925
assumptions in the reports, but would particularly ask why both studies assume a retiring age of the
THE LANCET
Medical Employment in 2000 A.D. IN any sphere of demand and supply the alternative to "market forces" is precise planning. Since in Britain market forces largely ceased to determine the employment of doctors thirty years ago, it is extraordinary that only now is any serious numerical study being done: all the more surprising in .
view of the debacle after Willink and the sad conclusion of the Todd Commission that the best they could do was to extrapolate the existing graph of doctor/population ratio. The rapid (and, to some medical schools, painful) growth of medical student numbers in the past twelve years was stimulated on that dubious mathematical basis; it is hardly surprising that the uncertainties of employment for this "bulge" have led to alarmed predictions of mass medical unemployment. Two new surveys, one from the University of York, promoted by the Royal Commission on the National Health Service, the other stimulated by the Department of Health itself,2 are a sane response to such prophecies. The documents, which seem to have been prepared independently, tackle the matter from slightly different angles, and both say that their conclusions can be only tentative because data are so scarce. Sometimes the Department of Health (which has an expensive vested interest in these matters) has shown a perverse disinclination to collect the
appropriate figures-for example, on emigration. If the two studies were completely independent it is encouraging that their main numerical conclusions are similar. Both expect a total doctor-stock in 2000 of just under 90 000. The York studyl calculates that this will increase doctor-costs by 33% (in 2000), which is not far away from the D.H.S.S. conclusion that (given a 2-5% growth in gross national product an annual increase of 1% will be available for doctor-costs. These conclusions depend on several assumptions which give much room for error in either direction. They will hardly satisfy those pessimists who stridently maintain that the N.H.S. will not be able to afford its current doctor growth (with the possibility of forcing down salaries even further); but, to carry conviction, these critics will have to produce more cogent reasons for their gloom. We could quibble with many 1.Maynard, A., Walker,
A. Doctor Manpower 1975-2000. H.M. Stationery Office, 1978. 2. Department of Health and Social Security, Scottish Home and Health Department, and Welsh Office. Medical Manpower—the Next Twenty Years. H.M. Stationery Office, 1978.
of 65 until the end of the century. This seems out of keeping with trends in business and industry. Nothing is said about that sensible notion, sabbaticals for consultants. Yet the total doctor-numbers (and gross revenue consequences) are not the most important area for concern. There are three problems likely to cause much more difficulty in the next 25 years. Both reports recognise them and give some statistical background. They offer no solutions, because any resolution will need professional acceptance of uncomfortable changes. These three are the regional disparities in doctor numbers (about twice as many doctors in proportion to population in Scotland as in Trent, for example), the wide variation in recruitment to different specialties, and the different staffing ratios demanded for training and service. If these problems are not resolved there will be a crisis of doctor-employment some time in the next 20 years. The solutions cannot be imposed from outside; they must be found by the profession, but they cannot emerge without disturbance of vested interests. The York study points out that, with the present rate of change, regional variation will not be rectified in 25 years. Incentives would be necessary, combined with compulsory freezing of some consultant posts as they fall vacant. Hitherto such freezes have been vigorously resisted in places where they have been proposed (Liverpool, for instance); and there has been no enthusiasm for regional incentive payments. Indeed the only regional payment introduced has been London weighting, which will do nothing to correct the discrepancies. The variation, in recruitment between specialties is even knottier. The York workers astutely point out that shortages in different specialties do not all have the same effects on health-care. For example, shortages in anaesthetics or radiology cannot readily be remedied by other disciplines: the same is not true of, say, geriatrics. There is also the difficulty in assessing the reality of "shortages", because specialty growth varies from time to time. Some shortages are illusory-simply the effect of rapid growth which will not be maintained indefinitely (the pattern -of consultantships in nephrology is a dramatic example of such an alteration over the past ten years). The profession must look at this matter with particular care, and so must the Department of Health. A specialty pattern for one area is not necessarily right for another; it depends not only on the population and its morbidity, but also on the aptitudes and enthusiasms of the existing staff. New-style contracts for consultants are not unimportant, here. How many shortages in, say, radiology might vanish if existing staff could take on extra sessions to do the work?
