- Email: [email protected]
FALLACIES IN MEDICAL EDUCATION
87
Round the World
Letters
U.S.A. A couple of years ago, when Robert McNamara as Secretary of Defense was busily phasing out military installations that had proved uneconomical, cars used to carry stickers on one bumper proclaiming " Go Navy " and on the other " Phase Out McNamara ". The methods of cost-benefit analysis that he had introduced stirred up great controversy, but now they seem to be generally accepted in the Department of Defense as well as in many large capitalist enterprises, and President Johnson has ordered similar schemes (known as planning programming budgetary systems or P.P.B.S.) to be introduced into other Government departments. The use of P.P.B.s. in the Department of Health, Education, and Welfare has lately been discussed in a series of articles in The Public
Interest.1
-
The man responsible for its introduction is William Gorham, assistant secretary for programme coordination in the department, and he owns that most Government decisions emerge from a political process, not a cost-analysis. The tools of analysis are still fairly primitive; the best they can do is to clarify some of the consequences of choice by displaying information about actual Government programmes, analysing costs of alternative methods, and by assessing the benefits of achieving the programmes’ objectives as quantitatively and
possible. He emphasises that nobody knows whether many Government programmes do any good, because data often do not exist, and would be difficult or costly to collect. Thus, with health expenditures it is often not known whether the patients get better. Moreover, benefits are often hard to define, and
fully
as
decide whether benefits to different citizens should be weighted equally: for this reason, P.P.B.S. cannot contribute much to deciding allocation of expenditure between such major categories as health, education, and welfare. But cost-effectiveness analysis may help in narrower choices between different health programmes, where the number of lives saved per dollar spent can be estimated. The process of analysis has the further merit of forcing people to think about the objectives of Government programmes and how to measure them. one must
Elizabeth Drew,
a
Washington journalist, describes
four
P.P.B.S. studies that were completed last year by the Department of Health, Education, and Welfare. One of these sought to compare different measures for disease-control in five
categories-road accidents, selected types of cancer, syphilis, tuberculosis, and arthritis. For example, in the accident category the value of preventing injury was estimated, includof medical care and loss of lifetime earnings in those Eight measures to reduce accidents-such as medical screening of candidates for drivers’ licences, educating the public not to drink, and promoting the use of seat-beltswere compared. A table gives for each measure the cost, financial reward, benefit/cost ratio, number of expected
ing
costs
killed.
deaths averted, and cost per life saved. The numbers in the table, however, seem (except for the calculated ratios) to be largely guesswork, and until data on the actual results of a
they are likely to remain so. pay off in the Department of Defense, and Miss Drew estimates that it will take longer in Health, Education, and Welfare. The last article, by Aaron Wildavsky, professor of political science in the University of California at Berkeley, is more philosophical and discursive. He considers that a single value should not triumph over other values, and that political rationality should be pursued with the same vigour and capability as economic efficiency.
