Editorial Director: Dr Abraham Marcus Managing Editor: Anne Patterson
Occupational Hazards in Medical Education
Med Teach Downloaded from informahealthcare.com by Florida International University on 12/26/14 For personal use only.
Consultant Editor: Professor Michael A. Simpson
Attention to public health issues, to occupational and work-place health hazards, has never been substantial within medical schools. Subeditor: Diana King When such issues are discussed, the examples used often seem remote and less than cogent to medical and nursing students. Yet highly relevant instances are available very close at hand, and deserve closer study. Hospitals and medical schools may be very concerned about the promotion and maintenance of health elsewhere, but there is reason to believe that they do not provide a healthy work environment Editorial Department: for their own students and staff. Update Publications Ltd In America, attention is beginning to be focussed on these con33/34 Alfred Place London W C l E 7DP, England cerns, as shown by a recent leading article’ in The New Physician Tel: 01-637 4544 (Journal of the American Medical Student Association): controversy over new and stricter standards of tolerable levels of ethylene oxide in Subscription and hospitals; studies of possible carcinogenic and mutagenic effects of the Circulation Department: ubiquitous formaldehyde and formalin exposure in medical schools; Update Publications Ltd the start of programmes administering hepatitis B vaccine to medical 2 High Street Petersfield, Hampshire students and residents as ‘high-risk groups’ for that disease; and the GU32 2JE imminent publication of the Federal government’s first comprehensive health and safety manual for hospital workers, which is expected Subscription Rates: to emphasize concerns that the health risks of hospital workers have Annual Subscription been underestimated. Other areas of current concern include radiUK: f 14.00 Overseas: E18.00 ation hazards (although precautions and protections are generally Air Mail: €25.00 defined and available, they are not always followed or used appropriately); back strain from lifting patients; exposure to infections and to Single Copies violent patients; inhalation of and skin contamination by toxic UK: E4.00 substances, dyes, xylene, Freon, needle puncture wounds, anaesOverseas: f5.00 thetic waste gases; and falls, fires and crime. For example, what is the extent and effect of cumulative casual x-ray exposure, from portable x-ray machines, on the many hospital workers who do not wear exposure indicators or protective garments? The forthcoming Health and Safety Manual for Hospital Workers, Contributions: due to be published by the National Institute of Safety and Health Contributions are invited in the (NIOSH), identifies a range of infectious diseases as occupational form of original papers, articles hazards in hospitals and medical schools, including hepatitis €3. of discussion and comment on tuberculosis, cytomegalovirus, rubella, mumps, herpetic whitlow, all aspects of health sciences education. chickenpox, mononucleosis, respiratory syncytial virus, and influenProspective contributors should za. A recent study found that 12.2 per cent of new house staff showed write to the Managing Editor, serological evidence of previous hepatitis B infection, as well as a Medical Teacher, Update significant proportion of recent converters of tuberculosis skin tests. Publications Ltd, 33/34 Alfred An Ontario study found tuberculosis morbidity to be higher among Place, London WClE 7DP, medical house-staff than in any other group of hospital workers, and England, before submitting manuscripts. nearly seven times higher than the population average. Reproductive risks from exposure to potential teratogens and Medical Teacher is published embryotoxic agents, especially among pregnant students and housequarterly. staff, rarely receive serious attention. Mutagenic effects can occur in @ Update Publications Ltd, 1982 both men and women. Then there are the more widely recognized 124
Medical Teacher Vol 4 No 4 I982
Med Teach Downloaded from informahealthcare.com by Florida International University on 12/26/14 For personal use only.
