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ROYAL COMMISSION ON MEDICAL EDUCATION
524
Letters
to
the Editor
WHERE ARE THE TEACHERS OF COMMUNITY MEDICINE ? SIR,-Most of us would agree with Professor Morris and Dr. Warren (Feb. 1, p. 249) in their diagnosis and even with Dr. Cochrane (Feb. 15, p. 367) in his treatment (particularly where he points an accusing finger at people like himself), but I think that they and the report writers have oversimplified the problem. Almost all the recent reports emphasise the importance of the contribution of university departments of social and community medicine to our health services, yet the harsh reality is that they are rarely used. One expects regional hospital boards to support and to make use of university departments of, for example, pathology or microbiology, to exchange junior staff with the university, and to sponsor their training. Most departments of social and community medicine could, in their way, provide as much, but they have no service role and rarely receive such support. Instead, regional board and local authority " research and intelligence ", or " management service " units, are sometimes to be found growing up beside the universities unconnected and even competing with them for scarce support and skill-a situation unthinkable for other clinical departments and one which suggests that not everyone agrees with your analysis of need. We are fortunate up here in our cooperative ventures but experience of successful relations with local services only emphasises how unnecessarily dependent are the departments of social and community medicine upon their good will. A more general recognition of our service role might be a start. Department of Public Health and Social Medicine, University, Aberdeen.
E. MAURICE BACKETT.
ROYAL COMMISSION ON MEDICAL EDUCATION of the Royal Commission on Medical SiR,ŅThe proposal Education to drop A-level biology, retaining only chemistry and physical science as compulsory subjects for entry to the medical profession, is part of the trend to degrade the study of structure and function, should give cause for concern, and will have wide consequences. It will make the task of teaching morphology, a subject from which everything in medicine flows, immeasurably greater. In the courses of cell biology so rightly proposed for them, medical students will need, never having heard of Robert Hooke and his successors, to assimilate the most basic knowledge. Is it seriously proposed to teach embryology, histology, and pathology to students whose first acquaintance with cell nuclei, chromosomes, meiosis, and mitosis, is at medical school, or some fearful cram course just before their entry? If so, the opportunity will be lost to educate and instruct them in the exciting developments of contemporary cytology and molecular biology. The possible omission of physics is almost as bad for different reasons: how are future doctors to study the special senses having little or no knowledge of the properties of light and sound, general metabolism when ignorant of heat, or joints when untutored in mechanics and hydrodynamics ? How are they to study the uses and effects of irradiation ? As Mr. Dempster (Feb. 22, p. 416) says, we have a sick society. The vitalistic views of Aristotle, Erasistratus, and Galen, of Italian humanism, of Harvey (who wrote of the blood’s wonderful and divine faculties), of Descartes and Stahl-all these at the present time may find little place set against the tradition formulated by Joseph Black and Lavoisier. The Pco2, as Mr. Dempster suggests, may become all important. Striving to find a way out of our dilemma, science we are told is the key which will unlock the door to Utopia. But if future generations of doctors are to have compelled learning only in the ideas of Demokritos and his successors, and are to
have
insight into the general scene of life, just how is it proposed that they shall communicate with the ideas of Darwin, Mendel, Pasteur, and Metchnikoff, or, among doctors, understand what Harvey meant by the " microcosm " ? It is true that, by proposing a reduction in the specified nature of entry requirements, the Royal Commission has attempted to ensure, through an intake of students from a variety of disciplines, including mathematics, that there shall be a broader appraisal of medicine, its approach to the patient, and its preventive aspects, than hitherto. But it is reasonable to argue that this would be better fostered at university-in the proposed optional courses. The medical student, being older, having achieved a basis of physical and natural science, and the goal of a place in medical school, should be more mature and receptive. And should not teaching in comparative religion and humanism be offered to those who aspire to the comprehension of man ? The study of the human aspects of biology, without the facility to compare them with the other aspects, would be an exercise bereft of much of its potential value. Among the new subjects so rightly proposed, ageing, sociology, and psychology would thereby be the poorer. By all means let us train doctors as applied chemists, having prodded them also into thinking what place mankind occupies in the scheme of things. But let us also ask the question-are we not fast approaching the no
stage when we Cosham, Portsmouth,
are
Hants.
guilty of obscurantism in reverse ? BRYAN WINTER.
