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ADVANCEMENT ALLOWANCES
498
In A
England Now
Letters to the Editor
Running Commentary by Peripatetic Correspondents
WHATEVER else may be said of Ardrey’s1 essay on comparative it does give one to think about parallels between animal and human behaviour. In the noyau of the godwit, for example, the members of the society are knit together in a constant state of mutual and abrasive antipathy; and then there is territory which seems to exist just to provide a periphery to defend-or attack. Invasion of a territory is accompanied by a great show of aggression and provokes an even stronger response in the defenders. There is a magnificent set-to, feathers (or fur) a-flying, and the aggressor duly retreats. Hardly anyone ever gets seriously hurt. It is all, in fact, ritual. S. has retired," writes my old friend, the senior physician, " and the Lab. is now a dull and earnest place. He often aggravated me and occasionally infuriated me, but it would take 6 of our present sort of pathologists to make one of him. It isn’t fun any more to take a specimen in on a Saturday morning." I’m working Saturday morning myself this week, with half a staff. The internists will invade my territory with their specimens which just must be examined and will ask me to see their patients. I shall dance my ritual dance of objection and they will dance with me, for we understand each other. Most of the specimens will be dealt with (if only by refrigeration) and the patients will be seen (if not till Monday). And honour will be satisfied. S. was a very good pathologist indeed, but he taught me more than he knew, long ago before the ethologists got wise to territory or anyone had heard of a noyau, when he made his display before a demanding physician on a Saturday morning. He knew his man and together they danced. It was fun. It still is. And it is essential if the patient is to be properly cared
ethology
"
for. ’*’
’*’
’*’
I know one or two people who combine medical teaching with writing, but my muse is a jealous-I was going to say bitch, but I can’t afford to insult her any more. I had been getting pretty desperate over a long unproductive spell all through term and the hangover of marking exams, and I promised my muse the week at Christmas, apart from the exigencies of family life. She took to this very well. She never lets me write in daylight, but at dusk each day I went straight from the garden to a bath (where she rather likes being wooed) and collected enough inspiration for a sturdy couple of thousand words before and after dinner, and a clear conscience to lie in almost to midday next morning. But this last evening of my holiday, with just one chapter to go, what happens ? No sooner have I relaxed in my bath and watched the steam rising out of it with a crunch, points at dreamily than she condenses " me accusingly and says You’ve a cheek, young man, asking me to call when you’re getting the 7.56 tomorrow morning. You can make up your mind whether it’s me or your work you want, but if there’s no breakfast in bed and a long lie-in afterwards, there’s no me ". And she sat on the bathroom stool upbraiding me, until she suddenly burst into tears and there was nothing to be seen of her except the drips on the bathroom wall. After that it was obvious that she wasn’t going to authorise a last chapter. But I suppose a good writer should have the guts to go it alone and make the most of what the muse offers, even if it’s a slap in the face with a cold loofah. ’*’
’*’
...
One of my duties as a port medical officer is to check the lists of ships engaged in international trade to confirm that crew members are protected against smallpox and yellow fever. The last entry on the crew list of a Norwegian oil tanker from Kristiansand read: name, Bissex; rank, ship’s-dog. The heading " state of smallpox and yellow-fever protection " had been crossed out and inserted in the space were the words " rabies vaccination certificate (dated 10-5-66)." crew
1.
Ardrey,
R. The Territorial
Imperative.
New
York, 1966.
ADVANCEMENT ALLOWANCES SiR,—This is a plea for the adoption, at least in principle, of the report recently circulated to all family doctors on the subject of additional allowances for special experience and service to general practice. At last we have a workable scheme for discussion which recognises the existence of quality amongst general practitioners. For years we have turned our backs on this question, fearing that invidious and unpopular comparisons may be made between one doctor and another. The selection procedure outlined in the report may not be acceptable to all, but it must be given a chance to prove itself before the scheme becomes cast away outright. Rejection of the plan will be a victory for the champions of mediocrity. Acceptance will show our faith in our own future as a large and respected branch of our profession, seeking to encourage high standards of work, both within and without the somewhat narrow vistas of our practices. Let us not be faint-hearted and let us give ourselves a chance to show what we are worth, both individually and collectively. D. S. NACHSHEN. London N.W.2.
