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SELECTION OF FUTURE DOCTORS LESSONS FROM THE PAST
407 A more versatile arrangement would be a projector which can be loaded with a number of magazines, each carrying a different film. One such device is described in an American patent (Heyer 1945). Several magazines can be placed on to the projector. On pressing button A on the control panel, film A is automatically passed through the apparatus and then on to a take-up spool. When the button for another magazine is pressed, the first film is rewound on to its original spool, whilst the second film is being shown. The lecturer can therefore arrive for his lecture, place his film on to the machine, and press the button at the appropriate moment. Such a projector, together with a library of films loaded into magazines, will make the use of short films no more difficult than
drawing
on a
blackboard. SUMMARY
Most
schools would be a practical proposition—the more so as these films can be made entirely factual, and the absence of comment will make them easier to integrate into the programmes of different teachers. The formation of deparmental or central libraries containing such records can be carried out on a restricted budget, and the teacher will find his material near at hand and readv for immediate use without the present cumbersome procedure of having to order films from an outside source several days in advance. AUTOMATIC PROJECTION
unnecessary.
The mechanics of projection can present considerable difficulties. Whilst a piece of chalk and a rag are the only requirements for drawing on the blackboard, a darkened room, a projector, and a projectionist are needed for the showing of films, however short they may be. Attempts are therefore being made to devise means whereby screening can take place in a well-lit room and without a
projectionist.
_
One solution is the use of loop films and back projection with a time-switch. The accompanying figure shows a projector with a device which permits the repeated showing of a length of film whose beginning and end have been joined together. The machine is fixed at right angles to a hollow box which carries a translucent screen at one end and a surface silvered mirror, arranged at 45° to the longitudinal axis, at the other end. The images are projected through a small aperture on to the mirror which reflects them back on to the screen. A brilliant image results, mainly because it is seen by transmitted light. The apparatus can be made to start and stop automatically by operating a variable time switch which breaks the electric circuit after a pre-set time interval. The screen size can be varied in different models, from a television-set type for individual students at a demonstration or seminar, to a much larger one suitable for lecture audiences. This arrangement can be used in a variety of teaching situations : (1) During a formal lecture the speaker can press the switch and show his film for a pre-determined number of times without the presence of a projectionist and without having to darken the lecture-theatre. (2) In set demonstrations and in museums the apparatus can be operated by individual students, when they are ready to study thp film. They press the button, look at the screen, and return to other work when they have seen enough. The projector will switch itself off automatically and is immediately ready for the next student. (3) The same apparatus can be used for group
discussions. The model constructed at Guy’s Hospital has also been fitted with a soundproofing box which fits over the
projector,
so
that noise is reduced to
a
existing medical films are too long and too diffuse to be really useful for teaching. " Animated lanternslides "-that is, films up to three minutes in length demonstrating movements in clinical symptoms, natural phenomena, or experiments--can be designed to satisfy a specific need for a definite audience. Such short films are relatively inexpensive and can therefore be assembled in central or departmental libraries, where they are available for immediate use. During a lecture or demonstration they can be used to illustrate the teacher’s argument or to enrich the students’ visual experience, without taking up too much time. Apparatus and methods are described which make the presence of a projectionist and the darkening of the room
minimum.
We are indebted to Mr. L. V. Hughes of the department of medical illustration, Guy’s Hospital, for building the apparatus. REFERENCES
Cardew, P. N. (1952) Health Education Journal, 10, 1, 21. Heyer, D. (1945) Automatic Projector (International Powermatic Corporation) U.S. patent no. 2568734.
