- Email: [email protected]
LOOKING BACKWARDS FROM 1975
1322 ment, and wards.
All sterilisers were checked originally by and intermittent checks are made regularly. When a her, steriliser is found to be inefficient, the i.c.s. informs the sister in charge and declares the steriliser temporarily unfit for use. In the central sterilising department of the hospital the contents and size of each variety of pack are standardised. At first, individual sterility tests for each variety of pack were carried out. Since then, tests for sterility have been made at suitable intervals using the thermophilic spore test. EPIDEMIOLOGICAL INVESTIGATIONS
Staphylococci in the Nose To determine the prevalence of nasal Staph. aureus in the operating-theatre personnel, all medical, nursing, and technical staff and wardsmen in the theatre were swabbed by the i.c.s. The main object was to pick out the persistent nasal carriers and then to render them non-carriers by means of neomycin and chlorhexidine nasal
cream.
Investigation of Cross-infection When a case of gas-gangrene occurred in a surgical ward, the bacteriologist, with the help of the i.c.s., isolated the organism from many articles in the ward. This made the nurses more aware of potential sources of cross-infection and much readier to join in attaining higher standards of hygiene.
Sterility of Operating-theatre Water-supply This is checked regularly by the i.c.s. CLINICAL TRIALS
In
a
teaching hospital,
any method introduced to reduce
hospital infection should be tested by properly conducted clinical trials. Here the i.c.s. has a very important part to play. At present we are determining the effect of local chemotherapy on the incidence of wound infection and the LC.S. is recording the data. MISCELLANEOUS DUTIES
Throughout the hospital the presence of the i.c.s. has created an interest in infection and cross-infection. This interest is increased by suitable posters. The subcommittee decides on their content, and the i.c.s. arranges for their display at suitable strategic points. SUMMARY AND CONCLUSIONS
In
infection control sister can Each month she can a complete list of wound infections, including those apparent only after the patient has left hospital. She can easily be trained to do the routine bacteriology associated with hospital infection. She looks exactly like an ordinary nursing sister, and can walk in and out of wards without attracting attention. In this way, she is in a good position to see that aseptic techniques are being carried out. She can also undertake the teaching and supervising of dressing procedures to new sisters and nurses who may be unfamiliar with the techniques. She regularly checks sterilisation procedures in all parts of the hospital and reports any defects. She can do the detailed work arising from epidemiological surveys and clinical trials. Finally, her very presence in the wards and in the theatre is a reminder of the problems of hospital infection. It is a pleasure to acknowledge the wisdom of the Department of Health and Home Affairs of Queensland in making possible the a
perform compile
major hospital
an
many useful functions.
appointment of a full-time infection control sister at the Princess Alexandra, Hospital. The Department cooperated originally by allowing Dr. J. Tonge, director of the Laboratory of Microbiology and Pathology, Sister S. Hillard, S.R.N., and Miss Y. Battey, B.sc., to undertake the initial investigation into the incidence of hospital infection at the hospital. It was the outstanding ability and qualities of Sister Hillard which impressed us so much that it became obvious that we should seek a permanent l.c.s. The Joint Hospitals Infection Committee helped us by recommending such an appointment to the Director General of Health. Sister N. Wernigk, S.R.N., holds the appointment of l.c.s., and we wish to record our sincere thanks to her for carrying out her duties so efficiently and conscientiously.
Very Special
Articles
LOOKING BACKWARDS FROM 1975 We are fortunate in being able to publish, twelve years before its delivery, the following message from an official of the Federal Government of the United States on the 200th anniversary of the First Continental Congress. This message, we understand, does not necessarily reflect the policies or positions of the U.S. Public Health Service as at
As
present constituted.—ED. L.
