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AWARENESS DURING AN OPERATION
277
Letters
to
the Editor
HOW MANY DOCTORS DO WE NEED ?
SIR,-It is unfortunate that Dr. Last, who has contributed
positively to discussions of British medical manpower, should have found it necessary in his article (July 20, p. 166) to attack the Royal Commission on Medical Education’s suggestion that there should be a large increase in the intake of the medical schools. He argues that the " reasoning leading to this recommendation may be founded on an over-pessimistic view of future emigration of doctors and takes too little account of the opportunities for improving productivity in medicine In the first instance Dr. Last thinks that it " seems absurd to project a graph of the doctor-population quotient, which has almost doubled over the past fifty years, into the middle of the 21st century, since there would then be a doctor for every 100 of the population. We are not told why it is absurd. The 50% increase in the present ratio of doctors to population, proposed by the Royal Commission for the years 1965-95, is a rate of expansion which is less than the likely growth of the economy during that same thirty-year period. It should also be clear that part of the expansion recommended by the Royal Commission is of an emergency nature owing to the contraction of medical-school output between 1953 and 1964, when the number of British medical graduates fell from 1910 to 1511 so
per annum. Dr. Last -claims that the " deliberations of Government committees in the years since the 1939-45 war have produced There have, in fact, no less than four changes of policy been not " four changes of policy but two-the Willink Committee’s call for a decrease in medical-school intake, and the subsequent abandoning of that policy. Three of the four reports he mentions have called for the expansion of medical
output-the one which called for restriction is now (and was rather quickly) discredited. Dr. Last believes that the probable consequences of the new U.S. immigration laws will be less emigration to that country. On April 8, 1968, the Committee on Government Operations of the U.S. House of Representatives introduced " A Bill to Amend the Immigration and Nationality Act " (HR 16509).2
Dr. Last expects increasing medical productivity to take the edge off the need for the number of doctors called for by the Royal Commission, and some of the factors he considers in this context will undoubtedly result in increased medical productivity. However, it would be dangerous indeed to base a nation’s health-manpower needs upon hoped-for future increases in medical productivity. Rashi Fein,has lately estimated that medical productivity gains in the U.S., between 1967 and 1980, will total between 5 and 10%. This figure represents nothing more than the difference between the number of doctors estimated to be in supply (from U.S. and foreign services) and the number estimated to be in demand. In other words, productivity is what is counted upon when no other way can be found to make supply balance demand. This is particularly true when it is considered that most health-caredemand forecasts have a way of falling short of reality. Past experiences have been that increases in medical productivity have gone hand-in-hand with increasing medical demand. Particularly in Britain and the U.S., medical demand is racing ahead of both productivity increases and manpower output. Dr. Last concludes by reminding us that: (1) there may be better ways of spending the national income than on curative medical services; (2) medicine may already have more than its fair share of " talented recruits ", and that such people are urgently needed in other fields. But is it really impossible for Britain to increase its medical-school intake by an average of 100 per year over the next 25 years, as recommended by the Royal Commission, without denying other professions their fair share of talented recruits ? Can there really be such a paucity of talent in this country ? Britain will not solve its medical-manpower shortage by " productivity miracles or by imagining that emigration will stop by itself. Modest productivity gains and the organisation of a proper hospital staffing structure, together with the reforms proposed by the Royal Commission, might go a long way to heading off the emigration problem, but there would still be the need for the expansion of medical-school intake envisaged by the Royal Commission. "
Science
Policy Research Unit, University of Sussex, Brighton BNI 9QN.
OSCAR GISH.
"
The Bill is intended to eliminate an unintentional discrimination against immigration from [developed countries] while moderating the brain drain from [developing countries] "3 and seems likely to have an early passage through the American Congress. The proposed legislation would share the quota of
17,000 third-preference (professional) immigration places
formerly large-national-quota countries (developed countries) and formerly small-national-quota countries (in Asia and Africa primarily) on the basis of the 1967 (fiscal year) division, which was fairly evenly divided between developed and developing countries. It is strange to hear that the Royal Commission’s assumptions about emigration of doctors [300 per year] are curiously pessimistic ": if anything they are, not so curiously, optimistic. The last authoritative figure we have for British medical emigration is 500 per year.4 Therefore an assumption for future emigration of 300 per year is either realistic, in that the changes envisioned in medical care and education will decrease emigration, or optimistic, in that those changes will take several years to become effective, and that any fall in emigration is not likely to precede those changes but will, at best, respond to them only over a time. However, the optimism of the between
"
AWARENESS DURING AN OPERATION
SiR,—The problem of consequence of the
Royal Commission on Medical Education 1965-68. Cmnd. 3569. H.M. Stationery Office, 1968. 2. Scientific Brain Drain from the Developing Countries; Twenty-third Report by the Committee on Government Operations. House Report no. 1215, U.S.G.P.O. Washington, 1968. 3. Washington Newsletter issued by the U.K. Scientific Mission, Washington, D.C., June-July, 1968. 4. Ash, R., Mitchell, H. D. Br. med. J. 1968, i, 569. House of Commons Hansard, June 11, 1968, col. 22. 1.