SELECTION OF FUTURE DOCTORS LESSONS FROM THE PAST
P. W. NATHAN M.D. Lond., M.R.C.P. OF THE NEUROLOGICAL RESEARCH
UNIT,
HOSPITAL, QUEEN SQUARE,
THE
NATIONAL
LONDON
THE question of how to choose the most suitable students to become future doctors has, in the past few years, become more important and more difficult ; for the guardians of the entrances to our profession are today faced by a glut of young people eager to be doctors. Those who have to choose the best material from the large number of candidates probably rely on their ability to judge character. and on a picture in their mind’s eye of a perfect doctor, capable of being a general practitioner, a pathologist, surgeon, physician, biochemist, or medical officer of health. It may be helpful to the selectors of future doctors to examine the characteristics and personalities of doctors who, in the past, added lustre to our profession. Yet to investigate the characters of a hundred or more meritorious doctors who have recently died would be a formidable task ; and it might throw more light on the prejudices of the investigator than on the characteristics of the investigated. Some Characters from
Neurology
There has
lately been published in the United States a very interesting book called (L’he Founclers of Neurology, edited by Haymaker (1953). Here are set out 133 short biographies of those doctors who contributed to neurology, written by 84 of their living colleagues. All these 133 people were outstandingly successful in their chosen fields, and therefore, judging by results, they were all suitable candidates for admission to the medical pro-
408 fession. One wonders if each of them, presenting himself to a selection board today, would have been chosen for a place in a medical school. Rather than imagine an answer to this question, it may be rewarding to examine some of the characteristics of these successful contributors to medicine, to see if we can learn how to evaluate the eminent doctor of the future, when seen as a young man. It is clearly not the purpose of the selectors of medical students to find future neurologists ; indeed, I am ready to believe that the rest of my profession may not regard neurologists as typical doctors, or even as a desirable type. But my argument is that all these neurologists were outstanding men who added to knowledge, so they should have been admitted to medical schools when they presented themselves as unknown candidates. As these biographies are contributed by so many writers, a certain objectivity is gained ; for ’the prejudices of the various contributors to some extent cancel each other out. And many of the biographers come from the same country as their subjects ; so national antipathies tend to be eliminated. Of these 133 short biographies, 100 are of some use to us in assessing the personality of the subject; for in this 100 at least some features of character, personality, and habits are recounted. No doubt many interesting characteristics have been omitted from the 100 useful biographies : one writer, for instance, will record that his subject is irascible and good at drawing, whereas another will not mention these features, although they may be more developed in his subject than in the previous one. Owing to such inadequacies, any kind of statistical examination of the material would be meaningless : the data are inadequate. An
Imaginary Interview
If we now imagine a candidate with some of the characteristics of these famous neurologists presenting himself for admission to a medical school, what would the selector think of him Perhaps the first question put to him would be about his school career. There should be no need for the young man or women to try to conceal the fact that it was highly unsatisfactory ; for it was probably no worse than that of Cajal, Clarke (the neuroanatomist), von Monakow, Spielmeyer, or Weir Mitchell. The selector might have a bias in favour of the young man who has always wanted to be a doctor ; yet there is an impressive list of great neurologists who were not interested in medicine before they came to study it, and who started out on other careers at the university : Charcot, Marie, Claude Bernard, Vulpian, Purkinje, Liepmann, and several others. Literature was the original choice of Claude Bernard, Brown-Sequard, and Magnus. And the following not only wrote poetry, but had it published : Purkinje, Bechterev, Meynert, Foix, and Weir Mitchell. (Sherrington, of course, springs to mind ; but he is not included in the book, for he was still living when the list of subjects was compiled.) As the selector is likely to be thinking of future general practitioners, ready to face the dull realities of everyday life, he may not think of finding out if the young person before him is artistic or not ; but this was a prominent feature in the personalities of 16 of these neurologists, including Gowers, Charcot, and Cajal. In Britain, the selector is likely to want to know if the young man is good at games. If he is, he will be in the company- of Pavlov, Weir Mitchell, Wagner, von Jauregg, Argyll Robertson, Campbell, who made the first architectonic maps of the cortex, and many others. But our imaginary candidate may prefer more studious pursuits and he now thinks that he has blotted his copybook by not concealing his lack of enthusiasm for sport ; he tends to withdraw into his shell. The selector notices this, and thinks that it will never do to have a doctor who is reserved and retiring ; but these characteristics were mentioned prominently in the biographies of Brodmann,
