1135 the existing contract and were detailed clearly under four headings in the British Medical_7ournal on June 23. Then they state that very few regional representatives had been given information before the Scottish Committee of Hospital Medical Services met on Sept. 25, at which time there was a "rush to put a decision through". In fact the SCHMS had met on June 22, and the minutes report a lengthy discussion on the principal decisions taken by the CCHMS, including the improvements in the existing contract. Committee members had before them Linkman Letter no. 8 (1978/79) which dealt with these matters and which had been sent out on June 18 to secretaries of the area committees for Hospital Medical Services and to at least eighty linkmen in Scotland. Finally, the SCHMS met on Sept. 25 and the minutes record "the Committee discussed at great length the effects of these proposals on Scottish Consultants and a motion to support them was put to the vote. The motion was carried by 27 votes to 13". As I recall it, the debate continued for some two hours and included contributions from very many speakers who reported from their respective areas. The SCHMS has not been informed of the results of the ballot other than by telephone or newspapers; however, we have asked the organisers if they could furnish the committee with an analysis of its significance from the Electoral Reform ments to
Society. It is reassuring, albeit curious, to read their last sentence -that the ballot was not held in an attempt to obtain a separate contract for Scottish consultants. Such a course would entail a risk which not even the universities are willing to con-
template. British Medical Association, Scottish Office, 7 Drumsheugh Gardens,
Edinburgh EH3
7QP
C. D. Scottish
FALCONER, Secretary,
B.M.A.
TRAINING OF DOCTORS IN DEVELOPING COUNTRIES
SIR,-Professor Cook’s provocative article (Aug. 11, p. 297) illustrates some of the major obstacles to changes in medical education and the delivery of health services-among which one could single out excessive emphasis on the care of hospital patients (who constitute less than 5% of all patients seen in most developing countries and are even less numerically significant when set against the unmet health problems) and strong resistance to the use of auxiliary personnel, the main professional providers of health care in many countries. The changing role of the doctor in developing countries has been much discussed in the past ten years’.2-and has lately been debated in your correspondence columns in the wake of Cook’s paper. For example Dr Haddock (Aug. 25, p. 418) has raised important reservations about Cook’s statements on the decline of quality in hospital care and on the "partial success" of medical auxiliaries, reservations with which we are in full agree-
is the conditions under which [medicine] is practised and the order of priorities in management" which make the third world and the Western world different.3 The study of conditions under which medicine is practised and the order of priorities in management are largely what community medicine is all about. Practical training in these matters does not require "very large numbers of well-trained physicians, surgeons,
obstetricians, pxdiatricians
Project Reinforcement des Services de Santé et Formation de Personnel, B.P. 457 Niamey, Niger
ment.
In the opinion of Cook and those who have supported his arguments (Sept. 8, p. 530; Sept. 22, p. 642) health care should be delivered by "first rate doctors" (undefined) with traditional training. There is indeed much wrong with the delivery of health care in developing (and other) countries. This may have a lot to do with the fact that our colleagues in developing countries, the "traditionally trained indigenous staff", usually receive no or little training in how "they [Cook’s italics] must bring medicine to the massess"; surely, this is a major deficiency in traditional medical education. Cook believes that "medicine in the rural areas of the developing world is practically the same as in developed countries"; that "medicine is basically the same the world over";3 and that "it 1. 2.
King M. Medicine in red and blue. Lancet 1972; i: 679-81. Bryant J. Health and the developing world Ithaca: Cornell University Press,
1969. 3. Cook GC. Book reviews. Trans
Roy Soc Trop Med Hyg 1978; 72: 447-48.
