- Email: [email protected]
CONSULTANTS' WORK LOAD
956 As Mrs Short admitted at the outset, the committee’s wide-ranging terms of reference have made it impossible for the M.p.s to look at every area of preventive medicine. But "we want if possible to get some ideas of how preventive medicine might replace some of the work that is now done and we hope save some money too, although perhaps that is being too ambitious". The M.p.s eventually found themselves concentrating on four areasnutrition, exercise, smoking, and alcohol. And as the evidence unfolded over the months it clearly showed that interest in these matters in Britain, particularly in the nation’s diet, was far less than in other countries. Prof. J. N. Morris, of the department of community health at the London School of Hygiene and Tropical Medicine, contrasted the low interest here with the "tremendous debate" going on in the United States between the medical lobby and agricultural and commercial interests about the levels of consumption of saturated fats and the effect which this debate has had on consumption. He referred to steps being taken in Finland to reduce the high rate of coronary heart-disease following public demand for community and Government action. Prof. E. M. Backett, professor of community health at Nottingham, said the Finns were switching their subsidies from butter to margarine. And the interest taken in this move by the committee suggests that the M.p.s might recommend something along these lines in this country. From the dietary point of view witnesses and committee were agreed that too often the wrong foods were being subsidised, making it virtually impossible to achieve Professor Morris’s aim of bringing about radical changes in our diet. Prof. John Yudkin, professor of nutrition in the University of London, who believes that sugar is the main dietary cause of ischaemic heart-disease, declared that what was required was intensive research into methods of persuading people to change their eating habits. This call for more research, echoed by most witnesses, is something on which the committee’s final report is bound to dwell. Professor Backett believed that the greatest need of all was for research ’into ways of preventing the progression of disease already present. He wanted to see large population studies to examine different methods of persuading people to alter their behaviour. He would find the money be reallocating funds from curative medicine. Not agrees,
unnaturally, the Health Education Council saying that the arguments for diverting resources from cure to prevention are overwhelming. Mr A. C. L. Mackie, the Council’s director-general, used the occasion of his appearance before the committee to attack the "extremely faint-hearted support" his Council received from the Department of Health and Social Security and the "absolutely massive inertia" in other Government departments. He protested at the enormous sum of money being poured unnecessarily into therapeutic medicine, for want of attention to the educative part of preventive medicine. At least one witness, Prof. C. E. Stroud, of the department of child health at King’s College Hospital Medical School, thought that doubling the Health Education Council’s incorre from 1 million to C,2 million would probably be one of the best investments of [1 million in health that could be made in this country.
Letters
to
the Editor
CONSULTANTS’ WORK LOAD
SIR,-Your issue of Apnl 3 contains contributions from Dr Loudon (p. 736), Mr Norcross (p. 737), and Dr Strube (p. 740): the important message in these contributions is that the supply of medical endeavour should be more clearly related to morbidity, that unnecessary work and expense should be avoided, and that this more economical matching of supply and demand can only be accomplished by doctors themselves. But how much "work" do consultants have to do? The prevalence of diseases withm a specialty and the referral-rates of patients will indicate some of a consultant’s work. In neurology, for example,I can calculate the rough probability of seeing a patient with any diagnosis. In the table I have used Kurland’s figures’ for neurological diseases. Consulting-rates were obtained from the O.P.C.S. morbidity survey2 and referralrates were had from the same source. The average population served by a general practitioner in England, is 2398.3 The average population served by one whole-time equivalent (W.T.E.) neurologist is 428 000.3 I do not suggest that all those referred with cerebrovascular disease, for example, will be seen by a neurologist rather than a physician. The point of the table is to give some indication of the relative frequency of various diseases, and the relative frequency of referral to hospital. Multiple sclerosis is generally considered to be.one of the