- Email: [email protected]
Doctor-managers and their performance as doctors
windsurfers and yachtsmen of acquiring virus infections. In
and cancellation of the £ 50 million building programme with great disappointment within the organisation. In October, 1990, radiologist 1 ceased to hold managerial appointments and returned to clinical work. At that stage sensitivity rose to a high level. The performance of each individual is part of the team effort since every film was read by two radiologists, so the unit’s detection rates were maintained throughout.’I It is, of course, beyond the capabilities of these figures to prove that the change in performance was attributable to the pressures of the managerial role, but every clinician in management will feel uncomfortable to match up the time relation. The affairs of the huge organisations that are our hospitals are a heavy burden on clinicians who attempt to manage them. They and those who appoint them must expect that to have a price for the clinical work of a consultant. It is not a matter of the time taken, but the pressure that pervades all they do with their responsibility for a large organisation and its problems.
the first 137 samples analysed, 93% of surfers (n=102) had serological evidence of exposure to astrovirus serotype 4, compared with only 22% of age-matched controls (n=35) who did not bathe in the sea. All these surfers had complained of diarrhoeal illness in the previous 12 months, whereas only 39% of controls had done so. Our studies were in adults, but the data suggesting children are at a greater risk of contracting gastroenteritis also suggest that viruses are even more important in this age group. We hope that not much more evidence needs to accumulate before the authorities stop discharging raw sewage into bathing water. Steven
Myint, Rupert Manley, David Cubitt
Department of Microbiology and Immunology, University of Leicester Medical School, Leicester LE1 9HN, UK; Truro, Cornwall; and Great Ormond Street Hospital for Children NHS Trust, London WC1
1
Havelaar AH, Olphen M, Drost YC. F-specific RNA bacteriophages are adequate model organisms for enteric viruses in fresh water. Appl Environ Microbiol 1993; 59: 2956-62.
Doctor-managers and their performance
Ruth Warren Princess Alexandra Hospital, Harlow, Essex CM20 1QX, UK
1
as
doctors SiR-Since the publication of the Griffiths report in 1985, there has been a growing trend to encourage UK doctors to take on managerial roles in conjunction with their clinical work. This trend has developed through the next round of organisational change and now every trust has a medical director with a major management role, and many other doctors lead large sections of these trusts while carrying full patient case-loads. Many find these combined duties very onerous, and for each one a balance between clinical and managerial elements needs to be achieved. The table is of interest in this context, because the data seem to show what every such doctor fears-the fall-off in medical performance under the considerable pressures of corporate-level management. The data form part of a study on the value of the second report of mammography the statistical work of which has been done by the screening, MRC Biostatistics Unit, Cambridge, UK. The table here relates to the individual performance of consultant radiologists, one of whom was the director of the service and was at that time chairman of the district consultants committee and consultant member of the district health
authority:
Warren R. Team 338: 514.
learning and breast cancer screening.
Dietary trans fatty acids and CHD SiR-Mann’s suggestion (May 21, p 1268) that trans fatty acids are responsible for the epidemic of coronary heart disease seems to be based on only two fragments of evidence: intake of trans fatty acids began after 1912 and trans fatty acids can raise plasma low-density lipoprotein (LDL)-cholesterol. But he gives no quantitative data about intakes of trans fatty acids; trans fatty acids have a smaller LDL-cholesterol raising effect than the more familiar 12-16 carbon saturated fatty acids.’ In Australia, the coronary death rate has declined by over 60% (age standardised) since the mid-1960s.’ During this time butter (low in trans fatty acids) has been largely replaced by polyunsaturated margarines containing 8-15% trans fatty acids. Our present trans fatty acid intake averages under 5 g per day (or 2% of total calories), which is about the same as Mann estimates that the Masai were eating 22 years ago. To correct some of Mann’s other assertions clinical trials, when put together in meta-analyses, have not failed to show that drug3 or dietary4 treatments are effective. In the largest prospective study (with over 361000 US men) coronary heart disease mortality doubled between total cholesterols of 5-3 and 6-9 mmol/L.5 There is nothing to suggest that the small amount of trans fatty acids in the diet causes the rise of plasma total cholesterol in pregnancy. High-densitylipoprotein cholesterols are part of the rise, and in huntergatherers eating no milk or processed food we showed high cholesterols in pregnancy. A Stewart Truswell, Samir Samman Human Nutrition Unit, University of Sydney, Sydney, 1
Radiologists 2 and 3 show performance consistency with a trend to improve in sensitivity with learning.’ The recall rates are characteristic to each individual. By contrast radiologist 1 shows a fall-off in sensitivity for the year from November, 1989, to October, 1990. This drop corresponds with a year of profound managerial crisis at corporate level, with the departure of one district general manager, an interregnum, followed by appointment of a popular dental clinician to the post, and her resignation nine months later,
Lancet 1991;
2 3
4 5
NSW 2006, Australia
Zock PL, Katan MB. Hydrogenation alternatives: effects of trans fatty acids and stearic acid versus linoleic acid on serum lipids and lipoproteins in humans. J Lipid Res 1992; 33: 399-410. Lloyd BL. Declining cardiovascular disease and environmental components. Aust NZ J Med 1994; 24: 124-32. Howes LG, Simons LA. Efficacy of drug intervention for lipids in the prevention of coronary artery disease. Aust NZ J Med 1994; 24: 107-12. Truswell AS. Review of dietary intervention studies: effect on coronary events and on total mortality. Aust NZ J Med 1994; 24: 98-106. Martin MJ, Hulley SB, Browner WS, et al. Serum cholesterol, blood pressure and mortality: implications for a cohort of 361 662 men. Lancet 1986; 2: 933-36.
