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MEDICAL EDUCATION: ENEMY OF THE GOOD?
210 LABORATORY SAFETY
SiR,-When in 1972 the D.H.S.S. published two handbooks
safety in the pathology laboratory and the other on in the post-mortem room-these were regarded as helpful codes of practice for the technical staff and at the same time useful in helping pathologists to secure funds for laboratory improvements. Both booklets were circulated in draft form to members of the Central Pathology Committee and their colleagues-a considerable and experienced body of hospital laboratory practice. My recollection, as chairman of the working-party, is that these publications were well received; the words "must" and "should" were used in circumstances
-one on
safety
that were generally acceptable. The concern that has attended the publication of the 1978 Code of Practice for the Prevention of Infection in Clinical Laboratories and Post-mortem Rooms, and the issue of draft regulations and draft guidance notes on dangerous pathogens by the Health and Safety Executive prompts two questions-why was it necessary to issue a rewritten publication (1978) and why was it necessary for the H.S.E. to rush out regulations that, in time, will certainly have statutory force? It would appear that, after the inquiries into the two smallpox incidents of 1973 and 1978 and the work of the Dangerous Pathogens Advisory Group, it was considered administratively necessary to take, without delay, general "preventive measures". The two safety booklets of 1972 were rewritten in one, with bacteriological emphasis, as a code of practice, and the H.S.E. drafted regulations. Neither exercise, in the judgment of many, was well done and the reaction of experienced microbiologists suggests that these steps were ill-advised and prob-
ably unnecessary. have been
forgotten that sound training and high standard form the bulwark of safety in laboratories and post-mortem rooms. Microbiologists have spent much time in contesting these recent measures and their probable effects, and more effort will be expended by other groups, as mentioned by Dr Taylor and his colleagues (Jan. 12, p. 101). I hope that reason will prevail. One area in hospitals where preventive measures are called for to diminish the risk of infection to patients is the hospital It
seems to
practical experience of
a
kitchen. Members of kitchen staff should be helped and encouraged to attend instruction courses on food hygiene and the handling of food. Such courses are organised throughout the U.K. in conjunction with colleges, and, as required, by the Royal Institute of Public Health and Hygiene, and provide, in a simple and direct way, the knowledge and understanding that prevent outbreaks of infection from food prepared in hospitals. This training should be given priority-the cost is small but the benefits are considerable. 94 Wynchgate, London N14 6RN
a cause of high medical costs, actually it is the I was in practice in the days before the Blue CrossBlue Shield and most other insurance plans in this country, when the patient paid his own bill and malpractice was not a major problem. We made every effort to keep the bill down by avoiding laboratory tests and hospital admission. Few patients have unlimited funds to spend on health.
to
J. F. HEGGIE
MEDICAL EDUCATION: ENEMY OF THE GOOD?
SIR,-Few will dispute the validity of your Nov. 10 editorial. Indeed
during the many years’ work I did overseas in underdeveloped countries with few staff and an overwhelming number of patients I often used the phrase "The perfect is the enemy of the good". In the United States at least there are some obstacles to acton your good suggestion. Malpractice is ever with us, a constant spectre urging the doctor to order all possible tests, especially X-rays, and to use many specialist consultants. Often none of these investigations and consultants are really needed. Next there is the usual cry "We want the best", a request often pressed most vociferously by those whose bills are being paid by welfare or social security. Finally the "third party payer" seems, to both the patient and the physician, as a never emptying well of dollars for medical care. Contrary to what you say about the private patient’s ability
ing
’
pay
being
reverse.
Westport Family Medicine Center, Westport, Massachusetts 02790, U.S.A.
