- Email: [email protected]
A GOVERNMENT THAT ENCOURAGES SMOKING
366 COMMUNITY MEDICINE
Not
utilising informed consent runs its own design risks. The experimenter may unknowingly choose to enter only those patients who are not motivated enough to carry out the experimental regimen. (This is opposite to the claim that only excessively motivated people ever knowingly enter trials.) Unwitting subjects, who consider themselves only patients, may be too quick to juggle their regimen to suit themselves, without informing the physician who, unknown to them, is really an experimenter. These risks reduce control over the experiment, thus interfering with the reliability of the results. Reliability is a function of experimental design. Where informed consent interferes with quality of the design the investigator has to choose-accept less good data, rework the design, forego the data, or give up informed consent-and the choice is
one
of values.
Department of Humanities, College of Medicine, Pennsylvania State University, Hershey, Pennsylvania 17033, U.S.A.
ARTHUR ZUCHER
A GOVERNMENT THAT ENCOURAGES SMOKING
SIR,-In Norway legislation to ban all forms of cigarette advertising has led to a substantial drop in the number of Norwegian children who smoke (May 30, p. 1221). Brazil’s politicians think differently. Recently (Jornal do Brasil, July 24) the Secretary of Federal Revenue suggested to cigarette companies that they should organise an even more massive sales campaign, consequently raising the country’s income from taxation on industrialised products to a target of 250 000 million cruzeiros (1500 million) during 1981. Representatives of R. J. Reynolds, Philip Morris, Souza Cruz (British American Tobacco), and Sudam were warned that if cigarette sales did not rise these companies would have to pay bigger
interested in Dr Meade’s letter on the practice of p. 1214). The Faculty of Community Medicine exists to promote the interests of community medicine, improve the training of community physicians, and thereby enable the community physicians as a group to contribute to the profession’s understanding of the nature, cause, prevention, and treatment of disease.
SIR,-I
was
epidemiology (May 30,
The contention that the
provide training
Faculty of Community Medicine should
courses
for academics
must
be welcomed.
However, one of the main tasks of the Faculty is to maintain training standards, which include ensuring that community physicians are properly qualified. No other Faculty would envisage accreditation without, experience in the specialty. The Faculty of Community Medicine’s part i examination is not designed to help academics to understand epidemiology, it is designed to ensure that community physicians in training will get the information, education and experience concomitant with the development of their role. The Royal Colleges of Psychiatrists or Physicians would not envisage a situation where academic applicants were admitted to part i of their membership examination without training and experience in the National Health Service, and the same should be true for community medicine. The major difficulty is probably the schism between academic and service work, which we must all deplore. Academic epidemiologists could only benefit by experience in the N.H.S. and the N.H.S. should benefit by their contribution. This surely is the way forward-not to argue that service experience is unnecessary for the attainment of the part i examination. West Midlands R.H.A., Birmingham B 16 9PA
MARY E. BRENNAN
taxes.
The tax on cigarette sales is one of the main sources of income of the Brazilian government. Because of this, the politicians forget about the ill-effects of smoking and they forget that Brazil spends more on the treatment ofsmoking-related diseases than it earns from the tobacco companies. Brazilian health workers should mobilise to reverse this policy. The help of all interested groups will be welcome. Department of Maternal and Child Health, Universidade Católica de Pelotas, Pelotas-RS, Brazil
FERNANDO C. BARROS
HEALTH CARE COSTS AND THE MEDICAL CURRICULUM
SIR,-In their joint letter (July 25, p. 206) the presidents whose Royal Colleges administer the MRCP (UK), after remarking upon the lack of basic skills of an increasing number of candidates, say that this may be due to the introduction into the undergraduate curriculum of "non-clinical additions". They continue, almost paradoxically: "To-day ... investigations are more sophisticated and much more expensive, and... management more effective, but potentially more dangerous" and without care in assessment ...
