- Email: [email protected]
DIRECT-ACCESS DIAGNOSTIC FACILITIES IN GENERAL PRACTICE
851
continued high urinary calcium can be derived only from bone, decalcification must eventually occur. Apparently, when possible, the bowel tries to compensate for a large
TABLE I-DIAGNOSTIC PATHOLOGY
urinary calcium loss by increased absorption; but when the intake is too low it has, of course, no chance of doing so. The mechanism accounting for this " intestinal compensation" may well encompass Nicolaysen’s " endogenous factor ". Possibly healthy subjects whose urinary calcium excretion happens to be in the high part of the range may develop osteoporosis if their intake is not high enough. This concept of the cause of osteoporosis is as yet
TABLE II-DIAGNOSTIC RADIOLOGY
"
"
unproven.
When hypercalciuria is found without increase in absorption, decalcification must be recurring (fig. 11). This happens in generalised neoplastic infiltrations of bone. In hyperparathyroidism with generalised osteitis fibrosa the intestinal absorption is actually quite high, but cannot keep pace with the bone destruction and hypercalciuria. In patients developing osteoporosis, of whatever origin, the urinary calcium must be greater than the net absorption. The mere presence of a high urinary calcium does not therefore denote that this is a cause of osteoporosis. Cushing’s syndrome and longstanding glucocorticoid therapy would, for example, be
included here. Thanks are due to Dr. R. Hoffenberg for helpful comments. Some of the figures have been previously published and are reprinted by permission of Prof. J. F. Brock, editor, and the publishers of Recent Advances in Human Nutrition, and of Prof. C. den Hartog, editor of Voeding.
References have been purposely omitted, but further discussion of basic details in calcium metabolism and their application may be found in: Albright, F., Reifenstein, E. C., Jr. The Parathyroid Glands and Metabolic Bone Disease; p. 96. Baltimore, 1948. Fourman, P. Calcium Metabolism and the Bone. Oxford, 1960. Jackson, W. P. U. in Recent Advances in Human Nutrition (edited by J. F. Brock); p. 293 et seq. London, 1961. Dancaster, C. P. J. clin. Endocrin. 1959, 19, 658. Malm, O. J. Scand. J. clin. Lab. Invest. 1958, 10, suppl. 36. Nicolaysen, R., Eeg-Larsen, N., Malm, O. J. Physiol. Rev. 1953, 33, 424. Nordin, B. E. C. Lancet, 1961, i, 1011. Rodahl, K. (editor). Bone as a Tissue. London, 1960. Urist, M. R. J. Amer. med. Ass. 1959, 169, 710. Walker, A. R. P. Amer. J. clin. Nutr. 1955, 3, 114. -
DIRECT-ACCESS DIAGNOSTIC FACILITIES IN GENERAL PRACTICE T. S. EIMERL D.S.C., V.R.D., M.D. Lpool FAMILY DOCTOR, PENKETH, LANCASHIRE; RESEARCH ASSISTANT, MEDICAL CARE RESEARCH UNIT, DEPARTMENT OF SOCIAL MEDICINE, UNIVERSITY OF MANCHESTER
of medical care given in of considerable moment. general practice Half the qualified doctors in Britain are engaged in providing such care, and if its value and efficiency are in doubt some serious questions arise for the future. For example, if modern conditions mean that each new generation of practitioners is professionally outmoded within a few years of qualification, considerable changes in medical education may be required. In this article, however, I confine myself to the question whether hospitals give the practitioner enough help in making his TODAY the range and are
own
quality
matters
diagnoses.
Dr. Macaulay’s full report, published in abridged form in The Lancet last week, contains information from the Ministry of Health about the use by general practitioners of the direct-access diagnostic facilities available to them in radiology and pathology. This information I have
summarised in a number of tables, and it seems to me to give little cause for satisfaction. Tablei shows that in England and Wales in 1960 only 6% of all investigations in pathology departments (including estimation of haemoglobin and erythrocyte-sedimentation rate, and examination of urine for albumin, sugar, and organisms) were made at the request of doctors in general practice. Table 11 shows that in radiology departments the corresponding figure was 9% (most of them for straight chest skiagrams). Why is it that with over 21,000 medical advisers freely available to 45 million people, such investigations are so seldom undertaken except for patients in a hospital clinic or ward ? There is something gravely wrong here. How is it possible that these advisers, who presumably had a good hospital training before they entered general practice, should apparently attach little importance even to
simple diagnostic procedures ?
