- Email: [email protected]
FUTURE OF POSTGRADUATE MEDICAL EDUCATION
1132
Letters to the Editor FUTURE OF POSTGRADUATE MEDICAL
schools of London, undergraduate and postgraduate, in new developments of postgraduate training and teaching. JOHN MCMICHAEL Director, British Postgraduate London W.C.1.
Medical Federation.
EDUCATION I
SIR,-On the problems of postgraduate education, nobody can speak with greater authority and accumulated wisdom than Dame Janet Vaughan (Nov. 8, p. 995). The Royal Commission, no doubt facing the complexity of training doctors for our evolving health service, was too introspective in concentrating on the training problems of British-born doctors. Dame Janet has taken a broader view and drawn attention to the enormous dimensions of the overseas demand, and the need for our universities to increase their staffs to meet postgraduate requirements, both in existing general units and also in the expansion of university provision in the major specialties. Only by so doing can they meet the needs of overseas trainees as well as the training of our future academic medical leaders and teachers, who are unlikely to emerge by following orthodox and standardised training curricula. Constraints on the development of the carefully selected best would reduce the standards of our service and increase our losses to other lands with greater flexibility of opportunities. Through the work of the Postgraduate Medical Federation, the University of London has indeed blazed a trail in the right direction and played a full role, though this is scarcely acknowledged in the Todd report. Specialism in medicine continues to grow apace with the vast expansion of our corpus of knowledge. In the specialist hospitals of London, academic facilities have been created for advanced teaching and research as well as training in the application of the relevant special clinical and technical skills. These facilities are in growing demand from our own doctors as well as from overseas trainees. Disruption or dispersal of these centres, or loss of the degree of autonomy they enjoy for intensive subject development, could be tragic for the status of the specialty and would constitute a backward step for British medicine as a whole. Subjects subordinate to the main clinical fields cannot develop freely in small departments in competition for funds in the general schools. In the latter the specialties can be studied in the background of general medicine, making a different but important supplementary type of contribution to knowledge. Vertical concentration on ophthalmology, for example, requires concentrations of expertise and special equipment deserving of academic development and support. It is agreed by most that these special facilities should be available not only to meet overseas demand but also for training and recruitment of our own trainee doctors into the field. Indeed they are now recognised, along with certain other special centres in the country, by the Department of Health for special advanced course secondments of consultants and senior registrars. As Dame Janet suggests, there should be an expanded national academic development of special facilities. London, as an important pioneering university in this major postgraduate effort, should also continue its facilities and not contract out of this special effort, as the Todd report seems to imply. The unitary universities outside London may have to do more. It would require much more money and a vast increase in expansion of multiple special departments before the undergraduate London schools, even in their paired forms, could undertake the whole postgraduate teaching responsibility which falls on this great metropolis. Indeed the Federation is coordinating the mobilisation of experts in all the medical
HAZARD OF VACU-DRAIN SYSTEM SIR,-Until a few months ago I was using theVacuDrain’ with increasing frequency; there is no doubt in my mind that suction drainage is, in principle, a useful method of ensuring adequate drainage, and it also saves the dressings from becoming saturated with wound discharges. I have, however, recently seen two very severe wound infections following the use of this system, one after a cholecystectomy and the other following a prostatectomy. These infections were probably due to drainage fluid being returned into the wound by inadvertent compression of the plastic drainage bottle. The factors making this possible are the comparatively short length of tubing between the wound and the bottle, the absence of any valve system, and the ready compressibility of the bottle. In addition, the advertising material suggests that the bottle should be strapped to the patient (Medical Equipment, September, 1969, p. 4). It is easy to imagine that the bottle could become detached from the patient, and that the patient might roll or turn over on top of it in his bed, with the consequences I have mentioned. Because of this possibility, and despite the delightful simplicity of the vacu-drain I shall not use it in its present form for wound drainage. The ’Redivac ’ method seems to offer the same advantages without this potential hazard. Department of Surgery, Brook General Hospital, A. P. WYATT. London S.E.18.
CARE OF THE MENTALLY SUBNORMAL a school of thought which favours dissolution of the mental-subnormality hospitals. This is not a new aspiration. Hospitals, and the medical and nursing profession, have always had the ideal of doing away with the need for themselves. The Ministry of Health’s circular, " Improving the Effectiveness of the Hospital Service for the Mentally Subnormal "pointed out that the aim of hospital care is, wherever possible, to enable a patient to return to life in the community. A survey of patients in two hospitals for the mentally subnormal at Todmorden (231 beds) and- Bradford (460 beds) gave the following results. Using the criteria at present applied by local authorities for hostel care in the community, 10% of the patients at the Todmorden Hospital, and 12% of the women and 27% of the men at the Bradford Hospital, could be discharged. The average age of these patients was 39 years, at both hospitals. Many of them were already on the waiting-list for hostel accommodation. As a result of more careful screening of admissions in the last few years, only a few children were suitable for hostels, and most of the children in this group were in the care of the children’s departments, which have no facilities for the longterm residential care of subnormal children. Hence, if more patients in these hospitals were to be discharged, or if these hospitals were to be replaced entirely by a,system of hostel care, the new hostels and the general community near them would have to accept, outside hospital, subnormal people with a much lower level of social competence than they do at present. A hostel for the profoundly subnormal and physically helpless cases would become a
SiR,—There is
1.
Ministry of Health. Improving the Effectiveness of the Hospital Service for the Mentally Subnormal. H.M. (65) 104.
