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PANEL AND CONTRACT PRACTICE
1366 contain a large proportion of its total energy value in the form of protective foods, the younger the person the greater being the proportion. Miss E. M. WIDDOWSON (research biochemist at King’s College Hospital) referred to the importance of the minerals in maintaining osmotic pressure and acid-base balance, and in regulating all chemical processes. Of the fifteen different mineral elements in the body, each of which had its own part to play, deficiency was most commonly found in calcium, iron, phosphorus, and iodine, the two most- often lacking in diets in this country being iron and calcium. To supplement calcium deficiency she advocated the greater use of cheese, milk, eggs, green leaf vegetables, and nuts ; of these, milk was the most important single source. Iron was found mostly in meat (especially liver), eggs, brown bread, and green
There was often a deficiency otiron during pregnancy. It was important that it should be given in a form in which it would be available to the body.
vegetables.
TUBERCULOSIS
Dr. R. A. YOUNG (consulting physician to the Middlesex Hospital) gave a presidential address to He spoke particularly the section of tuberculosis. of the need for early diagnosis and for teaching the laity to think bacteriologically. The undiagnosed case was dangerous to the community and he pleaded for the more thorough examination of all patients suffering from chronic bronchitis, from persistent cough and phlegm, from haemoptysis however slight, from pleurisy or from unexplained loss of weight or condition, or evening tiredness. Clinical examination should be supplemented by bacteriological tests and
radiography. Dr. F. G. CHANDLER (physician to St. Bartholomew’s Hospital) submitted that prolonged isolation of tuberculous patients was often unnecessary ; they could return to their homes if they and their relatives understood how the disease was spread, the necessity for care of the cough and the phlegm, and of handkerchiefs, pillow-slips, and sheets, and the importance of ventilation and fresh air. Dr. J. G. JOHNSTONE, speaking on tuberculosis of joints, said that the guiding principles in local treatment were to arrest the active disease, by stopping movement of the affected joint, and reduce the functional disability by immobilisation in the
position, and by preventing deformity in any joint. Dr. E. L. SANDILAND (medical superintendent of the East Lancashire Tuberculosis Colony) dealt with the after-care and re-employment of the tuberculous patient. The chronic tuberculous population could be correct
other
divided into the 15 per cent. of chronic invalids who would always remain a medical problem for others, the 50 per cent. who could return to their former employment or some modified form of it, and the 35 per cent. who could not return to their former employment either because ’it was unsuitable or because they could not compete with healthy men. The last group was the one for which after-care schemes were intended. The three principal forms of provision made were workshops set up by after-care committees or local authorities, the employment of ex-patients on the staffs of sanatoriums or similar institutions, and the establishment of village settlements, with industries attached, where the exsanatorium patient could have sheltered conditions, medical supervision, and a house away from his former
habitation. RHEUMATISM
The section on rheumatism and allied diseases met under the presidency of Sir ROBERT STANTON WOODS (physician in charge of the department of physical medicine at the London Hospital). Dr. SINCLAIR MILLER (medical director of the Harrogate Investigation Clinic) spoke on the aetiology of chronic arthritis, and Dr. DOUGLAS COLLINS (research fellow in rheumatism at the University of Leeds) referred particularly to the importance of trauma and infection as setiological factors. It was a mistake he thought to ignore the local condition of the joint while concentrating on the general physiological behaviour of the arthritic Dr. FORTESCUE Fox (president of the patient. International League against Rheumatism) read " a paper on vicious spirals " in chronic rheumatism ; Dr. JOHN POYNTON (consulting physician to University College Hospital) opened a discussion on the aetiology of rheumatism in children, and Sir FRANK Fox (organising secretary of the Empire Campaign against Rheumatism) summarised the history of the development of the movement. He pointed out that insufficient attention had been paid to rheumatism, in spite of the great suffering it caused, because it lacked the dramatic element.
PANEL AND CONTRACT PRACTICE What is
a
Partner ?