Table ill shows that the demand is least in the industrial conurbations (Liverpool, Sheffield, Birmingham) and greatest in the Oxford, South Western, and Wessex regions. The four Metropolitan regions have an average demand. It is in the teaching hospitals that the greater weaknesses appear: taken together, the London and provincial teaching hospitals perform about fifty investigations for their own patients for every investigation they perform at the request of a practitioner. Table iv, which compares Hospital X (in the south midlands), mentioned by Dr. Macaulay, with a hospital serving a town in south-west Lancashire, suggests that the way in which pathology departments are used is broadly similar in different parts of the country. These two samples-one of a wider cross-section of practitioners over a short period, the other of a smaller TABLE III-INVESTIGATIONS FOR PRACTITIONERS BY REGIONAL HOSPITALS AND TEACHING HOSPITALS
852 TABLE IV-USE OF PATHOLOGY DEPARTMENT BY GENERAL PRACTITIONER
number of
remarkably
practitioners over a longer period-agree showing some 70 requests per practi-
in
tioner per annum, and 2-2 items of service in each request. One of the main reasons why pathologists or radiologists are unwilling to give practitioners direct access to their departments is the fear that these will be swamped. But there is evidence that, where such access is given, the total load on the department does not increase. Dr. Macaulay shows that if a pathologist has an informed and sympathetic approach to the problems of his colleague in general practice, the use of his department by practitioners may rise threefold-from about 5% to 15% of the total load. But this brings benefits-not only to the patient (who saves time and possibly money) and to the doctor (whose level of practice improves) but also to the hospital (which has less demand on its inpatient and outpatient facilities) and to the taxpayer. That teaching hospitals should be so backward in offering these facilities for the practitioner is particularly unfortunate, because it helps to give students a wrong impression of general practice. When fewer than one in fifty of all diagnostic investigations carried out in teachinghospital departments of pathology are made at the request of a general practitioner, how can the value of such a service to the family doctor be demonstrated to the undergraduate ? And if the undergraduate eventually becomes a resident, a registrar, and perhaps a consultant, how can he begin to understand the basic requirements of an adequate level of domiciliary care ? With this demonstrably inefficient level of access alone within their ken, it is not surprising that some pathologists have little interest in making available to practitioners the diagnostic tools needed by anyone who aspires to a measure of professional competence. Similarly, when only one in every eighty radiological examinations in the teaching hospitals is performed at the practitioner’s request, how can the student-the potential general practitioner-learn the value of a simple chest skiagram and report by a radiologist ? He may be told that respiratory disorders are the commonest cause of morbidity in medical practice; but when does he come to know that his standard of medical care as a practitioner will depend largely on his ability to obtain rapidly and easily a specialist radiologist’s opinion in a sizeable proportion of the patients he treats ? If the student is not shown such standards of care being applied, serious results must follow. As Dr. Macaulay shows, the radiologist ought to be as readily available for consultation in general in hospital practice. Better medical care of the patient outside hospital will be attained only when the need for diagnostic pathology and radiology, speedily available to all doctors in or out of hospital, is understood throughout the National Health Service. Such understanding would affect even the physical design of hospitals: as
The front door of a hospital offering a full range of medical should not open on to administrative offices: these should be placed at the rear. The patient should be able to go straight care
diagnostic pathology and radiology departments (or equally easily, the casualty department). Behind these, at the functional front of the hospital, main corridors of communication on the same level should lead to the intensive-nursing-care wards. Behind or above this unit could be the day wards (9 A.M.-5 P.M.) for patients who do not need intensive nursing care. Patients attending for glucose-tolerance tests, fractional test-meals, and other similar time-taking investigations, could be admitted to these wards for the day. Improvement in general practice cannot be expected into the
until routine diagnostic pathology and radiology are provided on the same terms for patients of family doctors and hospital doctors. Failure to ensure this can result only in the extinction of good family doctoring as it is known
today. Some thirteen years after the inception of the National Health Service, we are still very far from being able to say that every general practitioner has all the technical facilities and brotherly professional understanding he needs if he is to use his skills fully and have a proper sense of accomplishment. Almost 90% of the requests made by general practitioners are for very simple investigations-e.g., haemoglobin estimation (with or without pathologist’s report on the blood-film) and urine microscopy. Often these requests are made because the British practitioner (unlike his Dutch or Scandinavian counterpart) has no greywedge photometer or even microscope. When he commonly has neither diagnostic equipment of his own nor full direct access to pathology or radiology departments, is it surprising that his level of diagnosis should so often rest at the symptomatic or presumptive level?