commoner neurological diseases, yet a, neurologist will see about one new case a month. A neurologist will see about a quarter of all prevalent cases each year. Huntington’s chorea is a disease known by name to many, but a G.P. would have to practise for over 80 years before seeing a new case. The incidence of myasthenia gravis and syringomyelia, disorders which figure prominently in undergraduate medical texts, is even lower. Referred patients with non-specific symptoms such as headache are very numerous. For every new case of multiple sclerosis in the community there will be about 100 referrals for non-specific headache and migraine. Our department at St. Bartholomew’s Hospital, supported by the Department of Health and Social Security, is attempting to analyse the expectations of patients with headaches, and of their general practitioners, on referral to hospital, but a further interesting area for research would be a study of how a young doctor, taught in terms of the pathology and management of specific. diseases, learns to cope with the non-specific complaints encountered in general practice and hospital clinics. One way in which he copes seems to be by limiting new outpatient attendances. Consultants may remain confident that they will be asked to see as an "urgent" or "extra" case those patients who are "really" ill. The M.P. for Essex (South East) told. the House of Commons that "In one district general hospital patients have to wait as long as 12 or .13 weeks for an urgent outpatient appointment, and routine new patient appointments are not available at all [my italics] in ,the general surgery, E.N.T. and orthopaedic departments"." This means that consultants at this hospital will only see a patient if the G.P. considers it really necessary-and that should be the basis of all referrals. In support of the hypothesis of limitation by consultants of the supply of their time, I have examined the numbers of new outpatient attendances and discharges and deaths per W,T.f, consultant in various specialties in England (figs. 1 and 2). The numbers in the left-hand part of fig. 1 have been calculated by dividing the numbers of new patients attending outpatient clinics in various specialties in 1963 and 1973 by the z
.
1.
Kurland, L. Epidemiology of Neurologic and Sense Organ Disorders. Cambridge, Mass., 1973.
2 Office of
Population Censuses and Surveys Morbidity Statistics from General Practice, Second National Study 1970-1971. H.M. Stationery Office, 1974; and personal communication with O.P.C.S. 3. Department of Health and Social Security Health and Personal Social Services Statistics for England. H.M. Stationery Office, 1974. 4. Hansard, 1975, 898, no. 186. col. 1089.
957 REFERRAL-RATES FOR SOME NEUROLOGICAL CONDITIONS
numbers of consultants, adjusted to w.T.E., in the same specialties in 1963 and 1973.3 If a consultant has five clinics a week, a psychiatrist will see only 1 new patient in each clinic, and a general physician only 3 new patients in each clinic. These figures take no account of assistance from junior staff. While I share Dr Loudon’s reservations about equating "work-load" with numbers, it may fairly be said that such figures do not imply a crushing burden of work. Over the past ten years the numbers of new outpatients seen per consultant has declined in virtually every specialty (median percentage decline 29%). Data on numbers of reattendances illustrated in fig. 2 and on numbers of discharges and deaths illustrated in the right-hand part of fig. 1 show that those specialties with comparatively light burdens of new referrals are not those with many reattendances (the same proportion of reattendances per new referral is generated whatever the speaatty), nor necessarily those with large numbers of discharges
from, and deaths in, their inpatient service. For example,
pared with a general
com-
general physician has only half the number of new outpatient attendances, two thirds the number of discharges and deaths, a sixth of the number of day cases and none of the operating. The numbers of patients seen by many medical specialists are surprisingly small. The incidence and prevalence of the dissurgeon
a
with which the consultant has been trained to cope is also small, and most of his patients are referred with vague disorders which fit uncertainly into his conceotual framework of disease. The only way in which he can limit such referrals is by limiting the numbers he is prepared to see, relying on the G.P. to press him to see those cases he "really" needs to see. The "productivity" of consultants has declined considerably over the past ten years. There is nothing in these arguments to encourage the belief that increasing the number of consultants will result in a more effective service to patients. eases
958
2-Relation between attendances.