FOR health insurance purposes a partner must, prescribed by Clause 11 (8) of the terms of service, be in the position of a principal in connexion with the practice and entitled to a share of the partnership profits which is not less than one third (in Scotland one half) of the share of any other partner. An insurance practitioner recently told an insurance committee that he had taken into partnership another practitioner. When asked whether the terms of the partnership agreement conformed to the requirements of Clause 11 (8) he said that his partner was not entitled to any stated share of the profits but was in receipt of a salary which, together with certain allowances, amounted to a sum greater than onethird share of the profits of the partnership. The Ministry of Health expressed the view that although there was nothing in the facts set out above which necessarily negatived the existence of a partnership it might be desirable for the insurance committee as
to satisfy themselves as to the position by an examination of the deed of partnership if any. The practitioners were unwilling to submit the deed for examination, and the committee felt some hesitation in accepting the view that the salaried partner could be considered in the circumstances as entitled to a " share of the profits " and they asked for further advice. The Ministry took the view that the word "salary" implied the payment of a fixed sum payable out of the profits so long as the profits were sufficient to meet it. Presumably the committee would also have to be satisfied that provision had been made for the salary of the junior partner to be increased if the profits of the partnership should increase to such an extent as to make his present salary and allowances insufficient to comply with the terms of service.
Visitation of Surgeries Cheshire insurance committee have been trying to arrive at agreement with the panel committee about the visitation of surgeries. They The
1367 asked the panel committee to appoint members to meet an equivalent number of members of the insurance committee to consider and report upon the general question of surgery and waiting-room accommodation, but the panel committee decided to take no action. The Ministry of Health was then asked what other course was open to the insurance committee to secure the provision by insurance practitioners of proper accommodation for their insured patients. The Ministry suggested that the panel committee would hardly withhold their coöperation in the event of any specific cases being brought to their notice where it appeared to the insurance
committee that there was ground for regarding the accommodation provided as unsatisfactory. And this proved to be the position. The secretary of the panel committee said that on a complaint being made they would be glad to cooperate, but they had a strong objection to a roving commission to examine anybody’s premises irrespective of complaints. After some discussion it was decided that any complaint as to the accommodation in a specific case, brought in duly authenticated form to the notice of the insurance committee, should be investigated by a joint committee of the insurance committee and the panel committee.
GRAINS AND SCRUPLES Under this various
heading appear week by week the unfettered thoughts of doctors in occupations. Each’ contributor is responsible. for the section for a month;; his name can be seen later in the half-yearly index.
FROM TWELFTH MAN
And how stereotyped must the reactions of lesser become. I sit at a bridge table with a fat lady as my partner, and she asks : "What is your call, doctor" It is with difficulty that I refrain from replying: " Three rye biscuits. Take one potato where three crept in. Eat as much of lean meat, of green vegetables-." Next to me sits a successful business man. " Your calling makes me giddy, doctor." I want to reply: " Take it easy. Avoid stress and strain. John Hunter said he was at the mercy of any man who made him lose his temper. Live within the limits of Grow old gracefully. Make your your circulation. changes of posture slow and deliberate My readers, if any, will recognise these records. They are part of our common heritage. Hippocrates played them. So we go through our professional life with our small group of conditioned responses. How worrying and how annoying it is when a patient presents a group of symptoms and signs that refuse to fit into a syndrome. As difficult as it was for Pavlov’s dog when his master altered the dinner bell by a semitone. Thus it is that our minds lack elasticity, and our flow of ideas is constipated. Thus it is that A Departmental Doctor wrote, " Regarded, at any rate as an interesting companion, as a desirable neighbour at dinner, the doctor was ranked considerably below the barrister and, a little more doubtfully, lower than the priest." Thus it is that so many were glad to accept the invitation to contribute to the Grains and Scruples series. Here was a stimulating chance for unfettered self-expression. men
