- Email: [email protected]
A Second Preregistration Year ?
318
effect of atrial stretch in reducing aldosterone secretion,25 though this has been questioned.26 Low aldosterone excretion was demonstrated in Ross’s four cases and in that of REES et al. 13 This, however, may not be the only reason for the natriuresis. REES et al. first reported aminoaciduria, glycosuria, and phosphaturia in this syndrome, which has since been noted by DALY et a1.,2’ and by Ross in two of his cases. These abnormalities suggest a proximal renal tubular lesion, and REES and his coworkers suggested that this was the only cause of the hyponatrxmia in their patient, in whom there was evidence of dehydration rather than overhydration. Studying this phenomenon more closely, Ross showed that in the two patients with aminoaciduria and glycosuria tubular " protein was also present in the urine, and that one of them showed an acidification defect after ammonium-chloride loading. Administration of aldosterone to the same patient resulted in a normal rate of reduction in renal sodium loss, indicating adequate distal tubular function. On the other hand, although in one of the patients without aminoaciduria, administration of 9a-fluorohydrocortisone resulted in almost total sodium retention and a water diuresis, in the patient with the presumed proximal tubular lesion large doses of the drug had little effect. Ross interpreted these findings as confirmation of the presence of normal proximal tubular reabsorption of sodium in the patient without aminoaciduria, in whom sodium loss was due to suppression of aldosterone secretion alone. In the patient with aminoaciduria, natriuresis is aggravated by the excessive sodium load reaching the distal tubule as a result of the proximal tubular lesion; and this could happen even in the presence of sodium-retaining steroids. The water diuresis after 9a-fluorohydrocortisone suggested A.D.H. suppression by steroids, a mechanism already demonstrated for glucocorticoids.28 It is thus clear that the hyponatrxmia of carcinoma of the bronchus is not always due to inappropriate A.D.H. secretion alone but may also be caused by a proximal renal tubular defect (in one case 13 this may have been the only cause). Whether the tubular lesion is the result of the potassium depletion demonstrated in some of these cases, as suggested by Ross, or whether it is yet another endocrine effect of the tumour is not apparent. Many questions remain unanswered about these syndromes associated with malignant disease. Why, for instance, should they arise most commonly with carcinoma of the bronchus ? Why should the cell type be relatively constant for any one syndrome ? Sometimes, it seems, more than one of the syndromes are present in the same patient: for instance, neuropathy has been reported in the hyponatrxmic syndrome.29 In the patients of REES et al. and DALY et al. there was evidence of early adrenal cortical overactivity as well as hyponatrocmia, and the first patient also had terminal hypercalcxmia. Perhaps these tumours may be capable of elaborating more than one hormone. Progress in the "
25.
Anderson, C. H., McCally, M., Farrell, G.
L.
Endocrinology, 1959, 64,
202. 26. 27. 28. 29.
Jones, N. F., Barraclough, M. A., Mills, I. H. Clin. Sci. 1963, 25, 449. Daly, J. J., Nelson, M. A., Rose, D. P. Postgrad. med. J. 1963, 39, 158. Dingman, J. F., Despointes, R. H. J. clin. Invest. 1960, 39, 1851. Ivy, H. K. Arch. intern. Med. 1961, 108, 115.
understanding of these processes may come from a combination of biochemical, histochemical, and embryological techniques. A Second
Preregistration Year
?
