NEW DEAL FOR JUNIOR HOSPITAL DOCTORS

541

units 4,13 are only a partial answer. We would rather urge the need for a comprehensive geriatric service, aimed principally at the over-75 age-group and headed by a geriatrician whose training and interests include psychiatry and social medicine as well as general and physical medicine. We thank Mr. A. R. Hammond, B.SC., of the Intelligence Unit of the Greater London Council, for most helpful advice on the statistical aspects of this investigation; and Mr. I. A. Syed, M.A., for the statistical analysis. This work was supported by research grants from the Department of Health and Social Security, and from the North East Metropolitan Regional ment

Hospital Board. Requests for reprints should

be addressed

to

A. G. M.

REFERENCES 1. 2.

3. 4. 5.

6. 7. 8. 9. 10. 11. 12.

13.

Mezey, A. G., Evans, E. Br. J. Psychiat. 1970, 117, 187. Mezey, A. G., Hodkinson, H. M., Evans, G. J. Br. med. J. 1968, iii, 16. Registrar General’s Statistical Review of England and Wales for the year 1966: part II, p. 8. H.M. Stationery Office, 1969. Kay, D. W. K., Roth, M., Hall, M. R. P. Br. med. J. 1966, ii, 967. Brocklehurst, J. C., Budd, W. E. R., Clark, A. N. G., Irvine, R. E. Development of Services for the Elderly and Elderly Confused: Report of a Working Party. South East Metropolitan Regional Hospital Board, 1971. Adams, G. F. Lancet, 1964, i, 1055. Brotherston, J. H. F. in Management and the Health Services (edited by A. Gatherer and M. D. Warren). Oxford, 1971. Logan, R. F., Klein, R. E., Ashley, J. S. Br. med. J. 1971, ii, 519. Wigley, G. Lancet, 1968, ii, 963. Kay, D. W. K., Beamish, P., Roth, M. Br. J. Psychiat. 1964, 110, 146. Williamson, J., Stokoe, I. H., Gray, S., Fisher, M., Smith, A., McGhee, A., Stephenson, E. Lancet, 1964, i, 1117. Anderson, W. F. in Medicine in Old Age (edited by J. N. Agate). London, 1966. Brothwood, J. in Recent Developments in Psychogeriatrics (edited by D. W. K. Kay and A. Walk). Ashford, Kent, 1971.

Points of View NEW DEAL FOR

JUNIOR HOSPITAL

DOCTORS PAUL NOONE* THE conditions of service and

training for the great medical staff are totally majority junior hospital Their sense of vocation is blatantly inadequate. the their skills while and use of organisation exploited, and labour are absurdly inefficient. of

Only six years ago, housemen took home E32 a month The publicity for approximately 420 hours on duty. militant junior doctors managed to obtain since then has compelled significant salary increases, so that a houseman can now expect the same weekly wage for his 102-hour week as a skilled industrial worker gets for 38 hours. As a further bizarre concession, pro-rata overtime payments are made for hours worked in excess of 102 a week (though some doctors have failed to claim overtime pay for fear of upsetting " old-fashioned " consultants who have to countersign any claim). Apart from salary increases little else has changed, despite publicity and widespread public

sympathy. Accommodation is appalling in very many old hospitals, with scarce provision of married quarters, while meals are often not available outside " normal " hours. Duties are ill-defined and allow the doctor to become a " dogsbody ", doing out-of-hours E.c.G.s (even routine E.C.G.S in some hospitals), drug dispensing, emergency pathology work, routine blood-taking, and anything else where there is a shortage of staff. In particular, clerical work-both paperwork and phoning for appointments, results of routine tests, and so on-consumes too much of the houseman’s time and energy. The junior doctor finds *

