1595
Britain and Ireland, which are sustained by many strong influences, including history and local pride. Others (the Australasians for example) have managed things better, and have a single College which houses all the specialist associations under one roof. You seem to favour a similar arrangement here, and it would be interesting to have your advice as to where the roof should be. You will be pleased to know that the Royal College of Surgeons of England intends that the diploma of fellow should be awarded only on the completion of specialist training, as signalled by passing the intercollegiate test. This development is in line with the thinking of the Association of Surgeons, the British Orthopaedic Association, and the Association of Surgeons in Training. The European Community directives that affect medicine have been in place since 1976, and nothing new will happen with the introduction of the single market, except perhaps a change in attitude. We in this College are entirely ready for 1992. During the Eurochirurgie meeting in Paris this October we will, at the request of our French colleagues, be expounding the role of the Royal Colleges, and suggesting that the reconstructed FRCS might well provide a benchmark for a future European diploma in surgery, such as already exists in anaesthesia thanks to the efforts of our sister College. We do not consider the environment of an integrated Europe as "hostile". We welcome such integration as an opportunity both to learn from our peers and to contribute to the development of surgery. A free-standing medical Royal College, answerable to the profession and independent of Government, was of course an object of fear and loathing to the totalitarian regime of Bonaparte, which was why he suppressed it. Luckily, Wellington saw to it that our College was spared. Dialogues with Continental colleagues suggest that many would like to see such organisations reintroducedindeed a meeting was held in Strasbourg only last month to further the establishment of a European College of Surgeons. You should not dismiss the social advantages of a body which is charitable, forbidden to act in its members’ interests, is concerned with training, maintenance of standards, and protection of the public, furthers scientific advance, and commissions studies designed to improve the delivery of surgical care. Royal College of Surgeons of 35-43 Lincoln’s Inn Fields, London WC2A 3PN, UK
England,
Prevention of pressure
ADRIAN
MARSTON,
Chairman, External Affairs Board
sores
in your June 2 editorial that the document the King’s Fund Pressure Sore Study Group1 addressed itself "mainly to nurses and paramedical workers" suggests that you had given our document only a cursory glance. We clearly state that to be effective a strategy for pressure sore prevention and management "must be initiated at District level, with managerial endorsement, adequate funding, and the commitment of all health care professionals". Furthermore you conclude that, "Only when every patient with a suspected spinal cord injury, new stroke, or femoral neck fracture can be routinely admitted onto an APAM [alternating pressure air mattress] and nursed on it--or provided with an equivalent manual method of pressure relief-throughout the acute phase of his or her illness will we begin to see the end of pressure sores". This regretfully restricts pressure sore prevention and management to that of nursing care alone. It also shows a lack of awareness of the importance of medical assessment to identify and correct the cardiovascular and other factors predisposing to tissue hypoperfusion and hypoxia in acutely ill patients. Elderly people (the group most at risk) can lie in bed at home for long periods every night for many years without pressure sores developing. Extrinsic pressure may only become a clinically significant factor when acute illness has already reduced tissue perfusion. Then, appropriate surfaces upon which to rest patients have an important role in pressure sore prevention and management. Before APAMs are considered, however, the first step should be to review the quality of existing hospital mattresses. At the King’s Fund Centre we have received accounts that up to
SIR,-The
statement
produced by
40% of
mattresses in a hospital have proved useless if not dangerous, and of wards where as many as 20 of 24 mattresses have been known for many months to need replacement. It is for these and other concerns that we produced our strategy document for health districts. Our aim was to help to reduce avoidable human suffering and financial waste by offering guidelines by which all health professionals could work together to improve the prevention and management of pressure sores. It is gratifying that representatives from some fifty health districts in the UK have contacted us during the past eighteen months. Many of them have already defined or are now working on their own district policies on the basis of our guidelines.1 Academic Unit for the Care of the Charing Cross Hospital, London W6 8RF, UK
1.
Elderly,
BRIAN LIVESLEY
Livesley B The prevention and management of pressure sores in health districts. King’s Fund Centre for Health Services Development, a document produced by the Pressure Sore Study Group 1989. Available from the Academic Unit for the Care of the Elderly, Charing Cross Hospital, London.