" MEDICAL education ", Sir CHARLES ILLINGWORTH says in the lecture which opens this issue, " is always worth discussing." But he goes on to suggest that a great deal of talk has produced palpably little action. The 1957 Recommendations of the General Medical Council on the medical curriculum were an open invitation to medical schools and universities to reform; but, though a number of enlightened proposals were provoked, undergraduate medicine remains very largely fixed in a nineteenth-century pattern. The reasons are complex, but they are probably rooted partly in the rigid departmental structure of most medical faculties, and partly in the uneasy compromise between scientific teaching and practical experience which simultaneous graduation and professional qualification seem to demand. As new subjects find their way into the curriculum, they have to compete for teaching time and examination space with the old; and medical students are in some danger of being extinguished between the two. On top of these faults in undergraduate education, there are grounds for doubting whether the preregistration appointments are properly fulfilling their function, The quality of experience, supervision, and teaching obviously varies considerably, and the careful survey by Dr. HUTTON and his colleagues1 suggests that many young doctors find these posts inadequate as a preparation for practice. ILLINGWORTH believes that the substitution of a second preregistration year for the third clinical year of the undergraduate course might be doubly advantageous. In addition to strengthening his purely vocational training, it could hasten the young doctor’s development by giving him earlier responsibility under supervision, and at the same time enforce a drastic revision and rethinking of undergraduate education. This suggestion, though not entirely new, deserves very serious consideration. A six-year undergraduate course tends ultimately to defeat its own object. The beginning of the clinical period, however welcome, is something of an anticlimax after the strenuous 2nd M.B. course. The methods of learning are different, and the long course, lacking the immediate incentive of an examination, tends to drift. Some things that are taught seem irrelevant and even time-wasting, and there is a danger that the need to acquire a broad practical experience may fragment the course among a number of specialist appointments. The loss of a year might well lead to a more compact educational experience without weakening the basic preparation for professional
qualification. There are, of course, obvious difficulties. It is hard to separate science from practice in medicine; and clinical clerking with access to plenty of patients can contribute much to the scientific humanism which ILLINGWORTH rightly sees as the basis of undergraduate 1. Hutton, P.
W., Williams, Jan. 4, 1964, p. 38.
P.
O., Graves, J. C., Graves, V. Lancet,
319
education. Again, the basic course in London lasts only four anda half or five years, and, if it were shortened, there could be a risk that certification might come before the student was near enough to maturity. In any case the change could be justified only if it was clearly understood to be a means of transferring a part of professional training from the undergraduate to the graduate period-and not as a means of increasing the number of junior qualified staff in
hospitals. Annotations RECRUITMENT TO MEDICINE
NEARLY four years ago, in their second thoughts on the Willink report of 1957, Lafitte and Squire1 forecast that " unless there is immediate action, something like a crisis in the supply of doctors may emerge around 1964 ". Action was taken, and the annual input of British students to our medical schools has increased by about 20 % over the past three years: in 1960 there were 1788 admissions (almost down to the 1760 advocated by the Willink committee) ; in 1961, 1896; in 1962, 2047; and last October, 2153.2 Quoting these figures last week at a meeting of the Association for the Study of Medical Education, Dr. Albertine Winner, of the Ministry of Health, said that soon we hoped to have more information than ever before on which to base an estimate of this country’s future needs in medical man-power; but the task was still extremely difficult. There was plainly a need for more doctors, but just how many ? The Government had accepted the advice of the University Grants Committee that at least one new medical school should be planned; and existing schools had been asked to see what more they could do as a " crash measure ". But not everyone at the ASME meeting was confident that the Ministry had in mind an increase in medical-school places that would prove adequate-or that the Treasury’s reaction would enable the schools to respond effectively to the U.G.C.’s appeal. As Dr. H. B. May, dean of The London, saw it, things would be very different if the schools were provided with the E60.000 capital and the E4000 a year which, Dr. May budgeted, were needed to place each extra student. Other faculties, however, have had to double their intake without anything like this kind of support. The meeting was discussing recruitment to the profession, the subject of a valuable B.M.A. report3 in 1962: and it heard from several of the many headmasters, hcadmistresses, and other teachers present. Mr. Richard Knight, the Oundle headmaster, had asked some of his boys what qualities they thought were needed to make a good doctor. The mystical sense of vocation headed the poll, with patience second; intelligence came a bad eighth and honesty nowhere at all. Though Mr. Knight believed that three A levels with good grades was no mean achievement for a five-year course beginning at the age of 13, Prof. Douglas Hubble was convinced that this was the standard that should be maintained. Three 50 °o passes or better was the best index we had of a good and well-trained intelligence; and if the boy also said he wanted to become a doctor-well, Professor Hubble was tempted to leave it at that and impose no further selection procedures; and he 1. Lafitte, F., Squire, J. R. Lancet, 1960, ii, 538. 2. House of Commons Hansard, Dec. 19, 1963, col. 1495. 3. See Lancet, 1962, i, 1060.
