- Email: [email protected]
Power or Persuasion ?
1241
SCHOEFL and FRENCH 34 studied the lactating mammary gland, where fat in chylomicra leaves the circulation in large amounts. They found no electron-microscopic evidence for the passage of intact chylomicra through the endothelium by any route. Chylomicra did, however, line themselves along the walls of capillaries in close contact with the endothelium, and some appeared to be in contact with scalloped portions of endothelial cells. Histochemical evidence was obtained for the hydrolysis of chylomicron triglyceride at these sites-a process presumably mediated by the clearing factor lipase, which was first characterised as an enzyme in the studies of FRENCH and his colleagues 35 36 and is known to be at least fairly closely associated with
endothelium. 3.7 As Lord FLOREY pointed out in his address, researchworkers in atherosclerosis are at present engaged in the painstaking accumulation of often seemingly trivial facts. But without this effort it is. difficult to see how progress can be made. And perhaps some of the facts about endothelium will prove to be not so trivial after all.
Power or Persuasion ? As our friends-and others-remark, a sure sign that the British are becoming serious about something is a proliferation of committees, each doing, a cynical voice adds, what is already being done. Since the muchneeded stimulus of the Christ Church conference in 1961,38 postgraduate medical education in this country has certainly begun to receive the serious attention it needed. And a committee has been formed 39-the Central Committee on Postgraduate Medical Education, with Sir ROBERT AITKEN as chairman. If it is to succeed in seizing all the ideas that are in the air and putting the good ones to use, it must clearly confound the cynic by doing much more than is already being done. If it is to provide a cutting edge to the variety of blunt instruments now being enthusiastically wielded at the tangle of medical postgraduate education, its terms of reference 39 may need strengthening, and to its present university and College members representatives of the General Medical Council, the Ministry of Health, and the regional authorities of the N.H.S. may have to be added. If it is to be effective, it must be adequately financed, partly perhaps from university and College funds and partly from N.H.S. funds (for the time being the committee is sustained by £60,000 set aside by the Nuffield Provincial Hospitals Trust to help it in its first five years). At the moment it is a purely advisory body, and, without statutory or quasi-statutory powers, it may prove feeble; and in its forthcoming report the Royal Comniission will surely discuss the future of the committee and its powers. Meanwhile, the Nuffield Trust has given further help by asking Dr. JOHN REVANS, senior 34. Schoefl, G. I., French, J. E. Proc. R. Soc. B. (in the press). 35. French, J. E., Robinson, D. S., Florey, H. W. Q. Jl exp. Physiol.
1953, 38, 101 36. Robinson, D. S., French, J. E. ibid. p. 233. 37. Robinson, D. S., French, J. E. Pharmac. Rev. 1960, 12, 241. 38. See Lancet, 1962, i, 361, 367. 39. ibid 1967,i, 1376
administrative medical officer of the Wessex Regional Hospital Board, and Mr. GORDON McLACHLAN, secretary of the Trust, to re-examine the situation; and their report 40 is the best analysis we have had of past progress (or hesitancy), today’s uncertainties, and further prospects for reorganisation and stimulation. In our efforts to move further away from the chaos that has beset postgraduate training (often non-training) 41 this text by REVANS and McLACHLAN may be a vital catalyst. The speed of progress must depend largely on the influence of the Aitken committee—and on its ability to act harmoniously with the Colleges and other bodies concerned in postgraduate education. If the Royal Commission recommends that powers be conferred on a central body, how will the Colleges react ? If they are then frightened into taking up defensive positions by the threat of a powerful central body telling them what to do, the impetus they have been gathering may be lost. A more effective approach to the training of specialists has happily become apparent-for instance, in the Wright report 42 of the Scottish Post-Graduate Medical Association-and the Colleges must on no account be deterred from accepting an increasing part in the promotion and supervision of postgraduate education. As REVANS and McLACHLAN put it, " if they are to cover the whole range of postgraduate medical education this would mean that in order to meet modern requirements, their functions must go far beyond the stage of the awarding of diplomas." Pressure from an independent non-statutory body, drawing its main strength from voluntary action, may be the right way not only to stimulate Government machinery but also to draw the best out of the voluntary bodies themselves. The report by REVANS and McLACHLAN points to the absence of three main elements in present arrangements for postgraduate medical education in the United Kingdom: a structure both for postgraduate and continuing education; adequate finance; and any mechanism for coordinating and incidentally focusing on the essentials. The focus must be provided by some central body able to speak with authority covering the needs and organisations of postgraduate education. The ideal is often said to be a strong central body with statutory powers, its membership drawn from all the authorities concerned with education and with service. Others look for a central body with well-defined powers which might in many ways overlap the responsibilities for the supervision of specialist training now being assumed by the Colleges. The central committee’s present brief, REVANS and McLACHLAN add, is vague, its constitution is extremely limited, and its financial foundations are anything but secure. " To believe in its ultimate effectiveness is to believe in the power of voluntary action to regulate and co-ordinate somehow or another the several responsibilities of a vast number of bodies of Medical Education: Retrospect and Prospect. By JOHN REVANS and GORDON McLACHLAN. Nuffield Provincial Hospitals Trust, 1967. Obtainable from the Trust at 3 Prince Albert Road, London N.W.1. 