Feminisation of medical
practice
SIR,—Those observers (May 12, p 1149) who believe that feminisation of medical practice would favourably affect the "veritable abattoir of hysterectomies" and the high rate of caesarean section would do well to look at India, where most obstetricians and gynaecologists are women. The two "wrongs", rather than being corrected, have got worse with the feminisation of obstetrics and gynaecology in India.1 An audit by us of one such "feminised" service in a private hospital revealed that the ratio of caesarean sections to vaginal deliveries rose from 1 in 19 in 1972 to 1 in 3 in 1988. The number of hysterectomies rose from 27 in 1983 to 121 by October, 1988, the number of beds and consultants in the specialty
remaining essentially unchanged. Whether women are "more empathic, and kinder and gentler altogether" in their dealings with other women is highly debatable. Our impression is that in India women are no different from men in their approach to patients-indeed, a prevalent belief among doctors is that women obstetricians tend to be brusque to the point of rudeness with patients in labour. One indulgent explanation offered is that, having gone through the experience themselves, such obstetricians believe the pain of childbirth to be quite bearable; and any empathy the obstetrician may have had with her patient rapidly diminishes with progression of the second stage. Surely, this aspect of human behaviour merits study rather than mere pious declarations by well-meaning feminists. SDM
Hospital,
Jaipur 302 015, India 1.
S. G. KABRA
RAMJI NARAYANAN
Pendey S, Jain M, Pandey LK. Ten year profile of caesarian section. J Obstet Gynaecol Ind 1986; 36: 448-51.
Centralised
laboratory services
SIR,-I was disappointed by Dr Webb’s (May 26, p 1284) interpretation of the Lothian Health Board’s review of its laboratory services. Unlike the arrangements you describe in your May 5 editorial on the Greater Glasgow Health Board, the review of laboratory services by the Lothian Health Board includes the heads of the laboratories, their senior technical colleagues, and doctors’ representatives. The Board has agreed, at least for the present, not to pursue competitive tendering of its laboratory services and to undertake this in-house review. There were two main reasons for this decision by the management team: firstly, I argued that effective National Health Service laboratories depend on close integration between their analytical, consultative, research, and teaching functions, which would be extremely vulnerable in a market based approach; and I secondly reported that I had been given assurances by all heads of laboratories that a review of their
Britain and Ireland, which are sustained by many strong influences, including history and local pride. Others (the Australasians for example) have managed things better, and have a single College which houses all the specialist associations under one roof. You seem to favour a similar arrangement here, and it would be interesting to have your advice as to where the roof should be. You will be pleased to know that the Royal College of Surgeons of England intends that the diploma of fellow should be awarded only on the completion of specialist training, as signalled by passing the intercollegiate test. This development is in line with the thinking of the Association of Surgeons, the British Orthopaedic Association, and the Association of Surgeons in Training. The European Community directives that affect medicine have been in place since 1976, and nothing new will happen with the introduction of the single market, except perhaps a change in attitude. We in this College are entirely ready for 1992. During the Eurochirurgie meeting in Paris this October we will, at the request of our French colleagues, be expounding the role of the Royal Colleges, and suggesting that the reconstructed FRCS might well provide a benchmark for a future European diploma in surgery, such as already exists in anaesthesia thanks to the efforts of our sister College. We do not consider the environment of an integrated Europe as "hostile". We welcome such integration as an opportunity both to learn from our peers and to contribute to the development of surgery. A free-standing medical Royal College, answerable to the profession and independent of Government, was of course an object of fear and loathing to the totalitarian regime of Bonaparte, which was why he suppressed it. Luckily, Wellington saw to it that our College was spared. Dialogues with Continental colleagues suggest that many would like to see such organisations reintroducedindeed a meeting was held in Strasbourg only last month to further the establishment of a European College of Surgeons. You should not dismiss the social advantages of a body which is charitable, forbidden to act in its members’ interests, is concerned with training, maintenance of standards, and protection of the public, furthers scientific advance, and commissions studies designed to improve the delivery of surgical care. Royal College of Surgeons of 35-43 Lincoln’s Inn Fields, London WC2A 3PN, UK
England,
Prevention of pressure
ADRIAN
MARSTON,
Chairman, External Affairs Board
sores
