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AN INSURANCE-MEDICAL-EXAMINATION DUTY ?
1223
Letters
to
the Editor
ENGINEERING IN MECHANICAL MAN SIR,-May I be allowed to expand your observation in your annotation (May 20, p. 1094) implying that it is unlikely that one person can be educated to think creatively in the interdisciplinary field of medicine and engineering by adding, "unless he has been medically trained, possesses a striking mechanical aptitude, a gift for invention, enthusiasm, and an indestructible optimism to back his determination to overcome the age-old resistance to new ideas " ? In the United States, doctors are taking a two-year course in engineering to fit them for work in biomechanics. But unless they possess these attributes, it is unlikely that they will be able to fulfil their function adequately. It might be useful to examine the training of dental surgeons, who are well acquainted with the anatomy and physiology of human tissues and trained to apply mechanical principles to the treatment of dental disease and the replacement of lost tissues, with the result that modern dentistry contains an advanced and sophisticated technology, with techniques which may well be adapted to orthopaedics and other surgical specialties. Until recently, much of the medico-mechanical innovation has stemmed from the workshops of mechanically minded doctors and dentists, who have constructed prototypes of their inventions at great cost to themselves in time and money. Many first-class devices have resulted, but the immense cost of modern engineering technology has made these amateur efforts almost impossible to continue. Neither the Ministry of Health nor most of the foundations will support the vitally necessary feasibility studies on new ideas, and industry will not or cannot underwrite the cost of a project until development has reached a stage when clinical results can be shown and medical acceptance can be reasonably assessed. For these reasons, many valuable new ideas are stillborn, and our country is falling behind the United States, where a more liberal attitude to the medical inventor and adequate financial support for feasibility studies and development encourage medical invention and put that country in the forefront of medical engineering. The Medical
22
Engineering Development Trust, Seymour Street, London W.1.
JOHN BUNYAN.
AN INSURANCE-MEDICAL-EXAMINATION DUTY ?
SIR,-A man, aged 52, was recently referred to this hospital with florid malignant hypertension, his diastolic blood-pressure being 160-180 mm.Hg. He was refused life insurance one and a half years ago-not unreasonably, for his diastolic pressure was then 140-150 mm.Hg. What to my mind is unreasonable and irresponsible is that the insurance company did not pass on this information to the family doctor, or even suggest to the patient that he consult his doctor. Surely, the medical officers of insurance companies have a moral duty in this respect-even though their official duty is to assess the risk of early demise. Bristol Royal Hospital, Royal Infirmary Branch, Bristol 2.
GEOFFREY H. ROBB.
RENAL STONES AND SODIUM SIR,-Your annotation (April 22, p. 889) refers favourably to Modlin’s hypothesis about formation of renal stones. Modlin’s findings interest us very much in Kuwait, where heat disorders particularly salt depletion, are common medical problems; and the incidence of urinary calculi’ is high in our population irrespective of racial differences. It seems reasonable to assume that salt depletion, manifested by low serum-sodium level and
low urinary sodium output, may play a part in the process of renal-stone formation. In the summer months in Kuwait, adverse climatic conditions, such as high atmospheric temperature, increased relative humidity, and sand-storms may lead to excessive loss of sodium in sweat and consequently to hyponatrsmia. Absence of sodium chloride in urine or its presence in negligible amount are common findings in people suffering from heat disorders. They sweat heavily and ingest large amounts of water without increase in salt intake. A planned study has been set up to test Modlin’s hypothesis. Gastroenterology and Tropical Medicine Research Unit, S. N. SALEM. Emirie Hospital, Kuwait.