LABORATORY LAW OF DIMINISHING RETURNS SIR,-Both clinicians and biochemists must sympathise with Dr. Robinson, who wrote last week (p. 433), and deplore the adverse effect that increasing tedium is having on laboratory standards. However, I, for one, cannot agree with his deduction implying that the sole answer lies in investing in automated analysis. The responsibility for the annual increment in laboratory work-load lies with the clinician. Any young doctor who has worked in an emergency laboratory service will tell how the requests for investigations from his young colleagues far exceed the benefit that even accurate results of these tests can bring The tendency to compensate for clinical to the patient. inexperience by superfluous demands on the biochemist is unfortunately perpetuated by the consultant who demands of his junior staff a quick answer to all the possibilities that may come to his mind when reviewing the patient. Small wonder that the houseman orders every possible investigation; even his career may be in jeopardy. Worse still the houseman may be under strain from competitive registrars engaging in the oneupmanship game. The enthusiasm of these young men would certainly be curbed if all intending physicians were required to spend a short period in the biochemical laboratory. Moreover, from this measure might arise a greater responsibility in teaching students the real value of laboratory tests. Another cause of concern is posed by those experienced clinicians whose training has not necessitated a mastery of laboratory investigation, and who would do better to rely on their laboratory colleagues as consultants in their respective specialties rather than as directors of a free-for-all laboratory service. There are many attitudes in the National Health Service that need to be changed. It is my opinion that the answer here lies not only in a rapprochement of clinician and pathologist or biochemist, but also in the establishment in each hospital of a discipline based on the classification of laboratory tests according to their use in patient-investigation (research and one-upmanship apart), with due regard to their expense and the time involved. Requests for such investigations should be staged in time as the clinical problem unravels, and exacting be supported by a senior signatory. No investigations should " investigation is routine ": each must be clearly justified. In so doing we shall produce better clinicians, and the laboratories will attract better biochemists who, one hopes, will have some time for fundamental investigations. Manchester
Royal Infirmary,
Oxford Road, Manchester 13.
E. N. WARDLE.
In A
England Now
Letters to the Editor
Running Commentary by Peripatetic Correspondents
WHATEVER else may be said of Ardrey’s1 essay on comparative it does give one to think about parallels between animal and human behaviour. In the noyau of the godwit, for example, the members of the society are knit together in a constant state of mutual and abrasive antipathy; and then there is territory which seems to exist just to provide a periphery to defend-or attack. Invasion of a territory is accompanied by a great show of aggression and provokes an even stronger response in the defenders. There is a magnificent set-to, feathers (or fur) a-flying, and the aggressor duly retreats. Hardly anyone ever gets seriously hurt. It is all, in fact, ritual. S. has retired," writes my old friend, the senior physician, " and the Lab. is now a dull and earnest place. He often aggravated me and occasionally infuriated me, but it would take 6 of our present sort of pathologists to make one of him. It isn’t fun any more to take a specimen in on a Saturday morning." I’m working Saturday morning myself this week, with half a staff. The internists will invade my territory with their specimens which just must be examined and will ask me to see their patients. I shall dance my ritual dance of objection and they will dance with me, for we understand each other. Most of the specimens will be dealt with (if only by refrigeration) and the patients will be seen (if not till Monday). And honour will be satisfied. S. was a very good pathologist indeed, but he taught me more than he knew, long ago before the ethologists got wise to territory or anyone had heard of a noyau, when he made his display before a demanding physician on a Saturday morning. He knew his man and together they danced. It was fun. It still is. And it is essential if the patient is to be properly cared
ethology
"
for. ’*’
’*’
’*’
I know one or two people who combine medical teaching with writing, but my muse is a jealous-I was going to say bitch, but I can’t afford to insult her any more. I had been getting pretty desperate over a long unproductive spell all through term and the hangover of marking exams, and I promised my muse the week at Christmas, apart from the exigencies of family life. She took to this very well. She never lets me write in daylight, but at dusk each day I went straight from the garden to a bath (where she rather likes being wooed) and collected enough inspiration for a sturdy couple of thousand words before and after dinner, and a clear conscience to lie in almost to midday next morning. But this last evening of my holiday, with just one chapter to go, what happens ? No sooner have I relaxed in my bath and watched the steam rising out of it with a crunch, points at dreamily than she condenses " me accusingly and says You’ve a cheek, young man, asking me to call when you’re getting the 7.56 tomorrow morning. You can make up your mind whether it’s me or your work you want, but if there’s no breakfast in bed and a long lie-in afterwards, there’s no me ". And she sat on the bathroom stool upbraiding me, until she suddenly burst into tears and there was nothing to be seen of her except the drips on the bathroom wall. After that it was obvious that she wasn’t going to authorise a last chapter. But I suppose a good writer should have the guts to go it alone and make the most of what the muse offers, even if it’s a slap in the face with a cold loofah. ’*’
’*’
...
