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LIMITATIONS OF MEDICAL CARE ATTRIBUTABLE TO MEDICAL EDUCATION
150
In
Now
England
Letters
A
Running Commentary by Peripatetic Correspondents twenty-five years I have been coming at intervals to London-partly on holiday and partly on a busman’s holiday to see my surgical colleagues operating. Each time I leave with the same feeling of irritation and frustration. Among the great centres of medical education London must rank high for time-wasting. Each day operation lists are sent to the Royal College of Surgeons, to B.M.A. House, and to the Royal Society of Medicine. They are made up late on the previous day and arrive by the first post on the morning of the operation session. The eager visitor’is thus far too late for the morning operations, at least if he takes the posted times seriously. It is some time before he realises that these are only token times. He rushes off, breakfastless, cursing the delays of public transport (when he has not a car with him), and arrives breathless at St. Patrick’s hoping to be in time to see the second operation on Mr. Skinner’s list. What he finds quite often is an anaathetist standing around disconsolately and sisters and registrars twiddling their thumbs. Mr. Skinner is late because (I suggest unkindly) he has probably been operating on a private case. When he finally gets down to his operation it is always a work of art and worth the vexation and the rush. But inevitably lunch engagements and arrangements for the afternoon go by the board. The eager visitor is faced with further frustrations in the jet age. He wants to see Mr. Skinner performing. He has come from the back-blocks with this as the highlight of his visit. But Mr. Skinner is off to
Chicago
to
deliver
a
lecture which he
medieval times. Then it was customary for students to move from Montpellier to Paris, to Amsterdam, to Padua, to sit at the feet of famous teachers. Now it is the teacher who flits from continent to continent. The situation calls for a kind of surgical Guide Michelin. Three forceps for Mr. Smith at the Far Western Hospital who operates at the stated time and stays put in London long enough to teach his students and his juniors. One blunt scalpel for Mr. Pilkington-Brown who isn’t quite sure whether he was in Yugoslavia or in Peru last week talking about his new operation which involves the use of three clamps instead of two. *
*
*
*
Seamus has been watching with the closest concern recent developments connected with the possible entry of Great Britain into the Common Market. A Francophile in principle, he said to me the other day: " Sure an’ nobody’s more pleased than meself to see France doin’ so well. I like to see the Gallic cock crowing again. But ye’d better see that it doesn’t use Britain for its dunghill. Ye’ve a fertile little country. What with the American Eagle, the German Eagle, and that barnyard fowl across the water, though, ye’d better watch out not to get Mammals are better for the too much guano everywhere. flowers, me boy, remember that." Seamus’s imagery sometimes makes me wonder whether the Irish influence in world politics is always for the best; but it certainly makes for interest. *
*
A scholar of Gonville and
*
Caius,
Contracted a lethal disaius. His thoughts became pious With penitent bias, Praying, Don’t send me down, if You "
you must first supply them with misleading information; this is a device of Admass. It has been used, unconsciously but successfully, by Professor McKeown (July 1). He pictures the teaching hospital as a place in which the patients are highly selected, and from which mental and long-term illnesses are " virtually " excluded. There is, of course, sufficient truth in this to make it plausible; but it ignores the fact that most teaching hospitals are also local hospitals, with large unselected outpatient clinics and a high proportion of emergency admissions. Although two decades of inattention has left them with facilities which are generally inadequate, and sometimes deplorable, they are at least medical communities with a tradition of good practice; and their defects will not be overcome by submerging them in a medical morass, whose size is limited only by the boiler-room or the laundry. The object of medical education is to enable young men and women to give personal care to their patients and to understand the scientific principles on which medicine is based. However difficult it may be to attain, our standard should be high, and undiluted by considering the various possible circumstances which may make it difficult to maintain in all countries at all times. Problems of the application of medical care are, in my view, secondary to a high standard of clinical care itself; they are not unimportant, but they should not be the focal point of medical education, nor should we change a well-tried pattern of hospital structure on the basis either of local surveys or of the estimated needs of medically lessdeveloped countries. I hope these conservative reflections will not lay me open to a charge of complacency about medical education, which needs great changes, but not, I think, those advocated by Professor McKeown. Department of Medicine, The Royal Infirmary, Manchester.
