Medical academics' concerns over pay SIR, - Dr I Alexander suggests that clinical academics refuse to teach undergraduates until the dispute over parity of salaries with NHS colleagues is settled.' On 5 August, at the general request of the Medical Academic Staff Committee, I wrote to Mr Clarke about this matter. I sent a copy of the letter to Dr Colin Smith, who acknowledged it within four days. It was another two weeks before I received a reply from the Department of Education and Science-not from Mr Clarke, but signed per pro by Gillian Wathen (or Watken) for Joan Taylor of Teachers Pay and General. The letter had my name and address at the top of the page but was not addressed personally to me, nor was there a finishing "yours sincerely." In short, I have received more personal letters from companies selling timeshares, presumably because they held my custom to be of more value than Mr Clarke holds my opinions. It is pointless withholding our teaching: we should withhold our clinical services pro rata, and request that our NHS colleagues support us in this by not covering our clinical work. A failure to increase our salaries by the 4% difference will then become a 4% decrease in service. NEVILLE W GOODMAN
University of Bristol and Southmead Hospital, Bristol BSIO 5SE I Alexander 1. Medical academics' concerns over pay. BMJ
1991;303:525. (31 August.)
MRCGP: examining the exam SIR,-Dr Fiona Godlee's article on the MRCGP examination addresses a key topic in postgraduate medical education.' Though, as she suggests, an open discussion of postgraduate examinations is useful, it is important that what is described is factually correct. I have recently completed a three year research project into the design of the MRCGP exam and wish to correct several possibly misleading sections of the text. Firstly, the critical reading paper is not designed to test "grasp of basic statistics and study design." The paper was conceived as a form of open book exam, which would allow candidates to show their critical abilities without depending on recall of facts. The candidates are asked to read a variety of printed materials and to evaluate them with a view to deciding whether, and how, the content might affect their practice. This may require the exercise of criticism with regard to experimental design but not in the academic mode which the article suggests. Secondly, the simulated surgery was developed in the Centre for Medical Education in Dundee on the basis of a study, with 200 general practitioners,
of the objective structured clinical examination. The simulated surgery differs from the conventional objective structured clinical examination in that the candidates control the length of the consultations and are also given written material that they might encounter as a general practitioner and to which they must respond. This is to be prioritised and dealt with in the time available. Scoring is based on two well validated systems, one developed in Australia by Richard Hayes, the other in the department of general practice at the University of Leicester. Thirdly, I did not recommend, as was reported in the article, that the viva should "contain no factual questions." I pointed out that the justifications given by examiners for failing candidates in the oral exam often related to deficiencies in their knowledge. As this had already been tested by the multiple choice questionnaire, which is much more reliable, I suggested that examiners should
BMJ
VOLUME
303
21 SEPTEMBER 1991
be asked to score the oral exam on the basis of characteristics other than factual recall. Dr Godlee herself refers to "looking for gaps in the candidate's knowledge" as the aim of the oral exam. I do not agree that this should be its function. When the report of my research project has been discussed within the college it will be published in several papers. An interim report has been
published.2 HELEN MULHOLLAND
Centre for Medical Education, University of Dundee, Ninewells Hospital and Medical School, Dundee DDI 9SY 1 Godlee F. MRCGP: examining the exam. BMJ 1991;303:235-8. (27 July.) 2 Lockie C, ed. Examination for membership of the Royal College of General Practitioners: development, current state, and future trends. London: RCGP, 1990. (Occasional paper No 46.)