Surgeon General of the U.S. Welfare Service, I
report that the most notable event of 1975 has been revival of an essential birth-rate after the disastrous drop in fertility which followed commercial introduction of a cola drink, called SafeTea, with properties which not only repressed ovulation but also prevented infection. Aphrodisiac and euphoric effects of the beverage assured its popularity. The drop in the tide of population, welcomed at first, was marred by economic events. Shocked by the bankruptcy of old-line beverage manufacturers who lacked the magic formula, the economy faltered. It sagged with an abrupt halt in construction of housing, although nothing suffered so much as the dairy industry, already hard hit by radioactivity. Food and drug regulations were invoked to restrict the sale of SafeTea and, with cooperation from the World Health Organisation, its distribution was prohibited internationally. To be sure, the popular appeal of SafeTea continues, and bootlegging persists despite firm methods of law enforcement. But a strong program of public education, supported by the Maternity League, headed by leading figures in the world of finance, is restoring the recommended level of 2.01 children per family. Another significant event has been agreement of the major Nuclear Powers, including Egypt, the People’s Republic of China, Israel, Argentina, and Sarawak, to refrain from further testing of nuclear devices, except under favorable circumstances, so as to retard progressive contamination of the environment. In this connection, the Agricultural Research Service has succeeded in obtaining milk of minimum radioactivity from cows raised under glass and watered and fed from decontaminating ionexchange tubes. The consequent spur to the construction industry for putting pastures under glass also helped to revive the sagging economy and reduced the Federal unemployment total to 10 million. Thanks to the pioneer efforts of the air-conditioning industry, every American citizen now eats, sleeps, and works under circumstances where he breathes only filtered air and drinks only treated water. For outdoor workers, the headgear for breathing is proving reasonably satisfactory, thanks to the development of clothing prepared originally for Space travel. All Americans, consequently, are now reasonably secure from internal radiation and from toxic chemicals except for the contaminants that continue to penetrate the food-processing systems. In another five years we shall also have reduced the hazards associated with the filtering mechanisms. The population is also well protected from external radiation, in view of the shielding program, so that the hazard is significant only for those who spend much time out of doors. The increased morbidity and mortality of those occupationally exposed to outdoor radiation, however, is being offset by our success
in
restoring fertility-rates.
As to the matter of
1323
defective mutations, we are maintaining a close surveillance of all new births, and in another generation or so we should have reasonably confident conclusions about the need for eugenic selection. The task of disposing of spent cores from nuclear power reactors appears to have been solved by shooting them into the sun. This system, justifying the Space missile program, has the dual advantage of restoring some small part of the energy which the sun releases every second, with the prospect that the eventual cooling of the sun, several billion years hence, may be retarded by a few months. Nuclear energy, of course, entails certain risks, as do all enterprises. The misfiring of a load of radioactive residues from the Dresden plant, with regrettable consequences to Albany, Georgia, may or may not have been an avoidable accident, but it is indicative of the care which must attend those procedures. Meanwhile, Federal efforts to confine radioactivity within the Albany area give every promise of success. We have managed to shut off all movement in and out of the contaminated section except for what is carried on prevailing winds, in ground water, and by surviving microbial and insect life. The progressively declining role of parasitic or infectious diseases has reached a point where we in this country may look with confidence for the eradication of plague, tuberculosis, venereal disease, malaria, smallpox, yellow fever, typhus, and typhoid fever within the next hundred years or so. The recent episodes in Seattle, Anaheim, Denver, and New Orleans simply underline our responsibility and capacity. The uninhibited appearance of carriers of tuberculosis and venereal disease in all ranks of society, where they keep alive the chain of infection, is simply a challenge to develop the social measures needed to support pharma-
cologic techniques. The single-shot immunisation method introduced in 1969 is meeting progressive acceptance everywhere, although no population as yet has reached the point where herd immunity may be likely. It is believed, however, that the American vaccine developed in Canada and England is far superior to that developed in the Soviet Union. Our epidemiologists are keeping a careful eye on reports of the diseases involved-including dengue, poliomyelitis, and tsutsugamushi fever-and they do not feel that any of the recent upsurge in cases reported can be directly attributed to the application of the vaccine. The progressive ageing of the population has infused a new sense of wisdom, tranquillity, and serenity in a population which has suffered