during
an
operation
as
use
SAFE-PERIOD STATISTICS
Royal
Commission about the number of British doctors available to British medicine only underlines the desperate need to quickly bring its recommendations into effect.
awareness
of muscle relaxants with light anasthesia has lately been discussed.Ijointly describedI apparent unconsciousness due to muscle relaxants over 20 years ago when tubocurarine chloride was first used to modify the convulsions of electroconvulsive therapy (E.C.T.). In the case then reported, the patient had apparently not yet recovered from the effects of E.C.T., and was thought to be quite unaware of his surroundings. This lack of sensory awareness was only apparent and, after recovering, his recollections of the doctors’ conversation during resuscitation corroborated his claim that he was very much aware of what was going on. Cherry Knowle Hospital, A. GILLIS. Ryhope, Sunderland, co. Durham. a
SIR,-In quoting the figure of 7-2 pregnancies per 100 women-years for the condom from an English study in 1963,$ Mr. Peel (July 20, p. 168) omits to mention two important facts. The first is that the postpartum period of amenorrhoea was not deducted. Since the mean duration of marriage at Fein, R. The Doctor Shortage: An Economic Diagnosis; Brookings Institute, Washington, D.C. 1967. 6. Lancet, 1968, i, 1188. 7. Gillis, A., Webster, D. D. Br. med. J. 1947, i, 451. 8. Fisher, M. Med. Offr, 1963, 110, 175.
5.
p. 94.
Letters
to
the Editor
HOW MANY DOCTORS DO WE NEED ?
SIR,-It is unfortunate that Dr. Last, who has contributed
positively to discussions of British medical manpower, should have found it necessary in his article (July 20, p. 166) to attack the Royal Commission on Medical Education’s suggestion that there should be a large increase in the intake of the medical schools. He argues that the " reasoning leading to this recommendation may be founded on an over-pessimistic view of future emigration of doctors and takes too little account of the opportunities for improving productivity in medicine In the first instance Dr. Last thinks that it " seems absurd to project a graph of the doctor-population quotient, which has almost doubled over the past fifty years, into the middle of the 21st century, since there would then be a doctor for every 100 of the population. We are not told why it is absurd. The 50% increase in the present ratio of doctors to population, proposed by the Royal Commission for the years 1965-95, is a rate of expansion which is less than the likely growth of the economy during that same thirty-year period. It should also be clear that part of the expansion recommended by the Royal Commission is of an emergency nature owing to the contraction of medical-school output between 1953 and 1964, when the number of British medical graduates fell from 1910 to 1511 so
per annum. Dr. Last -claims that the " deliberations of Government committees in the years since the 1939-45 war have produced There have, in fact, no less than four changes of policy been not " four changes of policy but two-the Willink Committee’s call for a decrease in medical-school intake, and the subsequent abandoning of that policy. Three of the four reports he mentions have called for the expansion of medical
output-the one which called for restriction is now (and was rather quickly) discredited. Dr. Last believes that the probable consequences of the new U.S. immigration laws will be less emigration to that country. On April 8, 1968, the Committee on Government Operations of the U.S. House of Representatives introduced " A Bill to Amend the Immigration and Nationality Act " (HR 16509).2
Dr. Last expects increasing medical productivity to take the edge off the need for the number of doctors called for by the Royal Commission, and some of the factors he considers in this context will undoubtedly result in increased medical productivity. However, it would be dangerous indeed to base a nation’s health-manpower needs upon hoped-for future increases in medical productivity. Rashi Fein,has lately estimated that medical productivity gains in the U.S., between 1967 and 1980, will total between 5 and 10%. This figure represents nothing more than the difference between the number of doctors estimated to be in supply (from U.S. and foreign services) and the number estimated to be in demand. In other words, productivity is what is counted upon when no other way can be found to make supply balance demand. This is particularly true when it is considered that most health-caredemand forecasts have a way of falling short of reality. Past experiences have been that