FRANK
J. LEPREAU
WOMAN’S LOT IN INDIA
SIR,-Iread Dr Rao’s article on attitudes to women and nutrition programmes in India (Dec. 22/29, p. 1357) with considerable interest. In India parents have to save a lot of money to be able to give a dowry when a daughter marries. In addition they are expected to spend considerable sums when their daughters’ children are born and when the grandchildren in turn marry. The task of looking after elderly parents-and of discharging their responsibilities if they themselves are unable to do so-falls upon the sons. In India daughters rarely help out their parents in this way, and the parents will not usually agree to accept help from daughters if they have a son who is prepared to discharge the sacred duty of helping parents in time of need. Once she marries, a daughter’s obligations to her parents cease while their obligations to her extend even further to include her husband, children, and in-laws. No wonder the birth of a girl is rarely a cause of celebration in India. The main cause for the plight of women in India is poverty. In most Indian families, the woman of the house will consume less than anyone of nutritious items such as milk, cheese, meat, fish, and butter. Whenever the family’s meagre resources are shared out, whether for food, for education, for medical care, it is the males who are given preference. This unequal distribution takes place with the full approval of the woman of the house. Food is normally allocated by the woman, and when food is scarce they tend to favour sons over daughters. Readers in the West may feel that women get the worst possible deal in India. However, although parents do not normally spend as much on the education of their daughters as they do on their sons, in the long run daughters very often get more than their fair share of the family’s fortunes because of the dowry system and other social customs. Polytechnic of Wales, Pontypridd, Mid-Glamorgan
S. K. GOYAL
PSYCHOLOGY OF REHABILITATION
SiR,—Dr Wright (Dec. 1, p. 1179) has testified to the importance of the geriatric patient in an institution perceiving that "discharge, rather than survival" is the main issue. Everyone will agree with the value of repeated reward: "Any personal effort on the part of the patient draws congratulation and encouragement from the staff." Yet there was no mention of the geriatric patient’s commonly experienced conflict between a wish for survival (however dependent upon remaining in the institution) and a desire to return home, a move which, in the patient’s mind, often poses greater risks, even with a fail-safe system of social support. At this institute we deal with this problem by inviting into an open-ended discussion group patients deemed ready but reluctant for discharge. The psychiatrist, head nurse, and resident geriatric physician take part in the group which offers a very useful forum for the expression of anxieties over separation from the institute and for promoting the idea that discharge home is a goal worth striving for. Geriatric patients, contrary to earlier expectations, are grateful for the opportunity to express freely doubts about coping, financial worries,
SiR,-When in 1972 the D.H.S.S. published two handbooks
safety in the pathology laboratory and the other on in the post-mortem room-these were regarded as helpful codes of practice for the technical staff and at the same time useful in helping pathologists to secure funds for laboratory improvements. Both booklets were circulated in draft form to members of the Central Pathology Committee and their colleagues-a considerable and experienced body of hospital laboratory practice. My recollection, as chairman of the working-party, is that these publications were well received; the words "must" and "should" were used in circumstances
-one on
safety
that were generally acceptable. The concern that has attended the publication of the 1978 Code of Practice for the Prevention of Infection in Clinical Laboratories and Post-mortem Rooms, and the issue of draft regulations and draft guidance notes on dangerous pathogens by the Health and Safety Executive prompts two questions-why was it necessary to issue a rewritten publication (1978) and why was it necessary for the H.S.E. to rush out regulations that, in time, will certainly have statutory force? It would appear that, after the inquiries into the two smallpox incidents of 1973 and 1978 and the work of the Dangerous Pathogens Advisory Group, it was considered administratively necessary to take, without delay, general "preventive measures". The two safety booklets of 1972 were rewritten in one, with bacteriological emphasis, as a code of practice, and the H.S.E. drafted regulations. Neither exercise, in the judgment of many, was well done and the reaction of experienced microbiologists suggests that these steps were ill-advised and prob-
ably unnecessary. have been
forgotten that sound training and high standard form the bulwark of safety in laboratories and post-mortem rooms. Microbiologists have spent much time in contesting these recent measures and their probable effects, and more effort will be expended by other groups, as mentioned by Dr Taylor and his colleagues (Jan. 12, p. 101). I hope that reason will prevail. One area in hospitals where preventive measures are called for to diminish the risk of infection to patients is the hospital It
seems to
practical experience of
a
kitchen. Members of kitchen staff should be helped and encouraged to attend instruction courses on food hygiene and the handling of food. Such courses are organised throughout the U.K. in conjunction with colleges, and, as required, by the Royal Institute of Public Health and Hygiene, and provide, in a simple and direct way, the knowledge and understanding that prevent outbreaks of infection from food prepared in hospitals. This training should be given priority-the cost is small but the benefits are considerable. 94 Wynchgate, London N14 6RN
a cause of high medical costs, actually it is the I was in practice in the days before the Blue CrossBlue Shield and most other insurance plans in this country, when the patient paid his own bill and malpractice was not a major problem. We made every effort to keep the bill down by avoiding laboratory tests and hospital admission. Few patients have unlimited funds to spend on health.
