Running Commentary by Peripatetic Correspondents B
OUR local Medical Engineering Institute is going to look at hospital chairs. And none too soon! The " sedentary " revolution of the modern hospital is now almost of age. We get our patients out of bed quicker after all sorts of illnesses and operations, and each mystic statistic, like " bed turnover rate " and " days per inpatient stay " keeps improving-so our administrators tell us. We get our patients up straight away after strokes, hernia operations, and attacks of left heart failure. We get them up if they are elderly lest they become incontinent, or, if they are young, because they are happier that way. We get them up with their catheters and drips attached. But-we
get them up into what ? In our ward, Sister has to put them into the mottliest old collection of chairs with wooden arms of uncompromising shape and cross-infecting upholstered seats about one foot off the floor. These chairs would be thrown out at a second-handfurniture auction, yet it took us six months to get two comfortable chairs, with seats high enough for a couple of not-sobad hemiplegics to get out of unaided when they wanted to go to the lavatory. Comrades, the sedentary revolution is not yet over. We need your support for the sit-in. Our masters still have not yet got the message. But what can we do ? One thing we can do at once is to stop talking about beds and talk about chairs instead. " I have ten acute medical chairs and " twenty geriatric chairs." "Sister, what is the dailychair-state ? " Nurse, give that patient a chair-pan." " This hospital has sixty acute surgical chairs, forty orthopaedic, and fifty medical chairs." (Yes, and whatever happened to the obstetric chair: isn’t it time that made a come-back ?) We need adaptable ambidextrous chairs to cope with left and right handed hemiplegics, we need reclining chairs, springassisted ejector-seat chairs, chairs with attachments for dripstands and urine bags, chairs for the elderly, chairs for the young. Reading stands, feeding trays, chair lockers. Plenty of room for study here. Dare we suggest our Engineering Institute sets up a special department-under a professor-a chair of chairs ? *
PROFESSIONAL ADVISORY COMMITTEES ? time has come to replace medical Sirsuggest that the " advisory committees by professional advisory committees ", both at hospital level and at regional-board and board-ofgovernors level. Such committees would include representatives of senior nursing staff and of senior hospital scientists as well as of medical staff. The Zuckerman report1 refers (paragraph 2.5) to strong support from both medical and non-medical organisations for the view that senior scientists should have comparable status to consultant medical staff and should be members of appropriate hospital advisory committees; it goes on (paragraph 6.3.3) to recommend that " The Regional Hospital Board should have a Regional Scientific Advisory Committee which should include medical and non-medical scientists with functions corresponding to those of the Medical Advisory Committee ". One of the defects of the National Health Service is the abundance of committees which it has engendered. If two committees advise a parent body on closely connected matters, the advice may be conflicting. The efficient answer is surely to have one committee. At present the views of the qualified nursing staff are conveyed through the matron. The extent to which these views may be modified depends upon one person. At a time when the implementation of the Salmon report2 is likely to make the nursing staff progressively more professional, it would be in the general interest to give senior members of the nursing profession a channel for putting their views before parent authorities without first having to convince a hierarchical superior. Most hospitals are now associating the junior medical staff with the work of the medical committee, and it is clear that an equally strong case will exist for representation of more junior hospital scientists and more junior-but qualified-members of the nursing staff. It is clearly desirable that hospital scientists and nursing staff should be represented within the divisional system when it becomes operative. ARTHUR JORDAN. Sheffield S10 3QP.
