- Email: [email protected]
FUTURE OF THE WESTMINSTER MEDICAL SCHOOL
839 FUTURE OF THE WESTMINSTER MEDICAL SCHOOL
THE PRACTICE OF EPIDEMIOLOGY
SIR,-I refer to recent correspondence on this subject. At a meeting held last autumn at the Institute of Child Health which was
reported in The Lancet of Nov. 1 (p. 957) and in the B.M.J. Prof. E.D. Acheson and his colleagues made an important plea for the recognition of epidemiology in the practice of medicine and in medical education. This has strong support from the Faculty of Community Medicine because we believe that it is central to the practice of our specialty and we make it a key subject in our training programmes.
We agree fully with Professor Acheson that
there is need for
a
considerable expansion of training in epidemiology for clinicians, in
hospital and in general practice, and would be glad to help as far as we can. We share his disquiet that the facilities are meagre because in consequence the subject cannot take its rightful place in either undergraduate or postgraduate education. The criticism is made that careers in community medicine do not seem to offer much opportunity for epidemiological work. We identify here the failure to recognise that epidemiology is the dominating theme in postgraduate education for the specialty of community medicine and although epidemiology has not yet become as general an activity in health authorities as we would like, there are an increasing number in which it is part of normal practice. These are to be found particularly where some of the community physicians have been through the recent training, and where there are registrars and senior registrars in training. Where this is happening a new and exciting spirit of inquiry has entered the service. We are sure that this will spread until it becomes the norm. However, for the present there are obstacles to progress. There
are
several reasons for this. In the first place the reorganisation in 1974 changed the nature of the task for many who moved from careers in public health or hospital administration to posts as community medicine specialists, and their earlier training and experience had not always placed the same emphasis on epidemiology. Secondly, many health authorities have had community medicine posts unfilled since the 1974 reorganisation because of the shortage of qualified candidates, and as a result of the priority given to posts with a specified local authority connection these vacancies are most acute in health care planning; in consequence, many of those in post have been under great pressure coping with immediate day-to-day problems, leaving little time to consider the longer term tasks of laying an epidemiological foundation for decision making. Furthermore, many in their new situation found themselves without the supporting staff necessary for epidemiological investigation. We are sure that these handicaps will steadily diminish. The requirements for higher specialist training in community medicine have been criticised on the grounds that they are too rigid and do not provide for the trainee who wishes to develop epidemiological skills without being committed to great involvement in Health Service administration. The criticism is unjustified because although most approved senior registrar posts are held in relation to one or more N.H.S. authorities, the Faculty’s education committee, acting as specialist advisory committee to the Joint Committee on Higher Medical Training has approved several ad hominem training programmes in which the major commitment IS to a university department, a research unit, or one of the Armed Forces. On completion of such a programme, together with the acquisition of the specialist qualification, the candidate would be eligible for accreditation without question. However, although the emphasis in such an ad hominem programme may be strongly academic, it is unlikely that it could be divorced from practice in a health service of one kind or another. In health services research it is essential to have knowledge of the setting in which problems to be investigated arise, to be sensitive to what questions should and could be researched, and to be able to make informed and realistic proposals as to how the results of the research can be implemented.
SIR,-Neither Westminster Hospital nor its Medical School have
adopted an attitude of "depressed acceptance" to the proposals currently advanced by the University of London. Your Parliamentary correspondent is quite wrong in his interpretation (April 4, p. 792). It ’is precisely because we have been at pains to work out the implications of every move, that F. S. has said that a merger with Charing Cross Medical School would amount to closure of Westminster Medical School. We are not all persuaded that a merger would have any value in terms of undergraduate medical education except to make it less efficient and more expensive. We see no reason why we, as one of the cheaper and academically efficient schools, should not be left alone to work out our future in association with Charing Cross Medical School. We are not, let it be clearly said, opposed to change. Cooperation, yes; merger, no; depressed acceptance, never. F. STARER, Chairman, Westminster Hospital
Campaign Committee C. WASTELL, Westminster Hospital, London SW1P 2AP.
