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CARDIOLOGY AS A SPECIALTY
1053
Annotations CARDIOLOGY AS A SPECIALTY
THE committee on cardiology of the Royal College of 2 Physicianshas reiterated its opinion, expressed in 1947,2 that a greater number of specialized consultant cardiologistsshould be appointed to our hospitals. It says that there should be a fully equipped department of cardiology at a main teaching hospital in every medical school; that a cardiologist should be appointed to every major hospital centre, where he would have a department "
including beds and outpatient sessions; and that one or more cardiologists should be appointed in every area where access to a major hospital is not easy. The " cardiologist is defined as " a physician trained in cardiology ", and "
recommendations
years’ training
are
after
made for
a
period
of
at
least five
registration.
All will agree with the committee that " cardiology remains an important part of medicine, and cannot, without danger to its own vitality, allow itself to become cut off from the larger whole ". But, as in 1947, we fear that some of its proposals may have just this separating effect. The proposed minimum requirements call for no work outside cardiology at any time after completion of a two-year registrarship in general medicine. Admittedly the training period cannot be indefinitely extended to provide deeper understanding of other subjects; but such understanding could be developed after training is completed. One way of encouraging this would be to appoint -in some of the smaller hospital centres, at leastdoctors who would work as general physicians as well as cardiologists. Even for research such appointments might prove fruitful; for progress in this subject, more perhaps than in most others, depends on knowledge of general medicine and acquaintance with other disciplines. Clinically, too, there is much to be said for the physiciancardiologist. It is one thing to have a regional cardiological centre where surgery is practised, intractable clinical problems are resolved, and research is encouraged. It is another to have pure cardiologists, in every major hospital centre and in every area where access to hospitals is difficult. This scheme consorts oddly with the committee’s view that recognition of specialized consultant cardiologists should in no way reduce the work or diminish the interest of general physicians in the many facets of cardiovascular disease." If specialists in cardiovascular diseases are to be readily available, they will erode the general physician’s already shrunken territory. Has the hospital service of the future any place at all in fact for the general physician ? This is the underlying question which needs to be deliberately faced. If present trends continue, it will answer itself. "
TUBERCULOSIS AMONG THE GURKHAS
OF the many ways of judging a medical service, none more valid than to measure it by the trust it inspires in those whom it serves. By this test the scheme which aims at eliminating tuberculosis among the Gurkhas in the British Army, and which has now been in operation for some years, ranks high. As part of a campaign to eradicate tuberculosis from the Brigade of Gurkhas and their families, a Gurkha sanatorium was established at Kinrara, a few miles outside Kuala Lumpur, in 1951 (the Gurkhas serve in Malaya,
perhaps is
1.
Royal College of Physicians of London: Committee report, October, 1958. 2. See Lancet, 1947, i, 873.
on
Cardiology;
Singapore, and Hong Kong). The sanatorium began with 18 beds; but within a few years the number of patients, including the families of soldiers, rose to 100 or more. These years of expansion coincided with the rapid increase in the scope and safety of surgery for pulmonary tuberculosis : and soon the Army authorities realised they must offer their patients the benefits of thoracic surgery as well those of the sanatorium. This involved the transfer of selected groups to this country, a task which needed more than skilled organisation, careful budgeting, and clinical judgment. Mackay-Dickrecently drew a vivid picture of some of the many difficulties encountered in getting the Gurkha soldier mentally attuned to the idea of having a planned operation on his chest for a chronic disease, particularly when it involves a journey across the world and removal of part of his lung. The difficulty was partly overcome by explaining to him that " we were all in the battle against the unseen enemy, the germ of tuberculosis, and that operation scars on the chest were really battle scars, the result of victory in the battle against tuberculosis ". The language may strike the medically sophisticated reader as over-dramatic; but it is well understood by the Gurkha. The emphasis is on the partnership between the patients and the medical and nursing staff, and at no time is this partnership more important than in the treatment of a chronic illness like tuberculosis-at no time put to a severer test. The patients, on the one hand, must have a clear idea of the difficulties ahead and of the doctors’ plans for overcoming them, and the doctor, for his part, must learn to appreciate the personal problems with which a long illness confronts his patients. The success of the Gurkha tuberculosis scheme reflects such a mutual understanding. The first 21 Gurkha patients left Kuala Lumpur by air in June, 1957, for surgical treatment at the Army Chest Centre in this country at the Connaught Hospital at Hindhead. 8 were operated on during the following month and could return to Malaya by sea in October; and 7 were accepted for further service in the Army. Since then well over 100 cases have been provisionally accepted for surgery, almost all for partial lung resection; and at present about 8 are being operated on every month. The medical interest of this work is considerable. All but a few of those accepted for resection have had at least twelve months’ uniform and carefully controlled chemotherapy; and bacteriological examination of the resected specimens has provided useful information with which to assess the value of chemotherapy in sterilising residual caseous foci.2 Some apparently solid areas of caseous or fibrocaseous disease cleared after twelve months or more of chemotherapy-an observation of much relevance in deciding when to operate, if at all. Chemotherapy is continued postoperatively for at least twelve months. Most of the patients are ultimately fit to resume their career in the Army: they are followed up and, when necessary, treated as outpatients. Those who return to Nepal as
supply of drugs; and it is hoped that radiological follow-up will eventually be possible. Mackay-Dick also envisages help from the World Health Organisation : " a tuberculin skin-test survey of Nepal, with successful B.C.G. vaccination of all negative reactors, together with chemotherapy for all infants and children under three years (in the absence of evidence of tuberculosis) would be a great first step in the conquest of receive three months’
1.
Mackay-Dick, J. N.A.P.T. Commonwealth Chest Conference, London,
2.
Mackay-Dick, J., Slattery, D. A. D. Brit. med. J. 1958, i, 888.
