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point of view. A new method is good if it helps to classify patients in such a way that we obtain better treatment results, and it is superfluous if that is not the case. New diagnostic methods, especially those which are expensive or liable to cause complications, ought to be subjected to controlled trials in order to prove that their routine tients’ advantage.

Schools Do Make

a

use

will be

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Difference

discredit to Prof. MICHAEL RUTTER and his colleagues that the impact of their book on "secondary schools and their effects on children"1 owes as much to the fact that it says what people are ready to hear as it does to the evidence which it adduces. What it says is simple and unsurprising-that children’s social and academic development is greatly affected by the character of the school they attend. But it is only a few years since a different message was coming through from American sociologists such as J. S. COLEMAN and SANDY JENCKS. The bowdlerised summary of their work was: "Schools make no difference". COLEMAN showed on the basis of massive surveys of American schools that differences between schools were unimportant by comparison with the differences which the pupils themselves brought to school. JENCKS emphasised the importance of social class and parental attitudes and questioned the value of largescale programmes aimed at compensating, through education, for social disadvantage. Of course, by the time COLEMAN and JENCKS spelled out their message in the early 1970s, Richard Nixon had succeeded Lyndon Johnson, and there was a reaction against open-handed federal spending on compensatory education programmes. Daniel Moynahan had coined his bon mot about benign neglect. The evidence collected by the researchers which produced the glib, shorthand conclusion that "schools don’t make any difference" was largely of a kind which was bound to minimise the school contribution and maximise that of the home and social environment. In a valuable introductory chapter to Fifteen Thousand .HoMf RUTTER and his colleagues review the previous work in this sphere and the false conclusions which popularisers have drawn. Many of the tests used in the American research depended as little as possible on the subject content of the school curriculum (how could it be otherwise in a vast survey spread over many school systems?). Many of the variables the Americans isolated proved to be irrelevant but measurable; those more relevant were too difficult to measure. Most important, the basis of the federal programmes to compensate educaIT is

no

1. Fifteen Thousand Hours. By MICHAEL RUTTER, BARBARA MAUGHAN, PETER MORTIMORE, and JANET OUSTON. London: Open Books. 1979. Pp. 279.

£7.50, hardback; £3.50, paperback.

disadvantage had been a quest for a more equal society: COLEMAN found little evidence that

tional

compensatory education could make up for social inequality generally. But this is not the same as showing the schools to be impotent or ineffective with regard to pupils’ learning. All this seems no more than common sense. But a great deal of interest still surrounds the subject of what schools can and cannot do, and why one school is better (or worse) than another. If differences in the quality of the children’s performance are wholly explained by differences. outside the school (such as social class and family attitudes) a debilitating determinism hangs over the whole educational system. The sociologists of education have successfully induced just this sense of powerlessness in many schools-just as, earlier in the century, a generation of psychologists succeeded in proving to teachers that the children under their instruction came with rigid predetermined limitations which could be expressed in terms of innate i.Q. Both these forms of pedagogic Calvinism contain enough truth to shape the climate of educational opinion. Both in their way are a hindrance to that combination of faith and works on which miracles of learn-

ing depend. have countered this with a aimed at isolating the effect of longitudinal study the school. They took the 1970 intake of twelve London comprehensive schools and tested, categorised, and generally appraised the pupils at the age of 10 (before they entered the secondary schools), again at the age of 14, and finally at the minimum leaving age of 16. Comparing the assessments at 10 with those at 14, and with examination results at 16, they found that the children in some schools did much better than those in others, and that the differences were not wholly explained by the difference identified at the age of 10. For example, school A received an entry of 65 pupils, 31% of whom had "behavioural difficulties". By the age of 14, this 31% had been reduced to less than 10%. School B, on the other hand, took in 34% of "bad hats" and 3 years later this had risen to 48%-"a five-fold difference between schools". The same kind of evidence was examined for academic performance, yielding the same conclusions about the schools’ direct contribution: the increment in some schools seems to be very good; in others, very poor, and this did not correspond closely to the early measure of verbal reasoning. The research design provided for a great deal of information to be collected by questionnaire, interview, and observation about the schools themselves. This brought out details of academic organisation and practice-about the amount of teaching and homework, the zeal or slackness of the staff, the use of the library, the attitude of the head to RUTTER and his

his

team

pastoral responsibilities,

and about

discipline.

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punishment, school uniform, prefect systems, and a whole lot more. From this the team built up a picture of how particular practices correlated with pupil behaviour and examination success. The "good" school offers few surprises. It is a place where discipline is firm but humane and academic emphasis is strong and consistent; teachers turn up on time and work conscientiously; homework is set and marked; there are likely to be prefects, school uniforms, and many of the trappings of the traditional school (though not much corporal punishment). There is ample praise and encouragefor success. Teachers are not out on a limb, but under the supervision and guidance of their head of department. To the layman outside the schools, all this may ment

point of banality. The most worrying thing, perhaps, is that RUTTER and his colleagues had to devote 9 years to proving it. Not so: this is going to be a book which sets off resonances throughout the education service. It sound sensible

to

the

reinforces the more conservative tendencies now at work in British education, providing a reasoned basis for a trend which is already present (and which will be reflected in the Department of Education and Science’s curriculum review to be published shortly, and by the Inspectorate’s secondary school survey later in the year. There are, -of course, plenty of loose ends-including the statistical arguments which usually linger over the use of multivariate analysis in this way. The actual tests and questionnaires need to be examined in detail to see if the surrogates used to establish particular characteristics of schools can bear the weight attached to them. But the importance of this book lies less in the elegance of its research methods than in the central point it is making-a point which is more philosophical than statistical-namely, that for teaching and learning cannot be shifted from the individual pupil and teacher to external and impersonal forces. Genes and social class may be important, but the job_of the schools is to help people make the best of whatever hand of cards they have been dealt.