given
to
the Editor
FALLACIES IN MEDICAL EDUCATION SIR,-Having recently emerged from the educational processes described by Professor Dornhorst and Dr. Hunter,! and being temporarily engaged in preclinical teaching, it was with interest that I read their analysis of the scientistic and pastoral fallacies which currently " vitiate thinking about medical education ". The difference between a rational appraisal of the role of general practitioners and some aspects of the " pastoral fallacy " which Professor Dornhorst and Dr. Hunter criticise, is not entirely clear. It is not only " cranks and faddists " who assert that some knowledge of social and preventive medicine may be useful, and to suggest that these subjects should be left to postgraduate education is to ignore the fact that such opportunities are strictly limited then. There is an unfortunate tendency for students to qualify with little or no idea of what goes on outside a teaching hospital and what will be expected of them. It would seem a mistake for specialists to brand efforts to remedy this as a "pastoral fallacy ", especially since the corollary of increasing specialisation is the greater importance of the more " pastoral " aspects of general practice. It is still possible to enter general practice with little knowledge of child health or disease, and very little grounding in the evaluation of statistics and clinical trials. Another example is that of family planning, which one would have thought was very much the province of a family doctor. Yet to my knowledge not one medical student in the country is comprehensively taught how to advise his patients about birth control and the techniques required. Indeed, any such training for this relies largely on an independent organisation after registration. It is an extraordinary reflection on the confusion of contemporary morality, both medical and otherwise, that scarcely any notice was taken of this fact during the recent publicity about abortion-law reform. There is, however, a good case for making some more realistic postgraduate requirements for general practice than the present preregistration year. A system of rotating internships would broaden preregistration experience, provide the necessary junior hospital staff, and might avoid some of the unnecessary administration and anxiety caused by junior doctors, often married, seeking new employment every six months. Such solutions lie largely in the hands of hospital specialists, but, until provision is made for them, the responsibility for training general practitioners rests firmly with the teaching hospitals and therefore again with hospital specialists. Those teaching hospitals which are moving out of central London to the more residential periphery have an opportunity of becoming the general hospitals for a local area and of functioning as an integral part of a community with strong ties with local practitioners to the benefit of all concerned, especially clinical students. Just as some integration of clinical material would make the preclinical course more stimulating, so would some contact with the external environment make the clinical course more relevant. Though advocating the first change, it is by no means clear whether Professor Dornhorst and Dr. Hunter would welcome the second. D. R. HANNAY. Manchester 13
programme are collected took about four years to
P.P.B.S.
1. The Public
Interest, Summer, 1967.
DOCTOR AS MANAGER
SIR,-Paradoxically, Dr. Hopkin (Dec. 30,
p.
1417)
appears
have demonstrated the converse of what he was attempting to. Because the funds available are limited it is even more important that hospital medical staff should be fully aware of the financial consequences of their actions. It is equally vital that the hospital management should be imaginative, decisive, and effective. Hospital management is concerned to see that
to
1.
Dornhorst, A. C., Hunter, A.
Lancet, 1967, ii,
666.
Round the World
Letters
U.S.A. A couple of years ago, when Robert McNamara as Secretary of Defense was busily phasing out military installations that had proved uneconomical, cars used to carry stickers on one bumper proclaiming " Go Navy " and on the other " Phase Out McNamara ". The methods of cost-benefit analysis that he had introduced stirred up great controversy, but now they seem to be generally accepted in the Department of Defense as well as in many large capitalist enterprises, and President Johnson has ordered similar schemes (known as planning programming budgetary systems or P.P.B.S.) to be introduced into other Government departments. The use of P.P.B.s. in the Department of Health, Education, and Welfare has lately been discussed in a series of articles in The Public
Interest.1
-
The man responsible for its introduction is William Gorham, assistant secretary for programme coordination in the department, and he owns that most Government decisions emerge from a political process, not a cost-analysis. The tools of analysis are still fairly primitive; the best they can do is to clarify some of the consequences of choice by displaying information about actual Government programmes, analysing costs of alternative methods, and by assessing the benefits of achieving the programmes’ objectives as quantitatively and
possible. He emphasises that nobody knows whether many Government programmes do any good, because data often do not exist, and would be difficult or costly to collect. Thus, with health expenditures it is often not known whether the patients get better. Moreover, benefits are often hard to define, and
fully
as
decide whether benefits to different citizens should be weighted equally: for this reason, P.P.B.S. cannot contribute much to deciding allocation of expenditure between such major categories as health, education, and welfare. But cost-effectiveness analysis may help in narrower choices between different health programmes, where the number of lives saved per dollar spent can be estimated. The process of analysis has the further merit of forcing people to think about the objectives of Government programmes and how to measure them. one must
Elizabeth Drew,
a
Washington journalist, describes
four
P.P.B.S. studies that were completed last year by the Department of Health, Education, and Welfare. One of these sought to compare different measures for disease-control in five
categories-road accidents, selected types of cancer, syphilis, tuberculosis, and arthritis. For example, in the accident category the value of preventing injury was estimated, includof medical care and loss of lifetime earnings in those Eight measures to reduce accidents-such as medical screening of candidates for drivers’ licences, educating the public not to drink, and promoting the use of seat-beltswere compared. A table gives for each measure the cost, financial reward, benefit/cost ratio, number of expected
ing
costs
killed.