effects of emotional and physical stress, poor nutrition and sleep deprivation, which are damaging in themselves and can reduce the attention paid to appropriate precautions as well as increasing vulnerability to illness. NIOSH last year recommended that formaldehyde be handled as a potential carcinogen, yet it is still widely used in ways that expose students to its effects. Ventilation in many anatomy laboratories is poor; laboratory coats and clothes of dissectors become saturated with formaldehyde vapour; yet students are usually discouraged from wearing gloves for dissection; and told if they ask, that the substance is not harmful. Despite concern aroused by animal research, only one formal study has begun to look at the formaldehyde levels to which students are exposed (finding levels comparable to industrial exposure) and at possible cytogenetic effects. A major national union of US hospital employees is considering suing OSHA (the Occupational Safety and Health Administration, already causing great concern by its responses to Reagan Administration pressures to make work-place safety standards less onerous for employers to observe) to force employers to measure levels of formaldehyde and to notify workers of the levels and attendant risks. OSHA has refused to take action. We must not indulge in the fantasy that people who work w i t h the sick will always themselves remain well, whatever their exposure to the hazards that harm others. Public and occupational health teaching should, with benefit. turn its attention to risks closer to home, and to more intimate dangers than those they usually study. Michael A. Simpson MD. Professor of Psychiatry, Family Practice and Community Health, Temple University School of Medicine, PA 19140. USA
Reference 'Haglund K . The occupational hazards of amedical education. New Physician 1982; 31: 18-22.
Continuing Education-the Old Shibboleths Still Abound About 35 people attended the June meeting on Continuity in Medical Education, organized by the Association for the Study of Medical Education, and held at The Royal College of Physicians in London. It was partly in the nature of a seminar, as written material had been circulated beforehand, so that all participants should have been seeded with common ideas. These papers were prepared by what have come to be known as keynote speakers, to be followed by a colloquium. Discussion was meant to centre around four themes: obstetrics (Professor Callum Macnaughton), levels of mastery (Professor Hugh Dudley), prescribing and therapeutics (Dr Andrew Herxheimer) and behavioural sciences in achieving continuity (Mrs Mildred Blaxter). These subjects were discussed in a very vague way and sometimes at length; yet very few of the extempore contributions really focussed on continuity. We were
Medical Teacher Vol 4 No 4 1982
forever harking back to the undergraduate curriculum and the university milieu, and largely ignoring the vast amount of graduate education (trainees, consultants and principals) going on within the National Health Service with very little input directly from the universities. It is particularly the continuity between undergraduate and graduate education that should have engaged us but it did not, at least not very much. Indeed, it was apparent that not many of those present understood what is happening in graduate medical education in the United Kingdom. Nor did they realize that it is a much bigger enterprise now, in sheer numbers, than undergraduate education. It is not really surprising that the meeting was inconclusive and did not seriously cope with the problem of continuity. It is still a dificult and nebulous subject, hard to pin down. The old shibboleths-there were plenty of these-have to be talked out of the system, until better ideas, policies and work can emerge. To this extent the meeting was helpful: it allowed catharsis. This can have the merit of stripping away inessentials so that the real problem of continuity can be looked at more clearly. Judging from what was said, it seems likely that we are moving towards a time when no one will be able to practise obstetrics unless he or she has a higher qualification, at least of the level of the DRCOG. The MB would then become an entry qualification and any specialty would need an exit qualification obtained after graduation. This is close to being mandatory, but should it now be stated formally by august educational bodies? As far as levels of mastery are concerned, it was suggested that education should be in serial steps, each one fully planned. The student, at whatever level, must master each step before moving on to the next one. This provoked much interest, but might involve some educators in a lot of very hard work. How this was to be achieved was not explored. Logistically the task of training graduates would be immense. Dr Herxheimer suggested a very detailed programme for prescribing and therapeutics. It could work, and it ought to be implemented. Unfortunately, it cannot easily be summarized, but the educational aims for undergraduates and for graduates in different specialties were well thought out (albeit inadequately discussed). Behavioural science is a messy term. Perhaps in medicine it would be wiser simply to refer to psychology and sociology. They are vastly important as they define the context of more purely physical diagnosis. They enter, or should enter, in some way into every encounter between doctor and patient, and should therefore be taught and emphasized at every phase of medical education. They still tend to be neglected as formal disciplines, everyone thinking we already know about them. When, and how, to introduce them was debated but not resolved. It was a curate's egg of a colloquium no doubt. But everyone, tacitly or vociferously, dipped in a spoon. Whether or not what they tasted was to their liking, only each person can say. But that was the intention of the gathering-not to achieve consensus. P. Rhodes, M A , FRCS. FRCOC;. FRAtMA. Regional Postgraduate Dean of Medical Studies, Southampton General Hospital, Southampton, UK.