ANTIDIURESIS IN DIABETES INSIPIDUS SIR,-Dr. Brown and his colleagues (Feb. 1, p. 237) advance the hypothesis that, in patients with diabetes insipidus, diuretics reduce urine flow via the renin/angiotensin system. They fail to discuss many physiological data which suggest that it is changes in proximal-tubule absorption of sodium that reduce the urine flow. Firstly, Brenner and Berliner1 observed increased reabsorption of sodium by the proximal tubule when acute sodium (and
volume) depletion was produced by dialysis. Similarly the sodium depletion that follows administration of a diuretic is associated with increased reabsorption of sodium and water by the proximal tubule.2 This increased reabsorption is prevented if the sodium lost in the urine is replaced intravenously.23 Secondly, in-vitro experiments 45 have shown that, in the presence of an osmotic gradient, fluid in the distal tubule and collecting duct attains osmotic equilibrium with the surrounding fluid by movement of water. This movement of water continues, though at a slower rate, when antidiuretic hormone (A.D.H.) is absent. In-vivo observations have shown that, when glomerular filtration-rate (G.F.R.) is reduced, urine may become hypertonic to plasma in the absence of A.D.H.6-8 Presumably, at a
lower G.F.R., the slower flow-rate in the distal tubules and
collecting duct allows a greater degree of equilibration of urine with the interstitial fluid. Thirdly, increased renin secretion is commonly observed in 10 response to diuretic-induced sodium depletion.9 We suggest that the following hypothesis is a more reasonable explanation of the " antidiuretic effect " of diuretic drugs. When a diuretic that inhibits sodium transport in the distal Berliner, R. W. Proceedings of the American Society of Nephrology, November, 1968; p. 7 (abstract). Dirks, J. H., Cirkensa, W. J., Berliner, R. W. J. clin. Invest. 1966, 45,
1. Brenner, B. M., 2.
1875. 3. Rector, F. C., Jr., Sellman, J. C., Martinez-Maldorado, M., Seldin, D. W. ibid. 1967, 46, 47. 4. Morgan, T., Sakai, F., Berliner, R. W. Am. J. Physiol. 1968, 214, 574. 5. Grantham, J. J., Burg, M. B. ibid. 1966, 211, 255. 6. del Greco, F., de Wardener, H. E. J. Physiol., Lond. 1956, 131, 307. 7. Berliner, R. W., Davidson, D. G. J. clin. Invest. 1957, 36, 1416. 8. Valtin, H. ibid. 1966, 45, 337. 9. Brown, T. C., Davis, J. O., Johnston, C. I. Am. J. Physiol. 1966, 211, 437. 10. Fraser, R., James, V. H. T., Brown, J. J., Isaac, P., Lever, A. F., Robertson, J. I. S. Lancet, 1965, ii, 989.
Letters
to
the Editor
WHERE ARE THE TEACHERS OF COMMUNITY MEDICINE ? SIR,-Most of us would agree with Professor Morris and Dr. Warren (Feb. 1, p. 249) in their diagnosis and even with Dr. Cochrane (Feb. 15, p. 367) in his treatment (particularly where he points an accusing finger at people like himself), but I think that they and the report writers have oversimplified the problem. Almost all the recent reports emphasise the importance of the contribution of university departments of social and community medicine to our health services, yet the harsh reality is that they are rarely used. One expects regional hospital boards to support and to make use of university departments of, for example, pathology or microbiology, to exchange junior staff with the university, and to sponsor their training. Most departments of social and community medicine could, in their way, provide as much, but they have no service role and rarely receive such support. Instead, regional board and local authority " research and intelligence ", or " management service " units, are sometimes to be found growing up beside the universities unconnected and even competing with them for scarce support and skill-a situation unthinkable for other clinical departments and one which suggests that not everyone agrees with your analysis of need. We are fortunate up here in our cooperative ventures but experience of successful relations with local services only emphasises how unnecessarily dependent are the departments of social and community medicine upon their good will. A more general recognition of our service role might be a start. Department of Public Health and Social Medicine, University, Aberdeen.
