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MEDICAL EDUCATION AND THE STATE
889
peripheral hospital units nearer their homes. of course, admirable medical policy, but it
This is, is brave
thinking when the difficulties of securing suitable sites in large towns are examined, even if developments in community care 18 reduce considerably the number of hospital beds required. Would it be possible to find enough nurses to staff a mixed hospital, with, say, 3000 beds on one site? Of the many problems which the hospital service has encountered, the shortage of nurses has been the most persistent, and an advance is still hopefully awaited. In planning huge district hospitals situated where sites are available, it must not be forgotten that married nurses on whom hospitals increasingly rely usually seek posts near their homes and, even if transport is provided, many complain of the waste of time getting to and from their work. Small general hospitals and larger specialised ones have often built up a loyal and devoted staff who might not take kindly to the hurly-burly of a large district hospital several miles away. The nursing implications of these new proposals require further study. Recruitment to general practice has been worryingly inadequate for many years, and although it has been tackled energetically, the situation is still unsatisfactory. The Ministry of Health team who visited North America in 1967 reported 19 that few of the former family doctors they interviewed would be willing to return to general practice in this country unless they could obtain hospital privileges similar to those they enjoyed in their The separation which the new environment. National Health Service has imposed between hospital and general practice is one of its chief deficiencies; and any plans for the district general hospital of the future must tackle this problem and suggest ways in which family doctors can be brought back into the hospitals, caring for their patients, if necessary under consultant supervision. This issue is not shirked by the committee, but family doctors will be disappointed at the scarcity of positive proposals. No-one will deny the added difficulty of running a hospital ward with several practitioners responsible for the treatment of only one or two patients each, or that it can be awkward for junior hospital doctors if they are expected to cope with emergencies when the family doctor is not immediately available; but more experimental schemes on these lines are urgently required for the good of general practice. The surge of interest in postgraduate education and the mixing of family doctors and hospital staff in the new postgraduate centres will, it is to be hoped, lead to a greater willingness "
"
by the consultant to accept the family doctor as an active member of his team, especially in general medicine, paediatrics, and obstetrics. 18. See Lancet, Sept. 19. Br. med. J. 1968,
27, 1969, p. 673. i, 45.
In a prefatory note to the report, the Secretary of State for Social Services and the Secretary of State for Wales say that before conclusions can be reached on its findings and recommendations, they will have to be further considered in the light of the likely pattern of community health and social services, and in particular a lot more thought must be given to the best way of providing for people who need long-term care and also to the functions of the smaller hospitals supplementary to the district hospitals. The pro-
vision of long-term care involves not only the medical and nursing professions but also the local authority services and voluntary organisations. It is a social problem as much as a medical one, and has to be seen against the background of limited housing accommodation and the employment of married women as a help to the economy of the country. At present too much is expected of the geriatric service and the long-stay hospitals which are so overcrowded that a breakdown here and there is inevitable. Recent disclosures have aroused public indignation 20 and a full inquiry is needed into the best way of providing long-term care for those who require it. That is a necessary adjunct to this important report. 20. See
Lancet, Oct. 4, 1969, p. 727.
Annotations MEDICAL EDUCATION AND THE STATE
TECHNOLOGICAL advances, the Welfare State, and increased taxation; these are some of the reasons why medical schools and research centres have been unable, since the 1940s, to get by on private endowments. Must their increasing dependence on the State mean control by the State ? And must State control lead to stagnation and mediocrity? Dr. R. V. Christie, this orator, believes that the answer to both year’s Harveian " questions is yes " unless powerful safeguards can be provided. Such safeguards are, he believes, absent in Britain today. In Dr. Christie’s view, State intervention has had a stultifying influence on medical education and research in Britain. It has encroached on the freedom of universities to reward excellence, and has encouraged uniformity. Money has been taken away from the strong and successful and given to the weak. Standards have been levelled down rather than up. The State, which has allowed the discrepancy between facilities and training to grow ever wider, has listened harder to the voice of expediency than to the voice of reason. And in research the State had been equally blameworthy. Money has too often been allocated on the basis of the size and reputation of departments rather than the value of the work in hand. Such departments commonly have to assess the value of their own work; and the most pedestrian often have the least insight.