125
Occupational Hazards in Medical Education
Med Teach Downloaded from informahealthcare.com by Florida International University on 12/26/14 For personal use only.
Consultant Editor: Professor Michael A. Simpson
Attention to public health issues, to occupational and work-place health hazards, has never been substantial within medical schools. Subeditor: Diana King When such issues are discussed, the examples used often seem remote and less than cogent to medical and nursing students. Yet highly relevant instances are available very close at hand, and deserve closer study. Hospitals and medical schools may be very concerned about the promotion and maintenance of health elsewhere, but there is reason to believe that they do not provide a healthy work environment Editorial Department: for their own students and staff. Update Publications Ltd In America, attention is beginning to be focussed on these con33/34 Alfred Place London W C l E 7DP, England cerns, as shown by a recent leading article’ in The New Physician Tel: 01-637 4544 (Journal of the American Medical Student Association): controversy over new and stricter standards of tolerable levels of ethylene oxide in Subscription and hospitals; studies of possible carcinogenic and mutagenic effects of the Circulation Department: ubiquitous formaldehyde and formalin exposure in medical schools; Update Publications Ltd the start of programmes administering hepatitis B vaccine to medical 2 High Street Petersfield, Hampshire students and residents as ‘high-risk groups’ for that disease; and the GU32 2JE imminent publication of the Federal government’s first comprehensive health and safety manual for hospital workers, which is expected Subscription Rates: to emphasize concerns that the health risks of hospital workers have Annual Subscription been underestimated. Other areas of current concern include radiUK: f 14.00 Overseas: E18.00 ation hazards (although precautions and protections are generally Air Mail: €25.00 defined and available, they are not always followed or used appropriately); back strain from lifting patients; exposure to infections and to Single Copies violent patients; inhalation of and skin contamination by toxic UK: E4.00 substances, dyes, xylene, Freon, needle puncture wounds, anaesOverseas: f5.00 thetic waste gases; and falls, fires and crime. For example, what is the extent and effect of cumulative casual x-ray exposure, from portable x-ray machines, on the many hospital workers who do not wear exposure indicators or protective garments? The forthcoming Health and Safety Manual for Hospital Workers, Contributions: due to be published by the National Institute of Safety and Health Contributions are invited in the (NIOSH), identifies a range of infectious diseases as occupational form of original papers, articles hazards in hospitals and medical schools, including hepatitis €3. of discussion and comment on tuberculosis, cytomegalovirus, rubella, mumps, herpetic whitlow, all aspects of health sciences education. chickenpox, mononucleosis, respiratory syncytial virus, and influenProspective contributors should za. A recent study found that 12.2 per cent of new house staff showed write to the Managing Editor, serological evidence of previous hepatitis B infection, as well as a Medical Teacher, Update significant proportion of recent converters of tuberculosis skin tests. Publications Ltd, 33/34 Alfred An Ontario study found tuberculosis morbidity to be higher among Place, London WClE 7DP, medical house-staff than in any other group of hospital workers, and England, before submitting manuscripts. nearly seven times higher than the population average. Reproductive risks from exposure to potential teratogens and Medical Teacher is published embryotoxic agents, especially among pregnant students and housequarterly. staff, rarely receive serious attention. Mutagenic effects can occur in @ Update Publications Ltd, 1982 both men and women. Then there are the more widely recognized 124
Medical Teacher Vol 4 No 4 I982
Med Teach Downloaded from informahealthcare.com by Florida International University on 12/26/14 For personal use only.
