- Email: [email protected]
CONSULTANT AND SPECIALIST
1352 I’ll give you 100 ; it will keep you well-stocked. No use making extra journeys to the surgery. You are busy enough I am sure. I was just goin’ to say, doctor ... Yes, Sarah ? Are you givin’ me a recipe for them tablets ... the
same
.
ones ? I am indeed .
exactly the same
... er
...
that’s what you
’
want isn’t it ?
No please, doctor. They were very good but sick an’ they didn’t really relieve the ... The pain ? Well you wouldn’t call it a pain... *
*
they
made
me
saw
the
*
play without pleasure, being
more
concerned, he says, with his endogenous throbbings in the head than the emotional ones on the stage. When he returned home that night he couldn’t remove the cottonwool which had been well and truly packed and being a considerate person sat with his head in his hands all night because of his discomfort before calling his own doctor in the morning. *
*
*
In the routine history I asked : short of breath ? " "
" Do you
ever
"
*
*
My patient, an elderly lady with a broken hip, shares a room in hospital with a younger lady who has recently undergone pelvic surgery. Weaning the latter from her catheter has been difficult and two days ago her doctor tried hypnotic suggestion. She still has her catheter. But my patient complains that she should have been given ear-plugs-she has had frequency ever since. *
*
*
I had some difficulty in making my American friend understand how to get to his destination. " You take the left fork at the doss-house," I explained. " What is a doss-house ? " A doss-house is a place where tramps put up for a night." " What is a tramp ? " A vagrant, a vagabond, wayfarer, loafer..." He looked at me blankly. A hoofer, a hobo, someone dressed in old clothes with a straggly beard who lives on the road," I continued desperately. Now I get you," he exclaimed at last. " You mean a bum.’’ "
"
"
"
*
*
Science Fiction Footnote.-He and took her in his arms.
*
chemotaxied towards
this information. In many areas there is known to be resistance by the profession to the appointment of more consultants. Our traumatic service cannot deal adea with quately rising accident-rate, but the resistance to proposals for remedying this is mainly medical. The situation is urgent. Many in the profession feel unable to voice their opinions openly. Consultants, in part, because the system by which merit awards are made discourages outspokenness, while senior registrars and their juniors obviously cannot put themselves in a position which diminishes still further their meagre chance of
promotion. There is need for change and this can only come from outside the present administration. General-practitioner distribution is being ensured by statutory means. It is, essential for Parliament to set up a committee forthwith to obtain the facts, so carefully guarded, and to make recommendations for immediate implementation. This would ensure that " waiting " is not regarded as normal for our hospital population and that senior registrars get the consultant appointments for which they have been trained. Central Middlesex Hospital, London, N.W.10.
HORACE JOULES.
SiR,-Your leader (June 1) and the correspondence
Only
*
are nearly 500,000 people on our waiting-lists ; patients and practitioners weary of waiting for outpatient consultations, and senior registrars, trained to deal with this situation, are unable to find a satisfying outlet. There is a great disparity of consultant distribution throughout the country-the facts are known, but not published. You, Sir, must have obtained some insight into these in your recent partial survey. The Ministry will not reveal the recommendations made by working parties of senior consultants in each region some five years ago and the Consultants and Specialists Committee does not appear to have been very insistent in demanding
get
since I’ve been doing my present job." And what is that ? " " Carrying gas cookers." " Oh. Well, how many stairs can you climb before you get breathless ? " Oo, carrying a gas cooker, only about three flights." "
CONSULTANT AND SPECIALIST SiR,-Your article and leader of June 1 are well timed and should instil a sense of urgency into those responsible for our hospital services. Stated simply, the problem is that our present hospital provision does not meet the needs of outpatient consultation and investigation or inpatient treatment.