890
The solution, Dr. Christie suggests, is to employ the kind of methods used by private benefactors in Britain earlier this century, or the methods used in Sweden and the United States today. The State would thus continue to provide the money for research and teaching, but priorities would be decided by expert committees. (The M.R.C. might well play a part in the assessments.) The tendency to preserve the status quo would be reversed, and much of the security of tenure (which Dr. Christie believes has a bad influence on research-workers and academics) would go. One area in which Dr. Christie would like to see more security is in the amount of money which the State allocates for education and research. These views have a trans-Atlantic ring, which is not surprising since Dr. Christie is dean of the faculty of medicine at McGill. But, as he points out, the Todd commission admitted (tacitly) that much could be learned from North America. He is not against the direct State financing of medical education and research-indeed, he points out that William Harvey himself was one of the more notable products of a university where the State provided the buildings and paid the teaching staff. But he pleads, eloquently, that decisions on the financing of education and research should be reached out of informed discussion rather than expediency, that merit should be recognised and rewarded, and that the trend towards in the medical schools should be resisted.
pointed out that if the immersion fluid contains silicone (dimethysiloxane), bacteria cannot be subcultured from the solution, third-degree burns do not become macerated even after long immersion, and the eschar separates early, leaving a thin granulation-tissue bed which does not hypertrophy on exposure to silicone and which is eminently suitable for grafting. Whether silicone compounds have specific effects in burns is not known, but interest has lately been shown in the effects of minerals and trace elements. Rob et al.recorded an increase in the rate of healing of granulating wounds after the ingestion of zinc sulphate, and early experience with this compound suggests that it promotes skin coverage after grafting for burns. A silicone-containing mud used as a burns dressing in South Africa was shown to have much the same effects as the purified compound.9 Batdorf et al.1o investigated the use of frequently changed gloves soaked in silicone. They report that patients become rapidly pain-free and that burn oedema quickly subsides. These benefits allow early mobilisation of the hand, and control of the oedema is valuable since its persistence endangers the complete return of function. Batdorf et al. also note an absence of infection and the appearance of healthy granulation tissue satisfactory for grafting. This treatment seems well worth investigating further.
uniformity
HOSPITAL ADVISORY SERVICE THE BURNED HAND
DESPITE careful treatment, poor functional results are still common after burns of the dorsum of the hand. Moncrief 1,2 advocates early excision and grafting, since tendon function is often intact at the time of the burn, only to be destroyed later by the bacterial autolysis which is invariable beneath a third-degree eschar.22 Grafting is not always possible, however, when the survival of a badly burned patient is in doubt, since a large area of skin may be needed. A difficult judgment may also be called for since immobilisation after grafting will encourage skin coverage, yet early mobilisation may be needed to preserve function.33 Research has thus been directed towards finding a technique which will prevent bacterial invasion and provide a suitable surface for grafting at the same time as preserving function. One suggestion 4,5 is to enclose the burned hand in a plastic bag and to exercise the hand gently while it is maintained within the bacteriostatic environment of hyperbaric oxygen. While bacterial growth is greatly reduced it still takes place below the eschar, when it forms. Continuous immersion in electrolyte solutions has also been used, but this does not prevent infection and it promotes maceration.6 American workers, 6,7 however, have 1. 2.
3. 4. 5. 6. 7.
Moncrief, J. A. Am. J. Surg. 1958, 96, 535. Moncrief, J. A., Switzer, W. E., Rose, L. R. Plast. reconstr. Surg. 1964, 33, 305. Robertson, D. C. J. Bone Jt Surg. 1958, 40A, 625. Irvin, T. T., Norman, J. N., Suwanagul, A., Smith, G. Lancet, 1966, i, 392. Smith, G., Irvin, T. T., Norman, J. N. in Research in Burns; p. 34. Edinburgh, 1966. Gerow, F. J., Hardy, S. B., Spira, M., Law, S. W. Surg. Forum, 1963, 14, 32. Miller, J., Hardy, S. B., Spira, M. J. Bone Jt Surg. 1965, 47A, 938.
WARD Fl of a provincial hospital for the mentally subnormal is a long way, geographically and administratively, from the Department of Health and Social Security. One of the points to emerge from the inquiry into incidents at Ely Hospital was the apparent ignorance-by the Department, the hospital board, the hospital management committee, and even within the hospital-about what was happening. Nurses with something to say about the Hospital Service may well find it hard to get through to those at the top. The Secretary of State’s answer to this crisis in communications has been to set up the Hospital Advisory Service, outside his Department but with direct access to him. Its first director has just been appointed (see p. 916), and the service is to start work next week. The service is to act as Mr. Crossman’s eyes and ears in the hospitals and will consider points put to it by staff at all levels. These terms of reference are so generous that the service will find it difficult to turn away anyone who brings a problem to its door: in practice the team will be so small that its members must hope that not too many people bother to knock. Since the service is not statutory (and is, therefore, flexible) it might have been wiser to restrict it, in the first place, to the special problems of these hospitals, for this in fact will be the area where the team will spend most of its time. For there can be little doubt that Mr. Crossman’s main concern here is with the 8. 9. 10.