would certainly not try to examine too closely the reasons for his choice. A recent analysisin Glasgow showed school examination results to be much better predictors of success than interviews; and the meeting seemed in the mood to scrap interviews altogether till two London deans declared themselves " still old-fashioned enough " to have interviews. Clear evidence of intellectual attainment was what everyone was seeking; and it was widely felt that success in examinations, in any subjects whatever, was one of the clearest signs. Many teachers were anxious to see a wider range of subjects in the entry requirements of medical schools; and Dr. F. B. Beswick referred to Manchester’s two-term course in biology (taken concurrently with 2nd M.B. work) for students with A levels in physics, chemistry, and mathematics. A recurrent difficulty was the need to award places before the A-level results were known (though Sheffield, for one, found it possible to wait for the news). Two solutions proposed were to hold the A-level examinations in December, or to start the university year in January. As it was, many had to share the August ordeal of Dr. J. M. Malins, who had restless summer nights after making 170 firm and binding offers when he had only 100 places to fill at Birmingham. It was certainly odd, Prof. J. H. F. Brotherston remarked, that we cunningly devised this examination so that the results came too late to be of any value in selection. The headmaster of Leeds Grammar School, Mr. E. E. Sabben-Clare, urged doctors to do what they could to support the efforts that were being made to remedy the terrible shortage of graduate teachers in science and mathematics. And he spoke sorrowfully of the questionmark hanging over the future of the maintained grammar schools and the direct-grant schools; comprehensive schools were satisfactory for the average and belowaverage pupils, but many people doubted whether they were able to bring out the best in the abler children. MORE ABOUT PARAINFLUENZA VIRUS TYPE 2
THE first of the parainfluenza viruses to be definitely isolated from man is now called type 2, although it was called croup-associated (C.A.) virus by Chanock5 and acute laryngotracheobronchitis (A.L.T.B.) virus by Beale and his colleagueswho first isolated it. As these names suggest, the virus was found in the respiratory secretions of young children admitted to hospital with a characteristic and severe disease. It has since been found in other similar cases, though in fact parainfluenza type-1 virus is probably a rather more important cause of the A.L.T.B. syndrome. 711 In fact in a recent study in Canada parainfluenza 1 virus was found in about 1 in 3 of 794 cases of A.L.T.B. and parainfluenza 2 in only 4 cases altogether.9 The isolation of parainfluenza 2 virus suggested that it caused the disease which affected the patients who were carrying it, but evidence was needed to prove this: it had to be shown that the virus could be recovered from cases but not from carefully matched subjects without respiratory disease, and that virus passed in the laboratory could cause disease when reinoculated to man. This information is now available. Anderson, J. R., Lennox, B., Low A. ibid. Jan. 11, 1964, p. 96. Chanock, R. M. J. exp. Med. 1956, 104, 555. Beale, A. J., McLeod, D. L., Stackiw, W., Rhodes, A. J. Brit. med. J. 1958, i, 302. 7. Parrott, R. H., Vargosko, A. J., Kim, H. W., Chanock, R. M. Amer. Rev. resp. Dis. 1963, 88, 73. 8. Ferris, A. A. Med. J. Aust. 1960, ii, 769. 9. McLean, D. M., Bach, R. D., Larke, R. P. B., McNaughton, G. A. Canad. med. Ass. J. 1963, 89, 1257. 4. 5. 6.