PROPOSED COLLEGE OF PATHOLOGISTS THE question whether a College of Pathologists should be established has been considered separately both by the Association of Clinical Pathologists and by the Pathological Society. The results of their referenda were interpreted in different ways/ but a joint committee of the Association and the Society has since come to the conclusion that there is enough support for a new college to justify its foundation. The committee proposed that all consultants in pathology in the National Health Service should be invited to become founder members, together with academic pathologists of comparable status. They believed that a higher qualification in pathology is necessary, but thought that its character should be left to the governing body of the college. Similarly, the desirability of two-tier membership, and of the admission or non-admission of non-medical members, should be left for consideration at a later stage. For the support of the college, founder members would be asked to pay an entrance fee of about E50, and annual subscriptions should be such as to yield at least E3000 a
year.
The
governing bodies of the Society and Association, having accepted this report, appointed a steering committee to act on its recommendations, the members being Prof. J. N. Howie (chairman), Prof. A. W. Downie, Prof. G. L. Montgomery, Prof. C. L. Oakley, Prof. R. W. Scarff, Prof. D. F. Cappell, Prof. T. Crawford, Dr. F. Hampson (secretary), Dr. A. G. Signy, and Dr. G. Stewart Smith. This committee has now sent the members of both societies a questionary asking whether they are in favour of the establishment of a college on the lines 1.
Lancet, 1961, i,
382.
continued high urinary calcium can be derived only from bone, decalcification must eventually occur. Apparently, when possible, the bowel tries to compensate for a large
TABLE I-DIAGNOSTIC PATHOLOGY
urinary calcium loss by increased absorption; but when the intake is too low it has, of course, no chance of doing so. The mechanism accounting for this " intestinal compensation" may well encompass Nicolaysen’s " endogenous factor ". Possibly healthy subjects whose urinary calcium excretion happens to be in the high part of the range may develop osteoporosis if their intake is not high enough. This concept of the cause of osteoporosis is as yet
TABLE II-DIAGNOSTIC RADIOLOGY
"
"
unproven.
When hypercalciuria is found without increase in absorption, decalcification must be recurring (fig. 11). This happens in generalised neoplastic infiltrations of bone. In hyperparathyroidism with generalised osteitis fibrosa the intestinal absorption is actually quite high, but cannot keep pace with the bone destruction and hypercalciuria. In patients developing osteoporosis, of whatever origin, the urinary calcium must be greater than the net absorption. The mere presence of a high urinary calcium does not therefore denote that this is a cause of osteoporosis. Cushing’s syndrome and longstanding glucocorticoid therapy would, for example, be
included here. Thanks are due to Dr. R. Hoffenberg for helpful comments. Some of the figures have been previously published and are reprinted by permission of Prof. J. F. Brock, editor, and the publishers of Recent Advances in Human Nutrition, and of Prof. C. den Hartog, editor of Voeding.