Pories, W. J., Henzel, J. H., Rob, C. G., Strain, W. H. Lancet, 1967, i, 121. Meeting of European Surgical Research Society, Davos, Switzerland, 1969. Batdorf, J. W., Cammack, K. V., Colquitt, R. D. Archs Surg., Chicago, 1969, 98, 469.
peripheral hospital units nearer their homes. of course, admirable medical policy, but it
This is, is brave
thinking when the difficulties of securing suitable sites in large towns are examined, even if developments in community care 18 reduce considerably the number of hospital beds required. Would it be possible to find enough nurses to staff a mixed hospital, with, say, 3000 beds on one site? Of the many problems which the hospital service has encountered, the shortage of nurses has been the most persistent, and an advance is still hopefully awaited. In planning huge district hospitals situated where sites are available, it must not be forgotten that married nurses on whom hospitals increasingly rely usually seek posts near their homes and, even if transport is provided, many complain of the waste of time getting to and from their work. Small general hospitals and larger specialised ones have often built up a loyal and devoted staff who might not take kindly to the hurly-burly of a large district hospital several miles away. The nursing implications of these new proposals require further study. Recruitment to general practice has been worryingly inadequate for many years, and although it has been tackled energetically, the situation is still unsatisfactory. The Ministry of Health team who visited North America in 1967 reported 19 that few of the former family doctors they interviewed would be willing to return to general practice in this country unless they could obtain hospital privileges similar to those they enjoyed in their The separation which the new environment. National Health Service has imposed between hospital and general practice is one of its chief deficiencies; and any plans for the district general hospital of the future must tackle this problem and suggest ways in which family doctors can be brought back into the hospitals, caring for their patients, if necessary under consultant supervision. This issue is not shirked by the committee, but family doctors will be disappointed at the scarcity of positive proposals. No-one will deny the added difficulty of running a hospital ward with several practitioners responsible for the treatment of only one or two patients each, or that it can be awkward for junior hospital doctors if they are expected to cope with emergencies when the family doctor is not immediately available; but more experimental schemes on these lines are urgently required for the good of general practice. The surge of interest in postgraduate education and the mixing of family doctors and hospital staff in the new postgraduate centres will, it is to be hoped, lead to a greater willingness "
"
by the consultant to accept the family doctor as an active member of his team, especially in general medicine, paediatrics, and obstetrics. 18. See Lancet, Sept. 19. Br. med. J. 1968,
27, 1969, p. 673. i, 45.
In a prefatory note to the report, the Secretary of State for Social Services and the Secretary of State for Wales say that before conclusions can be reached on its findings and recommendations, they will have to be further considered in the light of the likely pattern of community health and social services, and in particular a lot more thought must be given to the best way of providing for people who need long-term care and also to the functions of the smaller hospitals supplementary to the district hospitals. The pro-
vision of long-term care involves not only the medical and nursing professions but also the local authority services and voluntary organisations. It is a social problem as much as a medical one, and has to be seen against the background of limited housing accommodation and the employment of married women as a help to the economy of the country. At present too much is expected of the geriatric service and the long-stay hospitals which are so overcrowded that a breakdown here and there is inevitable. Recent disclosures have aroused public indignation 20 and a full inquiry is needed into the best way of providing long-term care for those who require it. That is a necessary adjunct to this important report. 20. See
Lancet, Oct. 4, 1969, p. 727.
Annotations MEDICAL EDUCATION AND THE STATE
TECHNOLOGICAL advances, the Welfare State, and increased taxation; these are some of the reasons why medical schools and research centres have been unable, since the 1940s, to get by on private endowments. Must their increasing dependence on the State mean control by the State ? And must State control lead to stagnation and mediocrity? Dr. R. V. Christie, this orator, believes that the answer to both year’s Harveian " questions is yes " unless powerful safeguards can be provided. Such safeguards are, he believes, absent in Britain today. In Dr. Christie’s view, State intervention has had a stultifying influence on medical education and research in Britain. It has encroached on the freedom of universities to reward excellence, and has encouraged uniformity. Money has been taken away from the strong and successful and given to the weak. Standards have been levelled down rather than up. The State, which has allowed the discrepancy between facilities and training to grow ever wider, has listened harder to the voice of expediency than to the voice of reason. And in research the State had been equally blameworthy. Money has too often been allocated on the basis of the size and reputation of departments rather than the value of the work in hand. Such departments commonly have to assess the value of their own work; and the most pedestrian often have the least insight.