...
physiotherapists, nutritionists,
medical social workers and other paramedical staff" (Aug. 25). Groups of up to twenty-five students at a time learnt to apply their bedside training under conditions similar to those of the rural majority in West Africa with limited tutorial supervision amounting to four full-time staff (nurse, social science worker, physicians) through resident clerkships in the limited facilities of standard health centres.4.5 Bedside teaching has an important place in the training of physicians anywhere, provided it can really teach the fundamental skills-listening to the patients’ complaints, correctly noting their signs, and evaluating their responses to treatment. The diseases encountered in selected urban teaching hospitals do not necessarily allow the trainee to undertake those fundamental tasks under realistic conditions: all too often the patient has already been "worked over" and teaching will tend to concentrate on intellectually stimulating but occasionaly esoteric adjustments in diagnosis or therapy. These will rely on a technology, the status of which, outside the teaching hospital, ranges from unavailable to irrelevant. On the matter of the orientation of medical training away from the individual patient-doctor relationship towards the treating of the masses, we do not feel as disturbed as Cook does: we doubt if he could cite many instances where training is not centered on the doctor’s responsibility towards the individual patient. What teachers of community medicine try to do, in cooperation with their clinical colleagues and those in the basic sciences, is: (1) to provide students with an understanding under which health problems are met in the country, and this does include explicit discussion of living conditions in villages; (2) to present scientific and quantifiable approaches towards the definition and resolution of the major health problems ; and (3) to show how better management can improve efficiency in the doctor-patient relationship, in the doctor’s role as adviser to the local authorities, and in his/her role as teacher, supervisor, and co-learner to other participants in health activities (nurses, sanitarians, dressers, patients). Insofar as medicine is a science, community medicine is one too, based as it is on the far from amorphous requirements of epidemiology, biostatistics, and planning methodology. In developing countries community medicine makes essential contribution to the basic education of all doctors6 in delivering health care to the majority of the population. E. A. JEANNÉE M. C. THURIAUX
CIMETIDINE IN BLEEDING PEPTIC ULCER
by
SIR,-We read with interest the results of the trial reported Dr Hoare and colleagues (Sept. 29, p. 671). We have done
study in patients over 65 years old with severe upper. gastrointestinal haemorrhage. Patients were allocated, double blind, to one of three groups: cimetidine, cimetidine plus chlorpheniramine, and placebo. All categories received conventional supportive therapy and a uniform antacid regimen. An older population was studied because it is this group in which greater morbidity and mortality occur after upper gastrointesa
similar
4. Monekosso GL, Thuriaux M. Le rôle du C.U.S.S. de Yaoundé dans la formation du personnel: La formation en équipe. Méd Afr Noire 1974; 21: 813-17. 5. Joseph SC. The health care team demonstration: An experiment in rural health training for nursing and medical students in central Africa. Trop Pediatr Envir Child Health 1974; 21: 325-30. 6. Waters WE. Teaching epidemiology to medical students. Int J Epidemiol
1977;6:329-30.
Society. It is reassuring, albeit curious, to read their last sentence -that the ballot was not held in an attempt to obtain a separate contract for Scottish consultants. Such a course would entail a risk which not even the universities are willing to con-
template. British Medical Association, Scottish Office, 7 Drumsheugh Gardens,
Edinburgh EH3
7QP
C. D. Scottish
FALCONER, Secretary,
B.M.A.
TRAINING OF DOCTORS IN DEVELOPING COUNTRIES
SIR,-Professor Cook’s provocative article (Aug. 11, p. 297) illustrates some of the major obstacles to changes in medical education and the delivery of health services-among which one could single out excessive emphasis on the care of hospital patients (who constitute less than 5% of all patients seen in most developing countries and are even less numerically significant when set against the unmet health problems) and strong resistance to the use of auxiliary personnel, the main professional providers of health care in many countries. The changing role of the doctor in developing countries has been much discussed in the past ten years’.2-and has lately been debated in your correspondence columns in the wake of Cook’s paper. For example Dr Haddock (Aug. 25, p. 418) has raised important reservations about Cook’s statements on the decline of quality in hospital care and on the "partial success" of medical auxiliaries, reservations with which we are in full agree-
is the conditions under which [medicine] is practised and the order of priorities in management" which make the third world and the Western world different.3 The study of conditions under which medicine is practised and the order of priorities in management are largely what community medicine is all about. Practical training in these matters does not require "very large numbers of well-trained physicians, surgeons,
obstetricians, pxdiatricians
Project Reinforcement des Services de Santé et Formation de Personnel, B.P. 457 Niamey, Niger
ment.