Chairman, Westminster Hospital Medical Executive Committee
CHEMICAL PATHOLOGY ON THE WARD
SIR,-The guidelines provided by the professional bodies
responsible for the maintenance of safe and excellent standards in chemical pathology (Feb. 28, p. 487) are useful and concise. But to my mind they beg the questions which underlie the growth in the number of assays done away from the service laboratory and are an inappropriate response from the professional chemical pathologists. First, by doing tests "at the bedside", the clinician has a form of quality control which is denied to the more remote laboratory. It is more usual, in my experience, to be asked to verify a clinically improbable result than for the patient to receive inappropriate treatment as the result of ward-testing. Second, the new generation of automated single-test analysers are particularly suited to the changing pattern of medicine, with its increasing numbers of emergency and high-risk medical and surgical procedures which benefit from- biochemical monitoring. Furthermore, the machines themselves are often designed to be operated by anyone able to work a "hi-fi" gramophone or a pop-up
‘
toaster.
No. The
from the Royal College of Pathologists and defensive. Instead of this apparent reluctance to see a growth in ward-testing, the chemical pathologist should embrace this new willingness on the part of clinical colleagues to take over the simple if essential emergency biochemistry and the hour-byhour monitoring of therapy. By all means, let us offer training, servicing, and quality control from centralised experts. But neither the capital costs of the equipment nor the loss of career structure should obscure what is the real problem of clinical biochemistry laboratories. It is the inevitable abandonment, under the mounds of technically undemanding everyday tests, of sophisticated and time consuming investigations for individual patients that limits the role of the central chemical pathology laboratory. It is becoming increasingly irrelevant to the practice of hospital medicine. Instead of defending the territory of emergency biochemistry, the official bodies might do well to encourage delegation of labour intensive, but technically trivial activities, therby sparing its highly trained personnel for exciting and provocative chemical measurements, which only the chemical pathology laboratory can
others is
statement
too
offer.
Faculty of Community Medicine of the Royal Colleges of Physicians of the is Portland Place, London W1N 4DE
U.K.,
JOHN BROTHERTON, President
Nuffield Department of Clinical Radcliffe Infirmary, Oxford OX2 6HE
Biochemistry,
B. D. Ross
THE PRACTICE OF EPIDEMIOLOGY
SIR,-I refer to recent correspondence on this subject. At a meeting held last autumn at the Institute of Child Health which was
reported in The Lancet of Nov. 1 (p. 957) and in the B.M.J. Prof. E.D. Acheson and his colleagues made an important plea for the recognition of epidemiology in the practice of medicine and in medical education. This has strong support from the Faculty of Community Medicine because we believe that it is central to the practice of our specialty and we make it a key subject in our training programmes.
We agree fully with Professor Acheson that
there is need for
a
considerable expansion of training in epidemiology for clinicians, in
hospital and in general practice, and would be glad to help as far as we can. We share his disquiet that the facilities are meagre because in consequence the subject cannot take its rightful place in either undergraduate or postgraduate education. The criticism is made that careers in community medicine do not seem to offer much opportunity for epidemiological work. We identify here the failure to recognise that epidemiology is the dominating theme in postgraduate education for the specialty of community medicine and although epidemiology has not yet become as general an activity in health authorities as we would like, there are an increasing number in which it is part of normal practice. These are to be found particularly where some of the community physicians have been through the recent training, and where there are registrars and senior registrars in training. Where this is happening a new and exciting spirit of inquiry has entered the service. We are sure that this will spread until it becomes the norm. However, for the present there are obstacles to progress. There
are
several reasons for this. In the first place the reorganisation in 1974 changed the nature of the task for many who moved from careers in public health or hospital administration to posts as community medicine specialists, and their earlier training and experience had not always placed the same emphasis on epidemiology. Secondly, many health authorities have had community medicine posts unfilled since the 1974 reorganisation because of the shortage of qualified candidates, and as a result of the priority given to posts with a specified local authority connection these vacancies are most acute in health care planning; in consequence, many of those in post have been under great pressure coping with immediate day-to-day problems, leaving little time to consider the longer term tasks of laying an epidemiological foundation for decision making. Furthermore, many in their new situation found themselves without the supporting staff necessary for epidemiological investigation. We are sure that these handicaps will steadily diminish. The requirements for higher specialist training in community medicine have been criticised on the grounds that they are too rigid and do not provide for the trainee who wishes to develop epidemiological skills without being committed to great involvement in Health Service administration. The criticism is unjustified because although most approved senior registrar posts are held in relation to one or more N.H.S. authorities, the Faculty’s education committee, acting as specialist advisory committee to the Joint Committee on Higher Medical Training has approved several ad hominem training programmes in which the major commitment IS to a university department, a research unit, or one of the Armed Forces. On completion of such a programme, together with the acquisition of the specialist qualification, the candidate would be eligible for accreditation without question. However, although the emphasis in such an ad hominem programme may be strongly academic, it is unlikely that it could be divorced from practice in a health service of one kind or another. In health services research it is essential to have knowledge of the setting in which problems to be investigated arise, to be sensitive to what questions should and could be researched, and to be able to make informed and realistic proposals as to how the results of the research can be implemented.