much in the past from aggressiveness, competition, and turbulence. Not the least of the achievements of our society in its regard for the aged has been the creation of the cyclical cell which automatically feeds, evacuates, and cleans those viable patients whose capacity for self-care has been impaired. In view of the immobility imposed by the cell, we have even provided recreation for the patients through closedcircuit TV programs selected according to their circumstances. For those with deficient hearing, old silent movies are shown. The question of the association of cigarette-smoking with cancer, heart-disease, kidney trouble, arthritis, cholelithiasis, amyotropic lateral sclerosis, and dental caries continues under investigation. The results as yet fail to justify a public policy of restricting the sale and advertising of cigarettes, beyond the present excise penalties. In this regard, the National Commission on Mental Health has cautioned that too many inhibitions and restrictions too
applied to simple pleasures and indulgences can contribute tension and instability. Accidents on the highway and in the home have been reduced decisively. Highway congestion, which imposed a speed of 10 miles an hour on private motor vehicles, has been an important factor in this development. The greatest influence on reducing injuries to children has been the popular custom of converting Tv rooms, recreation rooms, fallout shelters, and playrooms in the average home into padded cells. The American Home Rebuilders Institute estimates that 10 million padded cells have been to nervous
installed in domestic structures since 1971. The research effort is such that major breakthroughs are believed to be imminent in control of cancer, heartdisease, renal disease, and metabolic diseases. The knowledge accumulated in the past generation is bound to pay off sooner or later, we hope. With respect to the management of chronic diseases, the National College on Collagen Illness, after extensive investigation, has recommended that a most effective palliative for arthritic conditions is acetylsalicylic acid in doses prescribed by the attending physician. The fact that this medication, commonly known as aspirin, has been familiar to the treatment of headaches has tended to obscure some of its other
applications. Arrangements by the Department of Agriculture, the Postal Service, the Food Industries Council, and the Welfare Service to distribute prepared packaged meals three times a day, with mail deliveries, have made possible the issuance of a well-managed diet for each American citizen. The dietary requirements are established by individual examination, and a punch-card system delivery of the appropriate diet to each client. Public appreciation of this service, however, is well below expectations: there has been a cultural lag which expresses itself in a determination to eat fresh fruits and vegetables, fresh eggs, freshly caught fish, and freshly slaughtered meats, prepared in the home according to time-honored recipes. An education program of extraordinary dimensions is indicated for correcting this situation, as domestic cooking is generally wasteful and even unwholesome on occasion. The American Council on Nutrition has warned that home-cooked meals are contributing to the prevalence of obesity in the population. The National Research Council, however, reports that while many Americans eat more than they should, others aren’t eating enough. Progress in fluoridating municipal water-supplies has now reached the stage where almost as many cities have fluoridated water as before 1950. Since the population gains in these cities have been considerable, the number of children using fluoridated water would also have grown were it not for the lapse in fertility noted above. Environmental conditions are expected to improve as soon as the Federal budget can be revised in order to divert funds employed on Space programs, nuclear energy development, and defense. It is hoped that the construction of shelter, highways, schools, hospitals, water and sewage facilities, parks, playgrounds, gardens, recreation centers for all ages, and atmospheric controls, supported by training of essential personnel, may develop as soon as international tensions can be somewhat relaxed. Contamination of the environment, including food and water, by a variety of artifacts, including pesticides and detergents, was an issue of considerable concern 10 years ago. Today, it is no longer a basis for ungrounded fears. We have studied the issues to the saturation point and
1324 know that the fears expressed in the past were well grounded. Mental illness has been wiped out. This crowning achievement is credited mainly to the brilliant psychiatrist, Moishe Wlenczk, professor of public mentality, University of Vilna, who in a series of logical essays demonstrated that there is in modern society no valid distinction between mental illness and mental health. Ability to distinguish between right and wrong, concern for the consequences of one’s behavior, capacity to control or discipline one’s behavior, Wlenczk demonstrated, were conceptual artefacts of an older civilisation with no justification in modern society. Former mental hospitals have since been converted to vacation resorts, convalescent hotels, rest homes, camps, ranches, and night clubs. And the guests are on the whole as successful, effective, and well adjusted as the passengers on any cruise ship on the last night out. Medical-care programs have undergone a thorough, searching analysis. Our original goal for developing a pluralistic program, suitable to the variety of conditions and needs in our large population, has been carried to its logical conclusion. A different program has been evolved for each individual patient and, by abandoning the false gods of prepayment and social insurance, we have eliminated much unnecessary bookkeeping as well as a great deal of gratuitous, unwarranted, and undesirable medical care. This decade has written a Magna Carta for physician and patient alike: the physician is free to retire from practice and live on investments in real estate, and the patient is free to seek the services of faith-healers, voodoo priests, and gypsies. As a consequence, hospitals report drastic reductions in major surgery and the sale of prescription drugs has dwindled to a trickle. Mortality-rates, however, have not been affected.
now we
R.