One of my duties as a port medical officer is to check the lists of ships engaged in international trade to confirm that crew members are protected against smallpox and yellow fever. The last entry on the crew list of a Norwegian oil tanker from Kristiansand read: name, Bissex; rank, ship’s-dog. The heading " state of smallpox and yellow-fever protection " had been crossed out and inserted in the space were the words " rabies vaccination certificate (dated 10-5-66)." crew
1.
Ardrey,
R. The Territorial
Imperative.
New
York, 1966.
ADVANCEMENT ALLOWANCES SiR,—This is a plea for the adoption, at least in principle, of the report recently circulated to all family doctors on the subject of additional allowances for special experience and service to general practice. At last we have a workable scheme for discussion which recognises the existence of quality amongst general practitioners. For years we have turned our backs on this question, fearing that invidious and unpopular comparisons may be made between one doctor and another. The selection procedure outlined in the report may not be acceptable to all, but it must be given a chance to prove itself before the scheme becomes cast away outright. Rejection of the plan will be a victory for the champions of mediocrity. Acceptance will show our faith in our own future as a large and respected branch of our profession, seeking to encourage high standards of work, both within and without the somewhat narrow vistas of our practices. Let us not be faint-hearted and let us give ourselves a chance to show what we are worth, both individually and collectively. D. S. NACHSHEN. London N.W.2.
LABORATORY LAW OF DIMINISHING RETURNS SIR,-Both clinicians and biochemists must sympathise with Dr. Robinson, who wrote last week (p. 433), and deplore the adverse effect that increasing tedium is having on laboratory standards. However, I, for one, cannot agree with his deduction implying that the sole answer lies in investing in automated analysis. The responsibility for the annual increment in laboratory work-load lies with the clinician. Any young doctor who has worked in an emergency laboratory service will tell how the requests for investigations from his young colleagues far exceed the benefit that even accurate results of these tests can bring The tendency to compensate for clinical to the patient. inexperience by superfluous demands on the biochemist is unfortunately perpetuated by the consultant who demands of his junior staff a quick answer to all the possibilities that may come to his mind when reviewing the patient. Small wonder that the houseman orders every possible investigation; even his career may be in jeopardy. Worse still the houseman may be under strain from competitive registrars engaging in the oneupmanship game. The enthusiasm of these young men would certainly be curbed if all intending physicians were required to spend a short period in the biochemical laboratory. Moreover, from this measure might arise a greater responsibility in teaching students the real value of laboratory tests. Another cause of concern is posed by those experienced clinicians whose training has not necessitated a mastery of laboratory investigation, and who would do better to rely on their laboratory colleagues as consultants in their respective specialties rather than as directors of a free-for-all laboratory service. There are many attitudes in the National Health Service that need to be changed. It is my opinion that the answer here lies not only in a rapprochement of clinician and pathologist or biochemist, but also in the establishment in each hospital of a discipline based on the classification of laboratory tests according to their use in patient-investigation (research and one-upmanship apart), with due regard to their expense and the time involved. Requests for such investigations should be staged in time as the clinical problem unravels, and exacting be supported by a senior signatory. No investigations should " investigation is routine ": each must be clearly justified. In so doing we shall produce better clinicians, and the laboratories will attract better biochemists who, one hopes, will have some time for fundamental investigations. Manchester
Royal Infirmary,
Oxford Road, Manchester 13.
E. N. WARDLE.