D A. -’-" D. A K. K BLACK. BLACK
*
Transgressing the Pennines at an unusually early hour, I found myself in a railway carriage which was clearly on its way to the museum at York, but was being compelled by the iron hand of Dr. Beeching to work its passage with a few farepaying types. There were library facilities in the shape of a two-day-old paper; but there was neither hot nor cold in a place where one might have expected both, an old empty jug being the nearest approach to a locum for either. *
the Editor
LIMITATIONS OF MEDICAL CARE ATTRIBUTABLE TO MEDICAL EDUCATION SiR,-If you want people to reach the wrong conclusion,
FOR the last
gave last week in Barcelona and the week before in Pakistan. Ah, well, there is always Mr. Pilkington-Brown. But Mr. Pilkington-Brown is in Australia. It is a curious’inversion of
to
plaius."
ÆTIOLOGY OF ERYTHEMA NODOSUM IN CHILDREN SIR,-Understandably this inquiry (July 1) by a group of paediatricians combines the failings and merits of this
type of project-i.e., differences of opinion healthy in themselves imparted to the final report a commondenominator quality, and certain relevancies such as the absence of controls were not discussed. The omission of controls was legitimate to the extent that it avoided venepunctures in healthy children but it left two alternative courses: (1) to take into account in the interpretation of results those observations of others which have shown an appreciable incidence (a) of raised antistreptolysin 0 titres in healthy subjects, and (b) of averagerange A.S.O. titres in patients with proved streptococcal infections 1; and (2) largely to disregard these observations of others on the grounds that they did at best only contribute a set of unmatched controls. The second course was in fact adopted in the report, but not every one would consider this permissible, and it should perhaps on this account be indicated that similar conclusions would also have been reached had the first course been adopted. A representative abbreviated argument deriving from the first course would be as follows: 1.
McCarty, M. Rheumatic Fever: Epidemiology and Prevention. Oxford, 1959.
In
Now
England
Letters
A
Running Commentary by Peripatetic Correspondents twenty-five years I have been coming at intervals to London-partly on holiday and partly on a busman’s holiday to see my surgical colleagues operating. Each time I leave with the same feeling of irritation and frustration. Among the great centres of medical education London must rank high for time-wasting. Each day operation lists are sent to the Royal College of Surgeons, to B.M.A. House, and to the Royal Society of Medicine. They are made up late on the previous day and arrive by the first post on the morning of the operation session. The eager visitor’is thus far too late for the morning operations, at least if he takes the posted times seriously. It is some time before he realises that these are only token times. He rushes off, breakfastless, cursing the delays of public transport (when he has not a car with him), and arrives breathless at St. Patrick’s hoping to be in time to see the second operation on Mr. Skinner’s list. What he finds quite often is an anaathetist standing around disconsolately and sisters and registrars twiddling their thumbs. Mr. Skinner is late because (I suggest unkindly) he has probably been operating on a private case. When he finally gets down to his operation it is always a work of art and worth the vexation and the rush. But inevitably lunch engagements and arrangements for the afternoon go by the board. The eager visitor is faced with further frustrations in the jet age. He wants to see Mr. Skinner performing. He has come from the back-blocks with this as the highlight of his visit. But Mr. Skinner is off to
Chicago
to
deliver
a
lecture which he
medieval times. Then it was customary for students to move from Montpellier to Paris, to Amsterdam, to Padua, to sit at the feet of famous teachers. Now it is the teacher who flits from continent to continent. The situation calls for a kind of surgical Guide Michelin. Three forceps for Mr. Smith at the Far Western Hospital who operates at the stated time and stays put in London long enough to teach his students and his juniors. One blunt scalpel for Mr. Pilkington-Brown who isn’t quite sure whether he was in Yugoslavia or in Peru last week talking about his new operation which involves the use of three clamps instead of two. *
*
*
*
