- Email: [email protected]
OUTPATIENT FOLLOW-UP
37
mortality differences between the series. An alternative would
be to use the log-rank test, as suggested by Dr Haybittle, because this provides a comprehensive test of significance of the difference between the survival curves over their entire duration. Far from being inappropriate, as the authors suggest (June 12, p. 1291), the log-rank test represents the most satisfactory way of assessing fairly the reality of the mortality difference which they claim to exist. Mr McDonald and his colleagues estimate that the probability of occurrence of the observed mortality difference at one year between those lymph-node positive patients given routine postoperative radiotherapy and those not given radiotherapy routinely, if there is really no mortality difference between the series, is less than 0.05. However, because their calculations are inappropriate this estimate is likely to be too low, and perhaps much too low. The evidence the authors have presented for the higher mortality after routine postoperative radiotherapy in breast cancer patients with lymph-node involvement must therefore be regarded as much less strong than they claim, and it seems to be inadequate to justify the categoric statements in the discussion and summary of their paper. There is little advantage in having "direct evidence from a properly controlled clinical trial" unless that evidence is also properly evaluated statistically. M.R.C. Statistical Research and Services Unit, University College Hospital Medical School, London WC1E 6AS
IAN SUTHERLAND
to apply the same objectivity to statements about general practice that they would expect to be applied to therapeutic trials within their own specialty. Paulley4 asserts that "while many of one’s general practitioner colleagues are excellent ... quite frankly there are as
sultants
many who are not". How does he know? What criteria did he apply to end up by finding 50% excellent and 50% not? Elsewhere in his letter he asserts that G.P.s rush to the "consultant’s doorstep when they or their families take ill". Some may, but how many? Does he know? I suspect not. In our five-
partnership each of us chooses a partner with whom he family are registered. The partner who looks after my and does so superbly, uses the same criteria for referral family, to hospital as he does for all his patients; and so do the rest
man
and his
of us.
Paulley says that my figure of 10.6 new outpatients per week for each general physician is "undoubtedly wrong". I checked again and found that inadvertently I had stated that 10.6applied to whole-time equivalents: in fact it is the correct figure for the total number of consultants. The figure for whole-time equivalents is 12. 1. I apologise for the error. But Paulley’s suggestion that I should "check with consultant colleagues" to arrive at the "true" figure is so unscientific as to be ridiculous. The source of the data on which the figures are based is shown in the references at the end of my paper. Paulley’s final suggestion that either I or you (or both of us) deliberately distort the truth for political reasons is too absurd to be insulting.
OUTPATIENT FOLLOW-UP
SIR,-My paper and your editorial2 have provoked a number of letters that should be answered. There has never to my mind been any question of the importance of outpatient follow-up for uncommon serious disease such as renal failure3 or Crohn’s disease4 or certain other longdisease including those with multiple pathology.33 I also realise the educational value of follow-up appointments, especially in a specialty such as neurology.s The follow-up appointments that were considered unnecessary were the mindless routine appointments of no educational value, and of no advantage to the patient. Coggon and Goldacre6 illustrate very well indeed that while there may be a case for outpatient follow-up for serious complicated cases of common illnesses (such as appendicitis), routine follow-up of the rest is not only unnecessary but also ineffective as a guard against complications. I recognise that from the point of view of care after discharge from hospital (and from other points of view) there are bad G.P.S just as there are bad barristers and butchers, dentists and dockers, or members of any other profession or occupation. Olsen’s plan of identifying bad G.P.S in the patient’s notes by a code word seems to me a sensible plan compared to those who advocate routine outpatient follow-up because all or most or 50% of G.P.s are not to be trusted.4 The question of the quality of care provided by general practitioners often underlies statements in defence of the unnecessary follow-ups. Let us suppose that we could all agree on the criteria for measuring the quality of care provided by each G.P. (and criteria based on G.p./hospital contact would be only a part since this forms only a minority of our work). It would then, in theory, be possible to classify G.P.S into good, mediocre, and bad. This has not been done, and it surprises me how often consultants make sweeping statements about general practice (a branch of medicine of which they seldom have any postgraduate experience) based soley on subjective impressions. I would plead with conterm
major
1 Loudon, I. S. L.Lancet, 1976, i, 736. 2. ibid.p.1168. 3 Kerr, D. ibid. p. 1287. 4. Paulley, J. W. ibid p. 1347. 5. Matthews, W. B. ibid. p. 1287. 6. Coggon, D., Goldacre, M. J. ibid. p. 1346. 7. Olsen, N. D. L. ibid. p. 854.
