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MEDICAL ENTRY INTO UNITED STATES
716 Walters and Owen2 have shown haemolytic effects of pancreatic enzymes. Since pancreatin is given by mouth this mechanism seems unlikely. Furthermore, we start the treatment of upper respiratory infection simultaneously with the commencement of pancreatin administration, using antibiotics, mucolytic agents, and oxygen tent. Although patients do not as a rule show manifest impairment of pulmonary function at this stage, it seems possible that this therapy improves arterial oxygen saturation. This could explain a rapid decrease in haemoglobin, but it would not account for iron-deficiency anaemia. We hope that these speculations will stimulate further studies. OTMAR TÖNZ Department of Paediatrics, H. W. STRAHM. University of Berne, Switzerland.
"MEDICAL CARE" OR "SOCIAL MEDICINE"? SIR,-Few will disagree with the opinion of Dr. Fry (March 12) that " social medicine " is a creed outworn, but his suggestion that the discipline of " medical care " replace it does not go far enough. All the activities listed by Dr. Fry, and more besides, should properly come under the xgis of a university department of health care. There is more to the achievement and maintenance of health than the practice of medicine, however varied may be the branches of the medical art. A department of health care should include among its staff medical and non-medical experts in other fields, including sociology, genetics, and the environmental sciences. While departments could, as Dr. Fry suggests, be built on a existing foundations in Manchester, Oxford, and elsewhere, further experiment should be tried. An experimental " health care unit " should be set up at a university without a medical school, but with regional hospitals of high standard in its vicinity. General practice and public health should contribute to its design, direction, and staffing, as should the science departments of the parent university itself. R. J. F. H. PINSENT.
ROLE OF LIMB-FITTING CENTRES SIR,-Miss Rawlings (March 5) describes one aspect of the
problem for patients who have to learn to live with an artificial limb. Her plea for more consideration of the emotional problems of these patients is sympathetically expressed, timely, and largely original. I have several patients who wear artificial legs, and they, particularly the women, have often told me how distressed they are by an attendance for fitting or adjustment. Some never get used to the (to them) bizarre appearance of the prosthesis. Yet most feel ashamed of these feelings, which they put down to personal weakness, saying " everyone else seems to accept it all ". They had not mentioned their feelings to the prescribing doctor or the fitters. The effect on relatives may be even more disturbing. One patient owns four artificial legs, and his only complaint is that none of them fits him very well. ’His wife tells me that the sight of them lined up in the spare bedroom makes her " feel sick ". She does not appear to have adjusted to her husband’s disability. As a chiropodist I deal with the same problem when fitting patients with prostheses for missing toes and other parts of the foot. On questioning, many patients have reacted badly to false toes. In general a prosthesis with the feel and colour of skin is most acceptable, but a few patients have been upset by a lifelike appearance. Some are disturbed by the sight of the plaster model of a toe on which a protective shield has been made-and which there is no need for them to see. Insoles, inserts in shoes covered with leather that does not match the sock of the other shoe, corrective slings, and even simple replaceable toe-shields can arouse feelings of revulsion, though to professional workers they are matter-of-fact objects designed to help. Many foot prostheses and appliances are rejected by patients who say that they do not help or that they cause discomfort. I wonder how often an unconscious reaction 2.
Walters, T. R., Owen, P. Blood, 1963, 22, 812,
to
the appearance
or
the need for
an
appliance
could be the
reason.
Many implications are raised by Miss Rawlings’ letter; possibly the matter of appearance is not paramount, but how patients react to the prescribing, fitting, and appearance of the ingenious devices now available needs more investigation. J. C. DAGNALL.