effects of emotional and physical stress, poor nutrition and sleep deprivation, which are damaging in themselves and can reduce the attention paid to appropriate precautions as well as increasing vulnerability to illness. NIOSH last year recommended that formaldehyde be handled as a potential carcinogen, yet it is still widely used in ways that expose students to its effects. Ventilation in many anatomy laboratories is poor; laboratory coats and clothes of dissectors become saturated with formaldehyde vapour; yet students are usually discouraged from wearing gloves for dissection; and told if they ask, that the substance is not harmful. Despite concern aroused by animal research, only one formal study has begun to look at the formaldehyde levels to which students are exposed (finding levels comparable to industrial exposure) and at possible cytogenetic effects. A major national union of US hospital employees is considering suing OSHA (the Occupational Safety and Health Administration, already causing great concern by its responses to Reagan Administration pressures to make work-place safety standards less onerous for employers to observe) to force employers to measure levels of formaldehyde and to notify workers of the levels and attendant risks. OSHA has refused to take action. We must not indulge in the fantasy that people who work w i t h the sick will always themselves remain well, whatever their exposure to the hazards that harm others. Public and occupational health teaching should, with benefit. turn its attention to risks closer to home, and to more intimate dangers than those they usually study. Michael A. Simpson MD. Professor of Psychiatry, Family Practice and Community Health, Temple University School of Medicine, PA 19140. USA
Reference 'Haglund K . The occupational hazards of amedical education. New Physician 1982; 31: 18-22.
Continuing Education-the Old Shibboleths Still Abound About 35 people attended the June meeting on Continuity in Medical Education, organized by the Association for the Study of Medical Education, and held at The Royal College of Physicians in London. It was partly in the nature of a seminar, as written material had been circulated beforehand, so that all participants should have been seeded with common ideas. These papers were prepared by what have come to be known as keynote speakers, to be followed by a colloquium. Discussion was meant to centre around four themes: obstetrics (Professor Callum Macnaughton), levels of mastery (Professor Hugh Dudley), prescribing and therapeutics (Dr Andrew Herxheimer) and behavioural sciences in achieving continuity (Mrs Mildred Blaxter). These subjects were discussed in a very vague way and sometimes at length; yet very few of the extempore contributions really focussed on continuity. We were
Medical Teacher Vol 4 No 4 1982
forever harking back to the undergraduate curriculum and the university milieu, and largely ignoring the vast amount of graduate education (trainees, consultants and principals) going on within the National Health Service with very little input directly from the universities. It is particularly the continuity between undergraduate and graduate education that should have engaged us but it did not, at least not very much. Indeed, it was apparent that not many of those present understood what is happening in graduate medical education in the United Kingdom. Nor did they realize that it is a much bigger enterprise now, in sheer numbers, than undergraduate education. It is not really surprising that the meeting was inconclusive and did not seriously cope with the problem of continuity. It is still a dificult and nebulous subject, hard to pin down. The old shibboleths-there were plenty of these-have to be talked out of the system, until better ideas, policies and work can emerge. To this extent the meeting was helpful: it allowed catharsis. This can have the merit of stripping away inessentials so that the real problem of continuity can be looked at more clearly. Judging from what was said, it seems likely that we are moving towards a time when no one will be able to practise obstetrics unless he or she has a higher qualification, at least of the level of the DRCOG. The MB would then become an entry qualification and any specialty would need an exit qualification obtained after graduation. This is close to being mandatory, but should it now be stated formally by august educational bodies? As far as levels of mastery are concerned, it was suggested that education should be in serial steps, each one fully planned. The student, at whatever level, must master each step before moving on to the next one. This provoked much interest, but might involve some educators in a lot of very hard work. How this was to be achieved was not explored. Logistically the task of training graduates would be immense. Dr Herxheimer suggested a very detailed programme for prescribing and therapeutics. It could work, and it ought to be implemented. Unfortunately, it cannot easily be summarized, but the educational aims for undergraduates and for graduates in different specialties were well thought out (albeit inadequately discussed). Behavioural science is a messy term. Perhaps in medicine it would be wiser simply to refer to psychology and sociology. They are vastly important as they define the context of more purely physical diagnosis. They enter, or should enter, in some way into every encounter between doctor and patient, and should therefore be taught and emphasized at every phase of medical education. They still tend to be neglected as formal disciplines, everyone thinking we already know about them. When, and how, to introduce them was debated but not resolved. It was a curate's egg of a colloquium no doubt. But everyone, tacitly or vociferously, dipped in a spoon. Whether or not what they tasted was to their liking, only each person can say. But that was the intention of the gathering-not to achieve consensus. P. Rhodes, M A , FRCS. FRCOC;. FRAtMA. Regional Postgraduate Dean of Medical Studies, Southampton General Hospital, Southampton, UK.
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