effect of atrial stretch in reducing aldosterone secretion,25 though this has been questioned.26 Low aldosterone excretion was demonstrated in Ross’s four cases and in that of REES et al. 13 This, however, may not be the only reason for the natriuresis. REES et al. first reported aminoaciduria, glycosuria, and phosphaturia in this syndrome, which has since been noted by DALY et a1.,2’ and by Ross in two of his cases. These abnormalities suggest a proximal renal tubular lesion, and REES and his coworkers suggested that this was the only cause of the hyponatrxmia in their patient, in whom there was evidence of dehydration rather than overhydration. Studying this phenomenon more closely, Ross showed that in the two patients with aminoaciduria and glycosuria tubular " protein was also present in the urine, and that one of them showed an acidification defect after ammonium-chloride loading. Administration of aldosterone to the same patient resulted in a normal rate of reduction in renal sodium loss, indicating adequate distal tubular function. On the other hand, although in one of the patients without aminoaciduria, administration of 9a-fluorohydrocortisone resulted in almost total sodium retention and a water diuresis, in the patient with the presumed proximal tubular lesion large doses of the drug had little effect. Ross interpreted these findings as confirmation of the presence of normal proximal tubular reabsorption of sodium in the patient without aminoaciduria, in whom sodium loss was due to suppression of aldosterone secretion alone. In the patient with aminoaciduria, natriuresis is aggravated by the excessive sodium load reaching the distal tubule as a result of the proximal tubular lesion; and this could happen even in the presence of sodium-retaining steroids. The water diuresis after 9a-fluorohydrocortisone suggested A.D.H. suppression by steroids, a mechanism already demonstrated for glucocorticoids.28 It is thus clear that the hyponatrxmia of carcinoma of the bronchus is not always due to inappropriate A.D.H. secretion alone but may also be caused by a proximal renal tubular defect (in one case 13 this may have been the only cause). Whether the tubular lesion is the result of the potassium depletion demonstrated in some of these cases, as suggested by Ross, or whether it is yet another endocrine effect of the tumour is not apparent. Many questions remain unanswered about these syndromes associated with malignant disease. Why, for instance, should they arise most commonly with carcinoma of the bronchus ? Why should the cell type be relatively constant for any one syndrome ? Sometimes, it seems, more than one of the syndromes are present in the same patient: for instance, neuropathy has been reported in the hyponatrxmic syndrome.29 In the patients of REES et al. and DALY et al. there was evidence of early adrenal cortical overactivity as well as hyponatrocmia, and the first patient also had terminal hypercalcxmia. Perhaps these tumours may be capable of elaborating more than one hormone. Progress in the "
25.
Anderson, C. H., McCally, M., Farrell, G.
L.
Endocrinology, 1959, 64,
202. 26. 27. 28. 29.
Jones, N. F., Barraclough, M. A., Mills, I. H. Clin. Sci. 1963, 25, 449. Daly, J. J., Nelson, M. A., Rose, D. P. Postgrad. med. J. 1963, 39, 158. Dingman, J. F., Despointes, R. H. J. clin. Invest. 1960, 39, 1851. Ivy, H. K. Arch. intern. Med. 1961, 108, 115.
understanding of these processes may come from a combination of biochemical, histochemical, and embryological techniques. A Second
Preregistration Year
?