There
My friend has an inbred politeness which makes him unable to assert himself in small matters. His wife and he were at a London theatre and, just before the play started, his nose began to bleed. His technique, developed over the years, is not to fuss but hold his head over a basin and soon the bleeding stops. When he felt it coming on he accordingly left his seat and proceeded to a wash-basin. There the dripping went on as usual and was beginning to get less when a voice behind him said " Ah ! a nose-bleed. I’m a doctor. I’ll stop that for you." My friend protested, probably a little at a disadvantage with head forward and having to be careful where he aimed the blood, that he was quite all right, Was used to it, and that it would soon stop. The energetic doctor quickly returned with cotton-wool and despite spluttering protests proceeded to pack each nostril with what could have been an excess of therapeutic zeal, for when he had finished the patient said, in retrospect, he felt that his head was full of cotton-wool, and he felt faint. He asked if he could have a glass of brandy, a traditional syncopal remedy in which he had much faith, but the doctor said certainly not and that orange juice was the thing for him. Orange juice is anathema to this particular epistaxian, but having been shaken and probably speaking even more indistinctly he was unable to make this plain and at the point of the stethoscope he ingested a large glass of orange juice. The doctor
disappeared. My friend
Letters to the Editor
her
it have been headed Consultant and may be that at least some of our present discontents are linked with the circumstances which have caused this distinction to be created. In the days before the National Health Service, a patient looked in the first place, for medical advice and help, to his personal or family doctor, who gradually, as a consequence of the rise of specialism, came to be known as a general practitioner. When this personal medical attendant felt that he needed a second opinion, he called in a specialist of his choice, with whom he went into consultation. This was a conference between practitioners who were regarded as collaborators, and it was the personal attendant, and not the second opinion, who took the responsibility for the action which ensued from the meeting. If the patient could afford to pay for the specialist’s opinion, he was expected to do so, but if he could not, it was usual for him to go to a hospital or clinic at which the specialist gave his services freely, and as a consequence became known as an honorary surgeon or physician as the case might be. In some hospitals, each specialty might have more than one honorary accredited to it, and in such cases the senior honorary was designated accordingly. His juniors were specialists as he was, and in due time would probably step into his position. In the meantime, private consulting practice was open to the junior.
arising from Specialist. It
b
1353
point is that in that period a practitioner was called specialist because he practised a specialty, and when the word consultant was applied to him, it carried no implication that other specialists were of lower rank or had need of his supervision, although it was open to them to consult with him in a particular case if they The
a
so
wished. With the advent of the
health service, the word honorary " was no longer appropriate, and since the specialists concerned saw only patients referred to them general practitioners, they were given the title by " consultant." At the same time it was realised that some hospitals, mostly of the long-stay type, were giving treatment which was appropriate to the needs of the patients but could not be considered the practice of a specialty, and in others the assistant medical officers were working under the immediate supervision of a medical superintendent, and as a purely temporary expedient the title " senior hospital medical officer " was coined for such officers. At that time the criterion was the nature of the work carried out by the holder of the post, not his personal qualities or academic attainments ; the rate for the job," and it would be difficult in short, to quarrel with this principle. At that time the consultant appeared to be in line of succession to the pre-1948 honorary, and the s.H.M.o. was the successor of the hospital medical officer in the employ of local authorities and similar bodies, who provided treatment for patients who were in hospital for such long periods that they could no longer be regarded as being under the care of their own private or panel doctors. In the Terms and Conditions of Service of Hospital Medical and Dental Staff, published on June 7, 1949, s.H.M.o.s were defined as " senior officers performing clinical duties who are not of consultant status but not registrars." At this point it became clear that the criterion which defined the s.H.M.o. was not the nature of the work but the assessment of the holder of the post. On Oct. 5, 1950, circular R.H.B. (50) 96 appeared, and it became clear that the s.H.M.o. was now to be regarded, not as a senior practitioner who worked in hospital, but as a grade of specialist beneath the rank of consultant. and therefore suitable to be an assistant grade which would have the function of extending specialist treatment to fields which the existing consultants were not sufficiently numerous to cover, but which could be said to have consultant cover by reason of the supervision which the consultant was presumed to exercise over the s.H.M.o. At this point it became clear that the original understanding-that the s.H.M.o. grade was a temporary one which would tend to die out as the National Health Service developed-had been dropped. There is a widespread impression that it is proposed to perpetuate a species of subconsultant specialists in grade 111 of the Strachan proposals, at a rate in which the maximum would be comparable with the starting remuneration of the most junior consultant. It is difficult to imagine that any practitioner would accept this subordinate role as the summit of his ambitions. At present S.H.M.o.s constitute more than a third of the total specialist body, and if the impression is well founded, they might approach parity in numbers. The last paragraph of your editorial asserts that it is baseless to harbour a fear that the Ministry might ruthlessly seek to swell the ranks of specialists with the aim of securing cut-price consultants. Whether this is the Ministry’s aim is irrelevant. It would be the logical outcome if this impression proves to be well founded. C. B. V. WALKER. "
SiR,-I should like to support Dr. Herford’s views (June 15) which in many ways go to the rock bottom of our
principal troubles today.