Increasing documentation in general practice SIR,-A young woman and her 8 week old child attended today because they wished to register at the practice. She had a new patient assessment and her postnatal check, during which a cervical smear test was done; she said that she wished to start taking the contraceptive pill again. She also registered her baby, who was registered for child health surveillance and had his belated 6 week assessment and first immunisation. This attendance required the completion of our practice's new patient questionnaire, a registration form (HS22X), a new patient medical form (RF), a maternity form (MMS), a contraceptive form (FPIOO1; three carbon copies), and a cervical smear test request form. For her baby we completed the child's medical card, a child health surveillance registration form (CHS), our practice's developmental checklist, the developmental surveillance form for the health board (developmental surveillance record GP/HV/CMO; three carbon copies), and an immunisation form (CHS7). In addition, we needed to complete two separate forms for registering the mother and child at the central services agency (the equivalent of the family health services authority) (HS7; two carbon copies). This consultation generated 19 separate items of documentation, excluding standard medical records and computer summaries. Is this a record? DOMHNALL MACAULEY
Belfast BT 11 9FZ
Hand in glove SIR,-I write in response to Mr John Warden's report of a recent hearing of the Commons public accounts committee in which it was pointed out that British surgeons have a strong preference for one particular make of surgical gloves, namely Regent Hospital Products' range of medical gloves, and presumably more specifically Regent Biogel "powder-free" surgeons' gloves.' The reason for this preference can be clearly explained. Nearly all our competitors' gloves worldwide use a starch powder lubricant. There is much evidence in medical literature to implicate glove starch in postoperative complications, such as starch peritonitis and peritoneal adhesions, which have led to intestinal obstruction. The hydrogel coating on Biogel gloves means that starch is not required. British Standard BS4005 and Department of Health guidelines require a warning to be printed on each pack regarding the potential hazards of glove powder and it is a requirement that the powder from powdered gloves is washed off after the gloves have been put on. This is both time consuming and expensive as sterile water must be used for this procedure. Biogel gloves do not have
to be washed. The article ignores this fact in the comments on cost. Regent Biogel gloves have achieved their worldwide quality reputation through the critical control of a complex manufacturing process and a thorough testing programme. (Gloves are both individually tested and batch tested.) With the much publicised and real risk of both viral and bacterial infection, use of a 100% tested glove is naturally safer for both surgeon and patient. In addition to their superior safety, Regent Biogel gloves provide other safety characteristics through a combination of high tensile strength, sensitivity, durability, and hypoallergenicity. Indeed, this point is substantiated this month in an independent article that compares the powder free Biogel glove favourably for durability with its leading competitor.2 In summary, producing a high quality powder free glove to provide the best possible safety for both patient and surgeon costs money. Most surgeons in the United Kingdom recognise this fact. It is also worth noting that Biogel has established a strong and growing market share in mainland Europe and the United States, against large multinational healthcare competitors. N R HODGES
Regent Hospital Products, London E4 8QA 1 Warden J. Hand in glove. BMJ 1991;303:331. (10 August.) 2 Mehtar S, Tsakris A, Castro D, Mayet F. The effect of disinfectants on perforated gloves. J7 Hosp Infict 1991;18: 191-200.
Undergraduate medical education SIR, - I was interested in the recent correspondence on undergraduate medical education.' Being a mature medical student with a wife who is a lecturer in nursing studies, I am well aware that there is a large gap in medical education compared with nursing education. I am about to start my fourth year in clinical medicine and have found that teaching has been variable for three main reasons. Firstly, most of the responsibility for teaching lies with the firms that we are allocated to. These firms are already hard pressed with their own clinical work without having the extra responsibility of teaching students. This has resulted in many teaching sessions being cancelled, which reduces the students' interest and morale as well as depriving them of valuable education. Secondly, most of our teachers have had no formal training in education. Some doctors are naturally talented in educating students, but many are not. This is classically seen when the student is taught by humiliation, which is patronising and not conducive to learning. Thirdly, the course does not seem to have any structure, with little communication between the firms and the medical school. It would be helpful if guidelines, such as a syllabus, were drawn up so that the student and the firm had a core on which to build. In nurse education the responsibility for training lies with a clinical nurse tutor as well as the ward staff. This tutor gives lectures and tutorials, liaises with ward staff, and deals with any problems a student might have. The tutor has had formal teaching in education, which is vital when dealing with students. This sort of system should be introduced into medical courses with clinical medical and surgical teachers. This system would relieve already hard pressed ward staff from their teaching duties, allowing them to get on with their primary responsibility, their patients. The tutor would be able to monitor students' progress, give formal training in practical techniques (which seems to be lacking), and also give the student a
721
good grounding in medicine on which to build as a postgraduate. IPETER G THATCHER
bringing these approaches together, for instance by estimating the area effect in relation to the effect of variation among practitioners within areas.
King's College School of Mcdicinc and Dentistry. London SE5 9PJ I
DEBORAH BAKER RUDOLF KLEIN
Correspondence. Undergraduatc medical education. BMJ
1991;
303: 244-6.\ 27 July .)