" MEDICAL education ", Sir CHARLES ILLINGWORTH says in the lecture which opens this issue, " is always worth discussing." But he goes on to suggest that a great deal of talk has produced palpably little action. The 1957 Recommendations of the General Medical Council on the medical curriculum were an open invitation to medical schools and universities to reform; but, though a number of enlightened proposals were provoked, undergraduate medicine remains very largely fixed in a nineteenth-century pattern. The reasons are complex, but they are probably rooted partly in the rigid departmental structure of most medical faculties, and partly in the uneasy compromise between scientific teaching and practical experience which simultaneous graduation and professional qualification seem to demand. As new subjects find their way into the curriculum, they have to compete for teaching time and examination space with the old; and medical students are in some danger of being extinguished between the two. On top of these faults in undergraduate education, there are grounds for doubting whether the preregistration appointments are properly fulfilling their function, The quality of experience, supervision, and teaching obviously varies considerably, and the careful survey by Dr. HUTTON and his colleagues1 suggests that many young doctors find these posts inadequate as a preparation for practice. ILLINGWORTH believes that the substitution of a second preregistration year for the third clinical year of the undergraduate course might be doubly advantageous. In addition to strengthening his purely vocational training, it could hasten the young doctor’s development by giving him earlier responsibility under supervision, and at the same time enforce a drastic revision and rethinking of undergraduate education. This suggestion, though not entirely new, deserves very serious consideration. A six-year undergraduate course tends ultimately to defeat its own object. The beginning of the clinical period, however welcome, is something of an anticlimax after the strenuous 2nd M.B. course. The methods of learning are different, and the long course, lacking the immediate incentive of an examination, tends to drift. Some things that are taught seem irrelevant and even time-wasting, and there is a danger that the need to acquire a broad practical experience may fragment the course among a number of specialist appointments. The loss of a year might well lead to a more compact educational experience without weakening the basic preparation for professional
qualification. There are, of course, obvious difficulties. It is hard to separate science from practice in medicine; and clinical clerking with access to plenty of patients can contribute much to the scientific humanism which ILLINGWORTH rightly sees as the basis of undergraduate 1. Hutton, P.
W., Williams, Jan. 4, 1964, p. 38.
P.
O., Graves, J. C., Graves, V. Lancet,
319
education. Again, the basic course in London lasts only four anda half or five years, and, if it were shortened, there could be a risk that certification might come before the student was near enough to maturity. In any case the change could be justified only if it was clearly understood to be a means of transferring a part of professional training from the undergraduate to the graduate period-and not as a means of increasing the number of junior qualified staff in
hospitals. Annotations RECRUITMENT TO MEDICINE
NEARLY four years ago, in their second thoughts on the Willink report of 1957, Lafitte and Squire1 forecast that " unless there is immediate action, something like a crisis in the supply of doctors may emerge around 1964 ". Action was taken, and the annual input of British students to our medical schools has increased by about 20 % over the past three years: in 1960 there were 1788 admissions (almost down to the 1760 advocated by the Willink committee) ; in 1961, 1896; in 1962, 2047; and last October, 2153.2 Quoting these figures last week at a meeting of the Association for the Study of Medical Education, Dr. Albertine Winner, of the Ministry of Health, said that soon we hoped to have more information than ever before on which to base an estimate of this country’s future needs in medical man-power; but the task was still extremely difficult. There was plainly a need for more doctors, but just how many ? The Government had accepted the advice of the University Grants Committee that at least one new medical school should be planned; and existing schools had been asked to see what more they could do as a " crash measure ". But not everyone at the ASME meeting was confident that the Ministry had in mind an increase in medical-school places that would prove adequate-or that the Treasury’s reaction would enable the schools to respond effectively to the U.G.C.’s appeal. As Dr. H. B. May, dean of The London, saw it, things would be very different if the schools were provided with the E60.000 capital and the E4000 a year which, Dr. May budgeted, were needed to place each extra student. Other faculties, however, have had to double their intake without anything like this kind of support. The meeting was discussing recruitment to the profession, the subject of a valuable B.M.A. report3 in 1962: and it heard from several of the many headmasters, hcadmistresses, and other teachers present. Mr. Richard Knight, the Oundle headmaster, had asked some of his boys what qualities they thought were needed to make a good doctor. The mystical sense of vocation headed the poll, with patience second; intelligence came a bad eighth and honesty nowhere at all. Though Mr. Knight believed that three A levels with good grades was no mean achievement for a five-year course beginning at the age of 13, Prof. Douglas Hubble was convinced that this was the standard that should be maintained. Three 50 °o passes or better was the best index we had of a good and well-trained intelligence; and if the boy also said he wanted to become a doctor-well, Professor Hubble was tempted to leave it at that and impose no further selection procedures; and he 1. Lafitte, F., Squire, J. R. Lancet, 1960, ii, 538. 2. House of Commons Hansard, Dec. 19, 1963, col. 1495. 3. See Lancet, 1962, i, 1060.