deaths averted, and cost per life saved. The numbers in the table, however, seem (except for the calculated ratios) to be largely guesswork, and until data on the actual results of a
they are likely to remain so. pay off in the Department of Defense, and Miss Drew estimates that it will take longer in Health, Education, and Welfare. The last article, by Aaron Wildavsky, professor of political science in the University of California at Berkeley, is more philosophical and discursive. He considers that a single value should not triumph over other values, and that political rationality should be pursued with the same vigour and capability as economic efficiency.
given
to
the Editor
FALLACIES IN MEDICAL EDUCATION SIR,-Having recently emerged from the educational processes described by Professor Dornhorst and Dr. Hunter,! and being temporarily engaged in preclinical teaching, it was with interest that I read their analysis of the scientistic and pastoral fallacies which currently " vitiate thinking about medical education ". The difference between a rational appraisal of the role of general practitioners and some aspects of the " pastoral fallacy " which Professor Dornhorst and Dr. Hunter criticise, is not entirely clear. It is not only " cranks and faddists " who assert that some knowledge of social and preventive medicine may be useful, and to suggest that these subjects should be left to postgraduate education is to ignore the fact that such opportunities are strictly limited then. There is an unfortunate tendency for students to qualify with little or no idea of what goes on outside a teaching hospital and what will be expected of them. It would seem a mistake for specialists to brand efforts to remedy this as a "pastoral fallacy ", especially since the corollary of increasing specialisation is the greater importance of the more " pastoral " aspects of general practice. It is still possible to enter general practice with little knowledge of child health or disease, and very little grounding in the evaluation of statistics and clinical trials. Another example is that of family planning, which one would have thought was very much the province of a family doctor. Yet to my knowledge not one medical student in the country is comprehensively taught how to advise his patients about birth control and the techniques required. Indeed, any such training for this relies largely on an independent organisation after registration. It is an extraordinary reflection on the confusion of contemporary morality, both medical and otherwise, that scarcely any notice was taken of this fact during the recent publicity about abortion-law reform. There is, however, a good case for making some more realistic postgraduate requirements for general practice than the present preregistration year. A system of rotating internships would broaden preregistration experience, provide the necessary junior hospital staff, and might avoid some of the unnecessary administration and anxiety caused by junior doctors, often married, seeking new employment every six months. Such solutions lie largely in the hands of hospital specialists, but, until provision is made for them, the responsibility for training general practitioners rests firmly with the teaching hospitals and therefore again with hospital specialists. Those teaching hospitals which are moving out of central London to the more residential periphery have an opportunity of becoming the general hospitals for a local area and of functioning as an integral part of a community with strong ties with local practitioners to the benefit of all concerned, especially clinical students. Just as some integration of clinical material would make the preclinical course more stimulating, so would some contact with the external environment make the clinical course more relevant. Though advocating the first change, it is by no means clear whether Professor Dornhorst and Dr. Hunter would welcome the second. D. R. HANNAY. Manchester 13
programme are collected took about four years to
P.P.B.S.
1. The Public
Interest, Summer, 1967.
DOCTOR AS MANAGER
SIR,-Paradoxically, Dr. Hopkin (Dec. 30,
p.
1417)
appears
have demonstrated the converse of what he was attempting to. Because the funds available are limited it is even more important that hospital medical staff should be fully aware of the financial consequences of their actions. It is equally vital that the hospital management should be imaginative, decisive, and effective. Hospital management is concerned to see that
to
1.
Dornhorst, A. C., Hunter, A.
Lancet, 1967, ii,
666.