FLUORIDATION
SIR,-May I explain to Mr. Heald (March 5) that it is not enough simply to claim that the Ministry of Health’s policy is to keep fluoridation matters under constant review-they must be seen to be kept under review. That, Sir, is democratic administration, and that is what is lacking. A Fluoridation Research Committee may well exist, but it is a "secret"" committee. No reports are published, and no membership is
acknowledged. As far as the public is concerned the only inquiry into fluoridation mounted in this country was that reported by the United Kingdom Mission.1 The authors comprised 1 dental officer, 1 professor of dental surgery, 1 scientific officer, and 1 research lecturer. The complex medical problem of increasing everyone’s intake of the trace element fluorine by unknown amounts has not been seen to be deliberated upon by an independent medical body in this country. Many will agree with Dr. Prime (Feb. 19) that a new assessment of the evidence is due. MEG DOUGAL.
MEDICAL ENTRY INTO UNITED STATES
SIR,-What has not emerged from the correspondence on medical entry into the United States is the lack of reciprocity. While it is possible for American medical students and doctors to enter Britain and study or practise here with a minimum of red-tape and restrictions, the opposite is far from true. Is it not humiliating (and even unreasonable and short-sighted) for the United States to insist that a specialist in Britain takes the Educational Council for Foreign Medical Graduates (E.C.F.M.G.) certificate in basic medical subjects, perhaps twenty or more years after he has qualified, before permitting him to practise his specialty during a limited stay in the U.S. ? Dingleton Hospital, Melrose, J. K. W. MORRICE. Roxburghshire.
A HOSPITAL PLAN FOR 1966
SIR,-" Administrator" (March 5) writes that " hospital doctors and nurses are the prime source of user experience on which any planner must draw ", and he asks for more practical ways of reaching this fund of experience. For the past two years, each month, this centre has been inviting small groups of specialist ward or departmental sisters and discuss the function and varying designs of their departments. These meetings are held in close cooperation with nursing officers of the Ministry of Health, who have felt the need for closer contact with the users of these departments. The ward and departmental sisters give each other a great deal of help and support, and derive a new insight from exchanges of information with the nurses from the Ministry. The nurses from the Ministry in their turn take away many valuable points to remember when consulted about
to come
wards
or
writing or revising hospital building notes. These completely informal all-day discussions are recorded in the Nursing Times without participants or hospitals being named, thus permitting the printing of frank comments. Reprints of these records
are
available
at
the Hospital Centre,
1. The Fluoridation of Domestic Water Supplies in North America as a Means of Controlling Dental Caries: Report of the United Kingdom Mission. H.M. Stationery Office, 1953.
"MEDICAL CARE" OR "SOCIAL MEDICINE"? SIR,-Few will disagree with the opinion of Dr. Fry (March 12) that " social medicine " is a creed outworn, but his suggestion that the discipline of " medical care " replace it does not go far enough. All the activities listed by Dr. Fry, and more besides, should properly come under the xgis of a university department of health care. There is more to the achievement and maintenance of health than the practice of medicine, however varied may be the branches of the medical art. A department of health care should include among its staff medical and non-medical experts in other fields, including sociology, genetics, and the environmental sciences. While departments could, as Dr. Fry suggests, be built on a existing foundations in Manchester, Oxford, and elsewhere, further experiment should be tried. An experimental " health care unit " should be set up at a university without a medical school, but with regional hospitals of high standard in its vicinity. General practice and public health should contribute to its design, direction, and staffing, as should the science departments of the parent university itself. R. J. F. H. PINSENT.