2s. 6d. 41. See Lancet, 1966, ii, 1399. 42. Report of a Working Party on Post-Graduate Medical Education within the National Health Service in Scotland, 1967. 40.
Postgraduate
1242
and traditions and to make them relevant to modern conditions and the needs of the National Health Service." The key question is whether the central body can develop a high degree of prestige and influence quickly. It could do so, REVANS and McLACHLAN judge, if it became the main source of knowledge concerning postgraduate medical education and was prepared to be critical of any backwardness or waywardness on the part of any of the Colleges or universities, or the regional postgraduate committees or the Health Departments themselves. The money required for its stability and security is not very great, provided the vast potential of the universities, the Colleges, and the regional postgraduate committees is exploited through delegated powers. " Indeed there is much to be said for utilizing as much as possible all existing influential institutions which show awareness of the problems and vigour in tackling them. What the Colleges have set themselves to do about vocational training is impressive and they should have incentives to do this as effectively as possible." A remaining criticism is that the central committee as now constituted may have little influence in N.H.S. quarters because the Service is not represented
it. As the Nuffield Trust report observes, it can really gain in authority only if it becomes in effect the key adviser to the Ministry of Health on postgraduate education. But it should clearly be seen to remain independent and " be made responsible for monitoring all matters concerning postgraduate medical education in the National Health Service." The committee must also have continuous dialogue with the General Medical Council, the body likely to be responsible for maintaining specialist registers, should they be established. The committee has taken as its first task a review of preregistration posts. It must also strive-and quickly - to counter the confusion in the immediate postregistration period. If it can do that-or make even a successful start by creating the right atmosphere in which
Annotations
sentence. Many English thieves seemed to do well with fines, and house-breakers with probation orders. Money
differing strengths
SENTENCES BY THE COURTS
LOOKING back on forty-two years as magistrate and on the sentencing of about 20,000 offenders, Baroness Wootton of Abinger, in the Lloyd-Roberts lecture at the Royal Society of Medicine on Nov. 30, made some cogent points about changing practice in the courts. The concepts of guilt, punishment, and sentence had always been inextricably mixed, and they were changing. Technically, if guilty intent could not be proved, an offender could not be sentenced. In deciding sentence the magistrate was guided by the degree of heinousness of the offence and by mitigating circumstances; but unfortunately this tariff system was interpreted differently by different courts. For example, the lowest rate of sentencing to prison was 3 %, and in another court with similar offenders it was as high as 55%. Prison sentences of over three years were four times as common in England as in Scotland. Attempts were being made to standardise sentencing practice, notably by circulating to all j.p.s the national averages for the various offences, but as guilt could not be objectively measured no-one could know whether a standardised scheme would be less unfair than the
previous discrepancies. Social science (particularly criminological research) was now comparing the after-careers of offenders with the forms of sentence available-to determine their efficacy. Though the yield was so far small, the significant assumption
was
that the consequences of the court’s decision
were
potentially demonstrable. Magistrates, in short, could no longer expect to escape being proved wrong. Variations in skill between courts would doubtless emerge; and magistrates, like doctors, would be faced with the outcome of their decisions. Already it was possible to distinguish, by objective criteria, " risk classes " of offenders; and work in Scotland had shown a high reconviction-rate in shortsentence cases, compared with the use of a fine or a long
on
do it-its future seems assured. " What is now required," REVANs and McLACHLAN conclude, " is possibly the influence and authority that stems from the cool considered views of an intellectual elite, suggesting the form of a Society rather than a Board of Management. Perhaps the Central Committee is indeed the start of a British Academy of Medicine." It is there that the perturbed Colleges may find a successful and united future.43 to
43. See Lancet,
1967, i, 31.