To sit in the pavilion while one’s betters are batting be a disintegrating experience. For a week past I have sat in the pavilion. I have re-read all the contributions to this Grains and Scruples series from the very lively knock with which West-country Practitioner opened the innings last July to the sound and stylish display by A Medical Economist. I have been amused, instructed, stimulated-and, now, when it is my turn to go in I am heartened by the knowledge that if Twelfth Man edges a lucky ball between first and second slip to the boundary there is a ripple of surprised applause. can
*
*
*
Grains and Scruples have indeed been surprising. Here are twelve doctors (and more apparently to come) who are willing to write from five to ten thousand words about a broomstick or nothing at all. There can, I think, be but one reason for this. Many doctors have an unsatisfied desire for self-expression. This is the modern explanation for ill-behaviour in the nursery and it explains equally well these essays which have lightened for the last eleven months the pages of THE LANCET. That doctors lack self-expression is, I believe, true. Our unhappy function is, too often, to listen and, too often, when we talk it is to use " vain repetitions If we are having a preliminary as the heathen do." the weather or the films and there is gossip-well, when we come to the real business of the patient’s health how frequently we play the same record. I doubt whether the practice of a first-class physician equals in variety the practice of a leading counsel; it does not elicit a comparable number of mental responses nor stimulate as complicated a series of conditioned reflexes. The physician, for example, whose practice has an abdominal " bias will, in a year, see some hundreds of patients with an ulcer, an intestinal carcinoma, or an abdominal neurosis. How often must these patients receive advice in much the same terms. For the mutual convenience of physician and patient it is customary to have typewritten sheets of instructions for the victim’s future regimen. At the end of a hurried interview with a physician a A patient of mine was handed three such sheets. guinea a sheet. Do I pay you directly or does the money go into the slot-machine" asked my patient These
"
"
rudely.
*
*
*
This unsatisfied desire for self-expression may encourage the doctor off his guard into unwise confession to his patient. His wish to help the psychoneurotic may also lead him to confess a like frailty. I remember a dramatic instance of this. years ago a physician in the out-patient department of a large hospital was examining a boy in front of a class of students. He took the lad behind a screen and after a few minutes both emerged. The physician addressed the class : "Ithought so. The boy’s a masturbator." The boy burst out : " You sneak ! You said you wouldn’t tell, and anyway you said you did it yourself when you were a boy." Confession may be obligatory in an Oxford Group meeting but such sharing is out of place in a
Many
consulting-room. It is
Scruples
*
*
*
doubtless necessary for these Grains and articles to be temporarily anonymous,
There was often a deficiency otiron during pregnancy. It was important that it should be given in a form in which it would be available to the body.
vegetables.
TUBERCULOSIS
Dr. R. A. YOUNG (consulting physician to the Middlesex Hospital) gave a presidential address to He spoke particularly the section of tuberculosis. of the need for early diagnosis and for teaching the laity to think bacteriologically. The undiagnosed case was dangerous to the community and he pleaded for the more thorough examination of all patients suffering from chronic bronchitis, from persistent cough and phlegm, from haemoptysis however slight, from pleurisy or from unexplained loss of weight or condition, or evening tiredness. Clinical examination should be supplemented by bacteriological tests and
radiography. Dr. F. G. CHANDLER (physician to St. Bartholomew’s Hospital) submitted that prolonged isolation of tuberculous patients was often unnecessary ; they could return to their homes if they and their relatives understood how the disease was spread, the necessity for care of the cough and the phlegm, and of handkerchiefs, pillow-slips, and sheets, and the importance of ventilation and fresh air. Dr. J. G. JOHNSTONE, speaking on tuberculosis of joints, said that the guiding principles in local treatment were to arrest the active disease, by stopping movement of the affected joint, and reduce the functional disability by immobilisation in the
position, and by preventing deformity in any joint. Dr. E. L. SANDILAND (medical superintendent of the East Lancashire Tuberculosis Colony) dealt with the after-care and re-employment of the tuberculous patient. The chronic tuberculous population could be correct
other