Medical Education REFLECTIONS ON TEACHING L. S. MICHAELIS WHAT qualities should we look for in applicants for teaching posts ? At present these qualities do not seem to be clearly defined, and selection is commonly by hazard rather than design. As a branch of postgraduate medical work, teaching does not receive the attention, let alone the rewards, that it deserves. Too often it is a side-show, squeezed uneasily into a time-table crammed with research
clinical work and administration. Sometimes it is done supremely well-witness the obituaries in which the quality of their teachers is praised by their former pupils. Sometimes it is done very badly, as quite a number of students and postgraduates from a variety of schools will tell you. Nor are they alone in complaining. Some of those whose duties include teaching have spoken in no uncertain terms of the boredom and " waste of time " that teaching means for them. Bernard Shaw said, characteristically, " those who can’t, teach ". Those who can’t teach, sneer would be closer to the truth. Some of the great masters of original work in the laboratory, the ward, or the theatre have also been the finest teachers in their generation. They were lucky enough to combine in themselves the different, but by no means contradictory, gifts of a scientific imagination reaching out beyond the known facts and a command of or
"
these facts complete and integrated enough to enable them to lecture simply and lucidly. Just as there are first-rate research-workers, physicians, and surgeons who lack the gift of communicating the essence of their work to students in a coherent, clear, and stimulating manner, so there are teachers with this gift who have never made an original contribution to research. By laying the foundations of productive knowledge and inspired curiosity in their pupils, these men may do as much as the innovators for the progress of Medicine. " Born teachers ", less publicised than born researchers, are not held in sufficient esteem-not sought out and placed early enough in the posts where they could give of their best. Lectureships, readerships, and professorships too often go to people who cannot lecture, who have to read their talks, and whose " professions " are twenty years out of date. Instead, they should go to those whose outstanding gift and interest is teaching-in the widest sense-and who are prepared to seek the fruit of their labours in their pupils’ results rather than their own.
Teaching is planting, is tending the spirit of inquiry, the critical faculty, and the habit of thoroughness in those who may discover in themselves the soil on which unexpected gifts may grow. At the time they start their studies, none but the exceptional are aware of such gifts. And they may discover them only when-for career reasons-it is too late. Among these is an unawakened gift for teaching-an unploughed field in the academic landscape. There are today too many such fallow fields. By teaching I do not, of course, mean only coaching (the orderly stacking away of book and examination knowledge); nor training in the skills of the bedside, the theatre, or the bench. These important branches of teaching are best done by young postgraduates of registrar status who hand their own fresh experience to their juniors. Teaching by lecture or discussion is the province of the experienced worker who keeps his mind fresh by passing actively through successive waves of ideas and debunkings, by controversy as much as by collaboration with others. He must have shed an uncritical faith in the printed word, the automatic respect for authority, the undue pride of the beginner. He must, in fact, be mature and conscious of his great responsibility and good fortune. He must be and remain enthusiastic about this art of teaching. To stand in front of many younger
people-some eager, sceptical, some plain lazy-and to coax them into becoming active companions on your journey through a stretch of knowledge is an experience some
sleepy,
some
be missed. You will not achieve it unless you are sure of your technique, which includes mastery of inductive reasoning so that the theme develops from a spark to the bright light of communally acquired insight. It includes negative virtues like the avoidance of cliches, of cheap repeated jokes, of play-acting and showing off. It demands spontaneous and personal use of the language, the complete absence of a dusty text to be read from or even squinted at, and a clear, carrying, but never loud voice. Teaching, by lecture or discussion group, is to coaching and training what conducting is to practising and taking instrumental lessons. It should correlate, interpret, make meaningful the haphazard mixture of information from books and from notes taken in laboratory or ward-from the routines and the rarities the student collects and stores not to
All sterilisers were checked originally by and intermittent checks are made regularly. When a her, steriliser is found to be inefficient, the i.c.s. informs the sister in charge and declares the steriliser temporarily unfit for use. In the central sterilising department of the hospital the contents and size of each variety of pack are standardised. At first, individual sterility tests for each variety of pack were carried out. Since then, tests for sterility have been made at suitable intervals using the thermophilic spore test. EPIDEMIOLOGICAL INVESTIGATIONS
Staphylococci in the Nose To determine the prevalence of nasal Staph. aureus in the operating-theatre personnel, all medical, nursing, and technical staff and wardsmen in the theatre were swabbed by the i.c.s. The main object was to pick out the persistent nasal carriers and then to render them non-carriers by means of neomycin and chlorhexidine nasal
cream.