spent on this sort of research results could be applied-and
wasted unless the applied by j.p.s. Sentencing was becoming more of a science, and the substitution of lawyers for laymen on the benches was
clearly
was
were
enough. Stipendiary magistrates were usually trained only in Law. As Lady Wootton admitted sadly, not
"
I do not know whether my sentences have done more harm than good, or more good than harm, or how my practice compares with that of my colleagues." Social conscience, internal sanctions, Lady Wootton thought, were more effective than any penalty or threat thereof, but we did not know how these safeguards in the personality worked or how they could be stimulated. The efficacy of deterrence was clearly linked in her view, to the degree of malicious intent: deterrence did little for the burglar or professional criminal, but it was likely to be effective for the motorist, whose offences seldom carried the intention to do harm or damage. These were two classes of offender, and the study of one was of little help in the treatment of the other. The deterring of others by giving tough sentences set the magistrates ethical problems which doctors might grasp better if they could imagine themselves carrying out injurious and unnecessary operations on the first victims of an epidemic in order to stop the spread of the disease. Another big pressure on the practice of the courts was the " devastating influence of psychiatry on traditional assumptions of guilt." The traditional ideas of guilt had been watered down in Acts over the years so that treatment and punishment had become intermingled. Probation with a condition of treatment under the 1948 Act did not require a definition of the illness; in effect, it accepted the fact of the wickedness but said that treatment might
help. Failure to cooperate would lead to a penal sentence. Lay magistrates had the power (which they often did not realise) to make a hospital order without even recording a
SCHOEFL and FRENCH 34 studied the lactating mammary gland, where fat in chylomicra leaves the circulation in large amounts. They found no electron-microscopic evidence for the passage of intact chylomicra through the endothelium by any route. Chylomicra did, however, line themselves along the walls of capillaries in close contact with the endothelium, and some appeared to be in contact with scalloped portions of endothelial cells. Histochemical evidence was obtained for the hydrolysis of chylomicron triglyceride at these sites-a process presumably mediated by the clearing factor lipase, which was first characterised as an enzyme in the studies of FRENCH and his colleagues 35 36 and is known to be at least fairly closely associated with
endothelium. 3.7 As Lord FLOREY pointed out in his address, researchworkers in atherosclerosis are at present engaged in the painstaking accumulation of often seemingly trivial facts. But without this effort it is. difficult to see how progress can be made. And perhaps some of the facts about endothelium will prove to be not so trivial after all.
Power or Persuasion ? As our friends-and others-remark, a sure sign that the British are becoming serious about something is a proliferation of committees, each doing, a cynical voice adds, what is already being done. Since the muchneeded stimulus of the Christ Church conference in 1961,38 postgraduate medical education in this country has certainly begun to receive the serious attention it needed. And a committee has been formed 39-the Central Committee on Postgraduate Medical Education, with Sir ROBERT AITKEN as chairman. If it is to succeed in seizing all the ideas that are in the air and putting the good ones to use, it must clearly confound the cynic by doing much more than is already being done. If it is to provide a cutting edge to the variety of blunt instruments now being enthusiastically wielded at the tangle of medical postgraduate education, its terms of reference 39 may need strengthening, and to its present university and College members representatives of the General Medical Council, the Ministry of Health, and the regional authorities of the N.H.S. may have to be added. If it is to be effective, it must be adequately financed, partly perhaps from university and College funds and partly from N.H.S. funds (for the time being the committee is sustained by £60,000 set aside by the Nuffield Provincial Hospitals Trust to help it in its first five years). At the moment it is a purely advisory body, and, without statutory or quasi-statutory powers, it may prove feeble; and in its forthcoming report the Royal Comniission will surely discuss the future of the committee and its powers. Meanwhile, the Nuffield Trust has given further help by asking Dr. JOHN REVANS, senior 34. Schoefl, G. I., French, J. E. Proc. R. Soc. B. (in the press). 35. French, J. E., Robinson, D. S., Florey, H. W. Q. Jl exp. Physiol.