Letters to the Editor FUTURE OF POSTGRADUATE MEDICAL
schools of London, undergraduate and postgraduate, in new developments of postgraduate training and teaching. JOHN MCMICHAEL Director, British Postgraduate London W.C.1.
Medical Federation.
EDUCATION I
SIR,-On the problems of postgraduate education, nobody can speak with greater authority and accumulated wisdom than Dame Janet Vaughan (Nov. 8, p. 995). The Royal Commission, no doubt facing the complexity of training doctors for our evolving health service, was too introspective in concentrating on the training problems of British-born doctors. Dame Janet has taken a broader view and drawn attention to the enormous dimensions of the overseas demand, and the need for our universities to increase their staffs to meet postgraduate requirements, both in existing general units and also in the expansion of university provision in the major specialties. Only by so doing can they meet the needs of overseas trainees as well as the training of our future academic medical leaders and teachers, who are unlikely to emerge by following orthodox and standardised training curricula. Constraints on the development of the carefully selected best would reduce the standards of our service and increase our losses to other lands with greater flexibility of opportunities. Through the work of the Postgraduate Medical Federation, the University of London has indeed blazed a trail in the right direction and played a full role, though this is scarcely acknowledged in the Todd report. Specialism in medicine continues to grow apace with the vast expansion of our corpus of knowledge. In the specialist hospitals of London, academic facilities have been created for advanced teaching and research as well as training in the application of the relevant special clinical and technical skills. These facilities are in growing demand from our own doctors as well as from overseas trainees. Disruption or dispersal of these centres, or loss of the degree of autonomy they enjoy for intensive subject development, could be tragic for the status of the specialty and would constitute a backward step for British medicine as a whole. Subjects subordinate to the main clinical fields cannot develop freely in small departments in competition for funds in the general schools. In the latter the specialties can be studied in the background of general medicine, making a different but important supplementary type of contribution to knowledge. Vertical concentration on ophthalmology, for example, requires concentrations of expertise and special equipment deserving of academic development and support. It is agreed by most that these special facilities should be available not only to meet overseas demand but also for training and recruitment of our own trainee doctors into the field. Indeed they are now recognised, along with certain other special centres in the country, by the Department of Health for special advanced course secondments of consultants and senior registrars. As Dame Janet suggests, there should be an expanded national academic development of special facilities. London, as an important pioneering university in this major postgraduate effort, should also continue its facilities and not contract out of this special effort, as the Todd report seems to imply. The unitary universities outside London may have to do more. It would require much more money and a vast increase in expansion of multiple special departments before the undergraduate London schools, even in their paired forms, could undertake the whole postgraduate teaching responsibility which falls on this great metropolis. Indeed the Federation is coordinating the mobilisation of experts in all the medical
HAZARD OF VACU-DRAIN SYSTEM SIR,-Until a few months ago I was using theVacuDrain’ with increasing frequency; there is no doubt in my mind that suction drainage is, in principle, a useful method of ensuring adequate drainage, and it also saves the dressings from becoming saturated with wound discharges. I have, however, recently seen two very severe wound infections following the use of this system, one after a cholecystectomy and the other following a prostatectomy. These infections were probably due to drainage fluid being returned into the wound by inadvertent compression of the plastic drainage bottle. The factors making this possible are the comparatively short length of tubing between the wound and the bottle, the absence of any valve system, and the ready compressibility of the bottle. In addition, the advertising material suggests that the bottle should be strapped to the patient (Medical Equipment, September, 1969, p. 4). It is easy to imagine that the bottle could become detached from the patient, and that the patient might roll or turn over on top of it in his bed, with the consequences I have mentioned. Because of this possibility, and despite the delightful simplicity of the vacu-drain I shall not use it in its present form for wound drainage. The ’Redivac ’ method seems to offer the same advantages without this potential hazard. Department of Surgery, Brook General Hospital, A. P. WYATT. London S.E.18.
CARE OF THE MENTALLY SUBNORMAL a school of thought which favours dissolution of the mental-subnormality hospitals. This is not a new aspiration. Hospitals, and the medical and nursing profession, have always had the ideal of doing away with the need for themselves. The Ministry of Health’s circular, " Improving the Effectiveness of the Hospital Service for the Mentally Subnormal "pointed out that the aim of hospital care is, wherever possible, to enable a patient to return to life in the community. A survey of patients in two hospitals for the mentally subnormal at Todmorden (231 beds) and- Bradford (460 beds) gave the following results. Using the criteria at present applied by local authorities for hostel care in the community, 10% of the patients at the Todmorden Hospital, and 12% of the women and 27% of the men at the Bradford Hospital, could be discharged. The average age of these patients was 39 years, at both hospitals. Many of them were already on the waiting-list for hostel accommodation. As a result of more careful screening of admissions in the last few years, only a few children were suitable for hostels, and most of the children in this group were in the care of the children’s departments, which have no facilities for the longterm residential care of subnormal children. Hence, if more patients in these hospitals were to be discharged, or if these hospitals were to be replaced entirely by a,system of hostel care, the new hostels and the general community near them would have to accept, outside hospital, subnormal people with a much lower level of social competence than they do at present. A hostel for the profoundly subnormal and physically helpless cases would become a
SiR,—There is
1.
Ministry of Health. Improving the Effectiveness of the Hospital Service for the Mentally Subnormal. H.M. (65) 104.