References have been purposely omitted, but further discussion of basic details in calcium metabolism and their application may be found in: Albright, F., Reifenstein, E. C., Jr. The Parathyroid Glands and Metabolic Bone Disease; p. 96. Baltimore, 1948. Fourman, P. Calcium Metabolism and the Bone. Oxford, 1960. Jackson, W. P. U. in Recent Advances in Human Nutrition (edited by J. F. Brock); p. 293 et seq. London, 1961. Dancaster, C. P. J. clin. Endocrin. 1959, 19, 658. Malm, O. J. Scand. J. clin. Lab. Invest. 1958, 10, suppl. 36. Nicolaysen, R., Eeg-Larsen, N., Malm, O. J. Physiol. Rev. 1953, 33, 424. Nordin, B. E. C. Lancet, 1961, i, 1011. Rodahl, K. (editor). Bone as a Tissue. London, 1960. Urist, M. R. J. Amer. med. Ass. 1959, 169, 710. Walker, A. R. P. Amer. J. clin. Nutr. 1955, 3, 114. -
DIRECT-ACCESS DIAGNOSTIC FACILITIES IN GENERAL PRACTICE T. S. EIMERL D.S.C., V.R.D., M.D. Lpool FAMILY DOCTOR, PENKETH, LANCASHIRE; RESEARCH ASSISTANT, MEDICAL CARE RESEARCH UNIT, DEPARTMENT OF SOCIAL MEDICINE, UNIVERSITY OF MANCHESTER
of medical care given in of considerable moment. general practice Half the qualified doctors in Britain are engaged in providing such care, and if its value and efficiency are in doubt some serious questions arise for the future. For example, if modern conditions mean that each new generation of practitioners is professionally outmoded within a few years of qualification, considerable changes in medical education may be required. In this article, however, I confine myself to the question whether hospitals give the practitioner enough help in making his TODAY the range and are
own
quality
matters
diagnoses.
Dr. Macaulay’s full report, published in abridged form in The Lancet last week, contains information from the Ministry of Health about the use by general practitioners of the direct-access diagnostic facilities available to them in radiology and pathology. This information I have
summarised in a number of tables, and it seems to me to give little cause for satisfaction. Tablei shows that in England and Wales in 1960 only 6% of all investigations in pathology departments (including estimation of haemoglobin and erythrocyte-sedimentation rate, and examination of urine for albumin, sugar, and organisms) were made at the request of doctors in general practice. Table 11 shows that in radiology departments the corresponding figure was 9% (most of them for straight chest skiagrams). Why is it that with over 21,000 medical advisers freely available to 45 million people, such investigations are so seldom undertaken except for patients in a hospital clinic or ward ? There is something gravely wrong here. How is it possible that these advisers, who presumably had a good hospital training before they entered general practice, should apparently attach little importance even to
simple diagnostic procedures ?
Table ill shows that the demand is least in the industrial conurbations (Liverpool, Sheffield, Birmingham) and greatest in the Oxford, South Western, and Wessex regions. The four Metropolitan regions have an average demand. It is in the teaching hospitals that the greater weaknesses appear: taken together, the London and provincial teaching hospitals perform about fifty investigations for their own patients for every investigation they perform at the request of a practitioner. Table iv, which compares Hospital X (in the south midlands), mentioned by Dr. Macaulay, with a hospital serving a town in south-west Lancashire, suggests that the way in which pathology departments are used is broadly similar in different parts of the country. These two samples-one of a wider cross-section of practitioners over a short period, the other of a smaller TABLE III-INVESTIGATIONS FOR PRACTITIONERS BY REGIONAL HOSPITALS AND TEACHING HOSPITALS
852 TABLE IV-USE OF PATHOLOGY DEPARTMENT BY GENERAL PRACTITIONER
number of
remarkably
practitioners over a longer period-agree showing some 70 requests per practi-
in
tioner per annum, and 2-2 items of service in each request. One of the main reasons why pathologists or radiologists are unwilling to give practitioners direct access to their departments is the fear that these will be swamped. But there is evidence that, where such access is given, the total load on the department does not increase. Dr. Macaulay shows that if a pathologist has an informed and sympathetic approach to the problems of his colleague in general practice, the use of his department by practitioners may rise threefold-from about 5% to 15% of the total load. But this brings benefits-not only to the patient (who saves time and possibly money) and to the doctor (whose level of practice improves) but also to the hospital (which has less demand on its inpatient and outpatient facilities) and to the taxpayer. That teaching hospitals should be so backward in offering these facilities for the practitioner is particularly unfortunate, because it helps to give students a wrong impression of general practice. When fewer than one in fifty of all diagnostic investigations carried out in teachinghospital departments of pathology are made at the request of a general practitioner, how can the value of such a service to the family doctor be