it exists
in the National Health Service
as
If general practitioners had th’6 time and the inclination to do for their patients themselves all the work for which they were trained, to accept continuous care for them under all circumstances and all conditions, whether of body or mind, from the time they come on their lists till they depart or, die, if or when that becomes so, then
outpatient departments could become mere shadows of they once were. Consultants and specialists could
what
at long last have ample time to devote to those patients who were really in need of the services of a man of consultant rank, with consequent enormous saving in the
administration. With all due respect, Sir, I must entirely disagree with you when you suggest the appointment of assistant physicians and surgeons. Having made a special study of the working of the National Health Service since its inception, I am convinced that you may have the finest hospital and specialist staff in the world ; but if you have not got a first-class general-practitioner service as well you can no more wage a successful campaign against disease than can the general commanding an army in battle, who has been given a first-class team of experts to help him, but whose fighting troops are of poor quality. HAROLD LEESON. SEX DIFFERENCE IN GENETIC RISKS OF
RADIATION authorities on radiogenetics, among whom SiR,-Many Muller is one of the most prominent,1-s believe that increased radioactivity of the external medium, as a result of nuclear tests and of the peaceful utilisation of " heavy " nuclear energy, will prove detrimental to the future of the human race by unbalancing the ratio between the rate of mutations and the rate of eliminations. It is highly regrettable that humanity should waste enormous amounts of technical skill, money, and fissile material in merely destructive fields. Let us hope that in not too remote a day, common agreement of the great nuclear powers will stop this nonsensical bomb race. Nevertheless, the industrial use of atomic power faces humanity with serious problems, among which radioprotection is not the least important. I think that the present maximum permissible dose of ionising radiation (0-3r per week, which amounts to about 300-350r for the entire reproductive period of the human individual) is too high and needs urgent revision. But the possible genetic damage from irradiation may not be equal in both sexes. From a close scrutiny of the biology of reproductive cells of both sexes, it seems probable that male gametes are not so liable as the ova to transmit acquired radio-induced mutation. If we accept that the spontaneous mutation-rate found in mice is applicable to man, then one gene mutation per 40,000 gametes is likely to have little effect on the descendants,6 since millions of spermatozoa are produced, and only one (and we may suppose it the best qualified one) is accepted by the ovum. A monogenic mutation is likely to be transmitted only if the vast majority of male gametes bear it. Rare monogenic or oligogenic mutations, of the kind produced by ionising radiations, are likely to affect the biology of the bearer in such a way as not to permit it to compete with its brother gametes. On the other hand, the maturation-rate of spermatogonia and spermatocytes is so high that the accumulation of irradiation seems less perilous than for the female sexcells. The production and elimination of the ova is a slow process, during which radiations have time to act. one ovum takes part in the act of reproduction.
Only
1. Muller, H. J. 2. Muller, H. J. 3. Muller, H. J. 4. Muller, H. J. 5. Muller, H. J. 6. Sturtevant, A.
1954, 41, 5. Science, 1955, 121, 837. 199. J. hered. 1955, 46, Bull. atom. scient. 1955, 11, 329. Sci. Amer. 1955, 193, 58. H. Engng. Sci. 1955, 18, 9.