would certainly not try to examine too closely the reasons for his choice. A recent analysisin Glasgow showed school examination results to be much better predictors of success than interviews; and the meeting seemed in the mood to scrap interviews altogether till two London deans declared themselves " still old-fashioned enough " to have interviews. Clear evidence of intellectual attainment was what everyone was seeking; and it was widely felt that success in examinations, in any subjects whatever, was one of the clearest signs. Many teachers were anxious to see a wider range of subjects in the entry requirements of medical schools; and Dr. F. B. Beswick referred to Manchester’s two-term course in biology (taken concurrently with 2nd M.B. work) for students with A levels in physics, chemistry, and mathematics. A recurrent difficulty was the need to award places before the A-level results were known (though Sheffield, for one, found it possible to wait for the news). Two solutions proposed were to hold the A-level examinations in December, or to start the university year in January. As it was, many had to share the August ordeal of Dr. J. M. Malins, who had restless summer nights after making 170 firm and binding offers when he had only 100 places to fill at Birmingham. It was certainly odd, Prof. J. H. F. Brotherston remarked, that we cunningly devised this examination so that the results came too late to be of any value in selection. The headmaster of Leeds Grammar School, Mr. E. E. Sabben-Clare, urged doctors to do what they could to support the efforts that were being made to remedy the terrible shortage of graduate teachers in science and mathematics. And he spoke sorrowfully of the questionmark hanging over the future of the maintained grammar schools and the direct-grant schools; comprehensive schools were satisfactory for the average and belowaverage pupils, but many people doubted whether they were able to bring out the best in the abler children. MORE ABOUT PARAINFLUENZA VIRUS TYPE 2
THE first of the parainfluenza viruses to be definitely isolated from man is now called type 2, although it was called croup-associated (C.A.) virus by Chanock5 and acute laryngotracheobronchitis (A.L.T.B.) virus by Beale and his colleagueswho first isolated it. As these names suggest, the virus was found in the respiratory secretions of young children admitted to hospital with a characteristic and severe disease. It has since been found in other similar cases, though in fact parainfluenza type-1 virus is probably a rather more important cause of the A.L.T.B. syndrome. 711 In fact in a recent study in Canada parainfluenza 1 virus was found in about 1 in 3 of 794 cases of A.L.T.B. and parainfluenza 2 in only 4 cases altogether.9 The isolation of parainfluenza 2 virus suggested that it caused the disease which affected the patients who were carrying it, but evidence was needed to prove this: it had to be shown that the virus could be recovered from cases but not from carefully matched subjects without respiratory disease, and that virus passed in the laboratory could cause disease when reinoculated to man. This information is now available. Anderson, J. R., Lennox, B., Low A. ibid. Jan. 11, 1964, p. 96. Chanock, R. M. J. exp. Med. 1956, 104, 555. Beale, A. J., McLeod, D. L., Stackiw, W., Rhodes, A. J. Brit. med. J. 1958, i, 302. 7. Parrott, R. H., Vargosko, A. J., Kim, H. W., Chanock, R. M. Amer. Rev. resp. Dis. 1963, 88, 73. 8. Ferris, A. A. Med. J. Aust. 1960, ii, 769. 9. McLean, D. M., Bach, R. D., Larke, R. P. B., McNaughton, G. A. Canad. med. Ass. J. 1963, 89, 1257. 4. 5. 6.