926
Most difficult of all is the hospital career-strucIt has been said time and again that consultants in posts for 35 years must outnumber trainees by three to one if there are not to be drop-outs; yet hospital staffing is based largely on the very different ratio demanded by service needs. What possibilities for change exist? Neither report is bold enough even to hint, but the profession must approach this boldly, or risk mounting discontent among the young. The equation can be balanced by changes on both sides and any ideas could be tested on the computer model established by the York team towards the end of their work. More junior posts for those heading ultimately for general practice, and encouragement to overseas governments to send graduates for specific periods of training (rather than "open-end" appointments) are two ways to reduce the pressure for advancement. Increasing the number of specialists without a rise in their subordinates is harder. Has the consultant grade, as defined today, reached the end of its useful life ? Is a grade of specialist (properly accredited and independent) too dangerous for the profession to consider? Cannot we accelerate the take-over of junior-doctor functions by technicians, nurses, and other aides? Optimism about medical career prospects is still possible, but only if the profession shows itself willing to adapt to the changing world, and if the Department of Health accepts the financial consequences of such a change in the hospital environment as it eventually did when general practice was revolutionised 10-15 years ago. ture.
Hereditary Jaundice few
of knowledge in hepatology to which Dame SHEILA SHERLOCK has not contributed-a fact amply confirmed in the Festschrift issue of Gut. Twenty-three papers and reviews by past and present associates pay tribute to her far-reaching influence. The hereditary chronic hyperbilirubinsemias are no exception, and they are cogently reviewed by BERTHELOT and DHUMEAUX.1 Gilbert’s syndrome is the commonest of these and, although it was described seventyseven years ago,2 there is still confusion over its pathogenesis, to the extent that some regard it as merely the upper end of the normal distribution of bilirubin values in the population.3 Kinetic investigations with both mass amounts4-6 and tracer doses THERE
are a
areas
1. Berthelot, P., Dhumeaux, D. Gut, 1978, 19, 474. 2. Gilbert, C., Lereboullet, P. Semaine méd, 1901, 21, 241. 3. Bailey, A., Robinson, D., Dawson, A. M. Lancet, 1977, i, 931. 4. Billing, B. H., Williams, R., Richards, T. G. Clin. Sci. 1964, 27, 245. 5. Goresky, C. A., Gordon, E. R., Shaffer, E. A., Paré, P., Carassaras, D., Aronoff, A. Clin. Sci. mol. Med. 1978, 55, 63. 6. Okolicsanyi, L., Ghidini, O., Orlando, R., Cortelazzo, S., Beneditti, G., Naccarato, R. Manitto, P. ibid. 1978, 54, 539.
. of bilirubin 7,8 show
delayed plasma clearance in patients syndrome. The initial plasma disappearance-rate is normal,5 and the prolonged clearance is at least partly due to impaired glucuronidation. In support of this, the activity of uridine diphosphate glucuronyl transferase (U.D.P.G.T.) in needle and surgical biopsy specimens of liver is IOW9,10 although the reduced enzyme activity does not correlate closely with the raised plasma unconjugated-bilirubin concentration. Analysis of bile in these patients shows an increased proportion of bilirubin in monoglucuronide at the expense of diglucuronide, again suggesting an impaired conjugating mechanism.5 Although U.D.P.G.T. activities have been low in all patients studied, this is not the sole abnormality in all patients with Gilbert’s syndrome, for about 40% have a
with the clinical
a reduced red-cell-survival time, and hence an increased bilirubin-production rate.ll Abnormalities in uptake and- excretion of dyes have also been reported in some cases, even for indocyanine-green which does not require conjugation. 12 The practical importance of Gilbert’s syndrome lies in an awareness of its existence, so that serious liver disease is not diagnosed in error. It is common, occurring in 2-5% of the population, and is entirely benign. But how may the general physician establish the diagnosis without recourse to bilirubin kinetic studies or U.D.P.G.T. measurements? It remains primarily a diagnosis of exclusion, in a patient with mild unconjugated hyperbilirubinsemia and without evidence of liver disease or hxmolysis. Liver histology is normal, but needle biopsy should be unnecessary in all but the few patients in whom liver disease cannot be excluded by careful physical examination and conventional biochemical tests of liver function. A normal serum bile-acid concentration is helpful in excluding mild liver disease, and this investigation may become more widely available." Tests designed to provoke a diagnostic rise in plasma unconjugated bilirubin include fasting or reduced calorie intake14 and intravenous nicotinic acid. These have been compared, and the intravenous nicotinic-acid test was proved both more convenient and more discriminating.16 Whatever diagnostic method is used, it must be done with a minimum of delay and a maximum of explanation and reassurance so the patient does not acquire a "hepatic neurosis".