Fig.
new
outpatient
attendances and total
outpatient
All this does not mean that only those with "real disease" require help. Tuckettj and others have drawn a clear distinc-
tion between "illness" and "disease". There are those who are ill, but do not have diseases which require the technical resources of a hospital. We must find some way of coping with illness without the ritual of outpatient referral. These broader aspects of medical care have implications for undergraduate and postgraduate teaching and for medical staffing. I hope that the Royal Commission on the N.H.S. will consider them. Department of Neurology, St Bartholomew’s Hospital,
ANTHONY HOPKINS
London EC1A 7BE
CARE OF THE ELDERLY
Sip,—The report from the Royal College of Physicians and (April 10, p. 787) drawing attention to it are im-
your editorial
portant milestones on the way to better care for the elderly in Britain. The report is a thoughtful, constructive commentary on what is wrong with geriatric medicine, and where some of the solutions may lie. Rightly, it concentrates on recruitment and training as the most important problems. Young doctors, perhaps more able than their seniors to appreciate the demographic trends which will dictate the type of practice many will undertake in their working lives, by their experience as housephysicians of the influx of elderly patients to hospital, are interested in a career in geriatric medicine. Attitudes are slowly changing as the enormity of the problem filters through, but young doctors naturally remain apprehensive about entering a specialty which looks as if it will take the shine off their new M.R.C.P., and consign them to second-class citizenship. They need to be convinced that the specialty provides an intellectual challenge and will continue to do so. They rationalise their fears by saying that they would like to do acute medicine as well as their share of rehabilitation and long-term care. In doing so they are making a fundamental plea to practise good medicine. They want to see their patients through their illnesses, and to do so they need to be in at the beginning. Geriatrics has now come of age and has much to offer in the management of acute illness in the elderly. The time is past for geriatricians to stay in outlying units, worrying about their status, and taking patients from acute wards two or three months after their initial admissions for rehabilitation when
the game has already been lost. Their place is in the acute ward with their general and specialist colleagues, taking their share of emergencies and advising their colleagues on care of their elderly patients when necessary; channelling the patients to appropriate areas from the start; influencing junior staff by example; and teaching, teaching, teaching. Doctors in training must stay close to the care of the acutely ill because these are the skills that are most easily lost, and it is no easy matter to return to it after a year or two in a rehabilitation and long-stay unit. There is little chance nowadays that such a doctor will concentrate "more and more on acute medicine and less and less on his old people." The elderly form the bulk of all medical admissions and all physicians must learn to share in their care. The geriatrician should see himself as the patient’s ombudsman in the acute ward, but at the same time he is there to do it better than his general colleagues, and to teach them how. He can no longer afford to be a specialist (like the neurologist) and not to be responsible for acute unselected emergency referrals. How much time then does he spend on rehabilitation and in long-stay wards? Rehabilitation is difficult and demanding but the physician does not need to see patients in this area every day. His brief is to clearly define the aims, to ensure good staff morale, and to assess the patients’ progress regularly, but not necessarily daily. The management of long-stay wards is also important but need not be "time-consuming or disruptive" for the consultant. The Geriatrics Committee of the R.C.P. strike an unrealistic note when they say that "no one other than a specially trained doctor is likely to make much of the longerterm patient." Patients in this area in the main need total care, and they get it from first-class nursing care, good general-practitioner cover, occupational therapy, and voluntary visiting. The specially trained doctor has not much to add, but a weekly ward-round by the consultant (with perhaps a monthly discussion group) is essential if morale of staff is to be maintained. This work is often boring for the consultant but to neglect it is courting disaster. The term "geriatric" has done much harm to the patient and doctor alike, and its implication repells many who would embark on a career in the specialty. That career must be made more attractive and free from the loss of status, and bleak outlook that so many in the specialty still suffer. Junior doctors must never be made to feel that they have become something less than their M.R.c.P. indicates. It has trained them as acute physicians, and they cannot be expected to become rehabilitation experts and continuing-care specialists in the short time it takes them to get to a consultant post. These skills can only come with time and experience. I submit that it is not enough for the specialty to "act as pathfinders in the developing care and management of the elderly, and to set standards", as advocated by the Geriatrics Committee of R.C.P. The expertise of the specialty must be brought to bear as soon as the elderly patient enters hospital, and general physicians, if they have any sense, will welcome it into their midst. Department of Medicine (Geriatrics), General Hospital, Newcastle upon Tyne NE4 68E
FARMER’S LUNG: A NEGLECTED ANTIGEN
SIR,-Thermophilic actinomycetes occurring in very high numbers in mouldy hay have been implicated as the principal source of antigens inducing symptoms of farmer’s lung in agricultural workers.’ The two species studied in most detail have been identified as Micropolyspora fceni and Thermoactinomyces vulgaris2, and antigenic preparations have been extensively used in surveys to determine the incidence of antibodies 1.