1953, 38, 101 36. Robinson, D. S., French, J. E. ibid. p. 233. 37. Robinson, D. S., French, J. E. Pharmac. Rev. 1960, 12, 241. 38. See Lancet, 1962, i, 361, 367. 39. ibid 1967,i, 1376
administrative medical officer of the Wessex Regional Hospital Board, and Mr. GORDON McLACHLAN, secretary of the Trust, to re-examine the situation; and their report 40 is the best analysis we have had of past progress (or hesitancy), today’s uncertainties, and further prospects for reorganisation and stimulation. In our efforts to move further away from the chaos that has beset postgraduate training (often non-training) 41 this text by REVANS and McLACHLAN may be a vital catalyst. The speed of progress must depend largely on the influence of the Aitken committee—and on its ability to act harmoniously with the Colleges and other bodies concerned in postgraduate education. If the Royal Commission recommends that powers be conferred on a central body, how will the Colleges react ? If they are then frightened into taking up defensive positions by the threat of a powerful central body telling them what to do, the impetus they have been gathering may be lost. A more effective approach to the training of specialists has happily become apparent-for instance, in the Wright report 42 of the Scottish Post-Graduate Medical Association-and the Colleges must on no account be deterred from accepting an increasing part in the promotion and supervision of postgraduate education. As REVANS and McLACHLAN put it, " if they are to cover the whole range of postgraduate medical education this would mean that in order to meet modern requirements, their functions must go far beyond the stage of the awarding of diplomas." Pressure from an independent non-statutory body, drawing its main strength from voluntary action, may be the right way not only to stimulate Government machinery but also to draw the best out of the voluntary bodies themselves. The report by REVANS and McLACHLAN points to the absence of three main elements in present arrangements for postgraduate medical education in the United Kingdom: a structure both for postgraduate and continuing education; adequate finance; and any mechanism for coordinating and incidentally focusing on the essentials. The focus must be provided by some central body able to speak with authority covering the needs and organisations of postgraduate education. The ideal is often said to be a strong central body with statutory powers, its membership drawn from all the authorities concerned with education and with service. Others look for a central body with well-defined powers which might in many ways overlap the responsibilities for the supervision of specialist training now being assumed by the Colleges. The central committee’s present brief, REVANS and McLACHLAN add, is vague, its constitution is extremely limited, and its financial foundations are anything but secure. " To believe in its ultimate effectiveness is to believe in the power of voluntary action to regulate and co-ordinate somehow or another the several responsibilities of a vast number of bodies of Medical Education: Retrospect and Prospect. By JOHN REVANS and GORDON McLACHLAN. Nuffield Provincial Hospitals Trust, 1967. Obtainable from the Trust at 3 Prince Albert Road, London N.W.1. 2s. 6d. 41. See Lancet, 1966, ii, 1399. 42. Report of a Working Party on Post-Graduate Medical Education within the National Health Service in Scotland, 1967. 40.