NATIONAL OR PERSONAL HEALTH SERVICE? SIR,-In his letter (April 22, p. 895) Mr. Brian Inglis raises a real difficulty in relating payment to the quantity and quality of medical service. Ex hypothesi the patient is not versed in medical expertise. The problem of assessing the value or efficacy of his medical adviser or attendant and surgeon seems a bar to relating payment to service. Five observations are relevant. One, the problem is not special to medical care. The layman knows little or nothing about law, architecture, insurance, or any subject in which he wishes to acquire knowledge: yet he must choose a lawyer, an architect, an underwriter, or a teacher, and assess his value. In the last analysis he must learn by experience, or the experience of others. But he can also use the advice of specialists who know the market: brokers or others who advise on the selection of insurances, stocks and shares, and mortgages. In a sense the family doctor is a medical broker who advises on the choice of a specialist physician or surgeon. Two, assessment of the quality of service of a family doctor is not feasible unless a patient can reject those who are unsatisfactory. Hence the importance of choice. Shaw’s characteristic mixture of sense and nonsense led him to the Chinese conundrum that relates the payments of doctors to their ability to keep their patients well. But Shaw did not see that this is what, in the long run, patients do. They don’t go on paying doctors who do not keep ill-health at bay as far as they can judge. Neither does a newspaper pay a lawyer whose negligence exposes it to repeated actions for libel. Doctors can become rich by treating patients only if they have a monopoly from which their patients cannot escape. No-one will pay a doctor more if there are others as good who will accept less; but that requires the freedom to dismiss and to choose: hence the case for a market in medicine. The parallel of the journalist paid by the line again illustrates the symptoms of monopoly. The newspaper industry could absorb the unnecessary costs of paying journalists five times only to the extent that they were monopolistic. Suppliers in competition with one another cannot blandly tolerate avoidable costs in the hope of passing them on to consumers. And there is no unavoidable monopoly in medicine unless it is created by the state. Three, however much technical advances may enable doctors to replace the bedside manner by scientific equipment, medical care will never wholly become skill in deploying potions or surgical instruments. The subjective elements will remain: not merely because rising incomes will enable patients to pay for personal attention to individual preference, convenience, and comfort but also because these are elements in effective medical therapy. And increasing sophistication will distinguish between the doctors of integrity and the loquacious mendicant. The patient cannot judge perfectly; but who better ? The Minister of Health ? I do not think we should accept too readily the notion of some medical technocrats that science will replace personal service: the general practitioner will remain, however much can be done by scientifically equipped health centres and
hospitals. Four, the patient’s capacity
to
judge is least
emergency, but it does not follow that medical
administered
by benevolent, paternalist autocrats.
in
a
crisis
or
be Most medi-
care
must
Letters
to
the Editor
ENGINEERING IN MECHANICAL MAN SIR,-May I be allowed to expand your observation in your annotation (May 20, p. 1094) implying that it is unlikely that one person can be educated to think creatively in the interdisciplinary field of medicine and engineering by adding, "unless he has been medically trained, possesses a striking mechanical aptitude, a gift for invention, enthusiasm, and an indestructible optimism to back his determination to overcome the age-old resistance to new ideas " ? In the United States, doctors are taking a two-year course in engineering to fit them for work in biomechanics. But unless they possess these attributes, it is unlikely that they will be able to fulfil their function adequately. It might be useful to examine the training of dental surgeons, who are well acquainted with the anatomy and physiology of human tissues and trained to apply mechanical principles to the treatment of dental disease and the replacement of lost tissues, with the result that modern dentistry contains an advanced and sophisticated technology, with techniques which may well be adapted to orthopaedics and other surgical specialties. Until recently, much of the medico-mechanical innovation has stemmed from the workshops of mechanically minded doctors and dentists, who have constructed prototypes of their inventions at great cost to themselves in time and money. Many first-class devices have resulted, but the immense cost of modern engineering technology has made these amateur efforts almost impossible to continue. Neither the Ministry of Health nor most of the foundations will support the vitally necessary feasibility studies on new ideas, and industry will not or cannot underwrite the cost of a project until development has reached a stage when clinical results can be shown and medical acceptance can be reasonably assessed. For these reasons, many valuable new ideas are stillborn, and our country is falling behind the United States, where a more liberal attitude to the medical inventor and adequate financial support for feasibility studies and development encourage medical invention and put that country in the forefront of medical engineering. The Medical
22
Engineering Development Trust, Seymour Street, London W.1.
JOHN BUNYAN.
AN INSURANCE-MEDICAL-EXAMINATION DUTY ?