7. Berk, P. D., Bloomer, J. R., Howe, R. B., et al. Am. J. Med. 1970, 49, 296. 8. Black, M., Fevery, J., Parker, D., Jacobson, J., Billing, B., Carson, E. R. Clin. Sci. mol. Med. 1974, 46, 1. 9. Black, M., Billing, B. H. New Engl. J. Med. 280, 1266. 10. Felsher, B. F., Craig, J. R., Carpio, N. J. Lab. clin. Med. 1973, 81, 829. 11. Berk, P. D., Blaschke, T. F. Ann. intern. Med. 1972, 77, 527. 12. Martin, J. F., Vierling, J. M., Wolkoff, A. W., Scharschmidt, B. F., Vergalle, J., Waggoner, J. G., Berk, P. D. Gastroenterology, 1976, 70, 385. 13. British Medical Journal, 1978, i, 392. 14. Owens, D., Sherlock, S. ibid. 1973, iii, 559. 15. Fromke, V. L., Miller, D. Medicine, Baltimore, 1972, 51, 451. 16. Davidson, A. R., Rojas-Bueno, A., Thompson, R. P. H., Williams, R. Br.
med. J. 1975, ii, 480.
assumptions in the reports, but would particularly ask why both studies assume a retiring age of the
THE LANCET
Medical Employment in 2000 A.D. IN any sphere of demand and supply the alternative to "market forces" is precise planning. Since in Britain market forces largely ceased to determine the employment of doctors thirty years ago, it is extraordinary that only now is any serious numerical study being done: all the more surprising in .
view of the debacle after Willink and the sad conclusion of the Todd Commission that the best they could do was to extrapolate the existing graph of doctor/population ratio. The rapid (and, to some medical schools, painful) growth of medical student numbers in the past twelve years was stimulated on that dubious mathematical basis; it is hardly surprising that the uncertainties of employment for this "bulge" have led to alarmed predictions of mass medical unemployment. Two new surveys, one from the University of York, promoted by the Royal Commission on the National Health Service, the other stimulated by the Department of Health itself,2 are a sane response to such prophecies. The documents, which seem to have been prepared independently, tackle the matter from slightly different angles, and both say that their conclusions can be only tentative because data are so scarce. Sometimes the Department of Health (which has an expensive vested interest in these matters) has shown a perverse disinclination to collect the
appropriate figures-for example, on emigration. If the two studies were completely independent it is encouraging that their main numerical conclusions are similar. Both expect a total doctor-stock in 2000 of just under 90 000. The York studyl calculates that this will increase doctor-costs by 33% (in 2000), which is not far away from the D.H.S.S. conclusion that (given a 2-5% growth in gross national product an annual increase of 1% will be available for doctor-costs. These conclusions depend on several assumptions which give much room for error in either direction. They will hardly satisfy those pessimists who stridently maintain that the N.H.S. will not be able to afford its current doctor growth (with the possibility of forcing down salaries even further); but, to carry conviction, these critics will have to produce more cogent reasons for their gloom. We could quibble with many 1.Maynard, A., Walker,
A. Doctor Manpower 1975-2000. H.M. Stationery Office, 1978. 2. Department of Health and Social Security, Scottish Home and Health Department, and Welsh Office. Medical Manpower—the Next Twenty Years. H.M. Stationery Office, 1978.