"much money will be wasted and harm may
COSTING THE HOWIE REPORT
SIR,-Your note (Aug. p. 265) on my discussion paper on the Howie code of practice misses out on one essential point. My argument was that major policy changes in laboratory safety ought to be considered only after exploration of both costs and benefits. Current safety levels are much due to the application of commonsense precautions. The addition of expensive equipment may not necessarily result in major improvements in safety. One laboratory which rigidly enforces a rule forbidding the use of mouth pipettes is forced to install expensive safety cabinets because another laboratory is lax in enforcing this simple piece of common
1,
sense.
Aberdeen’s hospital laboratories are being made to spend anywhere up to 500 000 on upgrading, regardless of whether their current safety standards are high or low. This figure represents nothing more than the cost of upgrading equipment and facilities and says nothing about the need for improving standards, or by how much they are expected to improve as a result of the expenditure. Health Economics Research Unit, Department of Community Medicine, University Medical Buildings,
DAVID COHEN
Aberdeen AB9 2ZD
1. Cohen D. The Howie code: Is the price Unit, Aberdeen University, 1981.
of safety too high? Health
Economics Research
even
be done".
With these opinions few would dissent-save perhaps to remark that management is, or can be at least expensive as investigation. No, I suggest a paradox because avoidance of the waste of much money will only be achieved by insistence upon a fundamental "non-clinical addition"-namely, instruction and examination of both undergraduates and postgraduates in the science, and applied art, of costing health care. Or, more bluntly, to get maximum worth out of every pound, dollar, mark, franc, or yen available-from finite sources for infinite "need". Whether the source and system be by State or private purse or a combination is immaterial. What is, I believe, peculiar to our 33-year-old N.H.S. is that the doctors who man it have inevitably less experience (than those elsewhere in other systems) of market values and of the necessity to include an economic element in their therapeutic equation. Signing cheques on other people’s bank accounts cannot but tend towards this end.
To forestall replies, I do not advocate debasing the care of patients by the use of the cheapest-only that cost be considered. Still less do I suggest that because of this inherent weakness the N.H.S. should be replaced by some other system; awareness of the fault should lead to its correction. If some instruction were given (and precious little is at present) and if candidates in examinations knew that at least once they would be faced with this kind of compulsory question: "Discuss the
Not
utilising informed consent runs its own design risks. The experimenter may unknowingly choose to enter only those patients who are not motivated enough to carry out the experimental regimen. (This is opposite to the claim that only excessively motivated people ever knowingly enter trials.) Unwitting subjects, who consider themselves only patients, may be too quick to juggle their regimen to suit themselves, without informing the physician who, unknown to them, is really an experimenter. These risks reduce control over the experiment, thus interfering with the reliability of the results. Reliability is a function of experimental design. Where informed consent interferes with quality of the design the investigator has to choose-accept less good data, rework the design, forego the data, or give up informed consent-and the choice is
one
of values.
Department of Humanities, College of Medicine, Pennsylvania State University, Hershey, Pennsylvania 17033, U.S.A.
ARTHUR ZUCHER
A GOVERNMENT THAT ENCOURAGES SMOKING
SIR,-In Norway legislation to ban all forms of cigarette advertising has led to a substantial drop in the number of Norwegian children who smoke (May 30, p. 1221). Brazil’s politicians think differently. Recently (Jornal do Brasil, July 24) the Secretary of Federal Revenue suggested to cigarette companies that they should organise an even more massive sales campaign, consequently raising the country’s income from taxation on industrialised products to a target of 250 000 million cruzeiros (1500 million) during 1981. Representatives of R. J. Reynolds, Philip Morris, Souza Cruz (British American Tobacco), and Sudam were warned that if cigarette sales did not rise these companies would have to pay bigger
interested in Dr Meade’s letter on the practice of p. 1214). The Faculty of Community Medicine exists to promote the interests of community medicine, improve the training of community physicians, and thereby enable the community physicians as a group to contribute to the profession’s understanding of the nature, cause, prevention, and treatment of disease.
SIR,-I
was
epidemiology (May 30,
The contention that the
provide training
Faculty of Community Medicine should
courses
for academics
must
be welcomed.
