879 MENTAL HOSPITAL INQUIRIES

SIR,-Mr Inship and Dr Edwards (March 24, p. 658) fail to grasp the realities of the relationship between the N.H.S. and the medical profession. Hospital doctors do not find the concept of the medical superintendent acceptable, so it is not just to blame the Department of Health for the disappearance of the grade. The idea of a superintendent is no more valid for mental hospitals than for general ones and such a person, even if competent and well intentioned, could make the life of other consultants intolerable, the comparison being with the situation where each consultant bears full clinical responsibility for patients. Where the D.H.S.S. can be blamed, perhaps, is for not deciding, after consultation, and then indicating unequivocally that from April, 1974, consultants should accept that, matters of clinical diagnosis and treatment apart, the management team has a serious interest in and responsibility for everything related to the running of hospital premises and services. Unless this is appreciated and accepted the N.H.S. is not "manageable" in any recognisable sense: indeed I claim that the N.H.S. is not so much "mis-managed" as "unmanaged". The reorganised service structure may not be perfect but it does provide all professional groups with an opportunity to influence management (doctors more than others) but the responsibilities of health-authority members and management teams are often ignored and sometimes denigrated. In my experience the old health committees and the new health authorities were, and are not now unwilling to show leadership, but their right to manage is questioned and their legitimate shouldering of responsibility is unnecessarily frustrated.

the psychiatrist being an integral member of the medical team. Students on psychiatric firms see a very biased sample of patients, consisting mainly of a severely ill group with a predominance of schizophrenia and severe affective disorders. The exposure of the student to such a group of patients serves to accentuate the dualistic mind-body notion whereby psychiatry is conceptualised as a separate ideology with little in common with general medicine or "normal" people. The problem is compounded by the fact that the student usually lacks responsibility and involvement in patient care, and as a result becomes disenchanted and turns away from psychiatry. The remarks of a number of students at the A.P.I.T. meeting verified these depressing observations, which have recently provoked an American psychiatrist2 to suggest that psychiatric training which deals exclusively with psychiatric patients should have less emphasis. In another editorial (March 3, p. 478) you refer to the high prevalence of undetected and untreated psychiatric disorder in medical inpatients and outpatients. It seems clear that psychiatry could better serve medical students by incorporating these "psychiatric" patients within the general hospital into the teaching programme, and in so doing improve the skills of doctors in training so that they can more readily identify and manage this not inconsiderable group of patients.

chiatry service,

Department of Psychological Medicine, King’s College Hospital, London SE5 9RS

CHRISTOPHER M. BASS

A BAD DREAM

Holmby House, Greenhill Road, Sebastopol, Pontypool, Gwent

N. H. N. MILLS

RECRUITMENT TO PSYCHIATRY

SIR,-I was present at the open discussion with the theme "Who puts medical students off psychiatry?" organised at the London Hospital on Feb. 6 by the Association of Psychiatrists in Training and commented on in your editorial of March 3

(p.481). I agree with Professor Millar’s remarks (April 7, p. 780) a more respectful and informed attitude towards psychion the part of undergraduate teaching colleagues would go some way in improving the image of psychiatry amongst medical students. However, his suggestion that more intensive

that atry

exposure to the clinical problems of psychiatry at house-officer level would reap rewards is open to question. Medical students become more mechanistic as they progress through training, this change manifesting as a tendency to increasingly polarise the physical and psychological aspects of disease. By the time these students become house-officers they have usually been influenced toward the strictly and narrowly biological view of the patient as a possessor of a disease, with httle emphasis on psychological and social determinants of illness. This has occurred despite the introduction of behavioural-science teaching into the undergraduate curriculum. A better case can be made for directing the teaching of psychiatry toward the medical student or even the premedical student. There is some evidence that psychiatric teaching is more effective when directed towards medical students during their clerkships in the general hospital, especially when the emphasis is on proper patient management rather than psychiatry per se.’ This teaching should ideally continue throughout the clinical years and be coordinated by an efficient liaison psy1

McKegney,

F.

P. J

Nerv.

ment

Dis.

1972, 154, 198.

SIR,-Medical services in the United Kingdom will be debated in the weeks leading to the election on May 3. Leftwing doctors will dread a right-wing Government. Such a nightmare might mean the abolition of all full-time clinical consultant appointments; item-for-service payments instituted throughout the hospital and family doctor services; opting out of the N.H.S. with private health insurance made tax deductible ; tax-free loans for private hospitals and special building and land facilities for them especially near the centre of London ; community health physicians would be changed back into public health doctors who would be responsible for the public health and the greatly reduced social services; abortion would be made illegal; geriatric wards would be closed and old mental asylums reopened; tax would be removed from tobacco and spirits; administrators would only be employed if they were the possessor of a suitable Oxbridge degree; regional health boards would be re-introduced and run by suitable autocratic Scotsmen ; the Department of Health would be abolished and the medical services run by a consortium of the Royal Colleges and the Royal Society of Medicine. It is fortunate indeed that the clock can never really be turned back and such a nightmare can only remain a bad dream. New Cross Hospital, Wolverhampton

ALAN M. SMITH

HOW MANY SPECIALISTS?

SIR,-Professor Jennett has written a perceptive article (March 7, p. 594) but his statement that "everyone would benefit from the interposition of a well-trained general physician between the family doctor and the neurologist" must not be allowed to stand as self-evident truth. Long experience of open and closed clinics in many hospitals has convinced me that the rapid and economical management of patients presenting with neurological symptoms, whether "organic" or not, is probably 2. Roose, L. J. Int J. Psychiat. Med. 1977/8, 8, 53.

Mental hospital inquiries.

879 MENTAL HOSPITAL INQUIRIES SIR,-Mr Inship and Dr Edwards (March 24, p. 658) fail to grasp the realities of the relationship between the N.H.S. and...
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