Investigation of Cross-infection When a case of gas-gangrene occurred in a surgical ward, the bacteriologist, with the help of the i.c.s., isolated the organism from many articles in the ward. This made the nurses more aware of potential sources of cross-infection and much readier to join in attaining higher standards of hygiene.
Sterility of Operating-theatre Water-supply This is checked regularly by the i.c.s. CLINICAL TRIALS
In
a
teaching hospital,
any method introduced to reduce
hospital infection should be tested by properly conducted clinical trials. Here the i.c.s. has a very important part to play. At present we are determining the effect of local chemotherapy on the incidence of wound infection and the LC.S. is recording the data. MISCELLANEOUS DUTIES
Throughout the hospital the presence of the i.c.s. has created an interest in infection and cross-infection. This interest is increased by suitable posters. The subcommittee decides on their content, and the i.c.s. arranges for their display at suitable strategic points. SUMMARY AND CONCLUSIONS
In
infection control sister can Each month she can a complete list of wound infections, including those apparent only after the patient has left hospital. She can easily be trained to do the routine bacteriology associated with hospital infection. She looks exactly like an ordinary nursing sister, and can walk in and out of wards without attracting attention. In this way, she is in a good position to see that aseptic techniques are being carried out. She can also undertake the teaching and supervising of dressing procedures to new sisters and nurses who may be unfamiliar with the techniques. She regularly checks sterilisation procedures in all parts of the hospital and reports any defects. She can do the detailed work arising from epidemiological surveys and clinical trials. Finally, her very presence in the wards and in the theatre is a reminder of the problems of hospital infection. It is a pleasure to acknowledge the wisdom of the Department of Health and Home Affairs of Queensland in making possible the a
perform compile
major hospital
an
many useful functions.
appointment of a full-time infection control sister at the Princess Alexandra, Hospital. The Department cooperated originally by allowing Dr. J. Tonge, director of the Laboratory of Microbiology and Pathology, Sister S. Hillard, S.R.N., and Miss Y. Battey, B.sc., to undertake the initial investigation into the incidence of hospital infection at the hospital. It was the outstanding ability and qualities of Sister Hillard which impressed us so much that it became obvious that we should seek a permanent l.c.s. The Joint Hospitals Infection Committee helped us by recommending such an appointment to the Director General of Health. Sister N. Wernigk, S.R.N., holds the appointment of l.c.s., and we wish to record our sincere thanks to her for carrying out her duties so efficiently and conscientiously.
Very Special
Articles
LOOKING BACKWARDS FROM 1975 We are fortunate in being able to publish, twelve years before its delivery, the following message from an official of the Federal Government of the United States on the 200th anniversary of the First Continental Congress. This message, we understand, does not necessarily reflect the policies or positions of the U.S. Public Health Service as at
As
present constituted.—ED. L.