890
The solution, Dr. Christie suggests, is to employ the kind of methods used by private benefactors in Britain earlier this century, or the methods used in Sweden and the United States today. The State would thus continue to provide the money for research and teaching, but priorities would be decided by expert committees. (The M.R.C. might well play a part in the assessments.) The tendency to preserve the status quo would be reversed, and much of the security of tenure (which Dr. Christie believes has a bad influence on research-workers and academics) would go. One area in which Dr. Christie would like to see more security is in the amount of money which the State allocates for education and research. These views have a trans-Atlantic ring, which is not surprising since Dr. Christie is dean of the faculty of medicine at McGill. But, as he points out, the Todd commission admitted (tacitly) that much could be learned from North America. He is not against the direct State financing of medical education and research-indeed, he points out that William Harvey himself was one of the more notable products of a university where the State provided the buildings and paid the teaching staff. But he pleads, eloquently, that decisions on the financing of education and research should be reached out of informed discussion rather than expediency, that merit should be recognised and rewarded, and that the trend towards in the medical schools should be resisted.
pointed out that if the immersion fluid contains silicone (dimethysiloxane), bacteria cannot be subcultured from the solution, third-degree burns do not become macerated even after long immersion, and the eschar separates early, leaving a thin granulation-tissue bed which does not hypertrophy on exposure to silicone and which is eminently suitable for grafting. Whether silicone compounds have specific effects in burns is not known, but interest has lately been shown in the effects of minerals and trace elements. Rob et al.recorded an increase in the rate of healing of granulating wounds after the ingestion of zinc sulphate, and early experience with this compound suggests that it promotes skin coverage after grafting for burns. A silicone-containing mud used as a burns dressing in South Africa was shown to have much the same effects as the purified compound.9 Batdorf et al.1o investigated the use of frequently changed gloves soaked in silicone. They report that patients become rapidly pain-free and that burn oedema quickly subsides. These benefits allow early mobilisation of the hand, and control of the oedema is valuable since its persistence endangers the complete return of function. Batdorf et al. also note an absence of infection and the appearance of healthy granulation tissue satisfactory for grafting. This treatment seems well worth investigating further.
uniformity
HOSPITAL ADVISORY SERVICE THE BURNED HAND
DESPITE careful treatment, poor functional results are still common after burns of the dorsum of the hand. Moncrief 1,2 advocates early excision and grafting, since tendon function is often intact at the time of the burn, only to be destroyed later by the bacterial autolysis which is invariable beneath a third-degree eschar.22 Grafting is not always possible, however, when the survival of a badly burned patient is in doubt, since a large area of skin may be needed. A difficult judgment may also be called for since immobilisation after grafting will encourage skin coverage, yet early mobilisation may be needed to preserve function.33 Research has thus been directed towards finding a technique which will prevent bacterial invasion and provide a suitable surface for grafting at the same time as preserving function. One suggestion 4,5 is to enclose the burned hand in a plastic bag and to exercise the hand gently while it is maintained within the bacteriostatic environment of hyperbaric oxygen. While bacterial growth is greatly reduced it still takes place below the eschar, when it forms. Continuous immersion in electrolyte solutions has also been used, but this does not prevent infection and it promotes maceration.6 American workers, 6,7 however, have 1. 2.
3. 4. 5. 6. 7.
Moncrief, J. A. Am. J. Surg. 1958, 96, 535. Moncrief, J. A., Switzer, W. E., Rose, L. R. Plast. reconstr. Surg. 1964, 33, 305. Robertson, D. C. J. Bone Jt Surg. 1958, 40A, 625. Irvin, T. T., Norman, J. N., Suwanagul, A., Smith, G. Lancet, 1966, i, 392. Smith, G., Irvin, T. T., Norman, J. N. in Research in Burns; p. 34. Edinburgh, 1966. Gerow, F. J., Hardy, S. B., Spira, M., Law, S. W. Surg. Forum, 1963, 14, 32. Miller, J., Hardy, S. B., Spira, M. J. Bone Jt Surg. 1965, 47A, 938.
WARD Fl of a provincial hospital for the mentally subnormal is a long way, geographically and administratively, from the Department of Health and Social Security. One of the points to emerge from the inquiry into incidents at Ely Hospital was the apparent ignorance-by the Department, the hospital board, the hospital management committee, and even within the hospital-about what was happening. Nurses with something to say about the Hospital Service may well find it hard to get through to those at the top. The Secretary of State’s answer to this crisis in communications has been to set up the Hospital Advisory Service, outside his Department but with direct access to him. Its first director has just been appointed (see p. 916), and the service is to start work next week. The service is to act as Mr. Crossman’s eyes and ears in the hospitals and will consider points put to it by staff at all levels. These terms of reference are so generous that the service will find it difficult to turn away anyone who brings a problem to its door: in practice the team will be so small that its members must hope that not too many people bother to knock. Since the service is not statutory (and is, therefore, flexible) it might have been wiser to restrict it, in the first place, to the special problems of these hospitals, for this in fact will be the area where the team will spend most of its time. For there can be little doubt that Mr. Crossman’s main concern here is with the 8. 9. 10.
Pories, W. J., Henzel, J. H., Rob, C. G., Strain, W. H. Lancet, 1967, i, 121. Meeting of European Surgical Research Society, Davos, Switzerland, 1969. Batdorf, J. W., Cammack, K. V., Colquitt, R. D. Archs Surg., Chicago, 1969, 98, 469.