Explaining outputs of primary health care SIR,-The results presented by Dr Deborah Baker and Professor Rudolf Klein in their article on the role of population and practice factors in explaining outputs of primary health care could be misleading.' Their main objective was to examine whether variations in the activities of general practice among family health services authorities can be explained by the population characteristics and the organisation and resourcing of general practice. From the four examples investigated they showed that the standardised mortality ratios, the number of practitioners and the proportion aged over 65, and the number of ancillary staff per practitioner accounted for 69% of the variation in prescribing rates. The variation, however, related to the average prescribing rates for the 90 authorities, which were distributed with a coefficient of variation of only 13%. Each authority's rate is the average of between 75 and 500 general practitioners' individual rates. The coefficient of variation for prescribing rates for individual general practitioners will be several-fold greater than that for the authorities' means. Thus the four factors mentioned above may explain a much smaller percentage of the variation among general
practitioners. It is the idiosyncracies of individual practitioners (which the authors have explicity ignored) that are usually at the core of variability in referral rates and prescription rates among doctors. D L CROMBIE D M FLEMING
Royal College of General Practitioners, Birmingham B 17 9DB 1 Baker D, Klein R. Explaining outputs of primary health care: population and practice factors. BMJ 1991;303:225-9. (27
Centre for Analvsis of Social lPolicy, School of Social Sciences, University of Bath, Bath BA2 7AY
R B WOODWARD
I Robinson WS. Ecological correlations and the behaviour of indisiduals.American Soc tal Review 1950;15:351-7.
What your stereotypes may be reading SIR,-I was interested to read Dr Trisha Greenhaigh's review of medical columns in women's magazines' and heartened by the fact that the "light hearted smirk" with which she approached her task was replaced with respect for the quality and accuracy of most of what appears on our pages. I was bemused, however, by her assertion that "lost tampons, masturbating toddlers, and unmentionable fantasies still entertain readers of Woman's Weekly." No, they don't-and never have. Woman's Weekly's health column, written by the admirable Dr Penny Stanway (who bears very little resemblance to "the bespectacled, middle aged general practitioner" of Dr Greenhalgh's imagination) continues to present, accessibly but unsensationally, the facts about a variety of conditions and diseases, as well as news of research and answers to questions on topics suitable for family reading. In her quest for hyperbole and inaccurate reporting Dr Greenhalgh might have done better to turn her gaze from our pages towards her own. A case, perhaps, of "Physician, heal thyself?" JUDITH HALL
Editor, Woman's Weekly, IPC Magazines Ltd, London SE1 9LS I Greenhalgh T. What your stereotypes may be reading. BfMj
1991;303:475. (24 August.)
Fundholding: blight or blessing?
July.)
AUTHORS' REPLY,-We accept the valid statistical point made by Drs Crombie and Fleming, that the coefficient of variation for prescribing rates for individual general practitioners will be several-fold greater than that for the family health services authorities' means. Within the context of our study we have no scientific way of testing their hypothesis that the idiosyncracies of general practitioners are responsible for most of the variability in prescribing and referral. Our purpose was to compare activity of general practitioners at the aggregate level, among areas rather than among individual general practitioners. These are different levels of investigation: it would be unwise to assume that the associations produced at the aggregate level will also apply when comparing individual activity and thus fall foul of "the ecological fallacy." Robinson, in his classic illustration of this point, showed how correlations between literacy rates and ethnic group at an area level were very different from the associations observed at the individual level.' We suggest that variations in prescribing may be productively studied by using either the aggregate or the individual approach; different results emerging from such analyses may simply reflect the distinct impact of social and individualistic factors. In this context the important methodological challenge lies not in establishing that one approach is misleading and the other is not but in
722
commitment to patients' care. Ignoring needs such as this would be unthinkable. I agree wholeheartedly that these are days of rapid change and that serious debate about the advantages and perils of fundholding is needed. It is a pity that the debate is in danger of being submerged in hearsay and innuendo.