Surgeon General of the U.S. Welfare Service, I
report that the most notable event of 1975 has been revival of an essential birth-rate after the disastrous drop in fertility which followed commercial introduction of a cola drink, called SafeTea, with properties which not only repressed ovulation but also prevented infection. Aphrodisiac and euphoric effects of the beverage assured its popularity. The drop in the tide of population, welcomed at first, was marred by economic events. Shocked by the bankruptcy of old-line beverage manufacturers who lacked the magic formula, the economy faltered. It sagged with an abrupt halt in construction of housing, although nothing suffered so much as the dairy industry, already hard hit by radioactivity. Food and drug regulations were invoked to restrict the sale of SafeTea and, with cooperation from the World Health Organisation, its distribution was prohibited internationally. To be sure, the popular appeal of SafeTea continues, and bootlegging persists despite firm methods of law enforcement. But a strong program of public education, supported by the Maternity League, headed by leading figures in the world of finance, is restoring the recommended level of 2.01 children per family. Another significant event has been agreement of the major Nuclear Powers, including Egypt, the People’s Republic of China, Israel, Argentina, and Sarawak, to refrain from further testing of nuclear devices, except under favorable circumstances, so as to retard progressive contamination of the environment. In this connection, the Agricultural Research Service has succeeded in obtaining milk of minimum radioactivity from cows raised under glass and watered and fed from decontaminating ionexchange tubes. The consequent spur to the construction industry for putting pastures under glass also helped to revive the sagging economy and reduced the Federal unemployment total to 10 million. Thanks to the pioneer efforts of the air-conditioning industry, every American citizen now eats, sleeps, and works under circumstances where he breathes only filtered air and drinks only treated water. For outdoor workers, the headgear for breathing is proving reasonably satisfactory, thanks to the development of clothing prepared originally for Space travel. All Americans, consequently, are now reasonably secure from internal radiation and from toxic chemicals except for the contaminants that continue to penetrate the food-processing systems. In another five years we shall also have reduced the hazards associated with the filtering mechanisms. The population is also well protected from external radiation, in view of the shielding program, so that the hazard is significant only for those who spend much time out of doors. The increased morbidity and mortality of those occupationally exposed to outdoor radiation, however, is being offset by our success
in
restoring fertility-rates.
As to the matter of
1323
defective mutations, we are maintaining a close surveillance of all new births, and in another generation or so we should have reasonably confident conclusions about the need for eugenic selection. The task of disposing of spent cores from nuclear power reactors appears to have been solved by shooting them into the sun. This system, justifying the Space missile program, has the dual advantage of restoring some small part of the energy which the sun releases every second, with the prospect that the eventual cooling of the sun, several billion years hence, may be retarded by a few months. Nuclear energy, of course, entails certain risks, as do all enterprises. The misfiring of a load of radioactive residues from the Dresden plant, with regrettable consequences to Albany, Georgia, may or may not have been an avoidable accident, but it is indicative of the care which must attend those procedures. Meanwhile, Federal efforts to confine radioactivity within the Albany area give every promise of success. We have managed to shut off all movement in and out of the contaminated section except for what is carried on prevailing winds, in ground water, and by surviving microbial and insect life. The progressively declining role of parasitic or infectious diseases has reached a point where we in this country may look with confidence for the eradication of plague, tuberculosis, venereal disease, malaria, smallpox, yellow fever, typhus, and typhoid fever within the next hundred years or so. The recent episodes in Seattle, Anaheim, Denver, and New Orleans simply underline our responsibility and capacity. The uninhibited appearance of carriers of tuberculosis and venereal disease in all ranks of society, where they keep alive the chain of infection, is simply a challenge to develop the social measures needed to support pharma-
cologic techniques. The single-shot immunisation method introduced in 1969 is meeting progressive acceptance everywhere, although no population as yet has reached the point where herd immunity may be likely. It is believed, however, that the American vaccine developed in Canada and England is far superior to that developed in the Soviet Union. Our epidemiologists are keeping a careful eye on reports of the diseases involved-including dengue, poliomyelitis, and tsutsugamushi fever-and they do not feel that any of the recent upsurge in cases reported can be directly attributed to the application of the vaccine. The progressive ageing of the population has infused a new sense of wisdom, tranquillity, and serenity in a population which has suffered