Seamus has been watching with the closest concern recent developments connected with the possible entry of Great Britain into the Common Market. A Francophile in principle, he said to me the other day: " Sure an’ nobody’s more pleased than meself to see France doin’ so well. I like to see the Gallic cock crowing again. But ye’d better see that it doesn’t use Britain for its dunghill. Ye’ve a fertile little country. What with the American Eagle, the German Eagle, and that barnyard fowl across the water, though, ye’d better watch out not to get Mammals are better for the too much guano everywhere. flowers, me boy, remember that." Seamus’s imagery sometimes makes me wonder whether the Irish influence in world politics is always for the best; but it certainly makes for interest. *
*
A scholar of Gonville and
*
Caius,
Contracted a lethal disaius. His thoughts became pious With penitent bias, Praying, Don’t send me down, if You "
you must first supply them with misleading information; this is a device of Admass. It has been used, unconsciously but successfully, by Professor McKeown (July 1). He pictures the teaching hospital as a place in which the patients are highly selected, and from which mental and long-term illnesses are " virtually " excluded. There is, of course, sufficient truth in this to make it plausible; but it ignores the fact that most teaching hospitals are also local hospitals, with large unselected outpatient clinics and a high proportion of emergency admissions. Although two decades of inattention has left them with facilities which are generally inadequate, and sometimes deplorable, they are at least medical communities with a tradition of good practice; and their defects will not be overcome by submerging them in a medical morass, whose size is limited only by the boiler-room or the laundry. The object of medical education is to enable young men and women to give personal care to their patients and to understand the scientific principles on which medicine is based. However difficult it may be to attain, our standard should be high, and undiluted by considering the various possible circumstances which may make it difficult to maintain in all countries at all times. Problems of the application of medical care are, in my view, secondary to a high standard of clinical care itself; they are not unimportant, but they should not be the focal point of medical education, nor should we change a well-tried pattern of hospital structure on the basis either of local surveys or of the estimated needs of medically lessdeveloped countries. I hope these conservative reflections will not lay me open to a charge of complacency about medical education, which needs great changes, but not, I think, those advocated by Professor McKeown. Department of Medicine, The Royal Infirmary, Manchester.
D A. -’-" D. A K. K BLACK. BLACK
*
Transgressing the Pennines at an unusually early hour, I found myself in a railway carriage which was clearly on its way to the museum at York, but was being compelled by the iron hand of Dr. Beeching to work its passage with a few farepaying types. There were library facilities in the shape of a two-day-old paper; but there was neither hot nor cold in a place where one might have expected both, an old empty jug being the nearest approach to a locum for either. *
the Editor
LIMITATIONS OF MEDICAL CARE ATTRIBUTABLE TO MEDICAL EDUCATION SiR,-If you want people to reach the wrong conclusion,
FOR the last
gave last week in Barcelona and the week before in Pakistan. Ah, well, there is always Mr. Pilkington-Brown. But Mr. Pilkington-Brown is in Australia. It is a curious’inversion of
to
plaius."
ÆTIOLOGY OF ERYTHEMA NODOSUM IN CHILDREN SIR,-Understandably this inquiry (July 1) by a group of paediatricians combines the failings and merits of this
type of project-i.e., differences of opinion healthy in themselves imparted to the final report a commondenominator quality, and certain relevancies such as the absence of controls were not discussed. The omission of controls was legitimate to the extent that it avoided venepunctures in healthy children but it left two alternative courses: (1) to take into account in the interpretation of results those observations of others which have shown an appreciable incidence (a) of raised antistreptolysin 0 titres in healthy subjects, and (b) of averagerange A.S.O. titres in patients with proved streptococcal infections 1; and (2) largely to disregard these observations of others on the grounds that they did at best only contribute a set of unmatched controls. The second course was in fact adopted in the report, but not every one would consider this permissible, and it should perhaps on this account be indicated that similar conclusions would also have been reached had the first course been adopted. A representative abbreviated argument deriving from the first course would be as follows: 1.
McCarty, M. Rheumatic Fever: Epidemiology and Prevention. Oxford, 1959.