SIR, -I read Dr Martin Roland's article on fundholding with dismay. ' His statement that Triangle Health Care has given only six month contracts to the local hospitals that don't meet its standards is a considerable distortion of the truth. Our consortium has always given considerable thought to the effect that fundholding might have on the viability of the NHS. We have sought to maintain historical patterns of referrals to our usual five main hospitals, believing that we should work with them rather than "flex our new found muscles." Unfortunately, a problem arose involving lack of communication with one specialty in one hospital. We decided that we would, initially, not contract for a full 12 months while we tried to find a solution to the problem (which is serious). One of the options, of course, would be to refer our patients to another hospital - as has always been our right. We have as yet been unable to resolve this but have given the full 12 month contract to the hospital concerned in recognition of the difficulties that would otherwise ensue. I would also question Dr Roland's observation that "the average fundholder will think twice about referring a clumsy child to a child development centre knowing that the practice may have to pay for ongoing physiotherapy, speech therapy, and occupational therapy." My experience of the past 12 months leads me to believe that the average fundholder (whoever that is) has, over many meetings, thought long and hard about his or her
Chairman, Triangle Health Care, Ainsdale, Southport PR8 3HN 1 Roland M. Fundholding and cash limits in primary care: blight or blessing? BM 1991;303: 171-2. (20 July.)
Followed to the letter SIR,-There is an increasing tendency for letters from one doctor to another to be annotated "dictated but not signed," only sometimes to be followed by a signed copy. This is done, of course, to speed communication and facilitate treatmentbut where does the responsibility lie if something goes wrong? Transcription errors are easy to make but may be hard to spot. If patient injury results from such error who will shoulder the blame? A safety first procedure is for such letters to be returned to the author, immediately, for checking and signature. A less cumbersome approach would be to drop the practice. No journal would publish a letter that was "dictated but not signed." JOHN DOHERTY Birmingham B36 8AD
By any other name SIR,-Minerva's item on eponyms' reminds me of the two hazards of using them. The first is getting it wrong, as Minerva herself has done in her example. The syndrome of dysphagia, glossitis, and anaemia was first described in 1919 by Brown Kelly and Paterson-note the absence of a comma between Brown and Kelly: one person, not two. The second hazard, especially in an exam situation, is being asked who the eponymous person was. For the benefit of those who do not know, Adam Brown Kelly (surnames probably not hyphenated) was ear, nose, and throat surgeon to the Victoria Infirmary, Glasgow, and Donald Paterson was ear, nose, and throat surgeon to the Royal Infirmary, Cardiff. EWEN F FLINT Ear, Nose, and Throat Department, Dumfries and Galloway Royal Infirmary, Dumfries DG I 4AP 1 Minerva. BMJ 1991;303:530. (31 August.)
Correction Abortion rates still rising An editorial error occurred in this letter by Mr David T Baird. The symbols on the figure were transposed. The correct figure is given below. 16i 14-
p England and
/
912E
..
o
t10
/
8 8- d;/ 0
Wales(o)
Glasgow (a) Sotoand (o)
*Grampian(*)
6
c-6
t
0 0
Z 2
1970 1974 1976
BMJ
VOLUME
303
1980 1984 1988
21
SEPTEMBER
1991
University of Bristol and Southmead Hospital, Bristol BSIO 5SE I Alexander 1. Medical academics' concerns over pay. BMJ
1991;303:525. (31 August.)
MRCGP: examining the exam SIR,-Dr Fiona Godlee's article on the MRCGP examination addresses a key topic in postgraduate medical education.' Though, as she suggests, an open discussion of postgraduate examinations is useful, it is important that what is described is factually correct. I have recently completed a three year research project into the design of the MRCGP exam and wish to correct several possibly misleading sections of the text. Firstly, the critical reading paper is not designed to test "grasp of basic statistics and study design." The paper was conceived as a form of open book exam, which would allow candidates to show their critical abilities without depending on recall of facts. The candidates are asked to read a variety of printed materials and to evaluate them with a view to deciding whether, and how, the content might affect their practice. This may require the exercise of criticism with regard to experimental design but not in the academic mode which the article suggests. Secondly, the simulated surgery was developed in the Centre for Medical Education in Dundee on the basis of a study, with 200 general practitioners,
of the objective structured clinical examination. The simulated surgery differs from the conventional objective structured clinical examination in that the candidates control the length of the consultations and are also given written material that they might encounter as a general practitioner and to which they must respond. This is to be prioritised and dealt with in the time available. Scoring is based on two well validated systems, one developed in Australia by Richard Hayes, the other in the department of general practice at the University of Leicester. Thirdly, I did not recommend, as was reported in the article, that the viva should "contain no factual questions." I pointed out that the justifications given by examiners for failing candidates in the oral exam often related to deficiencies in their knowledge. As this had already been tested by the multiple choice questionnaire, which is much more reliable, I suggested that examiners should
BMJ
VOLUME
303
21 SEPTEMBER 1991
be asked to score the oral exam on the basis of characteristics other than factual recall. Dr Godlee herself refers to "looking for gaps in the candidate's knowledge" as the aim of the oral exam. I do not agree that this should be its function. When the report of my research project has been discussed within the college it will be published in several papers. An interim report has been
published.2 HELEN MULHOLLAND
Centre for Medical Education, University of Dundee, Ninewells Hospital and Medical School, Dundee DDI 9SY 1 Godlee F. MRCGP: examining the exam. BMJ 1991;303:235-8. (27 July.) 2 Lockie C, ed. Examination for membership of the Royal College of General Practitioners: development, current state, and future trends. London: RCGP, 1990. (Occasional paper No 46.)