Golgi, Claude Bernard, Friedreich, Erb, Wernicke, Hughlings Jackson, Berger, who discovered electroencephalography, and others. Indeed, Erb, Landouzy, Goltz, Hitzig, Brodmann, Flechsig, Meynert, and others are described as unfriendly, though it is to be admitted that in this respect they were definitely in a minority; most of these eminent neurologists lived an active social life. Meanwhile, the candidate has become embarrassed by the long silence, when the selector was remembering these facts about the eminent neurologists ; the selector observes this, and thinks that he must not choose as a future doctor someone who is so easily upset. But it is recorded that Hitzig, Mingazzini, and Remak were also
easily upset ; Wernicke, Mingazzini, Hitzig, Goltz, Remak, Meynert, Brodmann, Claude Bernard, and others were difficult to get on with ; and Erb, von Monakow, Brodmann, and Berger were all liable to To hide his embarrassment, the lose their tempers. now started blowing his own candidate has young trumpet ; he is obviously a conceited young man. So were Cajal, Hammond, Mingazzini, and Hitzig. Conceit, however, is unusual among eminent neurologists : 17 of the subjects of these biographies are described as being modest and lacking in all conceit. The atmosphere is now rather tense, so the selector turns to more general topics ; he is interested to note that the candidate is versatile, and has many interests outside medicine. But he may not know whether to favour this trait or not ; he should know that it was present in 16 of the famous neurologists. The conversation turns to music ; this turns out to be a passion of the young man’s ; and so it was of 15 of the neurologists. But, unfortunately the candidate’s views of what is good and what is bad in music are extremely dogmatic ; surely this will never do in a man who should have an objective scientific approach. Yet it did not hamper the careers of many of our neurologists. Now that the candidate has warmed up a little in giving his views on music, it becomes apparent that he is an impulsive young man ; surely impulsiveness is to be avoided in any kind of doctor ; one must look for an ability to weigh evidence coolly and to give a balanced judgment in all things. Yet impulsive " is used in describing von Monakow, Elsberg, who contributed largely to the surgery of the spinal cord, von Gudden, Remak, Mingazzini, Henschen, and BrownSequard. The young man now mentions politics. The selector feels he is on firm ground here : an interest in politics is deplorable. Yet twice as many of the neurologists were active in politics as were active in sport, and their names include those of Sir Victor H.orsley, Forel, Virchow, and Barany. The candidate now sees that he has spoilt his chance of entering a medical school and becoming a doctor ; he lets fall one or two sarcastic remarks ; here he is again in good company among famous neurologists, several of whom were said to be sarcastic. "
Energy is the Key
By now, may have come to the conclusion that it takes all sorts to make neurologists, and that probably the same applies to the rest of the profession. Is there, then, no single characteristic or trait, common to the majority of these successful men who laid the basis of neurology, which we should look for in the suitable candidate ? There is one characteristic which appears over and over again in these biographies and is far commoner than any other single feature : these men had an unusual amount of energy. They were capable of doing an exceptional amount of hard work ; and many of them spent a lot of energy in activities other than medicine. And so it might be suggested that somehow the examiner of young people who want to become doctors should try and find out if the candidate is full of energy or not. It is perhaps necessary to add, for an extroverted culture like ours, that this is not the same thing as we
409 for exuberance and joie de 1Jivre. A quiet girl living a very full life, looking after her invalid mother, coaching her fellow students to make some money, and learning German in her spare moments, because she had to do biology at school ; none of this information may be obtained in the interview. A young man may like to spend most of his time wandering in the country, and it is not readily discovered that he has acquired a great knowledge of bird-cries and the habits of badgers, and that he knows a lot about the geological basis of scenery ; yet much work and energy has gone into learning all this. Energy will be dealt with differently by different types : the more manic will scatter it over others will concentrate it on a wide field of interests ; one or two subjects. I suggest that it is more important to find out if the candidate commands a large supply of energy than if he is neurotic or not. The neurotic to be rejected is he whose energy is consumed in fruitless conflicts and who is too inhibited to be able to cope with the world around him. The neurotic who escapes from internal conflict into what is called reality, and the obsessional with a drive for work, these may be welcomed into the profession with open arms. It seems, then, that those selecting the doctors of the future should reject the candidate who is lazy, lacking in energy, and incapable of achievement in the world. How he finds this out is another question. lvheii he has rejected an obvious example of such a type, he may well learn later than this shut-in and asocial young man has become the chess champion of the world.
looking
may be
REFERENCE of
Haymaker, W. (1953) The Founders Ill.; see Lancet, 1953, ii, 763.