to
J. F. HEGGIE
MEDICAL EDUCATION: ENEMY OF THE GOOD?
SIR,-Few will dispute the validity of your Nov. 10 editorial. Indeed
during the many years’ work I did overseas in underdeveloped countries with few staff and an overwhelming number of patients I often used the phrase "The perfect is the enemy of the good". In the United States at least there are some obstacles to acton your good suggestion. Malpractice is ever with us, a constant spectre urging the doctor to order all possible tests, especially X-rays, and to use many specialist consultants. Often none of these investigations and consultants are really needed. Next there is the usual cry "We want the best", a request often pressed most vociferously by those whose bills are being paid by welfare or social security. Finally the "third party payer" seems, to both the patient and the physician, as a never emptying well of dollars for medical care. Contrary to what you say about the private patient’s ability
ing
’
pay
being
reverse.
Westport Family Medicine Center, Westport, Massachusetts 02790, U.S.A.
FRANK
J. LEPREAU
WOMAN’S LOT IN INDIA
SIR,-Iread Dr Rao’s article on attitudes to women and nutrition programmes in India (Dec. 22/29, p. 1357) with considerable interest. In India parents have to save a lot of money to be able to give a dowry when a daughter marries. In addition they are expected to spend considerable sums when their daughters’ children are born and when the grandchildren in turn marry. The task of looking after elderly parents-and of discharging their responsibilities if they themselves are unable to do so-falls upon the sons. In India daughters rarely help out their parents in this way, and the parents will not usually agree to accept help from daughters if they have a son who is prepared to discharge the sacred duty of helping parents in time of need. Once she marries, a daughter’s obligations to her parents cease while their obligations to her extend even further to include her husband, children, and in-laws. No wonder the birth of a girl is rarely a cause of celebration in India. The main cause for the plight of women in India is poverty. In most Indian families, the woman of the house will consume less than anyone of nutritious items such as milk, cheese, meat, fish, and butter. Whenever the family’s meagre resources are shared out, whether for food, for education, for medical care, it is the males who are given preference. This unequal distribution takes place with the full approval of the woman of the house. Food is normally allocated by the woman, and when food is scarce they tend to favour sons over daughters. Readers in the West may feel that women get the worst possible deal in India. However, although parents do not normally spend as much on the education of their daughters as they do on their sons, in the long run daughters very often get more than their fair share of the family’s fortunes because of the dowry system and other social customs. Polytechnic of Wales, Pontypridd, Mid-Glamorgan
S. K. GOYAL
PSYCHOLOGY OF REHABILITATION
SiR,—Dr Wright (Dec. 1, p. 1179) has testified to the importance of the geriatric patient in an institution perceiving that "discharge, rather than survival" is the main issue. Everyone will agree with the value of repeated reward: "Any personal effort on the part of the patient draws congratulation and encouragement from the staff." Yet there was no mention of the geriatric patient’s commonly experienced conflict between a wish for survival (however dependent upon remaining in the institution) and a desire to return home, a move which, in the patient’s mind, often poses greater risks, even with a fail-safe system of social support. At this institute we deal with this problem by inviting into an open-ended discussion group patients deemed ready but reluctant for discharge. The psychiatrist, head nurse, and resident geriatric physician take part in the group which offers a very useful forum for the expression of anxieties over separation from the institute and for promoting the idea that discharge home is a goal worth striving for. Geriatric patients, contrary to earlier expectations, are grateful for the opportunity to express freely doubts about coping, financial worries,