Increasing documentation in general practice SIR,-A young woman and her 8 week old child attended today because they wished to register at the practice. She had a new patient assessment and her postnatal check, during which a cervical smear test was done; she said that she wished to start taking the contraceptive pill again. She also registered her baby, who was registered for child health surveillance and had his belated 6 week assessment and first immunisation. This attendance required the completion of our practice's new patient questionnaire, a registration form (HS22X), a new patient medical form (RF), a maternity form (MMS), a contraceptive form (FPIOO1; three carbon copies), and a cervical smear test request form. For her baby we completed the child's medical card, a child health surveillance registration form (CHS), our practice's developmental checklist, the developmental surveillance form for the health board (developmental surveillance record GP/HV/CMO; three carbon copies), and an immunisation form (CHS7). In addition, we needed to complete two separate forms for registering the mother and child at the central services agency (the equivalent of the family health services authority) (HS7; two carbon copies). This consultation generated 19 separate items of documentation, excluding standard medical records and computer summaries. Is this a record? DOMHNALL MACAULEY
Belfast BT 11 9FZ
Hand in glove SIR,-I write in response to Mr John Warden's report of a recent hearing of the Commons public accounts committee in which it was pointed out that British surgeons have a strong preference for one particular make of surgical gloves, namely Regent Hospital Products' range of medical gloves, and presumably more specifically Regent Biogel "powder-free" surgeons' gloves.' The reason for this preference can be clearly explained. Nearly all our competitors' gloves worldwide use a starch powder lubricant. There is much evidence in medical literature to implicate glove starch in postoperative complications, such as starch peritonitis and peritoneal adhesions, which have led to intestinal obstruction. The hydrogel coating on Biogel gloves means that starch is not required. British Standard BS4005 and Department of Health guidelines require a warning to be printed on each pack regarding the potential hazards of glove powder and it is a requirement that the powder from powdered gloves is washed off after the gloves have been put on. This is both time consuming and expensive as sterile water must be used for this procedure. Biogel gloves do not have
to be washed. The article ignores this fact in the comments on cost. Regent Biogel gloves have achieved their worldwide quality reputation through the critical control of a complex manufacturing process and a thorough testing programme. (Gloves are both individually tested and batch tested.) With the much publicised and real risk of both viral and bacterial infection, use of a 100% tested glove is naturally safer for both surgeon and patient. In addition to their superior safety, Regent Biogel gloves provide other safety characteristics through a combination of high tensile strength, sensitivity, durability, and hypoallergenicity. Indeed, this point is substantiated this month in an independent article that compares the powder free Biogel glove favourably for durability with its leading competitor.2 In summary, producing a high quality powder free glove to provide the best possible safety for both patient and surgeon costs money. Most surgeons in the United Kingdom recognise this fact. It is also worth noting that Biogel has established a strong and growing market share in mainland Europe and the United States, against large multinational healthcare competitors. N R HODGES
Regent Hospital Products, London E4 8QA 1 Warden J. Hand in glove. BMJ 1991;303:331. (10 August.) 2 Mehtar S, Tsakris A, Castro D, Mayet F. The effect of disinfectants on perforated gloves. J7 Hosp Infict 1991;18: 191-200.
