation catheters are rarely useful in the early stages of resuscitation. Though many old treatments are of no value or have been superseded, the fact that a treatment is old is not in itself a measure of lack of value: foxglove, admittedly in a somewhat more secure formulation, is still the correct treatment for fast, established atrial fibrillation.' And not everyone would share Mr Plunkett's enthusiasm for SwanGanz catheters, which were described by Robin and Morin as accounting for "almost 1% (0 75%) of all personal health care costs in the United States in 1983! This for a test of unestablished benefit and with major risks!"4 Commenting on the debate, Winterbauer writes of the false sense of scientific
1160
elitism that follows the adoption of certain treatments and patterns of practice.4 One practice we must beware of in this time of limited resources coupled with availability of expensive equipment is the substitution of clinical measurement for clinical management. NEVILLE W GOODMAN
2 Home Office. Report of the working party on forensic pathology. London: HMSO, 1989. 3 House of Commons Home Affairs Committee. The forensic science service. London: HMSO, 1989. 4 Crowzn Court advance notice of expert evidence rules. London: HMSO, 1987. 5 Knight B, McKim Thompson I. The teaching of legal medicine in British medical schools. Med Educ 1986;20:246-58.
Southmead Hospital, Bristol BS10 5NB 1 Plunkett PK. How to save lives. BMJ 1990;301:675. (29
September.) 2 Baskett PJF. Resuscitation handbook. Philadelphia: Lippincott/ London: Gower Medical, 1989. 3 British Medical Association and Royal Pharmaceutical Society of Great Britain. British national fortnulary. No 20. London: Pharmaceutical Press, September 1990:52. 4 Matthay MA, Robin ED, Morin M, Winterbauer RH. A pulmonary artery catheter should be used in patients with respiratory failure. In: Gitnick G, Barnes HV, Duffy TP, Winterbauer RH, eds. Debates in medicine. Vol 2. Chicago: Year Book Publishers, 1989.
Forensic pathology SIR,-The negative tenor of Dr J D J Havard's editorial is difficult to comprehend,' in particular because nowhere does he state what he considers to be "the main problems" or "inevitable and radical reorganisation," which the report fails either to tackle or to propose. We believe that attention should be drawn to apparent errors and interpretations that render several of the implied or overt criticisms inappropriate or invalid. The Home Office forensic science service (itself the subject of a different report) may undertake work for parties other than the police,3 although, admittedly, the reluctance of other parties to use the service may be related to the fact that evidence has to be submitted by the police and that the results of analysis are made available to the prosecution. Such a practice, however, is not contrary to the spirit of current Crown Court rules4 and, therefore, should not constitute an unfair advantage. Although undergraduate training in forensic medicine was not within the remit of the working party, it is difficult to see how funding of new senior lectureships in university departments can have other than a beneficial effect on this neglected part of the medical curriculum.5 Such criticism would be better directed at the General Medical Council. Comparison with European medicolegal institutes is invalid. The legal basis of the investigation of deaths within the community differ between countries-in one country, at least, the decision on whether to perform a necropsy rests solely with the police. Experience with the bodies of British nationals repatriated from several European countries does not allow wholehearted confidence in their medicolegal systems. When, as a consequence of the deliberations of the working party, the provision of forensic pathological services for the police in London has not been free for several months and now stands on firmer foundation than ever before, pessimism seems unwarranted. The revitalisation of university departments outside London makes other practising forensic pathologists optimistic that they can build on these foundations. If there are any hard data on which the confident prediction of Dr Havard's final sentence is based perhaps we should be told. S LEADBEATTER B HULEWICZ Wales Institute of Forensic Medicine, Cardiff CF12 lSZ P VANEZIS
Charing Cross and Westminster Hospital School, London W6 8RF 1 Havard JDJ. Forensic pathology: a blinkered report. BMJ 1990;301:943-4. (27 October.)
SIR,-We were disappointed by Dr J D J Havard's editorial on the report of the working party on forensic pathology.' He attacks the report for not advocating the setting up in Britain of medicolegal institutes similar to those in Germany, which deal not only with forensic pathology but with forensic science and most aspects of forensic medicine, including, examining the victims of assault, industrial injuries, and diseases. In most of the English speaking world these disciplines have grown apart. There is now little connection between the scientific aspects of forensic pathology and the techniques of forensic science. We see little justification for setting up multidisciplinary medicolegal institutes, although we do welcome the increasingly close links with clinical forensic medicine and academic departments of law and public health. The aim of the medical members of the working party, of which we were two, was to strengthen university departments of forensic pathology and to ensure the continuing availability of pathologists with a special interest in forensic work in those subjects in which a university service is impracticable. In our view this is the most sensible way to provide a forensic pathology service and is not merely an interim solution. Given the government's financial restraints and political views, we believe that the working party's package is as much as could be expected and will substantially help solve the difficulties of forensic pathology in this country. The working party believes that its proposals will result in a considerable improvement in forensic pathology services to. London, and there are already signs that this is taking place. Financial negotiations between the University of London and the police authorities concerned have recently been satisfactorily concluded. Similar expansion of the university departments in Sheffield and Cardiff is also well under way. There are other aspects of the editorial that we are inclined to criticise, but we might be accused of nit picking. It was clearly written by a bystander rather than a player, and we hope that it will not be generally regarded as representing the profession's view. We must draw attention, however, to a seriously misleading misprint. The Home Office is setting up a policy advisory board, not a police advisory board. M A GREEN
Department of Forensic Pathology, Sheffield A C HUNT
Derriford Hospital,
Plymouth 1 Havard JDJ. Forensic pathology: a blinkered report. BMJ
1990;301:943-4. (27 October.)
SIR, -Dr J D J Havard's criticisms of the working party prompt me, not being a member, to write in the working party's defence. Advocating the development of medicolegal institutes in this country, similar to those found on the Continent, raises two important and distinct questions: the future of forensic medicine and the future of forensic science. Forensic science was not in the remit of the working party. There has been much disquiet about the forensic science service over the past decade. The Home Affairs Committee's latest report in 1989 lists 10 other reports since 1981.2 In common with
BMJ
VOLUME
301
17
NOVEMBER
1990