E. MAURICE BACKETT.
ROYAL COMMISSION ON MEDICAL EDUCATION of the Royal Commission on Medical SiR,ŅThe proposal Education to drop A-level biology, retaining only chemistry and physical science as compulsory subjects for entry to the medical profession, is part of the trend to degrade the study of structure and function, should give cause for concern, and will have wide consequences. It will make the task of teaching morphology, a subject from which everything in medicine flows, immeasurably greater. In the courses of cell biology so rightly proposed for them, medical students will need, never having heard of Robert Hooke and his successors, to assimilate the most basic knowledge. Is it seriously proposed to teach embryology, histology, and pathology to students whose first acquaintance with cell nuclei, chromosomes, meiosis, and mitosis, is at medical school, or some fearful cram course just before their entry? If so, the opportunity will be lost to educate and instruct them in the exciting developments of contemporary cytology and molecular biology. The possible omission of physics is almost as bad for different reasons: how are future doctors to study the special senses having little or no knowledge of the properties of light and sound, general metabolism when ignorant of heat, or joints when untutored in mechanics and hydrodynamics ? How are they to study the uses and effects of irradiation ? As Mr. Dempster (Feb. 22, p. 416) says, we have a sick society. The vitalistic views of Aristotle, Erasistratus, and Galen, of Italian humanism, of Harvey (who wrote of the blood’s wonderful and divine faculties), of Descartes and Stahl-all these at the present time may find little place set against the tradition formulated by Joseph Black and Lavoisier. The Pco2, as Mr. Dempster suggests, may become all important. Striving to find a way out of our dilemma, science we are told is the key which will unlock the door to Utopia. But if future generations of doctors are to have compelled learning only in the ideas of Demokritos and his successors, and are to
have
insight into the general scene of life, just how is it proposed that they shall communicate with the ideas of Darwin, Mendel, Pasteur, and Metchnikoff, or, among doctors, understand what Harvey meant by the " microcosm " ? It is true that, by proposing a reduction in the specified nature of entry requirements, the Royal Commission has attempted to ensure, through an intake of students from a variety of disciplines, including mathematics, that there shall be a broader appraisal of medicine, its approach to the patient, and its preventive aspects, than hitherto. But it is reasonable to argue that this would be better fostered at university-in the proposed optional courses. The medical student, being older, having achieved a basis of physical and natural science, and the goal of a place in medical school, should be more mature and receptive. And should not teaching in comparative religion and humanism be offered to those who aspire to the comprehension of man ? The study of the human aspects of biology, without the facility to compare them with the other aspects, would be an exercise bereft of much of its potential value. Among the new subjects so rightly proposed, ageing, sociology, and psychology would thereby be the poorer. By all means let us train doctors as applied chemists, having prodded them also into thinking what place mankind occupies in the scheme of things. But let us also ask the question-are we not fast approaching the no
stage when we Cosham, Portsmouth,
are
Hants.
guilty of obscurantism in reverse ? BRYAN WINTER.
ANTIDIURESIS IN DIABETES INSIPIDUS SIR,-Dr. Brown and his colleagues (Feb. 1, p. 237) advance the hypothesis that, in patients with diabetes insipidus, diuretics reduce urine flow via the renin/angiotensin system. They fail to discuss many physiological data which suggest that it is changes in proximal-tubule absorption of sodium that reduce the urine flow. Firstly, Brenner and Berliner1 observed increased reabsorption of sodium by the proximal tubule when acute sodium (and
volume) depletion was produced by dialysis. Similarly the sodium depletion that follows administration of a diuretic is associated with increased reabsorption of sodium and water by the proximal tubule.2 This increased reabsorption is prevented if the sodium lost in the urine is replaced intravenously.23 Secondly, in-vitro experiments 45 have shown that, in the presence of an osmotic gradient, fluid in the distal tubule and collecting duct attains osmotic equilibrium with the surrounding fluid by movement of water. This movement of water continues, though at a slower rate, when antidiuretic hormone (A.D.H.) is absent. In-vivo observations have shown that, when glomerular filtration-rate (G.F.R.) is reduced, urine may become hypertonic to plasma in the absence of A.D.H.6-8 Presumably, at a
lower G.F.R., the slower flow-rate in the distal tubules and
collecting duct allows a greater degree of equilibration of urine with the interstitial fluid. Thirdly, increased renin secretion is commonly observed in 10 response to diuretic-induced sodium depletion.9 We suggest that the following hypothesis is a more reasonable explanation of the " antidiuretic effect " of diuretic drugs. When a diuretic that inhibits sodium transport in the distal Berliner, R. W. Proceedings of the American Society of Nephrology, November, 1968; p. 7 (abstract). Dirks, J. H., Cirkensa, W. J., Berliner, R. W. J. clin. Invest. 1966, 45,
1. Brenner, B. M., 2.
1875. 3. Rector, F. C., Jr., Sellman, J. C., Martinez-Maldorado, M., Seldin, D. W. ibid. 1967, 46, 47. 4. Morgan, T., Sakai, F., Berliner, R. W. Am. J. Physiol. 1968, 214, 574. 5. Grantham, J. J., Burg, M. B. ibid. 1966, 211, 255. 6. del Greco, F., de Wardener, H. E. J. Physiol., Lond. 1956, 131, 307. 7. Berliner, R. W., Davidson, D. G. J. clin. Invest. 1957, 36, 1416. 8. Valtin, H. ibid. 1966, 45, 337. 9. Brown, T. C., Davis, J. O., Johnston, C. I. Am. J. Physiol. 1966, 211, 437. 10. Fraser, R., James, V. H. T., Brown, J. J., Isaac, P., Lever, A. F., Robertson, J. I. S. Lancet, 1965, ii, 989.