Everything I have written stems from my belief that the future of medicine in Britain is grim unless it is firmly based on general practice of high quality. The unnecessary routine follow-up does four things: (a) it leads, to overcrowding in outpatients; (b) it fails to be an effective guard against serious complications; (c) it removes all incentives for G.P.S to undertake the care of their patient on discharge from hospital; and (d) most of all, it devalues general practice in everyone’s eyes and undermines the mutual respect and confidence on which the care of our patient depends. Health Centre, Garston Lane,
Wantage,
I. S. L. LOUDON
Oxon OX12 7AS
SEROTYPING OF E. COLI
SIR,-We have expressed concern’
at the suggestion that of Escherichia coli is no serotyping longer necessary in the study of infantile enteritis and that the ability to detect enterotoxin may be all that is required. We welcome the letter by Dr Sackin which he supports the value of serotyping in the study of epidemic diarrhoeal disease. It has been shown in numerous studies that outbreaks of infantile enteritis in many countries are frequently caused by E. coli belonging to a restricted range of serotypes.3 Dr Sack doubts the value of serotyping E. coli from sporadic cases of diarrhoea in infants and children, but this argument does not take into account the common epidemiological pattern of hospital outbreaks of infantile enteritis. Outbreaks frequently occur in units housing young babies, and epidemic spread of infection follows the admission of a sporadic case. During a survey in a Dublin hospital4 E. coli 0142.H6 was found in 13 of 70 apparently sporadic cases of diarrhoea on admission to hospital. A cross-infection outbreak subsequently occurred, and 49 of 68 babies who developed diarrhoea after admission were shown to have acquired E. coli 0142.H6 whilst in hospital. Recognition of an enteropathogenic serotype in sporadic cases of diarrhoea on admission to hospital allows the 1. Rowe, B., Gross, R. J., Scotland, S. M. Lancet, 1975, ii, 925. 2. Sack, R. B. ibid. 1976, i, 1132. 3. Taylor, J. J. appl. Bact. 1961, 24, 316. 4. Hone, R., Fitzpatrick, S., Keane, C., Gross, R. J., Rowe, B. J. med. Microbiol. 1973, 6, 505
mortality differences between the series. An alternative would
be to use the log-rank test, as suggested by Dr Haybittle, because this provides a comprehensive test of significance of the difference between the survival curves over their entire duration. Far from being inappropriate, as the authors suggest (June 12, p. 1291), the log-rank test represents the most satisfactory way of assessing fairly the reality of the mortality difference which they claim to exist. Mr McDonald and his colleagues estimate that the probability of occurrence of the observed mortality difference at one year between those lymph-node positive patients given routine postoperative radiotherapy and those not given radiotherapy routinely, if there is really no mortality difference between the series, is less than 0.05. However, because their calculations are inappropriate this estimate is likely to be too low, and perhaps much too low. The evidence the authors have presented for the higher mortality after routine postoperative radiotherapy in breast cancer patients with lymph-node involvement must therefore be regarded as much less strong than they claim, and it seems to be inadequate to justify the categoric statements in the discussion and summary of their paper. There is little advantage in having "direct evidence from a properly controlled clinical trial" unless that evidence is also properly evaluated statistically. M.R.C. Statistical Research and Services Unit, University College Hospital Medical School, London WC1E 6AS
IAN SUTHERLAND
to apply the same objectivity to statements about general practice that they would expect to be applied to therapeutic trials within their own specialty. Paulley4 asserts that "while many of one’s general practitioner colleagues are excellent ... quite frankly there are as
sultants
many who are not". How does he know? What criteria did he apply to end up by finding 50% excellent and 50% not? Elsewhere in his letter he asserts that G.P.s rush to the "consultant’s doorstep when they or their families take ill". Some may, but how many? Does he know? I suspect not. In our five-
partnership each of us chooses a partner with whom he family are registered. The partner who looks after my and does so superbly, uses the same criteria for referral family, to hospital as he does for all his patients; and so do the rest
man
and his
of us.
Paulley says that my figure of 10.6 new outpatients per week for each general physician is "undoubtedly wrong". I checked again and found that inadvertently I had stated that 10.6applied to whole-time equivalents: in fact it is the correct figure for the total number of consultants. The figure for whole-time equivalents is 12. 1. I apologise for the error. But Paulley’s suggestion that I should "check with consultant colleagues" to arrive at the "true" figure is so unscientific as to be ridiculous. The source of the data on which the figures are based is shown in the references at the end of my paper. Paulley’s final suggestion that either I or you (or both of us) deliberately distort the truth for political reasons is too absurd to be insulting.