Undergraduate medical education SIR, - I was interested in the recent correspondence on undergraduate medical education.' Being a mature medical student with a wife who is a lecturer in nursing studies, I am well aware that there is a large gap in medical education compared with nursing education. I am about to start my fourth year in clinical medicine and have found that teaching has been variable for three main reasons. Firstly, most of the responsibility for teaching lies with the firms that we are allocated to. These firms are already hard pressed with their own clinical work without having the extra responsibility of teaching students. This has resulted in many teaching sessions being cancelled, which reduces the students' interest and morale as well as depriving them of valuable education. Secondly, most of our teachers have had no formal training in education. Some doctors are naturally talented in educating students, but many are not. This is classically seen when the student is taught by humiliation, which is patronising and not conducive to learning. Thirdly, the course does not seem to have any structure, with little communication between the firms and the medical school. It would be helpful if guidelines, such as a syllabus, were drawn up so that the student and the firm had a core on which to build. In nurse education the responsibility for training lies with a clinical nurse tutor as well as the ward staff. This tutor gives lectures and tutorials, liaises with ward staff, and deals with any problems a student might have. The tutor has had formal teaching in education, which is vital when dealing with students. This sort of system should be introduced into medical courses with clinical medical and surgical teachers. This system would relieve already hard pressed ward staff from their teaching duties, allowing them to get on with their primary responsibility, their patients. The tutor would be able to monitor students' progress, give formal training in practical techniques (which seems to be lacking), and also give the student a
721
good grounding in medicine on which to build as a postgraduate. IPETER G THATCHER
bringing these approaches together, for instance by estimating the area effect in relation to the effect of variation among practitioners within areas.
King's College School of Mcdicinc and Dentistry. London SE5 9PJ I
DEBORAH BAKER RUDOLF KLEIN
Correspondence. Undergraduatc medical education. BMJ
1991;
303: 244-6.\ 27 July .)
Explaining outputs of primary health care SIR,-The results presented by Dr Deborah Baker and Professor Rudolf Klein in their article on the role of population and practice factors in explaining outputs of primary health care could be misleading.' Their main objective was to examine whether variations in the activities of general practice among family health services authorities can be explained by the population characteristics and the organisation and resourcing of general practice. From the four examples investigated they showed that the standardised mortality ratios, the number of practitioners and the proportion aged over 65, and the number of ancillary staff per practitioner accounted for 69% of the variation in prescribing rates. The variation, however, related to the average prescribing rates for the 90 authorities, which were distributed with a coefficient of variation of only 13%. Each authority's rate is the average of between 75 and 500 general practitioners' individual rates. The coefficient of variation for prescribing rates for individual general practitioners will be several-fold greater than that for the authorities' means. Thus the four factors mentioned above may explain a much smaller percentage of the variation among general
practitioners. It is the idiosyncracies of individual practitioners (which the authors have explicity ignored) that are usually at the core of variability in referral rates and prescription rates among doctors. D L CROMBIE D M FLEMING
Royal College of General Practitioners, Birmingham B 17 9DB 1 Baker D, Klein R. Explaining outputs of primary health care: population and practice factors. BMJ 1991;303:225-9. (27
Centre for Analvsis of Social lPolicy, School of Social Sciences, University of Bath, Bath BA2 7AY
R B WOODWARD
I Robinson WS. Ecological correlations and the behaviour of indisiduals.American Soc tal Review 1950;15:351-7.
What your stereotypes may be reading SIR,-I was interested to read Dr Trisha Greenhaigh's review of medical columns in women's magazines' and heartened by the fact that the "light hearted smirk" with which she approached her task was replaced with respect for the quality and accuracy of most of what appears on our pages. I was bemused, however, by her assertion that "lost tampons, masturbating toddlers, and unmentionable fantasies still entertain readers of Woman's Weekly." No, they don't-and never have. Woman's Weekly's health column, written by the admirable Dr Penny Stanway (who bears very little resemblance to "the bespectacled, middle aged general practitioner" of Dr Greenhalgh's imagination) continues to present, accessibly but unsensationally, the facts about a variety of conditions and diseases, as well as news of research and answers to questions on topics suitable for family reading. In her quest for hyperbole and inaccurate reporting Dr Greenhalgh might have done better to turn her gaze from our pages towards her own. A case, perhaps, of "Physician, heal thyself?" JUDITH HALL
Editor, Woman's Weekly, IPC Magazines Ltd, London SE1 9LS I Greenhalgh T. What your stereotypes may be reading. BfMj
1991;303:475. (24 August.)
Fundholding: blight or blessing?
July.)