In the opinion of Cook and those who have supported his arguments (Sept. 8, p. 530; Sept. 22, p. 642) health care should be delivered by "first rate doctors" (undefined) with traditional training. There is indeed much wrong with the delivery of health care in developing (and other) countries. This may have a lot to do with the fact that our colleagues in developing countries, the "traditionally trained indigenous staff", usually receive no or little training in how "they [Cook’s italics] must bring medicine to the massess"; surely, this is a major deficiency in traditional medical education. Cook believes that "medicine in the rural areas of the developing world is practically the same as in developed countries"; that "medicine is basically the same the world over";3 and that "it 1. 2.
King M. Medicine in red and blue. Lancet 1972; i: 679-81. Bryant J. Health and the developing world Ithaca: Cornell University Press,
1969. 3. Cook GC. Book reviews. Trans
Roy Soc Trop Med Hyg 1978; 72: 447-48.
...
physiotherapists, nutritionists,
medical social workers and other paramedical staff" (Aug. 25). Groups of up to twenty-five students at a time learnt to apply their bedside training under conditions similar to those of the rural majority in West Africa with limited tutorial supervision amounting to four full-time staff (nurse, social science worker, physicians) through resident clerkships in the limited facilities of standard health centres.4.5 Bedside teaching has an important place in the training of physicians anywhere, provided it can really teach the fundamental skills-listening to the patients’ complaints, correctly noting their signs, and evaluating their responses to treatment. The diseases encountered in selected urban teaching hospitals do not necessarily allow the trainee to undertake those fundamental tasks under realistic conditions: all too often the patient has already been "worked over" and teaching will tend to concentrate on intellectually stimulating but occasionaly esoteric adjustments in diagnosis or therapy. These will rely on a technology, the status of which, outside the teaching hospital, ranges from unavailable to irrelevant. On the matter of the orientation of medical training away from the individual patient-doctor relationship towards the treating of the masses, we do not feel as disturbed as Cook does: we doubt if he could cite many instances where training is not centered on the doctor’s responsibility towards the individual patient. What teachers of community medicine try to do, in cooperation with their clinical colleagues and those in the basic sciences, is: (1) to provide students with an understanding under which health problems are met in the country, and this does include explicit discussion of living conditions in villages; (2) to present scientific and quantifiable approaches towards the definition and resolution of the major health problems ; and (3) to show how better management can improve efficiency in the doctor-patient relationship, in the doctor’s role as adviser to the local authorities, and in his/her role as teacher, supervisor, and co-learner to other participants in health activities (nurses, sanitarians, dressers, patients). Insofar as medicine is a science, community medicine is one too, based as it is on the far from amorphous requirements of epidemiology, biostatistics, and planning methodology. In developing countries community medicine makes essential contribution to the basic education of all doctors6 in delivering health care to the majority of the population. E. A. JEANNÉE M. C. THURIAUX
CIMETIDINE IN BLEEDING PEPTIC ULCER
by
SIR,-We read with interest the results of the trial reported Dr Hoare and colleagues (Sept. 29, p. 671). We have done
study in patients over 65 years old with severe upper. gastrointestinal haemorrhage. Patients were allocated, double blind, to one of three groups: cimetidine, cimetidine plus chlorpheniramine, and placebo. All categories received conventional supportive therapy and a uniform antacid regimen. An older population was studied because it is this group in which greater morbidity and mortality occur after upper gastrointesa
similar
4. Monekosso GL, Thuriaux M. Le rôle du C.U.S.S. de Yaoundé dans la formation du personnel: La formation en équipe. Méd Afr Noire 1974; 21: 813-17. 5. Joseph SC. The health care team demonstration: An experiment in rural health training for nursing and medical students in central Africa. Trop Pediatr Envir Child Health 1974; 21: 325-30. 6. Waters WE. Teaching epidemiology to medical students. Int J Epidemiol
1977;6:329-30.