divided into the 15 per cent. of chronic invalids who would always remain a medical problem for others, the 50 per cent. who could return to their former employment or some modified form of it, and the 35 per cent. who could not return to their former employment either because ’it was unsuitable or because they could not compete with healthy men. The last group was the one for which after-care schemes were intended. The three principal forms of provision made were workshops set up by after-care committees or local authorities, the employment of ex-patients on the staffs of sanatoriums or similar institutions, and the establishment of village settlements, with industries attached, where the exsanatorium patient could have sheltered conditions, medical supervision, and a house away from his former
habitation. RHEUMATISM
The section on rheumatism and allied diseases met under the presidency of Sir ROBERT STANTON WOODS (physician in charge of the department of physical medicine at the London Hospital). Dr. SINCLAIR MILLER (medical director of the Harrogate Investigation Clinic) spoke on the aetiology of chronic arthritis, and Dr. DOUGLAS COLLINS (research fellow in rheumatism at the University of Leeds) referred particularly to the importance of trauma and infection as setiological factors. It was a mistake he thought to ignore the local condition of the joint while concentrating on the general physiological behaviour of the arthritic Dr. FORTESCUE Fox (president of the patient. International League against Rheumatism) read " a paper on vicious spirals " in chronic rheumatism ; Dr. JOHN POYNTON (consulting physician to University College Hospital) opened a discussion on the aetiology of rheumatism in children, and Sir FRANK Fox (organising secretary of the Empire Campaign against Rheumatism) summarised the history of the development of the movement. He pointed out that insufficient attention had been paid to rheumatism, in spite of the great suffering it caused, because it lacked the dramatic element.
PANEL AND CONTRACT PRACTICE What is
a
Partner ?
FOR health insurance purposes a partner must, prescribed by Clause 11 (8) of the terms of service, be in the position of a principal in connexion with the practice and entitled to a share of the partnership profits which is not less than one third (in Scotland one half) of the share of any other partner. An insurance practitioner recently told an insurance committee that he had taken into partnership another practitioner. When asked whether the terms of the partnership agreement conformed to the requirements of Clause 11 (8) he said that his partner was not entitled to any stated share of the profits but was in receipt of a salary which, together with certain allowances, amounted to a sum greater than onethird share of the profits of the partnership. The Ministry of Health expressed the view that although there was nothing in the facts set out above which necessarily negatived the existence of a partnership it might be desirable for the insurance committee as
to satisfy themselves as to the position by an examination of the deed of partnership if any. The practitioners were unwilling to submit the deed for examination, and the committee felt some hesitation in accepting the view that the salaried partner could be considered in the circumstances as entitled to a " share of the profits " and they asked for further advice. The Ministry took the view that the word "salary" implied the payment of a fixed sum payable out of the profits so long as the profits were sufficient to meet it. Presumably the committee would also have to be satisfied that provision had been made for the salary of the junior partner to be increased if the profits of the partnership should increase to such an extent as to make his present salary and allowances insufficient to comply with the terms of service.
Visitation of Surgeries Cheshire insurance committee have been trying to arrive at agreement with the panel committee about the visitation of surgeries. They The
1367 asked the panel committee to appoint members to meet an equivalent number of members of the insurance committee to consider and report upon the general question of surgery and waiting-room accommodation, but the panel committee decided to take no action. The Ministry of Health was then asked what other course was open to the insurance committee to secure the provision by insurance practitioners of proper accommodation for their insured patients. The Ministry suggested that the panel committee would hardly withhold their coöperation in the event of any specific cases being brought to their notice where it appeared to the insurance
committee that there was ground for regarding the accommodation provided as unsatisfactory. And this proved to be the position. The secretary of the panel committee said that on a complaint being made they would be glad to cooperate, but they had a strong objection to a roving commission to examine anybody’s premises irrespective of complaints. After some discussion it was decided that any complaint as to the accommodation in a specific case, brought in duly authenticated form to the notice of the insurance committee, should be investigated by a joint committee of the insurance committee and the panel committee.
GRAINS AND SCRUPLES Under this various
heading appear week by week the unfettered thoughts of doctors in occupations. Each’ contributor is responsible. for the section for a month;; his name can be seen later in the half-yearly index.