We have all known a patient who carried out our instructions too literally, and it is nice to know that other professions have the same difficulties. Many years ago I heard of a child who was asked in an examination what he must do to obtain forgiveness of sin, and who replied that first he must sin. More recently I encountered a lecturer in methods of education who always impressed on his students the importance of making themselves crystal-clear when telling children what to do. While giving a demonstration lesson he noticed a child chewing gum; he pointed a finger at the offender and then gestured towards the waste-paper basket. The child didn’t move and again the admonitory finger pointed first at him and then at the basket. Finally comprehension dawned-the child came to the front of the classroom and stood in the waste-paper basket. The students were very impressed. *
A concert brought together five-hundred singers from dozen London hospitals, mostly nursing staff, who paraded in their uniforms, displaying all the possible permutations of the Nightingale theme. The greatest diversity was in the caps; some looking like small pin-cushions, others like inverted custard pies; one seemed to be crowned like a cock’s comb, another led back into a scorpion’s sting. The nurse’s cap is as vestigial as the academic’s hood, for long ago it ceased to act as a hygienic cover for her hair-but what a shame it would be if it disappeared, or (worse still) became a completely standard item of dress. After all, one of the nicest things about a nurse’s uniform is that it isn’t. a
PROGRESSIVE ASSESSMENT? SIR,-In its 1967 Recommendations as to Basic Medical Education,3 paragraphs 14 and 26-30, the General Medical Council gives qualified support to the idea of progressive assessment of students, though it states that " it is important to avoid the hazard of burdening the student with excessive and too frequent assessments." The Royal Commission on Medical Education4 also gives some support to progressive assessment in paragraphs 283-286 (p. 116). It says that the " assessment [should be] built up from periodic reports on the student’s performance, based where appropriate on written, oral or practical tests, and completed by a comprehensive review at the end of the course." There are signs that progressive assessment of postgraduates is being considered by the Royal Colleges and others who have a special interest in postgraduate medical education. There can be honest doubts about whether progressive assessment is fairer to students at all levels than a single test " at widely spaced intervals. Brian MacArthur writes 5: American students, moreover, have a lot more to complain about. They are tested every term and often in mid-term, and because of the importance of the graduate schools every performance is vital. There can be no relaxation and the British ...
Hospital Scientific and Technical Services: Report of the Committee, 1967-68. H.M. Stationery Office, 1968. See Lancet, 1968, ii, 1331. 2. Report of the Committee on Senior Nursing Staff Structure. H.M. Stationery Office, 1966. See Lancet, 1966, i, 1085. 3. See Lancet, 1967, i, 1141. 4. Royal Commission on Medical Education, 1965-68: Report. H.M. Stationery Office, 1968. See Lancet, 1968, i, 797, 809. 5. Times, Feb. 8, 1969. 1.
415 students who ask for continuous assessment instead of the all-in finals system would get a shock if they met students here." All tests of competence and fitness to proceed with a career must inevitably be a cause of anxiety to the examinee. I would welcome evidence that chronic anxiety is preferable to acute anxiety before we jump from the frying-pan into the fire. University Department of Gynæcology, St. Thomas’s Hospital Medical School, London S.E.1.
WHERE ARE THE TEACHERS OF COMMUNITY MEDICINE ? SIR,-Whilst welcoming the fact that Professor Morris and Dr. Warren (Feb. 1, p. 249) have drawn attention to the problem of training of teachers of community medicine, I agree with your editorial comment (Feb. 1, p. 245) that it might be unfortunate if an autonomous staff college were established solely for doctors. I am surprised that they made no mention of existing establishments such as the Hospital Administrative Staff College, which already does so much in the training of administrators and nursing officers within the hospital service. Could we not look to the King Edward’s Hospital Fund to expand this into a College of Health Service Administration which would cater for all professions, including medicine ? Discussion of these important matters is bedevilled by terminology, and there is an urgent need for clarification. Professor Morris and Dr. Warren refer both to " Academic departments of social medicine " and " departments of community medicine ". Are these synonymous, and, if not, what is the subtle distinction ? Again, what is community medicine ? Is it the sort of medicine practised in the community outside as opposed to that practised inside the hospital, is it medicine as applied to groups in the community as opposed to the treatment of the individual, or is it (in the Todd sense) a combination of the techniques currently employed by medical administrators in the hospital boards, local authorities, and central Government ?Finally, what is the community physician ? Is this term synonymous with the medical administrator, as Professor Morris and Dr. Warren appear to imply ? The green-paper1 refers separately to a chief medical officer at area-board level and to the community physician locally as though their functions bore no relationship. Health Department, Reading RG1 3EE.