SIR,-Neither Westminster Hospital nor its Medical School have
adopted an attitude of "depressed acceptance" to the proposals currently advanced by the University of London. Your Parliamentary correspondent is quite wrong in his interpretation (April 4, p. 792). It ’is precisely because we have been at pains to work out the implications of every move, that F. S. has said that a merger with Charing Cross Medical School would amount to closure of Westminster Medical School. We are not all persuaded that a merger would have any value in terms of undergraduate medical education except to make it less efficient and more expensive. We see no reason why we, as one of the cheaper and academically efficient schools, should not be left alone to work out our future in association with Charing Cross Medical School. We are not, let it be clearly said, opposed to change. Cooperation, yes; merger, no; depressed acceptance, never. F. STARER, Chairman, Westminster Hospital
Campaign Committee C. WASTELL, Westminster Hospital, London SW1P 2AP.
Chairman, Westminster Hospital Medical Executive Committee
CHEMICAL PATHOLOGY ON THE WARD
SIR,-The guidelines provided by the professional bodies
responsible for the maintenance of safe and excellent standards in chemical pathology (Feb. 28, p. 487) are useful and concise. But to my mind they beg the questions which underlie the growth in the number of assays done away from the service laboratory and are an inappropriate response from the professional chemical pathologists. First, by doing tests "at the bedside", the clinician has a form of quality control which is denied to the more remote laboratory. It is more usual, in my experience, to be asked to verify a clinically improbable result than for the patient to receive inappropriate treatment as the result of ward-testing. Second, the new generation of automated single-test analysers are particularly suited to the changing pattern of medicine, with its increasing numbers of emergency and high-risk medical and surgical procedures which benefit from- biochemical monitoring. Furthermore, the machines themselves are often designed to be operated by anyone able to work a "hi-fi" gramophone or a pop-up
‘
toaster.
No. The
from the Royal College of Pathologists and defensive. Instead of this apparent reluctance to see a growth in ward-testing, the chemical pathologist should embrace this new willingness on the part of clinical colleagues to take over the simple if essential emergency biochemistry and the hour-byhour monitoring of therapy. By all means, let us offer training, servicing, and quality control from centralised experts. But neither the capital costs of the equipment nor the loss of career structure should obscure what is the real problem of clinical biochemistry laboratories. It is the inevitable abandonment, under the mounds of technically undemanding everyday tests, of sophisticated and time consuming investigations for individual patients that limits the role of the central chemical pathology laboratory. It is becoming increasingly irrelevant to the practice of hospital medicine. Instead of defending the territory of emergency biochemistry, the official bodies might do well to encourage delegation of labour intensive, but technically trivial activities, therby sparing its highly trained personnel for exciting and provocative chemical measurements, which only the chemical pathology laboratory can
others is
statement
too
offer.
Faculty of Community Medicine of the Royal Colleges of Physicians of the is Portland Place, London W1N 4DE
U.K.,
JOHN BROTHERTON, President
Nuffield Department of Clinical Radcliffe Infirmary, Oxford OX2 6HE
Biochemistry,
B. D. Ross