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PSYCHOTHERAPY IN THE STUDENT HEALTH SERVICE
1236 Dr. Sanger (personal communication) to have apparently normal k and Kpb antigens. Nevertheless, the coexistence of a rare disease and a rare blood-type in at least four and probably five patients provides very strong evidence for some association between the inherited defect in white-cell function and the aberrant expression on red cells of Kell locus (autosomal) genes. The nature of this association is currently unknown. In the two patients who had the Ko phenotype, the C.G.D. was shown to be X-linked. The mode of inheritance in the other three cases was not examined. The occurrence of a rare Kell phenotype is not necessarily associated with C.G.D. In Seattle, we have recently tested the white-cell function of a healthy woman (Peltz) with the Ko phenotype whose blood was sent by Dr. Bruce Chown. The normal behaviour of her white cells in both staphylocidal activity and quantitative iodination was consistent with the assumption4 that her red-cell phenotype is due to homozygosity for a rare Ko gene. The main reason for this letter is to call attention to the potential transfusion hazards of the C.G.D./Kell-system association. Thus, we urge physicians who have patients with C.G.D. to determine their Kell phenotypes, using at least anti-K and anti-k, and preferably the other Kellsystem antibodies as well. Those with Ko or McLeod phenotypes should not be transfused unless their clinical situation is desperate. Conversely, the diagnosis of C.G.D. should be suspected in any child with recurrent infections for whom it is very difficult to find compatible blood. King County Central Blood Bank, Inc. and University of Washington School of Medicine. U.S. Public Health Service Hospital and University of Washington School of Medicine, Seattle, Washington 98105.
ELOISE R. GIBLETT. SEYMOUR J. KLEBANOFF STEPHANIE H. PINCUS.
JANE SWANSON University of Minnesota Hospitals, Minneapolis, Minnesota.
B. H. PARK JEFFREY MCCULLOUGH.
absence of gross dyskinesis, aneurysm formation, or persistent heart-failure, there seems little reason to prevent patients returning to a normal active life within six weeks of the coronary event. St. Vincent’s Hospital, Dublin 4.
RISTEARD MULCAHY.
PSYCHOTHERAPY IN THE STUDENT HEALTH SERVICE SIR,-Publication invites comment and criticism. Dr. Woodmansey’s article (May 29, p. 1122) deserves both. If I understand his thesis aright, mentally sick students are diagnosed by a student health physician or psychiatrist, and then referred for psychotherapy to tutors in social studies in their university. These apparently are employed because of a lack of suitably qualified medical personnel, and because they need practise " to develop their own casework skill ". Presumably because of their inexperience they in turn require " therapeutic support " from the consultant psychotherapist. For reasons which are not clear to me, the consultant psychotherapist has no direct dealings with the patients. Perhaps one is justified in asking why " therapeutic support " is not provided directly to the patients who need it, rather than to the social workers who cannot do the job unaided. Delegation is one thing: " covering" of lay personnel, who need to keep their hand in, is another, particularly when no personal assessment of the patients has been made by the doctor presumably responsible for the treatment. So much for the ethical aspects. With respect to the scientific aspects, we are asked to accept as a basis for further promotion of this work that " a number of severely disturbed students seem to have derived considerable benefit ". What number, and how much benefit ? And what about controls, or a trial of antidepressants ? The vagueness pertaining to the results might better have been applied to the assertions in the section " The Need for Psycho-
therapy ". PSYCHOLOGICAL HAZARDS OF CONVALESCENCE AFTER MYOCARDIAL INFARCTION
SIR,-Your editorial (May 22, p. 1055) emphasises a number of important p3ints which are often neglected in the rehabilitation of patients with coronary heart-disease. The failure to return patients with myocardial infarction to work quickly can be attributed to a number of attitudes. A principal one is lack of interest by physicians and cardiologists in long-term continuing care, and another is the cautious and restrictive attitude adopted towards these
patients. The purpose of this letter is to comment on a possibly restrictive recommendation in your editorial. You say that hard physical activity should not be undertaken within the first three months after an attack. On what evidence do you base this recommendation ? In our experience many patients with uncomplicated infarction are back to work well within the three-month period, and we do not advise them to restrict their physical activity in any way. We have reason to believe that the subsequent morbidity and mortality experience of these patients, as reported, are at least as good as the experience reported from other centres. You base your advice on the fact that healing of the infarct and the formation of firm fibrous tissue is not complete for six to twelve weeks. However, except possibly in the case of some large infarcts with dyskinesis or aneurysm formation, we can be confident of the integrity of the infarct within a week or two of the heart-attack. In the 1.
Mulcahy, R., Hickey,
N.
Scand. J. Rehab. Med. 1970, 2,
108.
such as this one described by Dr. would be less subject to the " sceptical which seems to hurt the feelings of social workers so much if " rigorous assessment " were applied to the work presented, rather than that promised. Treatment
policies
Woodmansey disapproval " Royal Devon
and Exeter Hospital, Exeter EX1 1PQ.