D. E. CULLINGTON.
DRUG INTERACTIONS IN ALCOHOLISM TREATMENT
SIR,-Although Dr. MacCallum (Feb. 8, p. 313) presents interesting clinical observations on the disulfiram/alcohol reaction and its potentiation or otherwise by psychotropic drugs, we feel that even allowing for the absence of data these findings can be otherwise explained. Many alcoholism-treatment centres, including the unit in Edinburgh, have discontinued theAntabuse’ test-reaction because of the widely reported severe, unpredictable, and sometimes fatal effects. Such unpredictability was notably described by the original workers on antabuse, Hald et al. in 1948-that is, before the modern-psychiatric-drug era.2 Calcium carbimide (’Abstem’), reputedly more reliable, may also have produced fatal test-reactions.3 Disquiet about the use of these drugs as adjuncts to alcoholism therapy has stimulated
carry out biochemical research.
1. National Health Service: Administrative Structure of the Medical and Related Services in England and Wales. H.M. Stationery Office, 1968. See Lancet, 1968, ii, 210; ibid. Jan. 4, 1969, p. 31. 2. Hald, J., Jacobsen, E., Larson, V. Acta Pharmac. tox. 1948, 4, 285. 3. Rodger, W. Br. med. J. 1962, ii, 989.
Our findings in abstinent alcoholics, soon to be published, indicate that striking changes in the integrity of serumproteins, amounting to denaturation, occur while on a maintenance dose of 0-5 g. of disulfiram daily. Conversely, those patients not on antabuse have serum-protein values more and more approaching the normal the longer the patient remains abstinent. We believe that these findings are in keeping with the increasing evidence of direct alcohol toxicity on human organs, especially the liver 4-6; and that, in studying drug effects in alcoholism (with all that this illness means in terms of hepatic dysfunction), it must be remembered that individual patients will vary in their propensity to metabolise and detoxicate ingested products of disulfiram or ethanol and/or both. Finally, Dr. MacCallum’s statement that the " strength of [the antabuse/alcohol] reaction " is due to the speed and buildup of acetaldehyde in the systemic circulation is questionable in view of the work of Casier and Merleverde,who showed that the correlation between " la maladie rouge " and bloodacetaldehyde levels was poor, and that reactions could be ascribed to the production of a toxic quaternary-ammonium
compound. Royal Edinburgh Hospital, Morningside Park, Edinburgh 10. Department of Pharmacology, University of Edinburgh Medical School, Edinburgh 8.
G. B. BURNETT.
H. W. READING.
ROYAL COMMISSION ON MEDICAL EDUCATION SIR,-One can sympathise with Sir Michael Woodruff (Feb. 8, p. 309), and others at Edinburgh for their concern about the future teaching of anatomy, physiology, and biochemistry in the undergraduate medical curriculum, but are they not intellectually standing still ? Surely Sir Michael does not feel badly let down because he was not taught more immunology as an undergraduate student ? His own distinguished immunological studies can now be resolved into a few generalised statements which a student might absorb in one lecture. Surely The Tissues of the Body by Le Gros Clark heralded the end of old-time anatomy? Just take a glance at the abstracts of papers presented at’ the 1968 summer meeting of the Anatomical Society and one will wonder whether it was not, in fact, a meeting of an immunological society. The approach to anatomy has changed and has been changing for some eighty years. Indeed, one can perhaps see the change exemplified in the life of Sir Arthur Keith, who regarded himself as a fly-by-night anatomist. In the teaching of anatomy, the Edinburgh school held a unique position from the time of the Monroe brothers, yet I can recall Sir John Fraser complaining bitterly that students arriving for instruction in clinical surgery had no understanding or feeling for the kind of anatomy he needed in his surgical practice. Then physiology: this has changed too. A reasonable exposition of the lung as a chamber for gas exchange and the ventilation-perfusion ratio can demonstrate more dynamic ventilatory principles in an hour or two than can be taught in weeks of learning about reflexes which do not seem to matter any
assistants, will be required to know, perhaps above all else, the significance of the Pco,. And the physiology of the other organs can be equally well cut and shaped to fit the present needs of undergraduate general instruction. The young graduate of today seems to have effortlessly absorbed the principles of the Krebs cycle and other systematised biochemical concepts, whereas our current elders either failed to understand them or discounted their significance, and already the frontiers are moving again. 4. 5. 6 7.
Lieber, C. S., Davidson, C. S. Am. J. Med. 1962, 33, 319. Lancet, 1964, i, 1263. Klatskin, G. Gastroenterology, 1961, 41, 443. Casier, H. ,Merleverde, E. Archs Int. Pharmacodyn. Thér. 1962,139 165.