increases in medical productivity have gone hand-in-hand with increasing medical demand. Particularly in Britain and the U.S., medical demand is racing ahead of both productivity increases and manpower output. Dr. Last concludes by reminding us that: (1) there may be better ways of spending the national income than on curative medical services; (2) medicine may already have more than its fair share of " talented recruits ", and that such people are urgently needed in other fields. But is it really impossible for Britain to increase its medical-school intake by an average of 100 per year over the next 25 years, as recommended by the Royal Commission, without denying other professions their fair share of talented recruits ? Can there really be such a paucity of talent in this country ? Britain will not solve its medical-manpower shortage by " productivity miracles or by imagining that emigration will stop by itself. Modest productivity gains and the organisation of a proper hospital staffing structure, together with the reforms proposed by the Royal Commission, might go a long way to heading off the emigration problem, but there would still be the need for the expansion of medical-school intake envisaged by the Royal Commission. "
Science
Policy Research Unit, University of Sussex, Brighton BNI 9QN.
OSCAR GISH.
"
The Bill is intended to eliminate an unintentional discrimination against immigration from [developed countries] while moderating the brain drain from [developing countries] "3 and seems likely to have an early passage through the American Congress. The proposed legislation would share the quota of
17,000 third-preference (professional) immigration places
formerly large-national-quota countries (developed countries) and formerly small-national-quota countries (in Asia and Africa primarily) on the basis of the 1967 (fiscal year) division, which was fairly evenly divided between developed and developing countries. It is strange to hear that the Royal Commission’s assumptions about emigration of doctors [300 per year] are curiously pessimistic ": if anything they are, not so curiously, optimistic. The last authoritative figure we have for British medical emigration is 500 per year.4 Therefore an assumption for future emigration of 300 per year is either realistic, in that the changes envisioned in medical care and education will decrease emigration, or optimistic, in that those changes will take several years to become effective, and that any fall in emigration is not likely to precede those changes but will, at best, respond to them only over a time. However, the optimism of the between
"
AWARENESS DURING AN OPERATION
SiR,—The problem of consequence of the
Royal Commission on Medical Education 1965-68. Cmnd. 3569. H.M. Stationery Office, 1968. 2. Scientific Brain Drain from the Developing Countries; Twenty-third Report by the Committee on Government Operations. House Report no. 1215, U.S.G.P.O. Washington, 1968. 3. Washington Newsletter issued by the U.K. Scientific Mission, Washington, D.C., June-July, 1968. 4. Ash, R., Mitchell, H. D. Br. med. J. 1968, i, 569. House of Commons Hansard, June 11, 1968, col. 22. 1.
during
an
operation
as
use
SAFE-PERIOD STATISTICS
Royal
Commission about the number of British doctors available to British medicine only underlines the desperate need to quickly bring its recommendations into effect.
awareness
of muscle relaxants with light anasthesia has lately been discussed.Ijointly describedI apparent unconsciousness due to muscle relaxants over 20 years ago when tubocurarine chloride was first used to modify the convulsions of electroconvulsive therapy (E.C.T.). In the case then reported, the patient had apparently not yet recovered from the effects of E.C.T., and was thought to be quite unaware of his surroundings. This lack of sensory awareness was only apparent and, after recovering, his recollections of the doctors’ conversation during resuscitation corroborated his claim that he was very much aware of what was going on. Cherry Knowle Hospital, A. GILLIS. Ryhope, Sunderland, co. Durham. a
SIR,-In quoting the figure of 7-2 pregnancies per 100 women-years for the condom from an English study in 1963,$ Mr. Peel (July 20, p. 168) omits to mention two important facts. The first is that the postpartum period of amenorrhoea was not deducted. Since the mean duration of marriage at Fein, R. The Doctor Shortage: An Economic Diagnosis; Brookings Institute, Washington, D.C. 1967. 6. Lancet, 1968, i, 1188. 7. Gillis, A., Webster, D. D. Br. med. J. 1947, i, 451. 8. Fisher, M. Med. Offr, 1963, 110, 175.
5.
p. 94.