5. I uckett, D. An Introduction
to
Medical
Sociology. London,
1976.
R. G. COPER
P. A., Festenstein, G N., Gregory, P. H., Lacey, M E., Skinner, F A Lancet, 1963, ii, 607. 2. Cross, T., Maciver, A. M., Lacey, J. J. gen. Microbiol. 1968, 50, 351.
Pepys, J, Jenkins,
unnaturally, the Health Education Council saying that the arguments for diverting resources from cure to prevention are overwhelming. Mr A. C. L. Mackie, the Council’s director-general, used the occasion of his appearance before the committee to attack the "extremely faint-hearted support" his Council received from the Department of Health and Social Security and the "absolutely massive inertia" in other Government departments. He protested at the enormous sum of money being poured unnecessarily into therapeutic medicine, for want of attention to the educative part of preventive medicine. At least one witness, Prof. C. E. Stroud, of the department of child health at King’s College Hospital Medical School, thought that doubling the Health Education Council’s incorre from 1 million to C,2 million would probably be one of the best investments of [1 million in health that could be made in this country.
Letters
to
the Editor
CONSULTANTS’ WORK LOAD
SIR,-Your issue of Apnl 3 contains contributions from Dr Loudon (p. 736), Mr Norcross (p. 737), and Dr Strube (p. 740): the important message in these contributions is that the supply of medical endeavour should be more clearly related to morbidity, that unnecessary work and expense should be avoided, and that this more economical matching of supply and demand can only be accomplished by doctors themselves. But how much "work" do consultants have to do? The prevalence of diseases withm a specialty and the referral-rates of patients will indicate some of a consultant’s work. In neurology, for example,I can calculate the rough probability of seeing a patient with any diagnosis. In the table I have used Kurland’s figures’ for neurological diseases. Consulting-rates were obtained from the O.P.C.S. morbidity survey2 and referralrates were had from the same source. The average population served by a general practitioner in England, is 2398.3 The average population served by one whole-time equivalent (W.T.E.) neurologist is 428 000.3 I do not suggest that all those referred with cerebrovascular disease, for example, will be seen by a neurologist rather than a physician. The point of the table is to give some indication of the relative frequency of various diseases, and the relative frequency of referral to hospital. Multiple sclerosis is generally considered to be.one of the commoner neurological diseases, yet a, neurologist will see about one new case a month. A neurologist will see about a quarter of all prevalent cases each year. Huntington’s chorea is a disease known by name to many, but a G.P. would have to practise for over 80 years before seeing a new case. The incidence of myasthenia gravis and syringomyelia, disorders which figure prominently in undergraduate medical texts, is even lower. Referred patients with non-specific symptoms such as headache are very numerous. For every new case of multiple sclerosis in the community there will be about 100 referrals for non-specific headache and migraine. Our department at St. Bartholomew’s Hospital, supported by the Department of Health and Social Security, is attempting to analyse the expectations of patients with headaches, and of their general practitioners, on referral to hospital, but a further interesting area for research would be a study of how a young doctor, taught in terms of the pathology and management of specific. diseases, learns to cope with the non-specific complaints encountered in general practice and hospital clinics. One way in which he copes seems to be by limiting new outpatient attendances. Consultants may remain confident that they will be asked to see as an "urgent" or "extra" case those patients who are "really" ill. The M.P. for Essex (South East) told. the House of Commons that "In one district general hospital patients have to wait as long as 12 or .13 weeks for an urgent outpatient appointment, and routine new patient appointments are not available at all [my italics] in ,the general surgery, E.N.T. and orthopaedic departments"." This means that consultants at this hospital will only see a patient if the G.P. considers it really necessary-and that should be the basis of all referrals. In support of the hypothesis of limitation by consultants of the supply of their time, I have examined the numbers of new outpatient attendances and discharges and deaths per W,T.f, consultant in various specialties in England (figs. 1 and 2). The numbers in the left-hand part of fig. 1 have been calculated by dividing the numbers of new patients attending outpatient clinics in various specialties in 1963 and 1973 by the z
.