Acta radiol., Stockh.
same
.
ones ? I am indeed .
exactly the same
... er
...
that’s what you
’
want isn’t it ?
No please, doctor. They were very good but sick an’ they didn’t really relieve the ... The pain ? Well you wouldn’t call it a pain... *
*
they
made
me
saw
the
*
play without pleasure, being
more
concerned, he says, with his endogenous throbbings in the head than the emotional ones on the stage. When he returned home that night he couldn’t remove the cottonwool which had been well and truly packed and being a considerate person sat with his head in his hands all night because of his discomfort before calling his own doctor in the morning. *
*
*
In the routine history I asked : short of breath ? " "
" Do you
ever
"
*
*
My patient, an elderly lady with a broken hip, shares a room in hospital with a younger lady who has recently undergone pelvic surgery. Weaning the latter from her catheter has been difficult and two days ago her doctor tried hypnotic suggestion. She still has her catheter. But my patient complains that she should have been given ear-plugs-she has had frequency ever since. *
*
*
I had some difficulty in making my American friend understand how to get to his destination. " You take the left fork at the doss-house," I explained. " What is a doss-house ? " A doss-house is a place where tramps put up for a night." " What is a tramp ? " A vagrant, a vagabond, wayfarer, loafer..." He looked at me blankly. A hoofer, a hobo, someone dressed in old clothes with a straggly beard who lives on the road," I continued desperately. Now I get you," he exclaimed at last. " You mean a bum.’’ "
"
"
"
*
*
Science Fiction Footnote.-He and took her in his arms.
*
chemotaxied towards
this information. In many areas there is known to be resistance by the profession to the appointment of more consultants. Our traumatic service cannot deal adea with quately rising accident-rate, but the resistance to proposals for remedying this is mainly medical. The situation is urgent. Many in the profession feel unable to voice their opinions openly. Consultants, in part, because the system by which merit awards are made discourages outspokenness, while senior registrars and their juniors obviously cannot put themselves in a position which diminishes still further their meagre chance of
promotion. There is need for change and this can only come from outside the present administration. General-practitioner distribution is being ensured by statutory means. It is, essential for Parliament to set up a committee forthwith to obtain the facts, so carefully guarded, and to make recommendations for immediate implementation. This would ensure that " waiting " is not regarded as normal for our hospital population and that senior registrars get the consultant appointments for which they have been trained. Central Middlesex Hospital, London, N.W.10.
HORACE JOULES.
SiR,-Your leader (June 1) and the correspondence
Only
*
are nearly 500,000 people on our waiting-lists ; patients and practitioners weary of waiting for outpatient consultations, and senior registrars, trained to deal with this situation, are unable to find a satisfying outlet. There is a great disparity of consultant distribution throughout the country-the facts are known, but not published. You, Sir, must have obtained some insight into these in your recent partial survey. The Ministry will not reveal the recommendations made by working parties of senior consultants in each region some five years ago and the Consultants and Specialists Committee does not appear to have been very insistent in demanding
get
since I’ve been doing my present job." And what is that ? " " Carrying gas cookers." " Oh. Well, how many stairs can you climb before you get breathless ? " Oo, carrying a gas cooker, only about three flights." "
CONSULTANT AND SPECIALIST SiR,-Your article and leader of June 1 are well timed and should instil a sense of urgency into those responsible for our hospital services. Stated simply, the problem is that our present hospital provision does not meet the needs of outpatient consultation and investigation or inpatient treatment.