ROLE OF LIMB-FITTING CENTRES SIR,-Miss Rawlings (March 5) describes one aspect of the
problem for patients who have to learn to live with an artificial limb. Her plea for more consideration of the emotional problems of these patients is sympathetically expressed, timely, and largely original. I have several patients who wear artificial legs, and they, particularly the women, have often told me how distressed they are by an attendance for fitting or adjustment. Some never get used to the (to them) bizarre appearance of the prosthesis. Yet most feel ashamed of these feelings, which they put down to personal weakness, saying " everyone else seems to accept it all ". They had not mentioned their feelings to the prescribing doctor or the fitters. The effect on relatives may be even more disturbing. One patient owns four artificial legs, and his only complaint is that none of them fits him very well. ’His wife tells me that the sight of them lined up in the spare bedroom makes her " feel sick ". She does not appear to have adjusted to her husband’s disability. As a chiropodist I deal with the same problem when fitting patients with prostheses for missing toes and other parts of the foot. On questioning, many patients have reacted badly to false toes. In general a prosthesis with the feel and colour of skin is most acceptable, but a few patients have been upset by a lifelike appearance. Some are disturbed by the sight of the plaster model of a toe on which a protective shield has been made-and which there is no need for them to see. Insoles, inserts in shoes covered with leather that does not match the sock of the other shoe, corrective slings, and even simple replaceable toe-shields can arouse feelings of revulsion, though to professional workers they are matter-of-fact objects designed to help. Many foot prostheses and appliances are rejected by patients who say that they do not help or that they cause discomfort. I wonder how often an unconscious reaction 2.
Walters, T. R., Owen, P. Blood, 1963, 22, 812,
to
the appearance
or
the need for
an
appliance
could be the
reason.
Many implications are raised by Miss Rawlings’ letter; possibly the matter of appearance is not paramount, but how patients react to the prescribing, fitting, and appearance of the ingenious devices now available needs more investigation. J. C. DAGNALL.
FLUORIDATION
SIR,-May I explain to Mr. Heald (March 5) that it is not enough simply to claim that the Ministry of Health’s policy is to keep fluoridation matters under constant review-they must be seen to be kept under review. That, Sir, is democratic administration, and that is what is lacking. A Fluoridation Research Committee may well exist, but it is a "secret"" committee. No reports are published, and no membership is
acknowledged. As far as the public is concerned the only inquiry into fluoridation mounted in this country was that reported by the United Kingdom Mission.1 The authors comprised 1 dental officer, 1 professor of dental surgery, 1 scientific officer, and 1 research lecturer. The complex medical problem of increasing everyone’s intake of the trace element fluorine by unknown amounts has not been seen to be deliberated upon by an independent medical body in this country. Many will agree with Dr. Prime (Feb. 19) that a new assessment of the evidence is due. MEG DOUGAL.
MEDICAL ENTRY INTO UNITED STATES
SIR,-What has not emerged from the correspondence on medical entry into the United States is the lack of reciprocity. While it is possible for American medical students and doctors to enter Britain and study or practise here with a minimum of red-tape and restrictions, the opposite is far from true. Is it not humiliating (and even unreasonable and short-sighted) for the United States to insist that a specialist in Britain takes the Educational Council for Foreign Medical Graduates (E.C.F.M.G.) certificate in basic medical subjects, perhaps twenty or more years after he has qualified, before permitting him to practise his specialty during a limited stay in the U.S. ? Dingleton Hospital, Melrose, J. K. W. MORRICE. Roxburghshire.
A HOSPITAL PLAN FOR 1966
SIR,-" Administrator" (March 5) writes that " hospital doctors and nurses are the prime source of user experience on which any planner must draw ", and he asks for more practical ways of reaching this fund of experience. For the past two years, each month, this centre has been inviting small groups of specialist ward or departmental sisters and discuss the function and varying designs of their departments. These meetings are held in close cooperation with nursing officers of the Ministry of Health, who have felt the need for closer contact with the users of these departments. The ward and departmental sisters give each other a great deal of help and support, and derive a new insight from exchanges of information with the nurses from the Ministry. The nurses from the Ministry in their turn take away many valuable points to remember when consulted about
to come
wards
or
writing or revising hospital building notes. These completely informal all-day discussions are recorded in the Nursing Times without participants or hospitals being named, thus permitting the printing of frank comments. Reprints of these records
are
available
at
the Hospital Centre,
1. The Fluoridation of Domestic Water Supplies in North America as a Means of Controlling Dental Caries: Report of the United Kingdom Mission. H.M. Stationery Office, 1953.