However, one of the main tasks of the Faculty is to maintain training standards, which include ensuring that community physicians are properly qualified. No other Faculty would envisage accreditation without, experience in the specialty. The Faculty of Community Medicine’s part i examination is not designed to help academics to understand epidemiology, it is designed to ensure that community physicians in training will get the information, education and experience concomitant with the development of their role. The Royal Colleges of Psychiatrists or Physicians would not envisage a situation where academic applicants were admitted to part i of their membership examination without training and experience in the National Health Service, and the same should be true for community medicine. The major difficulty is probably the schism between academic and service work, which we must all deplore. Academic epidemiologists could only benefit by experience in the N.H.S. and the N.H.S. should benefit by their contribution. This surely is the way forward-not to argue that service experience is unnecessary for the attainment of the part i examination. West Midlands R.H.A., Birmingham B 16 9PA
MARY E. BRENNAN
taxes.
The tax on cigarette sales is one of the main sources of income of the Brazilian government. Because of this, the politicians forget about the ill-effects of smoking and they forget that Brazil spends more on the treatment ofsmoking-related diseases than it earns from the tobacco companies. Brazilian health workers should mobilise to reverse this policy. The help of all interested groups will be welcome. Department of Maternal and Child Health, Universidade Católica de Pelotas, Pelotas-RS, Brazil
FERNANDO C. BARROS
HEALTH CARE COSTS AND THE MEDICAL CURRICULUM
SIR,-In their joint letter (July 25, p. 206) the presidents whose Royal Colleges administer the MRCP (UK), after remarking upon the lack of basic skills of an increasing number of candidates, say that this may be due to the introduction into the undergraduate curriculum of "non-clinical additions". They continue, almost paradoxically: "To-day ... investigations are more sophisticated and much more expensive, and... management more effective, but potentially more dangerous" and without care in assessment ...
"much money will be wasted and harm may
COSTING THE HOWIE REPORT
SIR,-Your note (Aug. p. 265) on my discussion paper on the Howie code of practice misses out on one essential point. My argument was that major policy changes in laboratory safety ought to be considered only after exploration of both costs and benefits. Current safety levels are much due to the application of commonsense precautions. The addition of expensive equipment may not necessarily result in major improvements in safety. One laboratory which rigidly enforces a rule forbidding the use of mouth pipettes is forced to install expensive safety cabinets because another laboratory is lax in enforcing this simple piece of common
1,
sense.
Aberdeen’s hospital laboratories are being made to spend anywhere up to 500 000 on upgrading, regardless of whether their current safety standards are high or low. This figure represents nothing more than the cost of upgrading equipment and facilities and says nothing about the need for improving standards, or by how much they are expected to improve as a result of the expenditure. Health Economics Research Unit, Department of Community Medicine, University Medical Buildings,
DAVID COHEN
Aberdeen AB9 2ZD
1. Cohen D. The Howie code: Is the price Unit, Aberdeen University, 1981.
of safety too high? Health
Economics Research
even
be done".
With these opinions few would dissent-save perhaps to remark that management is, or can be at least expensive as investigation. No, I suggest a paradox because avoidance of the waste of much money will only be achieved by insistence upon a fundamental "non-clinical addition"-namely, instruction and examination of both undergraduates and postgraduates in the science, and applied art, of costing health care. Or, more bluntly, to get maximum worth out of every pound, dollar, mark, franc, or yen available-from finite sources for infinite "need". Whether the source and system be by State or private purse or a combination is immaterial. What is, I believe, peculiar to our 33-year-old N.H.S. is that the doctors who man it have inevitably less experience (than those elsewhere in other systems) of market values and of the necessity to include an economic element in their therapeutic equation. Signing cheques on other people’s bank accounts cannot but tend towards this end.
To forestall replies, I do not advocate debasing the care of patients by the use of the cheapest-only that cost be considered. Still less do I suggest that because of this inherent weakness the N.H.S. should be replaced by some other system; awareness of the fault should lead to its correction. If some instruction were given (and precious little is at present) and if candidates in examinations knew that at least once they would be faced with this kind of compulsory question: "Discuss the