1.
Kurland, L. Epidemiology of Neurologic and Sense Organ Disorders. Cambridge, Mass., 1973.
2 Office of
Population Censuses and Surveys Morbidity Statistics from General Practice, Second National Study 1970-1971. H.M. Stationery Office, 1974; and personal communication with O.P.C.S. 3. Department of Health and Social Security Health and Personal Social Services Statistics for England. H.M. Stationery Office, 1974. 4. Hansard, 1975, 898, no. 186. col. 1089.
957 REFERRAL-RATES FOR SOME NEUROLOGICAL CONDITIONS
numbers of consultants, adjusted to w.T.E., in the same specialties in 1963 and 1973.3 If a consultant has five clinics a week, a psychiatrist will see only 1 new patient in each clinic, and a general physician only 3 new patients in each clinic. These figures take no account of assistance from junior staff. While I share Dr Loudon’s reservations about equating "work-load" with numbers, it may fairly be said that such figures do not imply a crushing burden of work. Over the past ten years the numbers of new outpatients seen per consultant has declined in virtually every specialty (median percentage decline 29%). Data on numbers of reattendances illustrated in fig. 2 and on numbers of discharges and deaths illustrated in the right-hand part of fig. 1 show that those specialties with comparatively light burdens of new referrals are not those with many reattendances (the same proportion of reattendances per new referral is generated whatever the speaatty), nor necessarily those with large numbers of discharges
from, and deaths in, their inpatient service. For example,
pared with a general
com-
general physician has only half the number of new outpatient attendances, two thirds the number of discharges and deaths, a sixth of the number of day cases and none of the operating. The numbers of patients seen by many medical specialists are surprisingly small. The incidence and prevalence of the dissurgeon
a
with which the consultant has been trained to cope is also small, and most of his patients are referred with vague disorders which fit uncertainly into his conceotual framework of disease. The only way in which he can limit such referrals is by limiting the numbers he is prepared to see, relying on the G.P. to press him to see those cases he "really" needs to see. The "productivity" of consultants has declined considerably over the past ten years. There is nothing in these arguments to encourage the belief that increasing the number of consultants will result in a more effective service to patients. eases
958
2-Relation between attendances.
Fig.
new
outpatient
attendances and total
outpatient
All this does not mean that only those with "real disease" require help. Tuckettj and others have drawn a clear distinc-
tion between "illness" and "disease". There are those who are ill, but do not have diseases which require the technical resources of a hospital. We must find some way of coping with illness without the ritual of outpatient referral. These broader aspects of medical care have implications for undergraduate and postgraduate teaching and for medical staffing. I hope that the Royal Commission on the N.H.S. will consider them. Department of Neurology, St Bartholomew’s Hospital,
ANTHONY HOPKINS
London EC1A 7BE
CARE OF THE ELDERLY
Sip,—The report from the Royal College of Physicians and (April 10, p. 787) drawing attention to it are im-
your editorial
portant milestones on the way to better care for the elderly in Britain. The report is a thoughtful, constructive commentary on what is wrong with geriatric medicine, and where some of the solutions may lie. Rightly, it concentrates on recruitment and training as the most important problems. Young doctors, perhaps more able than their seniors to appreciate the demographic trends which will dictate the type of practice many will undertake in their working lives, by their experience as housephysicians of the influx of elderly patients to hospital, are interested in a career in geriatric medicine. Attitudes are slowly changing as the enormity of the problem filters through, but young doctors naturally remain apprehensive about entering a specialty which looks as if it will take the shine off their new M.R.C.P., and consign them to second-class citizenship. They need to be convinced that the specialty provides an intellectual challenge and will continue to do so. They rationalise their fears by saying that they would like to do acute medicine as well as their share of rehabilitation and long-term care. In doing so they are making a fundamental plea to practise good medicine. They want to see their patients through their illnesses, and to do so they need to be in at the beginning. Geriatrics has now come of age and has much to offer in the management of acute illness in the elderly. The time is past for geriatricians to stay in outlying units, worrying about their status, and taking patients from acute wards two or three months after their initial admissions for rehabilitation when