OUTPATIENT FOLLOW-UP
SIR,-My paper and your editorial2 have provoked a number of letters that should be answered. There has never to my mind been any question of the importance of outpatient follow-up for uncommon serious disease such as renal failure3 or Crohn’s disease4 or certain other longdisease including those with multiple pathology.33 I also realise the educational value of follow-up appointments, especially in a specialty such as neurology.s The follow-up appointments that were considered unnecessary were the mindless routine appointments of no educational value, and of no advantage to the patient. Coggon and Goldacre6 illustrate very well indeed that while there may be a case for outpatient follow-up for serious complicated cases of common illnesses (such as appendicitis), routine follow-up of the rest is not only unnecessary but also ineffective as a guard against complications. I recognise that from the point of view of care after discharge from hospital (and from other points of view) there are bad G.P.S just as there are bad barristers and butchers, dentists and dockers, or members of any other profession or occupation. Olsen’s plan of identifying bad G.P.S in the patient’s notes by a code word seems to me a sensible plan compared to those who advocate routine outpatient follow-up because all or most or 50% of G.P.s are not to be trusted.4 The question of the quality of care provided by general practitioners often underlies statements in defence of the unnecessary follow-ups. Let us suppose that we could all agree on the criteria for measuring the quality of care provided by each G.P. (and criteria based on G.p./hospital contact would be only a part since this forms only a minority of our work). It would then, in theory, be possible to classify G.P.S into good, mediocre, and bad. This has not been done, and it surprises me how often consultants make sweeping statements about general practice (a branch of medicine of which they seldom have any postgraduate experience) based soley on subjective impressions. I would plead with conterm
major
1 Loudon, I. S. L.Lancet, 1976, i, 736. 2. ibid.p.1168. 3 Kerr, D. ibid. p. 1287. 4. Paulley, J. W. ibid p. 1347. 5. Matthews, W. B. ibid. p. 1287. 6. Coggon, D., Goldacre, M. J. ibid. p. 1346. 7. Olsen, N. D. L. ibid. p. 854.
Everything I have written stems from my belief that the future of medicine in Britain is grim unless it is firmly based on general practice of high quality. The unnecessary routine follow-up does four things: (a) it leads, to overcrowding in outpatients; (b) it fails to be an effective guard against serious complications; (c) it removes all incentives for G.P.S to undertake the care of their patient on discharge from hospital; and (d) most of all, it devalues general practice in everyone’s eyes and undermines the mutual respect and confidence on which the care of our patient depends. Health Centre, Garston Lane,
Wantage,
I. S. L. LOUDON
Oxon OX12 7AS
SEROTYPING OF E. COLI
SIR,-We have expressed concern’
at the suggestion that of Escherichia coli is no serotyping longer necessary in the study of infantile enteritis and that the ability to detect enterotoxin may be all that is required. We welcome the letter by Dr Sackin which he supports the value of serotyping in the study of epidemic diarrhoeal disease. It has been shown in numerous studies that outbreaks of infantile enteritis in many countries are frequently caused by E. coli belonging to a restricted range of serotypes.3 Dr Sack doubts the value of serotyping E. coli from sporadic cases of diarrhoea in infants and children, but this argument does not take into account the common epidemiological pattern of hospital outbreaks of infantile enteritis. Outbreaks frequently occur in units housing young babies, and epidemic spread of infection follows the admission of a sporadic case. During a survey in a Dublin hospital4 E. coli 0142.H6 was found in 13 of 70 apparently sporadic cases of diarrhoea on admission to hospital. A cross-infection outbreak subsequently occurred, and 49 of 68 babies who developed diarrhoea after admission were shown to have acquired E. coli 0142.H6 whilst in hospital. Recognition of an enteropathogenic serotype in sporadic cases of diarrhoea on admission to hospital allows the 1. Rowe, B., Gross, R. J., Scotland, S. M. Lancet, 1975, ii, 925. 2. Sack, R. B. ibid. 1976, i, 1132. 3. Taylor, J. J. appl. Bact. 1961, 24, 316. 4. Hone, R., Fitzpatrick, S., Keane, C., Gross, R. J., Rowe, B. J. med. Microbiol. 1973, 6, 505