of 65 until the end of the century. This seems out of keeping with trends in business and industry. Nothing is said about that sensible notion, sabbaticals for consultants. Yet the total doctor-numbers (and gross revenue consequences) are not the most important area for concern. There are three problems likely to cause much more difficulty in the next 25 years. Both reports recognise them and give some statistical background. They offer no solutions, because any resolution will need professional acceptance of uncomfortable changes. These three are the regional disparities in doctor numbers (about twice as many doctors in proportion to population in Scotland as in Trent, for example), the wide variation in recruitment to different specialties, and the different staffing ratios demanded for training and service. If these problems are not resolved there will be a crisis of doctor-employment some time in the next 20 years. The solutions cannot be imposed from outside; they must be found by the profession, but they cannot emerge without disturbance of vested interests. The York study points out that, with the present rate of change, regional variation will not be rectified in 25 years. Incentives would be necessary, combined with compulsory freezing of some consultant posts as they fall vacant. Hitherto such freezes have been vigorously resisted in places where they have been proposed (Liverpool, for instance); and there has been no enthusiasm for regional incentive payments. Indeed the only regional payment introduced has been London weighting, which will do nothing to correct the discrepancies. The variation, in recruitment between specialties is even knottier. The York workers astutely point out that shortages in different specialties do not all have the same effects on health-care. For example, shortages in anaesthetics or radiology cannot readily be remedied by other disciplines: the same is not true of, say, geriatrics. There is also the difficulty in assessing the reality of "shortages", because specialty growth varies from time to time. Some shortages are illusory-simply the effect of rapid growth which will not be maintained indefinitely (the pattern -of consultantships in nephrology is a dramatic example of such an alteration over the past ten years). The profession must look at this matter with particular care, and so must the Department of Health. A specialty pattern for one area is not necessarily right for another; it depends not only on the population and its morbidity, but also on the aptitudes and enthusiasms of the existing staff. New-style contracts for consultants are not unimportant, here. How many shortages in, say, radiology might vanish if existing staff could take on extra sessions to do the work?
926
Most difficult of all is the hospital career-strucIt has been said time and again that consultants in posts for 35 years must outnumber trainees by three to one if there are not to be drop-outs; yet hospital staffing is based largely on the very different ratio demanded by service needs. What possibilities for change exist? Neither report is bold enough even to hint, but the profession must approach this boldly, or risk mounting discontent among the young. The equation can be balanced by changes on both sides and any ideas could be tested on the computer model established by the York team towards the end of their work. More junior posts for those heading ultimately for general practice, and encouragement to overseas governments to send graduates for specific periods of training (rather than "open-end" appointments) are two ways to reduce the pressure for advancement. Increasing the number of specialists without a rise in their subordinates is harder. Has the consultant grade, as defined today, reached the end of its useful life ? Is a grade of specialist (properly accredited and independent) too dangerous for the profession to consider? Cannot we accelerate the take-over of junior-doctor functions by technicians, nurses, and other aides? Optimism about medical career prospects is still possible, but only if the profession shows itself willing to adapt to the changing world, and if the Department of Health accepts the financial consequences of such a change in the hospital environment as it eventually did when general practice was revolutionised 10-15 years ago. ture.