1958.
Annotations CARDIOLOGY AS A SPECIALTY
THE committee on cardiology of the Royal College of 2 Physicianshas reiterated its opinion, expressed in 1947,2 that a greater number of specialized consultant cardiologistsshould be appointed to our hospitals. It says that there should be a fully equipped department of cardiology at a main teaching hospital in every medical school; that a cardiologist should be appointed to every major hospital centre, where he would have a department "
including beds and outpatient sessions; and that one or more cardiologists should be appointed in every area where access to a major hospital is not easy. The " cardiologist is defined as " a physician trained in cardiology ", and "
recommendations
years’ training
are
after
made for
a
period
of
at
least five
registration.
All will agree with the committee that " cardiology remains an important part of medicine, and cannot, without danger to its own vitality, allow itself to become cut off from the larger whole ". But, as in 1947, we fear that some of its proposals may have just this separating effect. The proposed minimum requirements call for no work outside cardiology at any time after completion of a two-year registrarship in general medicine. Admittedly the training period cannot be indefinitely extended to provide deeper understanding of other subjects; but such understanding could be developed after training is completed. One way of encouraging this would be to appoint -in some of the smaller hospital centres, at leastdoctors who would work as general physicians as well as cardiologists. Even for research such appointments might prove fruitful; for progress in this subject, more perhaps than in most others, depends on knowledge of general medicine and acquaintance with other disciplines. Clinically, too, there is much to be said for the physiciancardiologist. It is one thing to have a regional cardiological centre where surgery is practised, intractable clinical problems are resolved, and research is encouraged. It is another to have pure cardiologists, in every major hospital centre and in every area where access to hospitals is difficult. This scheme consorts oddly with the committee’s view that recognition of specialized consultant cardiologists should in no way reduce the work or diminish the interest of general physicians in the many facets of cardiovascular disease." If specialists in cardiovascular diseases are to be readily available, they will erode the general physician’s already shrunken territory. Has the hospital service of the future any place at all in fact for the general physician ? This is the underlying question which needs to be deliberately faced. If present trends continue, it will answer itself. "
TUBERCULOSIS AMONG THE GURKHAS
OF the many ways of judging a medical service, none more valid than to measure it by the trust it inspires in those whom it serves. By this test the scheme which aims at eliminating tuberculosis among the Gurkhas in the British Army, and which has now been in operation for some years, ranks high. As part of a campaign to eradicate tuberculosis from the Brigade of Gurkhas and their families, a Gurkha sanatorium was established at Kinrara, a few miles outside Kuala Lumpur, in 1951 (the Gurkhas serve in Malaya,
perhaps is
1.
Royal College of Physicians of London: Committee report, October, 1958. 2. See Lancet, 1947, i, 873.
on
Cardiology;
Singapore, and Hong Kong). The sanatorium began with 18 beds; but within a few years the number of patients, including the families of soldiers, rose to 100 or more. These years of expansion coincided with the rapid increase in the scope and safety of surgery for pulmonary tuberculosis : and soon the Army authorities realised they must offer their patients the benefits of thoracic surgery as well those of the sanatorium. This involved the transfer of selected groups to this country, a task which needed more than skilled organisation, careful budgeting, and clinical judgment. Mackay-Dickrecently drew a vivid picture of some of the many difficulties encountered in getting the Gurkha soldier mentally attuned to the idea of having a planned operation on his chest for a chronic disease, particularly when it involves a journey across the world and removal of part of his lung. The difficulty was partly overcome by explaining to him that " we were all in the battle against the unseen enemy, the germ of tuberculosis, and that operation scars on the chest were really battle scars, the result of victory in the battle against tuberculosis ". The language may strike the medically sophisticated reader as over-dramatic; but it is well understood by the Gurkha. The emphasis is on the partnership between the patients and the medical and nursing staff, and at no time is this partnership more important than in the treatment of a chronic illness like tuberculosis-at no time put to a severer test. The patients, on the one hand, must have a clear idea of the difficulties ahead and of the doctors’ plans for overcoming them, and the doctor, for his part, must learn to appreciate the personal problems with which a long illness confronts his patients. The success of the Gurkha tuberculosis scheme reflects such a mutual understanding. The first 21 Gurkha patients left Kuala Lumpur by air in June, 1957, for surgical treatment at the Army Chest Centre in this country at the Connaught Hospital at Hindhead. 8 were operated on during the following month and could return to Malaya by sea in October; and 7 were accepted for further service in the Army. Since then well over 100 cases have been provisionally accepted for surgery, almost all for partial lung resection; and at present about 8 are being operated on every month. The medical interest of this work is considerable. All but a few of those accepted for resection have had at least twelve months’ uniform and carefully controlled chemotherapy; and bacteriological examination of the resected specimens has provided useful information with which to assess the value of chemotherapy in sterilising residual caseous foci.2 Some apparently solid areas of caseous or fibrocaseous disease cleared after twelve months or more of chemotherapy-an observation of much relevance in deciding when to operate, if at all. Chemotherapy is continued postoperatively for at least twelve months. Most of the patients are ultimately fit to resume their career in the Army: they are followed up and, when necessary, treated as outpatients. Those who return to Nepal as
supply of drugs; and it is hoped that radiological follow-up will eventually be possible. Mackay-Dick also envisages help from the World Health Organisation : " a tuberculin skin-test survey of Nepal, with successful B.C.G. vaccination of all negative reactors, together with chemotherapy for all infants and children under three years (in the absence of evidence of tuberculosis) would be a great first step in the conquest of receive three months’
1.
Mackay-Dick, J. N.A.P.T. Commonwealth Chest Conference, London,
2.
Mackay-Dick, J., Slattery, D. A. D. Brit. med. J. 1958, i, 888.
1958.