FROM TWELFTH MAN
And how stereotyped must the reactions of lesser become. I sit at a bridge table with a fat lady as my partner, and she asks : "What is your call, doctor" It is with difficulty that I refrain from replying: " Three rye biscuits. Take one potato where three crept in. Eat as much of lean meat, of green vegetables-." Next to me sits a successful business man. " Your calling makes me giddy, doctor." I want to reply: " Take it easy. Avoid stress and strain. John Hunter said he was at the mercy of any man who made him lose his temper. Live within the limits of Grow old gracefully. Make your your circulation. changes of posture slow and deliberate My readers, if any, will recognise these records. They are part of our common heritage. Hippocrates played them. So we go through our professional life with our small group of conditioned responses. How worrying and how annoying it is when a patient presents a group of symptoms and signs that refuse to fit into a syndrome. As difficult as it was for Pavlov’s dog when his master altered the dinner bell by a semitone. Thus it is that our minds lack elasticity, and our flow of ideas is constipated. Thus it is that A Departmental Doctor wrote, " Regarded, at any rate as an interesting companion, as a desirable neighbour at dinner, the doctor was ranked considerably below the barrister and, a little more doubtfully, lower than the priest." Thus it is that so many were glad to accept the invitation to contribute to the Grains and Scruples series. Here was a stimulating chance for unfettered self-expression. men
To sit in the pavilion while one’s betters are batting be a disintegrating experience. For a week past I have sat in the pavilion. I have re-read all the contributions to this Grains and Scruples series from the very lively knock with which West-country Practitioner opened the innings last July to the sound and stylish display by A Medical Economist. I have been amused, instructed, stimulated-and, now, when it is my turn to go in I am heartened by the knowledge that if Twelfth Man edges a lucky ball between first and second slip to the boundary there is a ripple of surprised applause. can
*
*
*
Grains and Scruples have indeed been surprising. Here are twelve doctors (and more apparently to come) who are willing to write from five to ten thousand words about a broomstick or nothing at all. There can, I think, be but one reason for this. Many doctors have an unsatisfied desire for self-expression. This is the modern explanation for ill-behaviour in the nursery and it explains equally well these essays which have lightened for the last eleven months the pages of THE LANCET. That doctors lack self-expression is, I believe, true. Our unhappy function is, too often, to listen and, too often, when we talk it is to use " vain repetitions If we are having a preliminary as the heathen do." the weather or the films and there is gossip-well, when we come to the real business of the patient’s health how frequently we play the same record. I doubt whether the practice of a first-class physician equals in variety the practice of a leading counsel; it does not elicit a comparable number of mental responses nor stimulate as complicated a series of conditioned reflexes. The physician, for example, whose practice has an abdominal " bias will, in a year, see some hundreds of patients with an ulcer, an intestinal carcinoma, or an abdominal neurosis. How often must these patients receive advice in much the same terms. For the mutual convenience of physician and patient it is customary to have typewritten sheets of instructions for the victim’s future regimen. At the end of a hurried interview with a physician a A patient of mine was handed three such sheets. guinea a sheet. Do I pay you directly or does the money go into the slot-machine" asked my patient These
"
"
rudely.
*
*
*
This unsatisfied desire for self-expression may encourage the doctor off his guard into unwise confession to his patient. His wish to help the psychoneurotic may also lead him to confess a like frailty. I remember a dramatic instance of this. years ago a physician in the out-patient department of a large hospital was examining a boy in front of a class of students. He took the lad behind a screen and after a few minutes both emerged. The physician addressed the class : "Ithought so. The boy’s a masturbator." The boy burst out : " You sneak ! You said you wouldn’t tell, and anyway you said you did it yourself when you were a boy." Confession may be obligatory in an Oxford Group meeting but such sharing is out of place in a
Many
consulting-room. It is
Scruples
*
*
*
doubtless necessary for these Grains and articles to be temporarily anonymous,