G. H. HALL.
TRAINING OF CHEMICAL PATHOLOGISTS
SiR,—Time for another airing of one of the hardy annuals of the medical scene; what training should the vanishing medical entrant to chemical pathology receive ? We feel a man who enters the chemical pathology laboratory for the first time, with his B.sc.Hons., his PH.D. in " preclinical biochemistry ", and his M.B. to boot (May 22) may well be trained in biochemistry, he will certainly be getting on in years, but he will still be a junior trainee in chemical pathology, several years away from his professional qualification (M.R.C.PATH.). In this respect Professor Lathe’s letter (May 1, p. 909), which advocates greater opportunity for the medical graduate to acquire suitable additional training within reasonable time-limits, is to be welcomed. Now that the primary examination for the M.R.C.PATH. can be taken by medical and non-medical graduates alike in chemical pathology alone, the case for pseudo "-chemical pathologists who are ineligible for or unable to pass the final M.R.C.PATH. is weaker than ever. Specialty training in medicine, whether clinical or laboratory, is still based on an apprenticeship system; surely the place to learn chemical pathology is in the "
ELOISE R. GIBLETT. SEYMOUR J. KLEBANOFF STEPHANIE H. PINCUS.
JANE SWANSON University of Minnesota Hospitals, Minneapolis, Minnesota.
B. H. PARK JEFFREY MCCULLOUGH.
absence of gross dyskinesis, aneurysm formation, or persistent heart-failure, there seems little reason to prevent patients returning to a normal active life within six weeks of the coronary event. St. Vincent’s Hospital, Dublin 4.
RISTEARD MULCAHY.
PSYCHOTHERAPY IN THE STUDENT HEALTH SERVICE SIR,-Publication invites comment and criticism. Dr. Woodmansey’s article (May 29, p. 1122) deserves both. If I understand his thesis aright, mentally sick students are diagnosed by a student health physician or psychiatrist, and then referred for psychotherapy to tutors in social studies in their university. These apparently are employed because of a lack of suitably qualified medical personnel, and because they need practise " to develop their own casework skill ". Presumably because of their inexperience they in turn require " therapeutic support " from the consultant psychotherapist. For reasons which are not clear to me, the consultant psychotherapist has no direct dealings with the patients. Perhaps one is justified in asking why " therapeutic support " is not provided directly to the patients who need it, rather than to the social workers who cannot do the job unaided. Delegation is one thing: " covering" of lay personnel, who need to keep their hand in, is another, particularly when no personal assessment of the patients has been made by the doctor presumably responsible for the treatment. So much for the ethical aspects. With respect to the scientific aspects, we are asked to accept as a basis for further promotion of this work that " a number of severely disturbed students seem to have derived considerable benefit ". What number, and how much benefit ? And what about controls, or a trial of antidepressants ? The vagueness pertaining to the results might better have been applied to the assertions in the section " The Need for Psycho-
therapy ". PSYCHOLOGICAL HAZARDS OF CONVALESCENCE AFTER MYOCARDIAL INFARCTION
SIR,-Your editorial (May 22, p. 1055) emphasises a number of important p3ints which are often neglected in the rehabilitation of patients with coronary heart-disease. The failure to return patients with myocardial infarction to work quickly can be attributed to a number of attitudes. A principal one is lack of interest by physicians and cardiologists in long-term continuing care, and another is the cautious and restrictive attitude adopted towards these
patients. The purpose of this letter is to comment on a possibly restrictive recommendation in your editorial. You say that hard physical activity should not be undertaken within the first three months after an attack. On what evidence do you base this recommendation ? In our experience many patients with uncomplicated infarction are back to work well within the three-month period, and we do not advise them to restrict their physical activity in any way. We have reason to believe that the subsequent morbidity and mortality experience of these patients, as reported, are at least as good as the experience reported from other centres. You base your advice on the fact that healing of the infarct and the formation of firm fibrous tissue is not complete for six to twelve weeks. However, except possibly in the case of some large infarcts with dyskinesis or aneurysm formation, we can be confident of the integrity of the infarct within a week or two of the heart-attack. In the 1.
Mulcahy, R., Hickey,
N.
Scand. J. Rehab. Med. 1970, 2,
108.
such as this one described by Dr. would be less subject to the " sceptical which seems to hurt the feelings of social workers so much if " rigorous assessment " were applied to the work presented, rather than that promised. Treatment
policies
Woodmansey disapproval " Royal Devon
and Exeter Hospital, Exeter EX1 1PQ.
G. H. HALL.
TRAINING OF CHEMICAL PATHOLOGISTS
SiR,—Time for another airing of one of the hardy annuals of the medical scene; what training should the vanishing medical entrant to chemical pathology receive ? We feel a man who enters the chemical pathology laboratory for the first time, with his B.sc.Hons., his PH.D. in " preclinical biochemistry ", and his M.B. to boot (May 22) may well be trained in biochemistry, he will certainly be getting on in years, but he will still be a junior trainee in chemical pathology, several years away from his professional qualification (M.R.C.PATH.). In this respect Professor Lathe’s letter (May 1, p. 909), which advocates greater opportunity for the medical graduate to acquire suitable additional training within reasonable time-limits, is to be welcomed. Now that the primary examination for the M.R.C.PATH. can be taken by medical and non-medical graduates alike in chemical pathology alone, the case for pseudo "-chemical pathologists who are ineligible for or unable to pass the final M.R.C.PATH. is weaker than ever. Specialty training in medicine, whether clinical or laboratory, is still based on an apprenticeship system; surely the place to learn chemical pathology is in the "