demonstrated to the undergraduate ? And if the undergraduate eventually becomes a resident, a registrar, and perhaps a consultant, how can he begin to understand the basic requirements of an adequate level of domiciliary care ? With this demonstrably inefficient level of access alone within their ken, it is not surprising that some pathologists have little interest in making available to practitioners the diagnostic tools needed by anyone who aspires to a measure of professional competence. Similarly, when only one in every eighty radiological examinations in the teaching hospitals is performed at the practitioner’s request, how can the student-the potential general practitioner-learn the value of a simple chest skiagram and report by a radiologist ? He may be told that respiratory disorders are the commonest cause of morbidity in medical practice; but when does he come to know that his standard of medical care as a practitioner will depend largely on his ability to obtain rapidly and easily a specialist radiologist’s opinion in a sizeable proportion of the patients he treats ? If the student is not shown such standards of care being applied, serious results must follow. As Dr. Macaulay shows, the radiologist ought to be as readily available for consultation in general in hospital practice. Better medical care of the patient outside hospital will be attained only when the need for diagnostic pathology and radiology, speedily available to all doctors in or out of hospital, is understood throughout the National Health Service. Such understanding would affect even the physical design of hospitals: as
The front door of a hospital offering a full range of medical should not open on to administrative offices: these should be placed at the rear. The patient should be able to go straight care
diagnostic pathology and radiology departments (or equally easily, the casualty department). Behind these, at the functional front of the hospital, main corridors of communication on the same level should lead to the intensive-nursing-care wards. Behind or above this unit could be the day wards (9 A.M.-5 P.M.) for patients who do not need intensive nursing care. Patients attending for glucose-tolerance tests, fractional test-meals, and other similar time-taking investigations, could be admitted to these wards for the day. Improvement in general practice cannot be expected into the
until routine diagnostic pathology and radiology are provided on the same terms for patients of family doctors and hospital doctors. Failure to ensure this can result only in the extinction of good family doctoring as it is known
today. Some thirteen years after the inception of the National Health Service, we are still very far from being able to say that every general practitioner has all the technical facilities and brotherly professional understanding he needs if he is to use his skills fully and have a proper sense of accomplishment. Almost 90% of the requests made by general practitioners are for very simple investigations-e.g., haemoglobin estimation (with or without pathologist’s report on the blood-film) and urine microscopy. Often these requests are made because the British practitioner (unlike his Dutch or Scandinavian counterpart) has no greywedge photometer or even microscope. When he commonly has neither diagnostic equipment of his own nor full direct access to pathology or radiology departments, is it surprising that his level of diagnosis should so often rest at the symptomatic or presumptive level?
PROPOSED COLLEGE OF PATHOLOGISTS THE question whether a College of Pathologists should be established has been considered separately both by the Association of Clinical Pathologists and by the Pathological Society. The results of their referenda were interpreted in different ways/ but a joint committee of the Association and the Society has since come to the conclusion that there is enough support for a new college to justify its foundation. The committee proposed that all consultants in pathology in the National Health Service should be invited to become founder members, together with academic pathologists of comparable status. They believed that a higher qualification in pathology is necessary, but thought that its character should be left to the governing body of the college. Similarly, the desirability of two-tier membership, and of the admission or non-admission of non-medical members, should be left for consideration at a later stage. For the support of the college, founder members would be asked to pay an entrance fee of about E50, and annual subscriptions should be such as to yield at least E3000 a
year.
The
governing bodies of the Society and Association, having accepted this report, appointed a steering committee to act on its recommendations, the members being Prof. J. N. Howie (chairman), Prof. A. W. Downie, Prof. G. L. Montgomery, Prof. C. L. Oakley, Prof. R. W. Scarff, Prof. D. F. Cappell, Prof. T. Crawford, Dr. F. Hampson (secretary), Dr. A. G. Signy, and Dr. G. Stewart Smith. This committee has now sent the members of both societies a questionary asking whether they are in favour of the establishment of a college on the lines 1.
Lancet, 1961, i,
382.