Postgraduate
1242
and traditions and to make them relevant to modern conditions and the needs of the National Health Service." The key question is whether the central body can develop a high degree of prestige and influence quickly. It could do so, REVANS and McLACHLAN judge, if it became the main source of knowledge concerning postgraduate medical education and was prepared to be critical of any backwardness or waywardness on the part of any of the Colleges or universities, or the regional postgraduate committees or the Health Departments themselves. The money required for its stability and security is not very great, provided the vast potential of the universities, the Colleges, and the regional postgraduate committees is exploited through delegated powers. " Indeed there is much to be said for utilizing as much as possible all existing influential institutions which show awareness of the problems and vigour in tackling them. What the Colleges have set themselves to do about vocational training is impressive and they should have incentives to do this as effectively as possible." A remaining criticism is that the central committee as now constituted may have little influence in N.H.S. quarters because the Service is not represented
it. As the Nuffield Trust report observes, it can really gain in authority only if it becomes in effect the key adviser to the Ministry of Health on postgraduate education. But it should clearly be seen to remain independent and " be made responsible for monitoring all matters concerning postgraduate medical education in the National Health Service." The committee must also have continuous dialogue with the General Medical Council, the body likely to be responsible for maintaining specialist registers, should they be established. The committee has taken as its first task a review of preregistration posts. It must also strive-and quickly - to counter the confusion in the immediate postregistration period. If it can do that-or make even a successful start by creating the right atmosphere in which
Annotations
sentence. Many English thieves seemed to do well with fines, and house-breakers with probation orders. Money
differing strengths
SENTENCES BY THE COURTS
LOOKING back on forty-two years as magistrate and on the sentencing of about 20,000 offenders, Baroness Wootton of Abinger, in the Lloyd-Roberts lecture at the Royal Society of Medicine on Nov. 30, made some cogent points about changing practice in the courts. The concepts of guilt, punishment, and sentence had always been inextricably mixed, and they were changing. Technically, if guilty intent could not be proved, an offender could not be sentenced. In deciding sentence the magistrate was guided by the degree of heinousness of the offence and by mitigating circumstances; but unfortunately this tariff system was interpreted differently by different courts. For example, the lowest rate of sentencing to prison was 3 %, and in another court with similar offenders it was as high as 55%. Prison sentences of over three years were four times as common in England as in Scotland. Attempts were being made to standardise sentencing practice, notably by circulating to all j.p.s the national averages for the various offences, but as guilt could not be objectively measured no-one could know whether a standardised scheme would be less unfair than the
previous discrepancies. Social science (particularly criminological research) was now comparing the after-careers of offenders with the forms of sentence available-to determine their efficacy. Though the yield was so far small, the significant assumption
was
that the consequences of the court’s decision
were
potentially demonstrable. Magistrates, in short, could no longer expect to escape being proved wrong. Variations in skill between courts would doubtless emerge; and magistrates, like doctors, would be faced with the outcome of their decisions. Already it was possible to distinguish, by objective criteria, " risk classes " of offenders; and work in Scotland had shown a high reconviction-rate in shortsentence cases, compared with the use of a fine or a long
on
do it-its future seems assured. " What is now required," REVANs and McLACHLAN conclude, " is possibly the influence and authority that stems from the cool considered views of an intellectual elite, suggesting the form of a Society rather than a Board of Management. Perhaps the Central Committee is indeed the start of a British Academy of Medicine." It is there that the perturbed Colleges may find a successful and united future.43 to
43. See Lancet,
1967, i, 31.
spent on this sort of research results could be applied-and
wasted unless the applied by j.p.s. Sentencing was becoming more of a science, and the substitution of lawyers for laymen on the benches was
clearly
was
were
enough. Stipendiary magistrates were usually trained only in Law. As Lady Wootton admitted sadly, not
"
I do not know whether my sentences have done more harm than good, or more good than harm, or how my practice compares with that of my colleagues." Social conscience, internal sanctions, Lady Wootton thought, were more effective than any penalty or threat thereof, but we did not know how these safeguards in the personality worked or how they could be stimulated. The efficacy of deterrence was clearly linked in her view, to the degree of malicious intent: deterrence did little for the burglar or professional criminal, but it was likely to be effective for the motorist, whose offences seldom carried the intention to do harm or damage. These were two classes of offender, and the study of one was of little help in the treatment of the other. The deterring of others by giving tough sentences set the magistrates ethical problems which doctors might grasp better if they could imagine themselves carrying out injurious and unnecessary operations on the first victims of an epidemic in order to stop the spread of the disease. Another big pressure on the practice of the courts was the " devastating influence of psychiatry on traditional assumptions of guilt." The traditional ideas of guilt had been watered down in Acts over the years so that treatment and punishment had become intermingled. Probation with a condition of treatment under the 1948 Act did not require a definition of the illness; in effect, it accepted the fact of the wickedness but said that treatment might
help. Failure to cooperate would lead to a penal sentence. Lay magistrates had the power (which they often did not realise) to make a hospital order without even recording a