PRESSURE TO SELL

PRESSURE TO SELL

991 extraordinary expansion in the number of personal chairs in clinical subjects, particularly in London. This has not always been a direct result o...

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extraordinary expansion in the number of personal chairs in clinical subjects, particularly in London. This has not always been a direct result of distinguished achievement". This comment has caused understandable distress to several distinguished members of the clinical academic profession in the University of London. In justice to the people concerned and to set Booth’s comments in their true perspective, two points deserve emphasis. Firstly, in the University of London conferment of title (i.e., personal chairs) is by

general problem remains-namely, that decisions on resource take place in units which go beyond the size ofa single diagnostic group in the hospital. While evaluations of individual diseases and treatments are valuable, wider appraisals will be necessary if changes in treatments are not to generate new resource problems while solving old medical ones. the

use

Department of Community Medicine, St Thomas’s Hospital Medical School, London SE1 7EH

system of peer review-a system to which the Medical Research Council attaches great value-by both external and internal experts. Secondly, over the past nine years the number of conferred clinical titles in the Faculty of Medicine of this university has declined, such that in the first three years of this period the number of such conferments was over twice that in the past three years.

PETER A. WEST

a

MESOTHELIOMA AND THE DEATH CERTIFICATE 1

SiR,—The report Medical Aspects of Death Certification emphasises the high proportion of necropsies that are requested by The main purpose of these post-mortem examinations is establish the cause of death, but the report recommends that me,dicolegal necropsies should involve a complete review of all diseases present. The following two cases, identified in a review of deaths from mesothelial tumours between 1975 and 1980 in two factory cohorts, suggest that the report should also have recommended that important post-mortem findings are reflected in the death certificate. A woman of 73 died in 198Q. The necropsy report contained a hist ory of asbestos exposure as a young girl and gave further details of the history characteristic of pleural mesothelioma. However, the patient had symptoms of myocardial infarction and died on the day of admission to hospital. The necropsy report describes the con dition of the left lung in detail, as well as the ruptured and infarcted heart, and gave the cause of death as (I) rupture of the heart due to myocardial infarction due to coronary thrombosis; (II) left pleural effusion due to ? malignant mesothelioma. The report was signed by a consultant histopathologist. However, the death entry was completed by the coroner who gave the cause of death as (I) (a) ru,pture of the heart, (b) myocardial infarction, (c) coronary thrombosis; (II) left pleural effusion, natural causes. The necropsy report of a man who had worked for over 16 years at a London asbestos factory described thickening of the right pleura andt pleural plaques-and also acute pyelonephritis papillites necroticans and obliteration of the neck of the bladder by enlarged prostatic medium lobe. There is also a note that histological exaonination had revealed asbestos bodies and mesothelial infiltration of the thickened pleura. The consultant pathologist sigrung the report states that the cause of death was renal failure due comners.

Senate House, University of London, London WC1E 7HU

to

pyelonephritis due to benign prostatic hyperplasia. The death entry signed by the coroner repeats this exactly. Blocks of the tumour were referred to a pneumoconiosis panel. Mesothelioma of the pleura and peritoneum has been a prescribed disease (no. 44) since 1968. It is not known whether either of these cases was receiving industrial injury benefit for their disease, but the verdict of "natural causes" in the case of the woman would militate against compensation. The consequences to epidemiological research of such incomplete certification are obvious. Occupational Health,

SIR,-Belabouring pharmacist advertising (Oct. 2, p. 750) you remark: "if you want to know whether you need a haircut, don’t ask a barber". Presumably, once the decision is reached to obtain a haircut, the barber will ask his client what kind of haircut would be most appropriate. The patient seeking advice from the pharmacist concerning self-treatment is in an excellent position to assess the quality of information provided as it relates to the outcome of the treatment. Perhaps an audit of treatments as selected by patients themselves versus those as suggested by pharmacists would offer further insight. Department of Pharmacy, Saint Francis Memorial Hospital, San Francisco, California 94120, U.S.A.

SIR,-You have asked how pharmacists can insulate themselves against the lures of commerce. Why concern yourself with the pharmaceutical profession when it is very evident that the lures of commerce (profit) are only too prevalent in the ranks of dispensing doctors where one sees evidence of touting for patients to come on to the dispensing list-for example, by the display of directives in some surgeries telling patients that they must get their medicines at the surgery or by use of the local press. A West Country newspaper has described how a group of doctors, having invested ;[2000 in influenza vaccine, have issued a circular letter inviting their elderly patients to avail themselves, without charge, of this prophylaxis. 2000 is a lot of money to invest, and what happens if there is no influenza epidemic? I wonder what the discount was on that amount of vaccine-there is

no clawback either or overhead costs, which have already been allowed for in the practice allowances on staff salaries.

Wiveliscombe, Taunton, Somerset

Tropical Medicine, London WC1E 7HT

,

JAMES R. JANSEN

JOHN DAVIES

8 High Street,

London School of Hygiene and

QUESNE,

PRESSURE TO SELL

to acute

T.U.C. Centenary Institute of

L. P. LE

Dean, Faculty of Medicine

Hon

Secretary,

Rural Pharmacists Association

MURIEL L. NEWHOUSE

LONDON’S PERSONAL CHAIRS a professor of medicine in the Umversity of London and now Director of the M.R.C. Clinical Research Centre, criticises the approach of the Royal College of Physicians to the problems facing academic medicine in the U.K. (Sept. 18, p. 666). Many of those concerned with this problem will agree with him that there are several factors other than a lack of money which contribute to the present difficulties, and his letter is of value in drawing attention to these aspects. 1r. view of this it is all the more unfortunate that in his final paragraph Booth writes: "There has been in recent years an

SiR,-Dr Booth, formerly

1 Medical aspects of death certification: a joint report of the Royal College of Physicians and the Royal College of Pathologists. J Roy Coll Physns 1982; 16: 3-14.

ANALGESIA AND SATISFACTION IN CHILDBIRTH

SIR,-We welcome the long overdue objective approach to the provision of pain relief in labour adopted by Dr Barbara Morgan and her colleagues (Oct. 9, p. 808). We agree that her data invite reappraisal of the role of epidural analgesia in labour. Unfortunately, the information obtained from the Queen Charlotte’s 1000 Mother Survey cannot be fully interpreted because of the failure to differentiate between primigravidae and multigravidae. Almost all aspects of labour differ in these groups. For instance, prolonged labour and forceps delivery are ten times more common in primigravidae. Pain relief in labour should never be considered in isolation; the need for analgesia is influenced by the management of labour, attention of a personal nurse, and attendance at childbirth classes.