much in the past from aggressiveness, competition, and turbulence. Not the least of the achievements of our society in its regard for the aged has been the creation of the cyclical cell which automatically feeds, evacuates, and cleans those viable patients whose capacity for self-care has been impaired. In view of the immobility imposed by the cell, we have even provided recreation for the patients through closedcircuit TV programs selected according to their circumstances. For those with deficient hearing, old silent movies are shown. The question of the association of cigarette-smoking with cancer, heart-disease, kidney trouble, arthritis, cholelithiasis, amyotropic lateral sclerosis, and dental caries continues under investigation. The results as yet fail to justify a public policy of restricting the sale and advertising of cigarettes, beyond the present excise penalties. In this regard, the National Commission on Mental Health has cautioned that too many inhibitions and restrictions too
applied to simple pleasures and indulgences can contribute tension and instability. Accidents on the highway and in the home have been reduced decisively. Highway congestion, which imposed a speed of 10 miles an hour on private motor vehicles, has been an important factor in this development. The greatest influence on reducing injuries to children has been the popular custom of converting Tv rooms, recreation rooms, fallout shelters, and playrooms in the average home into padded cells. The American Home Rebuilders Institute estimates that 10 million padded cells have been to nervous
installed in domestic structures since 1971. The research effort is such that major breakthroughs are believed to be imminent in control of cancer, heartdisease, renal disease, and metabolic diseases. The knowledge accumulated in the past generation is bound to pay off sooner or later, we hope. With respect to the management of chronic diseases, the National College on Collagen Illness, after extensive investigation, has recommended that a most effective palliative for arthritic conditions is acetylsalicylic acid in doses prescribed by the attending physician. The fact that this medication, commonly known as aspirin, has been familiar to the treatment of headaches has tended to obscure some of its other
applications. Arrangements by the Department of Agriculture, the Postal Service, the Food Industries Council, and the Welfare Service to distribute prepared packaged meals three times a day, with mail deliveries, have made possible the issuance of a well-managed diet for each American citizen. The dietary requirements are established by individual examination, and a punch-card system delivery of the appropriate diet to each client. Public appreciation of this service, however, is well below expectations: there has been a cultural lag which expresses itself in a determination to eat fresh fruits and vegetables, fresh eggs, freshly caught fish, and freshly slaughtered meats, prepared in the home according to time-honored recipes. An education program of extraordinary dimensions is indicated for correcting this situation, as domestic cooking is generally wasteful and even unwholesome on occasion. The American Council on Nutrition has warned that home-cooked meals are contributing to the prevalence of obesity in the population. The National Research Council, however, reports that while many Americans eat more than they should, others aren’t eating enough. Progress in fluoridating municipal water-supplies has now reached the stage where almost as many cities have fluoridated water as before 1950. Since the population gains in these cities have been considerable, the number of children using fluoridated water would also have grown were it not for the lapse in fertility noted above. Environmental conditions are expected to improve as soon as the Federal budget can be revised in order to divert funds employed on Space programs, nuclear energy development, and defense. It is hoped that the construction of shelter, highways, schools, hospitals, water and sewage facilities, parks, playgrounds, gardens, recreation centers for all ages, and atmospheric controls, supported by training of essential personnel, may develop as soon as international tensions can be somewhat relaxed. Contamination of the environment, including food and water, by a variety of artifacts, including pesticides and detergents, was an issue of considerable concern 10 years ago. Today, it is no longer a basis for ungrounded fears. We have studied the issues to the saturation point and
1324 know that the fears expressed in the past were well grounded. Mental illness has been wiped out. This crowning achievement is credited mainly to the brilliant psychiatrist, Moishe Wlenczk, professor of public mentality, University of Vilna, who in a series of logical essays demonstrated that there is in modern society no valid distinction between mental illness and mental health. Ability to distinguish between right and wrong, concern for the consequences of one’s behavior, capacity to control or discipline one’s behavior, Wlenczk demonstrated, were conceptual artefacts of an older civilisation with no justification in modern society. Former mental hospitals have since been converted to vacation resorts, convalescent hotels, rest homes, camps, ranches, and night clubs. And the guests are on the whole as successful, effective, and well adjusted as the passengers on any cruise ship on the last night out. Medical-care programs have undergone a thorough, searching analysis. Our original goal for developing a pluralistic program, suitable to the variety of conditions and needs in our large population, has been carried to its logical conclusion. A different program has been evolved for each individual patient and, by abandoning the false gods of prepayment and social insurance, we have eliminated much unnecessary bookkeeping as well as a great deal of gratuitous, unwarranted, and undesirable medical care. This decade has written a Magna Carta for physician and patient alike: the physician is free to retire from practice and live on investments in real estate, and the patient is free to seek the services of faith-healers, voodoo priests, and gypsies. As a consequence, hospitals report drastic reductions in major surgery and the sale of prescription drugs has dwindled to a trickle. Mortality-rates, however, have not been affected.
now we
R.