There
My friend has an inbred politeness which makes him unable to assert himself in small matters. His wife and he were at a London theatre and, just before the play started, his nose began to bleed. His technique, developed over the years, is not to fuss but hold his head over a basin and soon the bleeding stops. When he felt it coming on he accordingly left his seat and proceeded to a wash-basin. There the dripping went on as usual and was beginning to get less when a voice behind him said " Ah ! a nose-bleed. I’m a doctor. I’ll stop that for you." My friend protested, probably a little at a disadvantage with head forward and having to be careful where he aimed the blood, that he was quite all right, Was used to it, and that it would soon stop. The energetic doctor quickly returned with cotton-wool and despite spluttering protests proceeded to pack each nostril with what could have been an excess of therapeutic zeal, for when he had finished the patient said, in retrospect, he felt that his head was full of cotton-wool, and he felt faint. He asked if he could have a glass of brandy, a traditional syncopal remedy in which he had much faith, but the doctor said certainly not and that orange juice was the thing for him. Orange juice is anathema to this particular epistaxian, but having been shaken and probably speaking even more indistinctly he was unable to make this plain and at the point of the stethoscope he ingested a large glass of orange juice. The doctor
disappeared. My friend
Letters to the Editor
her
it have been headed Consultant and may be that at least some of our present discontents are linked with the circumstances which have caused this distinction to be created. In the days before the National Health Service, a patient looked in the first place, for medical advice and help, to his personal or family doctor, who gradually, as a consequence of the rise of specialism, came to be known as a general practitioner. When this personal medical attendant felt that he needed a second opinion, he called in a specialist of his choice, with whom he went into consultation. This was a conference between practitioners who were regarded as collaborators, and it was the personal attendant, and not the second opinion, who took the responsibility for the action which ensued from the meeting. If the patient could afford to pay for the specialist’s opinion, he was expected to do so, but if he could not, it was usual for him to go to a hospital or clinic at which the specialist gave his services freely, and as a consequence became known as an honorary surgeon or physician as the case might be. In some hospitals, each specialty might have more than one honorary accredited to it, and in such cases the senior honorary was designated accordingly. His juniors were specialists as he was, and in due time would probably step into his position. In the meantime, private consulting practice was open to the junior.
arising from Specialist. It
b
1353
point is that in that period a practitioner was called specialist because he practised a specialty, and when the word consultant was applied to him, it carried no implication that other specialists were of lower rank or had need of his supervision, although it was open to them to consult with him in a particular case if they The
a
so
wished. With the advent of the
health service, the word honorary " was no longer appropriate, and since the specialists concerned saw only patients referred to them general practitioners, they were given the title by " consultant." At the same time it was realised that some hospitals, mostly of the long-stay type, were giving treatment which was appropriate to the needs of the patients but could not be considered the practice of a specialty, and in others the assistant medical officers were working under the immediate supervision of a medical superintendent, and as a purely temporary expedient the title " senior hospital medical officer " was coined for such officers. At that time the criterion was the nature of the work carried out by the holder of the post, not his personal qualities or academic attainments ; the rate for the job," and it would be difficult in short, to quarrel with this principle. At that time the consultant appeared to be in line of succession to the pre-1948 honorary, and the s.H.M.o. was the successor of the hospital medical officer in the employ of local authorities and similar bodies, who provided treatment for patients who were in hospital for such long periods that they could no longer be regarded as being under the care of their own private or panel doctors. In the Terms and Conditions of Service of Hospital Medical and Dental Staff, published on June 7, 1949, s.H.M.o.s were defined as " senior officers performing clinical duties who are not of consultant status but not registrars." At this point it became clear that the criterion which defined the s.H.M.o. was not the nature of the work but the assessment of the holder of the post. On Oct. 5, 1950, circular R.H.B. (50) 96 appeared, and it became clear that the s.H.M.o. was now to be regarded, not as a senior practitioner who worked in hospital, but as a grade of specialist beneath the rank of consultant. and therefore suitable to be an assistant grade which would have the function of extending specialist treatment to fields which the existing consultants were not sufficiently numerous to cover, but which could be said to have consultant cover by reason of the supervision which the consultant was presumed to exercise over the s.H.M.o. At this point it became clear that the original understanding-that the s.H.M.o. grade was a temporary one which would tend to die out as the National Health Service developed-had been dropped. There is a widespread impression that it is proposed to perpetuate a species of subconsultant specialists in grade 111 of the Strachan proposals, at a rate in which the maximum would be comparable with the starting remuneration of the most junior consultant. It is difficult to imagine that any practitioner would accept this subordinate role as the summit of his ambitions. At present S.H.M.o.s constitute more than a third of the total specialist body, and if the impression is well founded, they might approach parity in numbers. The last paragraph of your editorial asserts that it is baseless to harbour a fear that the Ministry might ruthlessly seek to swell the ranks of specialists with the aim of securing cut-price consultants. Whether this is the Ministry’s aim is irrelevant. It would be the logical outcome if this impression proves to be well founded. C. B. V. WALKER. "
SiR,-I should like to support Dr. Herford’s views (June 15) which in many ways go to the rock bottom of our
principal troubles today.