the game has already been lost. Their place is in the acute ward with their general and specialist colleagues, taking their share of emergencies and advising their colleagues on care of their elderly patients when necessary; channelling the patients to appropriate areas from the start; influencing junior staff by example; and teaching, teaching, teaching. Doctors in training must stay close to the care of the acutely ill because these are the skills that are most easily lost, and it is no easy matter to return to it after a year or two in a rehabilitation and long-stay unit. There is little chance nowadays that such a doctor will concentrate "more and more on acute medicine and less and less on his old people." The elderly form the bulk of all medical admissions and all physicians must learn to share in their care. The geriatrician should see himself as the patient’s ombudsman in the acute ward, but at the same time he is there to do it better than his general colleagues, and to teach them how. He can no longer afford to be a specialist (like the neurologist) and not to be responsible for acute unselected emergency referrals. How much time then does he spend on rehabilitation and in long-stay wards? Rehabilitation is difficult and demanding but the physician does not need to see patients in this area every day. His brief is to clearly define the aims, to ensure good staff morale, and to assess the patients’ progress regularly, but not necessarily daily. The management of long-stay wards is also important but need not be "time-consuming or disruptive" for the consultant. The Geriatrics Committee of the R.C.P. strike an unrealistic note when they say that "no one other than a specially trained doctor is likely to make much of the longerterm patient." Patients in this area in the main need total care, and they get it from first-class nursing care, good general-practitioner cover, occupational therapy, and voluntary visiting. The specially trained doctor has not much to add, but a weekly ward-round by the consultant (with perhaps a monthly discussion group) is essential if morale of staff is to be maintained. This work is often boring for the consultant but to neglect it is courting disaster. The term "geriatric" has done much harm to the patient and doctor alike, and its implication repells many who would embark on a career in the specialty. That career must be made more attractive and free from the loss of status, and bleak outlook that so many in the specialty still suffer. Junior doctors must never be made to feel that they have become something less than their M.R.c.P. indicates. It has trained them as acute physicians, and they cannot be expected to become rehabilitation experts and continuing-care specialists in the short time it takes them to get to a consultant post. These skills can only come with time and experience. I submit that it is not enough for the specialty to "act as pathfinders in the developing care and management of the elderly, and to set standards", as advocated by the Geriatrics Committee of R.C.P. The expertise of the specialty must be brought to bear as soon as the elderly patient enters hospital, and general physicians, if they have any sense, will welcome it into their midst. Department of Medicine (Geriatrics), General Hospital, Newcastle upon Tyne NE4 68E
FARMER’S LUNG: A NEGLECTED ANTIGEN
SIR,-Thermophilic actinomycetes occurring in very high numbers in mouldy hay have been implicated as the principal source of antigens inducing symptoms of farmer’s lung in agricultural workers.’ The two species studied in most detail have been identified as Micropolyspora fceni and Thermoactinomyces vulgaris2, and antigenic preparations have been extensively used in surveys to determine the incidence of antibodies 1.
5. I uckett, D. An Introduction
to
Medical
Sociology. London,
1976.
R. G. COPER
P. A., Festenstein, G N., Gregory, P. H., Lacey, M E., Skinner, F A Lancet, 1963, ii, 607. 2. Cross, T., Maciver, A. M., Lacey, J. J. gen. Microbiol. 1968, 50, 351.
Pepys, J, Jenkins,