responsibility

MISSING THREADS A SUBSTANTIAL number of women fitted with an intrauterine contraceptive device (I.U.C.D.) are referred to hospital gynaecological departments with the marker threads missing. The incidence of this complication is uncertain, but some of the causes are well recorded. Expulsion-rates vary, with device, from 2 to 20%, and about 20% of patients are unaware of the expulsion.2 Translocation occurs in 0.05 to 13 per 1000 insertions.l Pregnancy may cause the threads to retract, owing to uterine enlargement, and the pregnancy-rate with a correctly positioned LU.C.D. is 1-4% of women in the first year after insertion, becoming lower in succeeding years. In most cases of missing threads, the I.U.C.D. is in 1 Gentile, G. P., Siegler, A. M. Obstet. gynec. Surv. 1977, 32, 627. Tietze, C. and Lewit, S. Stud. Fam. Plann. 1970, 1, no. 55. p. 1.

2

the uterus without pregnancy. With the Lippes loop the threads may become retracted in as many as 10% of insertions.4 The packaging of the ’Gravigard’ (copper 7) partly loaded with the thread looped alongside it may particularly predispose to thread retraction.I.5 At a family-planning clinic, investigations are usually limited to excluding pregnancy and ensuring that the threads are not accessible within the cervical canal, by exploration of the canal with forceps or a cotton-wooltipped swab. When pregnancy has been excluded, some workers sound the uterus in the hope of locating the device, though the newer devices are not easily palpated and the investigation may be inconclusive or frankly misleading. Specialist referral usually follows. Ultra-6 sound is the safest and most reliable investigation,3,6 being greatly preferable to previous methods such as

plain X-ray,’ hysterosalpingogram,8 fluoroscopy,9 hysteroscopy,10 or the ‘Beolocator’.4Ultrasound will also diagnose pregnancy within 4 weeks of conception. If ultrasound fails to show the device within the uterus, a plain abdomen X-ray will differentiate between expulsion and translocation. If the l.u.c.D. is correctly positioned and the patient is not pregnant, some workers advise no further action,’ but most patients request replacement or removal of the device. This may be specially true of the group who regularly check that they can feel the threads." Removal is commonly done under general anaesthesia, which means a wait for hospital admission, the risks of anaesthesia, and considerable expense. Evans 12 calculated that in the United States in 1972 the hospital cost of this procedure averaged $240’8and estimated that, if such admissions could be avoided, the saving in hospital costs would exceed half a million dollars even if there were as few as 600 000 1. U. C. D. S in use. Outpatient procedures for removing LU.C.D.S with missing threads have been applied with variable success and discomfort to the patient. These include hysteroscopy,to exploration of the uterine cavity with an endometrial biopsy curette8 or hook," or even insertion of a second I:U.C.D. which when removed later may bring down the thread of the first. I2 Guillebaud and Kasonde 14 have reported a method for retrieving missing threads with a 4 mm disposable vacuum aspiration curette which they believed suitable for use by trained personnel in the normal family-planning clinic milieu. The method may require local anxsthesia for cervical dilatation, which limits its application outside hospital and may explain why it has not been widely accepted. This is the background to the work of Dr Husemeyer and Mr Gordon of Northwick Park Hospital, who on p. 807 this week describe the use of a simple plastic device for the retrieval of missing threads. If their results are confirmed by larger series, this instrument may prove suitable for clinic use (in women known not to be pregnant), sparing many patients of anxiety and risk and health services of much money. 3. McArdle, C. R. Obstet. Gynec. 1977, 51, 330. 4. Rosen, E. Am. J. Obstet, Gynec. 1965, 93, 896. 5. Sparks, R. A. Br. Med. J. 1977, ii, 1351. 6. Meire, H. B. Renton, P. ibid. 1977, i, 713. 7. Frampton, J. ibid. p. 445. 8. Ansari, A. H. Obstet. Gynec. 1974, 44, 727. 9. Spence, M. R. ibid. 1975, 45, 693. 10. Siegler, A. M., Kemmann, E. ibid. 1975, 46, 604. 11. Chamberlain, G. Br. med. J. 1978, i, 237 12. Evans, G. T. Obstet. Gynec. 1974, 44, 155. 13. Sapiro, A. G. ibid. 1977, 49, 238. 14. Guillebaud, J., Kasonde, J. ibid. 1974, iv, 167.

Schools do make a difference.

810 point of view. A new method is good if it helps to classify patients in such a way that we obtain better treatment results, and it is superfluous...
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