Chairman, Junior Hospital Doctors Section, M.P.U./A.S.T.M.S

himself frustratingly with less and less time to spend with his patients and their relatives; less time to liaise with G.P.s, social workers, and health visitors; and without time to discuss the clinical and social content of his work with his colleagues in his own or other departments (including those offering diagnostic and therapeutic services). Most contracts for junior hospital doctors at present are simply blank cheques for the hospital authorities to use junior staff as they wish. One of the perennial complaints is doubling up on ward and casualty-department dutiesa dangerous practice which can involve improperly supervised preregistration housemen, as well as S.H.o.s and registrars, who can find themselves having to choose between attending a victim of a road-traffic accident in casualty or a patient whose condition has suddenly deteriorated in the ward. A further source of frustration and dissatisfaction is the present haphazard system of training. Very few schemes allow the young doctor to progress systematically through training posts to a chosen specialty as G.P., hospital consultant, or community physician. Little serious thought has been given (and still less action has been taken) to lay down the length of our training, its direction, purpose, or content. Few of those few who are attempting to train their junior staff have had any training themselves for training or teaching. To become a hospital specialist, one usually needs to jump some Royal College examination hurdle, but even then, in all but a few specialties, much depends on possessing powerful patrons. Long years are spent in the registrar grades by many mature doctors who are nevertheless considered quite competent enough in many cases to deputise regularly for their consultant in his N.H.S. clinics, operating sessions, ward rounds, and so on. The main reasons preventing junior doctors from open revolt are (1) a misplaced sense of " my profession right or wrong " (even though that profession is dominated by pressure groups concerned above all with perpetuating their power, prestige, and private practice), and (2) a deep fear of consultant wrath and the need to have good references to pursue any sort of career. (As a colleague remarked: " They’ve got us by the testimonials.")

It is against this background that the Junior Hospital Doctors Section of the Medical Practitioners Union (M.P.U.) has emerged. M.P.U. has been greatly

strengthened by its recent merger with the Association of Scientific, Technical and Managerial Staffs (A.S.T.M.S.), a union with a remarkable record of organising professional people. With the help of A.S.T.M.S. legal experts, the junior doctors have launched a model contract as the centrepiece of a campaign to mobilise junior hospital medical staff throughout the United Kingdom. Some of the principal demands of this contract are: (1) Duties to be specified and limited-with suitable provisions for dealing with unforeseen emergencies. (2) Accommodation to be adequate (initially D.H.S.S. recommendations should be the minimum standard actually provided), with married quarters available. (3) Arbitration procedure for when there is a disputed

dismissal.

(4) Study leave and study time guaranteed.

to

be

specified

and

(5) Losses of property on hospital premises to be the responsibility of the authorities. (6) A genuine attempt by the employing authorities to secure continuity of employment in a systematic training programme. (7) Hours of duty to be limited to 192 in any 4-week period, with overtime payments or equivalent leave for

542 hours worked in excess of this. There is also an attempt to introduce the idea of compulsory breaks of duty (as for airline pilots or long-distance lorry drivers), so that the doctor " may not imperil his efficiency through fatigue " or

" otherwise

prejudice

his paramount duty

to

*’

"

This is not fair to the doctor, nor is it in the best interests of the patient. The time has come for doctors to organise their duties (seniors as well as juniors) in the same manner

flexible shift system with proper responsibilities between teams, a medical progress report on each patient. Can anyone accuse nurses of not providing continuity of care ? Indeed, the patient can only benefit from having more doctors concerned with his welfare. The doctors too will learn from one another, drawing from a wider pool of clinical experience. Of course, this will mean a radical change in the rigid " firm " system of organisation, which is choking the development of hospital medicine today. In fact it is this " firm " system, coupled with the excessive policy-making powers enjoyed by hospital consultants, which has been allowed, in a number of hospitals, to hold up such generally accepted developments as the provision of intensive-care units and infectious-disease isolation units; and the introduction and implementation of antibiotic policy or improved operating-theatre practice. It is also the consultant committees which are allowed to turn a purpose-built isolation unit in a new hospital into a ward for private patients. No doubt junior doctors will have to show collective strength to get necessary improvements in the N.H.S. past such bodies. But this is simply to realise that the campaign for better working and training conditions for junior medical staff is really part of the larger campaign for a better N.H.S.; for better conditions of service for the bulk of N.H.S. staff who are grossly exploited; and for the democratisation of the N.H.S. Power to decide policy should be shared by the elected representatives of the people (patients and relatives) and of all sections of N.H.S. staff, including junior doctors. as