it exists
in the National Health Service
as
If general practitioners had th’6 time and the inclination to do for their patients themselves all the work for which they were trained, to accept continuous care for them under all circumstances and all conditions, whether of body or mind, from the time they come on their lists till they depart or, die, if or when that becomes so, then
outpatient departments could become mere shadows of they once were. Consultants and specialists could
what
at long last have ample time to devote to those patients who were really in need of the services of a man of consultant rank, with consequent enormous saving in the
administration. With all due respect, Sir, I must entirely disagree with you when you suggest the appointment of assistant physicians and surgeons. Having made a special study of the working of the National Health Service since its inception, I am convinced that you may have the finest hospital and specialist staff in the world ; but if you have not got a first-class general-practitioner service as well you can no more wage a successful campaign against disease than can the general commanding an army in battle, who has been given a first-class team of experts to help him, but whose fighting troops are of poor quality. HAROLD LEESON. SEX DIFFERENCE IN GENETIC RISKS OF
RADIATION authorities on radiogenetics, among whom SiR,-Many Muller is one of the most prominent,1-s believe that increased radioactivity of the external medium, as a result of nuclear tests and of the peaceful utilisation of " heavy " nuclear energy, will prove detrimental to the future of the human race by unbalancing the ratio between the rate of mutations and the rate of eliminations. It is highly regrettable that humanity should waste enormous amounts of technical skill, money, and fissile material in merely destructive fields. Let us hope that in not too remote a day, common agreement of the great nuclear powers will stop this nonsensical bomb race. Nevertheless, the industrial use of atomic power faces humanity with serious problems, among which radioprotection is not the least important. I think that the present maximum permissible dose of ionising radiation (0-3r per week, which amounts to about 300-350r for the entire reproductive period of the human individual) is too high and needs urgent revision. But the possible genetic damage from irradiation may not be equal in both sexes. From a close scrutiny of the biology of reproductive cells of both sexes, it seems probable that male gametes are not so liable as the ova to transmit acquired radio-induced mutation. If we accept that the spontaneous mutation-rate found in mice is applicable to man, then one gene mutation per 40,000 gametes is likely to have little effect on the descendants,6 since millions of spermatozoa are produced, and only one (and we may suppose it the best qualified one) is accepted by the ovum. A monogenic mutation is likely to be transmitted only if the vast majority of male gametes bear it. Rare monogenic or oligogenic mutations, of the kind produced by ionising radiations, are likely to affect the biology of the bearer in such a way as not to permit it to compete with its brother gametes. On the other hand, the maturation-rate of spermatogonia and spermatocytes is so high that the accumulation of irradiation seems less perilous than for the female sexcells. The production and elimination of the ova is a slow process, during which radiations have time to act. one ovum takes part in the act of reproduction.
Only
1. Muller, H. J. 2. Muller, H. J. 3. Muller, H. J. 4. Muller, H. J. 5. Muller, H. J. 6. Sturtevant, A.
1954, 41, 5. Science, 1955, 121, 837. 199. J. hered. 1955, 46, Bull. atom. scient. 1955, 11, 329. Sci. Amer. 1955, 193, 58. H. Engng. Sci. 1955, 18, 9.
Acta radiol., Stockh.