SIR,-A man, aged 52, was recently referred to this hospital with florid malignant hypertension, his diastolic blood-pressure being 160-180 mm.Hg. He was refused life insurance one and a half years ago-not unreasonably, for his diastolic pressure was then 140-150 mm.Hg. What to my mind is unreasonable and irresponsible is that the insurance company did not pass on this information to the family doctor, or even suggest to the patient that he consult his doctor. Surely, the medical officers of insurance companies have a moral duty in this respect-even though their official duty is to assess the risk of early demise. Bristol Royal Hospital, Royal Infirmary Branch, Bristol 2.
GEOFFREY H. ROBB.
RENAL STONES AND SODIUM SIR,-Your annotation (April 22, p. 889) refers favourably to Modlin’s hypothesis about formation of renal stones. Modlin’s findings interest us very much in Kuwait, where heat disorders particularly salt depletion, are common medical problems; and the incidence of urinary calculi’ is high in our population irrespective of racial differences. It seems reasonable to assume that salt depletion, manifested by low serum-sodium level and
low urinary sodium output, may play a part in the process of renal-stone formation. In the summer months in Kuwait, adverse climatic conditions, such as high atmospheric temperature, increased relative humidity, and sand-storms may lead to excessive loss of sodium in sweat and consequently to hyponatrsmia. Absence of sodium chloride in urine or its presence in negligible amount are common findings in people suffering from heat disorders. They sweat heavily and ingest large amounts of water without increase in salt intake. A planned study has been set up to test Modlin’s hypothesis. Gastroenterology and Tropical Medicine Research Unit, S. N. SALEM. Emirie Hospital, Kuwait.
NATIONAL OR PERSONAL HEALTH SERVICE? SIR,-In his letter (April 22, p. 895) Mr. Brian Inglis raises a real difficulty in relating payment to the quantity and quality of medical service. Ex hypothesi the patient is not versed in medical expertise. The problem of assessing the value or efficacy of his medical adviser or attendant and surgeon seems a bar to relating payment to service. Five observations are relevant. One, the problem is not special to medical care. The layman knows little or nothing about law, architecture, insurance, or any subject in which he wishes to acquire knowledge: yet he must choose a lawyer, an architect, an underwriter, or a teacher, and assess his value. In the last analysis he must learn by experience, or the experience of others. But he can also use the advice of specialists who know the market: brokers or others who advise on the selection of insurances, stocks and shares, and mortgages. In a sense the family doctor is a medical broker who advises on the choice of a specialist physician or surgeon. Two, assessment of the quality of service of a family doctor is not feasible unless a patient can reject those who are unsatisfactory. Hence the importance of choice. Shaw’s characteristic mixture of sense and nonsense led him to the Chinese conundrum that relates the payments of doctors to their ability to keep their patients well. But Shaw did not see that this is what, in the long run, patients do. They don’t go on paying doctors who do not keep ill-health at bay as far as they can judge. Neither does a newspaper pay a lawyer whose negligence exposes it to repeated actions for libel. Doctors can become rich by treating patients only if they have a monopoly from which their patients cannot escape. No-one will pay a doctor more if there are others as good who will accept less; but that requires the freedom to dismiss and to choose: hence the case for a market in medicine. The parallel of the journalist paid by the line again illustrates the symptoms of monopoly. The newspaper industry could absorb the unnecessary costs of paying journalists five times only to the extent that they were monopolistic. Suppliers in competition with one another cannot blandly tolerate avoidable costs in the hope of passing them on to consumers. And there is no unavoidable monopoly in medicine unless it is created by the state. Three, however much technical advances may enable doctors to replace the bedside manner by scientific equipment, medical care will never wholly become skill in deploying potions or surgical instruments. The subjective elements will remain: not merely because rising incomes will enable patients to pay for personal attention to individual preference, convenience, and comfort but also because these are elements in effective medical therapy. And increasing sophistication will distinguish between the doctors of integrity and the loquacious mendicant. The patient cannot judge perfectly; but who better ? The Minister of Health ? I do not think we should accept too readily the notion of some medical technocrats that science will replace personal service: the general practitioner will remain, however much can be done by scientifically equipped health centres and
hospitals. Four, the patient’s capacity
to
judge is least
emergency, but it does not follow that medical
administered
by benevolent, paternalist autocrats.
in
a
crisis
or
be Most medi-
care
must