nurses,

using

over

a

of

SEVERE NEUROLOGICAL DAMAGE ASSOCIATED WITH METHOTREXATE THERAPY

his

patients ". The really revolutionary aspect of this model contract is the way it sets out clearly the obligations of the hospital authorities to provide proper terms of service and opportunities for systematic training of junior medical staff (by definition training grades "). Many doctors might well baulk at the idea of a 48-hour week. But this is absolutely essential. As long as doctors are a reservoir of cheap labour they will remain dogsbodies. If hospital authorities have to pay overtime after 48 hours a week instead of 102, there is a powerful incentive for them to employ doctors for medical duties and to provide a fully staffed ancillary team on a 24-hour basis. Of course, other doctors (usually those who sleep at home most nights and weekends) will mutter about " continuity of patient care " as though this means one doctor muddling through 24 hours a day, 7 days a week. Modern medicine, with its incredible development of investigative and therapeutic techniques, is now more than ever a discipline practised by a team of specialists, all with responsibilities to the patient, liaising much more closely with the primarycare physician (G.P.) and paramedical staffs both in hospital and in health centres. It is also becoming essential, if standards are to be maintained or raised, to have such teams of doctors and paramedical staff in hospital, providing an alert and experienced 24-hour-service. No longer can junior doctors be expected to hold the fort " out of hours.

handing including

Letters to the Editor

SIR,-We wish to draw attention to a serious neurological condition which appears to be a complication of methotrexate therapy. In the past year we have seen seven cases, aged 3 to 24, of acute lymphoblastic leukaemia with meningeal disease who developed neurological signs and dementia during, or shortly after, a period of methotrexate therapy. The main signs were confusion, irritability, somnolence, ataxia, and dementia, with major epileptic fits in two cases, and progression to coma and death in one. In all cases these signs appeared when all evidence of meningeal leukxmia had disappeared-i.e., when symptoms such as headache and vomiting were no longer present and when the cerebrospinal fluid had become free of cells. Radiotherapy in three cases aimed at supposed leukaemic deposits was entirely ineffectual and no cultural or serological evidence of viral encephalitis has been obtained. Electroencephalograms showed excessive slow-wave activity. At necropsy of the one fatal case, patchy areas of necrosis were seen in the temporal and parietal lobes of the cerebrum. Microscopy of these lesions shows what appear to be infarcts in which there is fibrinoid necrosis of small blood-vessels with thrombosis and extravasation of red cells. The patients had had intrathecal methotrexate therapy, the total accumulated dose varying from 78 to 213 mg., while oral and parenteral methotrexate had been given for periods of 29 to 84 weeks with total doses ranging from 944 to’ 4458 mg. In five of the seven cases onset was during a course of intrathecal methotrexate; in one, the youngest child, a period of two weeks elapsed after the last dose before signs were noted, and in another case, where the onset was insidious, the 4 weeks which elapsed between the intrathecal course and the detection of abnormal behaviour were occupied by oral methotrexate therapy. Where the condition has been recognised, the administration of folinic and folic acids has arrested the progress of the condition, and there has been partial recovery which is still continuing. However, some of these patients, at least, will probably have a residual defect, including partial blindness in one case, with ataxia and intellectual impairment in the majority. The exact aetiology of this condition remains obscure,. and it is curious that it has not been previously reported. There is possibly one similar case in a publication by Pinkel et all which also indicates that radiotherapy plus intrathecal methotrexate can sometimes, perhaps, effect radical cure of meningeal leukxmia. The situation therefore presents us with a therapeutic dilemma, and the proper course is not obvious, but physicians treating this disease should be aware of the hazard. These

cases

will be

published

Royal Marsden Hospital and Institute of Cancer Research, Sutton, Surrey. Queen Mary’s Hospital for

Children, Carshalton. Royal Hospital for Sick Children, Edinburgh.

1.

in full

shortly.

H. E. M. KAY P. J. KNAPTON J. P. O’SULLIVAN D. G. WELLS. RUTH F. HARRIS. ELIZABETH M. INNES.

Children’s Hospital,

J. STUART

Birmingham. Llandough Hospital, Penarth, Glamorgan.

EILEEN N. THOMPSON.

F. C. M. SCHWARTZ.

Pinkel, D., Hernandez, K., Borella, L., Holton, C., Aur, R., Samoy, G., Pratt, C. Cancer, 1971, 27, 247.