Medical Education REFLECTIONS ON TEACHING L. S. MICHAELIS WHAT qualities should we look for in applicants for teaching posts ? At present these qualities do not seem to be clearly defined, and selection is commonly by hazard rather than design. As a branch of postgraduate medical work, teaching does not receive the attention, let alone the rewards, that it deserves. Too often it is a side-show, squeezed uneasily into a time-table crammed with research
clinical work and administration. Sometimes it is done supremely well-witness the obituaries in which the quality of their teachers is praised by their former pupils. Sometimes it is done very badly, as quite a number of students and postgraduates from a variety of schools will tell you. Nor are they alone in complaining. Some of those whose duties include teaching have spoken in no uncertain terms of the boredom and " waste of time " that teaching means for them. Bernard Shaw said, characteristically, " those who can’t, teach ". Those who can’t teach, sneer would be closer to the truth. Some of the great masters of original work in the laboratory, the ward, or the theatre have also been the finest teachers in their generation. They were lucky enough to combine in themselves the different, but by no means contradictory, gifts of a scientific imagination reaching out beyond the known facts and a command of or
"
these facts complete and integrated enough to enable them to lecture simply and lucidly. Just as there are first-rate research-workers, physicians, and surgeons who lack the gift of communicating the essence of their work to students in a coherent, clear, and stimulating manner, so there are teachers with this gift who have never made an original contribution to research. By laying the foundations of productive knowledge and inspired curiosity in their pupils, these men may do as much as the innovators for the progress of Medicine. " Born teachers ", less publicised than born researchers, are not held in sufficient esteem-not sought out and placed early enough in the posts where they could give of their best. Lectureships, readerships, and professorships too often go to people who cannot lecture, who have to read their talks, and whose " professions " are twenty years out of date. Instead, they should go to those whose outstanding gift and interest is teaching-in the widest sense-and who are prepared to seek the fruit of their labours in their pupils’ results rather than their own.
Teaching is planting, is tending the spirit of inquiry, the critical faculty, and the habit of thoroughness in those who may discover in themselves the soil on which unexpected gifts may grow. At the time they start their studies, none but the exceptional are aware of such gifts. And they may discover them only when-for career reasons-it is too late. Among these is an unawakened gift for teaching-an unploughed field in the academic landscape. There are today too many such fallow fields. By teaching I do not, of course, mean only coaching (the orderly stacking away of book and examination knowledge); nor training in the skills of the bedside, the theatre, or the bench. These important branches of teaching are best done by young postgraduates of registrar status who hand their own fresh experience to their juniors. Teaching by lecture or discussion is the province of the experienced worker who keeps his mind fresh by passing actively through successive waves of ideas and debunkings, by controversy as much as by collaboration with others. He must have shed an uncritical faith in the printed word, the automatic respect for authority, the undue pride of the beginner. He must, in fact, be mature and conscious of his great responsibility and good fortune. He must be and remain enthusiastic about this art of teaching. To stand in front of many younger
people-some eager, sceptical, some plain lazy-and to coax them into becoming active companions on your journey through a stretch of knowledge is an experience some
sleepy,
some
be missed. You will not achieve it unless you are sure of your technique, which includes mastery of inductive reasoning so that the theme develops from a spark to the bright light of communally acquired insight. It includes negative virtues like the avoidance of cliches, of cheap repeated jokes, of play-acting and showing off. It demands spontaneous and personal use of the language, the complete absence of a dusty text to be read from or even squinted at, and a clear, carrying, but never loud voice. Teaching, by lecture or discussion group, is to coaching and training what conducting is to practising and taking instrumental lessons. It should correlate, interpret, make meaningful the haphazard mixture of information from books and from notes taken in laboratory or ward-from the routines and the rarities the student collects and stores not to