Hereditary Jaundice few
of knowledge in hepatology to which Dame SHEILA SHERLOCK has not contributed-a fact amply confirmed in the Festschrift issue of Gut. Twenty-three papers and reviews by past and present associates pay tribute to her far-reaching influence. The hereditary chronic hyperbilirubinsemias are no exception, and they are cogently reviewed by BERTHELOT and DHUMEAUX.1 Gilbert’s syndrome is the commonest of these and, although it was described seventyseven years ago,2 there is still confusion over its pathogenesis, to the extent that some regard it as merely the upper end of the normal distribution of bilirubin values in the population.3 Kinetic investigations with both mass amounts4-6 and tracer doses THERE
are a
areas
1. Berthelot, P., Dhumeaux, D. Gut, 1978, 19, 474. 2. Gilbert, C., Lereboullet, P. Semaine méd, 1901, 21, 241. 3. Bailey, A., Robinson, D., Dawson, A. M. Lancet, 1977, i, 931. 4. Billing, B. H., Williams, R., Richards, T. G. Clin. Sci. 1964, 27, 245. 5. Goresky, C. A., Gordon, E. R., Shaffer, E. A., Paré, P., Carassaras, D., Aronoff, A. Clin. Sci. mol. Med. 1978, 55, 63. 6. Okolicsanyi, L., Ghidini, O., Orlando, R., Cortelazzo, S., Beneditti, G., Naccarato, R. Manitto, P. ibid. 1978, 54, 539.
. of bilirubin 7,8 show
delayed plasma clearance in patients syndrome. The initial plasma disappearance-rate is normal,5 and the prolonged clearance is at least partly due to impaired glucuronidation. In support of this, the activity of uridine diphosphate glucuronyl transferase (U.D.P.G.T.) in needle and surgical biopsy specimens of liver is IOW9,10 although the reduced enzyme activity does not correlate closely with the raised plasma unconjugated-bilirubin concentration. Analysis of bile in these patients shows an increased proportion of bilirubin in monoglucuronide at the expense of diglucuronide, again suggesting an impaired conjugating mechanism.5 Although U.D.P.G.T. activities have been low in all patients studied, this is not the sole abnormality in all patients with Gilbert’s syndrome, for about 40% have a
with the clinical
a reduced red-cell-survival time, and hence an increased bilirubin-production rate.ll Abnormalities in uptake and- excretion of dyes have also been reported in some cases, even for indocyanine-green which does not require conjugation. 12 The practical importance of Gilbert’s syndrome lies in an awareness of its existence, so that serious liver disease is not diagnosed in error. It is common, occurring in 2-5% of the population, and is entirely benign. But how may the general physician establish the diagnosis without recourse to bilirubin kinetic studies or U.D.P.G.T. measurements? It remains primarily a diagnosis of exclusion, in a patient with mild unconjugated hyperbilirubinsemia and without evidence of liver disease or hxmolysis. Liver histology is normal, but needle biopsy should be unnecessary in all but the few patients in whom liver disease cannot be excluded by careful physical examination and conventional biochemical tests of liver function. A normal serum bile-acid concentration is helpful in excluding mild liver disease, and this investigation may become more widely available." Tests designed to provoke a diagnostic rise in plasma unconjugated bilirubin include fasting or reduced calorie intake14 and intravenous nicotinic acid. These have been compared, and the intravenous nicotinic-acid test was proved both more convenient and more discriminating.16 Whatever diagnostic method is used, it must be done with a minimum of delay and a maximum of explanation and reassurance so the patient does not acquire a "hepatic neurosis".
7. Berk, P. D., Bloomer, J. R., Howe, R. B., et al. Am. J. Med. 1970, 49, 296. 8. Black, M., Fevery, J., Parker, D., Jacobson, J., Billing, B., Carson, E. R. Clin. Sci. mol. Med. 1974, 46, 1. 9. Black, M., Billing, B. H. New Engl. J. Med. 280, 1266. 10. Felsher, B. F., Craig, J. R., Carpio, N. J. Lab. clin. Med. 1973, 81, 829. 11. Berk, P. D., Blaschke, T. F. Ann. intern. Med. 1972, 77, 527. 12. Martin, J. F., Vierling, J. M., Wolkoff, A. W., Scharschmidt, B. F., Vergalle, J., Waggoner, J. G., Berk, P. D. Gastroenterology, 1976, 70, 385. 13. British Medical Journal, 1978, i, 392. 14. Owens, D., Sherlock, S. ibid. 1973, iii, 559. 15. Fromke, V. L., Miller, D. Medicine, Baltimore, 1972, 51, 451. 16. Davidson, A. R., Rojas-Bueno, A., Thompson, R. P. H., Williams, R. Br.
med. J. 1975, ii, 480.