AUTHORS' REPLY,-We accept the valid statistical point made by Drs Crombie and Fleming, that the coefficient of variation for prescribing rates for individual general practitioners will be several-fold greater than that for the family health services authorities' means. Within the context of our study we have no scientific way of testing their hypothesis that the idiosyncracies of general practitioners are responsible for most of the variability in prescribing and referral. Our purpose was to compare activity of general practitioners at the aggregate level, among areas rather than among individual general practitioners. These are different levels of investigation: it would be unwise to assume that the associations produced at the aggregate level will also apply when comparing individual activity and thus fall foul of "the ecological fallacy." Robinson, in his classic illustration of this point, showed how correlations between literacy rates and ethnic group at an area level were very different from the associations observed at the individual level.' We suggest that variations in prescribing may be productively studied by using either the aggregate or the individual approach; different results emerging from such analyses may simply reflect the distinct impact of social and individualistic factors. In this context the important methodological challenge lies not in establishing that one approach is misleading and the other is not but in
722
commitment to patients' care. Ignoring needs such as this would be unthinkable. I agree wholeheartedly that these are days of rapid change and that serious debate about the advantages and perils of fundholding is needed. It is a pity that the debate is in danger of being submerged in hearsay and innuendo.
SIR, -I read Dr Martin Roland's article on fundholding with dismay. ' His statement that Triangle Health Care has given only six month contracts to the local hospitals that don't meet its standards is a considerable distortion of the truth. Our consortium has always given considerable thought to the effect that fundholding might have on the viability of the NHS. We have sought to maintain historical patterns of referrals to our usual five main hospitals, believing that we should work with them rather than "flex our new found muscles." Unfortunately, a problem arose involving lack of communication with one specialty in one hospital. We decided that we would, initially, not contract for a full 12 months while we tried to find a solution to the problem (which is serious). One of the options, of course, would be to refer our patients to another hospital - as has always been our right. We have as yet been unable to resolve this but have given the full 12 month contract to the hospital concerned in recognition of the difficulties that would otherwise ensue. I would also question Dr Roland's observation that "the average fundholder will think twice about referring a clumsy child to a child development centre knowing that the practice may have to pay for ongoing physiotherapy, speech therapy, and occupational therapy." My experience of the past 12 months leads me to believe that the average fundholder (whoever that is) has, over many meetings, thought long and hard about his or her
Chairman, Triangle Health Care, Ainsdale, Southport PR8 3HN 1 Roland M. Fundholding and cash limits in primary care: blight or blessing? BM 1991;303: 171-2. (20 July.)
Followed to the letter SIR,-There is an increasing tendency for letters from one doctor to another to be annotated "dictated but not signed," only sometimes to be followed by a signed copy. This is done, of course, to speed communication and facilitate treatmentbut where does the responsibility lie if something goes wrong? Transcription errors are easy to make but may be hard to spot. If patient injury results from such error who will shoulder the blame? A safety first procedure is for such letters to be returned to the author, immediately, for checking and signature. A less cumbersome approach would be to drop the practice. No journal would publish a letter that was "dictated but not signed." JOHN DOHERTY Birmingham B36 8AD
By any other name SIR,-Minerva's item on eponyms' reminds me of the two hazards of using them. The first is getting it wrong, as Minerva herself has done in her example. The syndrome of dysphagia, glossitis, and anaemia was first described in 1919 by Brown Kelly and Paterson-note the absence of a comma between Brown and Kelly: one person, not two. The second hazard, especially in an exam situation, is being asked who the eponymous person was. For the benefit of those who do not know, Adam Brown Kelly (surnames probably not hyphenated) was ear, nose, and throat surgeon to the Victoria Infirmary, Glasgow, and Donald Paterson was ear, nose, and throat surgeon to the Royal Infirmary, Cardiff. EWEN F FLINT Ear, Nose, and Throat Department, Dumfries and Galloway Royal Infirmary, Dumfries DG I 4AP 1 Minerva. BMJ 1991;303:530. (31 August.)
Correction Abortion rates still rising An editorial error occurred in this letter by Mr David T Baird. The symbols on the figure were transposed. The correct figure is given below. 16i 14-
p England and
/
912E
..
o
t10
/
8 8- d;/ 0
Wales(o)
Glasgow (a) Sotoand (o)
*Grampian(*)
6
c-6
t
0 0
Z 2
1970 1974 1976
BMJ
VOLUME
303
1980 1984 1988
21
SEPTEMBER
1991