in your June 2 editorial that the document the King’s Fund Pressure Sore Study Group1 addressed itself "mainly to nurses and paramedical workers" suggests that you had given our document only a cursory glance. We clearly state that to be effective a strategy for pressure sore prevention and management "must be initiated at District level, with managerial endorsement, adequate funding, and the commitment of all health care professionals". Furthermore you conclude that, "Only when every patient with a suspected spinal cord injury, new stroke, or femoral neck fracture can be routinely admitted onto an APAM [alternating pressure air mattress] and nursed on it--or provided with an equivalent manual method of pressure relief-throughout the acute phase of his or her illness will we begin to see the end of pressure sores". This regretfully restricts pressure sore prevention and management to that of nursing care alone. It also shows a lack of awareness of the importance of medical assessment to identify and correct the cardiovascular and other factors predisposing to tissue hypoperfusion and hypoxia in acutely ill patients. Elderly people (the group most at risk) can lie in bed at home for long periods every night for many years without pressure sores developing. Extrinsic pressure may only become a clinically significant factor when acute illness has already reduced tissue perfusion. Then, appropriate surfaces upon which to rest patients have an important role in pressure sore prevention and management. Before APAMs are considered, however, the first step should be to review the quality of existing hospital mattresses. At the King’s Fund Centre we have received accounts that up to
SIR,-The
statement
produced by
40% of
mattresses in a hospital have proved useless if not dangerous, and of wards where as many as 20 of 24 mattresses have been known for many months to need replacement. It is for these and other concerns that we produced our strategy document for health districts. Our aim was to help to reduce avoidable human suffering and financial waste by offering guidelines by which all health professionals could work together to improve the prevention and management of pressure sores. It is gratifying that representatives from some fifty health districts in the UK have contacted us during the past eighteen months. Many of them have already defined or are now working on their own district policies on the basis of our guidelines.1 Academic Unit for the Care of the Charing Cross Hospital, London W6 8RF, UK
1.
Elderly,
BRIAN LIVESLEY
Livesley B The prevention and management of pressure sores in health districts. King’s Fund Centre for Health Services Development, a document produced by the Pressure Sore Study Group 1989. Available from the Academic Unit for the Care of the Elderly, Charing Cross Hospital, London.
Feminisation of medical
practice
SIR,—Those observers (May 12, p 1149) who believe that feminisation of medical practice would favourably affect the "veritable abattoir of hysterectomies" and the high rate of caesarean section would do well to look at India, where most obstetricians and gynaecologists are women. The two "wrongs", rather than being corrected, have got worse with the feminisation of obstetrics and gynaecology in India.1 An audit by us of one such "feminised" service in a private hospital revealed that the ratio of caesarean sections to vaginal deliveries rose from 1 in 19 in 1972 to 1 in 3 in 1988. The number of hysterectomies rose from 27 in 1983 to 121 by October, 1988, the number of beds and consultants in the specialty
remaining essentially unchanged. Whether women are "more empathic, and kinder and gentler altogether" in their dealings with other women is highly debatable. Our impression is that in India women are no different from men in their approach to patients-indeed, a prevalent belief among doctors is that women obstetricians tend to be brusque to the point of rudeness with patients in labour. One indulgent explanation offered is that, having gone through the experience themselves, such obstetricians believe the pain of childbirth to be quite bearable; and any empathy the obstetrician may have had with her patient rapidly diminishes with progression of the second stage. Surely, this aspect of human behaviour merits study rather than mere pious declarations by well-meaning feminists. SDM
Hospital,
Jaipur 302 015, India 1.
S. G. KABRA
RAMJI NARAYANAN
Pendey S, Jain M, Pandey LK. Ten year profile of caesarian section. J Obstet Gynaecol Ind 1986; 36: 448-51.
Centralised
laboratory services
SIR,-I was disappointed by Dr Webb’s (May 26, p 1284) interpretation of the Lothian Health Board’s review of its laboratory services. Unlike the arrangements you describe in your May 5 editorial on the Greater Glasgow Health Board, the review of laboratory services by the Lothian Health Board includes the heads of the laboratories, their senior technical colleagues, and doctors’ representatives. The Board has agreed, at least for the present, not to pursue competitive tendering of its laboratory services and to undertake this in-house review. There were two main reasons for this decision by the management team: firstly, I argued that effective National Health Service laboratories depend on close integration between their analytical, consultative, research, and teaching functions, which would be extremely vulnerable in a market based approach; and I secondly reported that I had been given assurances by all heads of laboratories that a review of their