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and cancellation of the £ 50 million building programme with great disappointment within the organisation. In October, 1990, radiologist 1 ceased to hold managerial appointments and returned to clinical work. At that stage sensitivity rose to a high level. The performance of each individual is part of the team effort since every film was read by two radiologists, so the unit’s detection rates were maintained throughout.’I It is, of course, beyond the capabilities of these figures to prove that the change in performance was attributable to the pressures of the managerial role, but every clinician in management will feel uncomfortable to match up the time relation. The affairs of the huge organisations that are our hospitals are a heavy burden on clinicians who attempt to manage them. They and those who appoint them must expect that to have a price for the clinical work of a consultant. It is not a matter of the time taken, but the pressure that pervades all they do with their responsibility for a large organisation and its problems.
the first 137 samples analysed, 93% of surfers (n=102) had serological evidence of exposure to astrovirus serotype 4, compared with only 22% of age-matched controls (n=35) who did not bathe in the sea. All these surfers had complained of diarrhoeal illness in the previous 12 months, whereas only 39% of controls had done so. Our studies were in adults, but the data suggesting children are at a greater risk of contracting gastroenteritis also suggest that viruses are even more important in this age group. We hope that not much more evidence needs to accumulate before the authorities stop discharging raw sewage into bathing water. Steven
Myint, Rupert Manley, David Cubitt
Department of Microbiology and Immunology, University of Leicester Medical School, Leicester LE1 9HN, UK; Truro, Cornwall; and Great Ormond Street Hospital for Children NHS Trust, London WC1
1
Havelaar AH, Olphen M, Drost YC. F-specific RNA bacteriophages are adequate model organisms for enteric viruses in fresh water. Appl Environ Microbiol 1993; 59: 2956-62.
Doctor-managers and their performance
Ruth Warren Princess Alexandra Hospital, Harlow, Essex CM20 1QX, UK
1
as
doctors SiR-Since the publication of the Griffiths report in 1985, there has been a growing trend to encourage UK doctors to take on managerial roles in conjunction with their clinical work. This trend has developed through the next round of organisational change and now every trust has a medical director with a major management role, and many other doctors lead large sections of these trusts while carrying full patient case-loads. Many find these combined duties very onerous, and for each one a balance between clinical and managerial elements needs to be achieved. The table is of interest in this context, because the data seem to show what every such doctor fears-the fall-off in medical performance under the considerable pressures of corporate-level management. The data form part of a study on the value of the second report of mammography the statistical work of which has been done by the screening, MRC Biostatistics Unit, Cambridge, UK. The table here relates to the individual performance of consultant radiologists, one of whom was the director of the service and was at that time chairman of the district consultants committee and consultant member of the district health
authority:
Warren R. Team 338: 514.
learning and breast cancer screening.
Dietary trans fatty acids and CHD SiR-Mann’s suggestion (May 21, p 1268) that trans fatty acids are responsible for the epidemic of coronary heart disease seems to be based on only two fragments of evidence: intake of trans fatty acids began after 1912 and trans fatty acids can raise plasma low-density lipoprotein (LDL)-cholesterol. But he gives no quantitative data about intakes of trans fatty acids; trans fatty acids have a smaller LDL-cholesterol raising effect than the more familiar 12-16 carbon saturated fatty acids.’ In Australia, the coronary death rate has declined by over 60% (age standardised) since the mid-1960s.’ During this time butter (low in trans fatty acids) has been largely replaced by polyunsaturated margarines containing 8-15% trans fatty acids. Our present trans fatty acid intake averages under 5 g per day (or 2% of total calories), which is about the same as Mann estimates that the Masai were eating 22 years ago. To correct some of Mann’s other assertions clinical trials, when put together in meta-analyses, have not failed to show that drug3 or dietary4 treatments are effective. In the largest prospective study (with over 361000 US men) coronary heart disease mortality doubled between total cholesterols of 5-3 and 6-9 mmol/L.5 There is nothing to suggest that the small amount of trans fatty acids in the diet causes the rise of plasma total cholesterol in pregnancy. High-densitylipoprotein cholesterols are part of the rise, and in huntergatherers eating no milk or processed food we showed high cholesterols in pregnancy. A Stewart Truswell, Samir Samman Human Nutrition Unit, University of Sydney, Sydney, 1
Radiologists 2 and 3 show performance consistency with a trend to improve in sensitivity with learning.’ The recall rates are characteristic to each individual. By contrast radiologist 1 shows a fall-off in sensitivity for the year from November, 1989, to October, 1990. This drop corresponds with a year of profound managerial crisis at corporate level, with the departure of one district general manager, an interregnum, followed by appointment of a popular dental clinician to the post, and her resignation nine months later,
Lancet 1991;
2 3
4 5
NSW 2006, Australia
Zock PL, Katan MB. Hydrogenation alternatives: effects of trans fatty acids and stearic acid versus linoleic acid on serum lipids and lipoproteins in humans. J Lipid Res 1992; 33: 399-410. Lloyd BL. Declining cardiovascular disease and environmental components. Aust NZ J Med 1994; 24: 124-32. Howes LG, Simons LA. Efficacy of drug intervention for lipids in the prevention of coronary artery disease. Aust NZ J Med 1994; 24: 107-12. Truswell AS. Review of dietary intervention studies: effect on coronary events and on total mortality. Aust NZ J Med 1994; 24: 98-106. Martin MJ, Hulley SB, Browner WS, et al. Serum cholesterol, blood pressure and mortality: implications for a cohort of 361 662 men. Lancet 1986; 2: 933-36.
1641