Neurology.
Springfield,
MEDICAL CARE OF STUDENTS BIRMINGHAM BATTERY OR MANCHESTER
QUESTIONNAIRE ? R. F. L. LOGAN M.D. Belf., M.R.C.P., D.I.H. PHYSICIAN IN CHARGE OF THE UNIVERSITY HEALTH MANCHESTER
SERVICE,
volunteers ; but treatment can be given only by the practitioners in the town, with whom the undergraduate is temporarily registered. Wales, Glasgow, Manchester, North Staffordshire, and probably in future the London School of Economics and St. Andrews, whilst advising the student to register with a local practitioner, also their own consultant and advisory services and run provide treatment-rooms staffed by nursing sisters. This arrangement is basically similar to the industrial medical services in large and progressive factories, and in fact two of the university medical officers are also part-time industrial medical officers. Sheffield, Bristol, Nottingham, Leeds, and Belfast largely oblige students who live away from home to register with the university medical officer as their temporary N.H.S. practitioner (as do most boardingschools ; but the reduced capitation fee of about 14s. is perhaps unfair in the case of universities). Edinburgh in 1929, and later Aberdeen, were the first universities to establish health services, and as pioneers gained valuable experience for the others to use after the war. Oxford and Birmingham began in 1946. Belfast, Bristol, Sheffield, and Cambridge followed. Leeds began in 1949, Liverpool in 1950, and Manchester in 1951. Whilst not so dependent on N.H.S. registrations and with a sick-bay (as have Leeds, Sheffield, and Birmingham also) the Scottish universities have other aspects similar to industrial medical services. University College, London, is uliique in that it was largely sponsored by the students themselves : six of the teaching staff and six students are the committee, but all officers except the treasurer are students. A student contributes 5s. each year (in contrast to the ;S5 often paid in the U.S.A.). They are the only ones in Britain to do so, but their organisation is really democratic. The type of service and medical care given, and the ratio of doctors employed, vary considerably between the universities ; so it does not follow that where the student medical officer is also the N.H.S. doctor to students in hall or in lodgings the service is less expensive to the university. In fact, with 11/2 doctors to 6000 students and staff in Manchester, the annual total cost is only 12s. per head. In contrast, despite the N.H.S. capitation fees in Leeds, Birmingham, Sheffield, Bristol, Aberdeen, and London, the cost may rise to 30s. per head. Much of this, however, is due to the varying requirements for medical examination by the university. For example, Belfast and Leeds make it compulsory for all freshmen to be medically examined, while Liverpool and Leeds require an annual chest X-ray examination. Again, some medical officers also supervise the health of nurses in the neighbouring teaching hospitals (as in Sheffield), which needs two or three full-time doctors for 2000 students and 700 nurses. It is thus seen that, although there is usually one doctor per 1000 students, there are variations in the ratio and in the scope of medical examination and care.
ALMOST every university in Britain has now a health These services, however, differ service for students. considerably in their organisation, which may depend on their history, or whether they were founded before or after the National Health Service in 1948, or how far the university is residential, or on the local customs. Not enough thought, perhaps, has been given to these differences. Perhaps, too, the minds of doctors, like the tools of craftsmen, contain their own resistance to the work they have to do. It therefore may be worth while, after glancing at some of the variations, to examine the medical needs of university students in Britain today and then see how these are already met by the N.I.S. Some Characteristics of a University Population and how the university services may fill any gaps. Since 1948, every student has been entitled to compreThe university population is highly selected by hensive medical care under the N.H.S. (including free intelligence and comprises less than 2% of its narrow dental treatment up to the age of 21). If the student has age-group in the community. This age-group, moreover, to live away from home in hall or in lodgings, he is entitled makes the lowest demands on the medical services. to register temporarily with a local general practitioner. Young people have the lowest rates for attendance at the In theory, therefore, in Durham and several of the surgeries of general practitioners (Pemberton 1949) or London colleges where there is still no student health as outpatients and inpatients of hospitals (Nuffield 1949), service, a sick student can obtain medical treatment and enjoy better health than those of any other age. from a general practitioner whose list lie joins. In 1951 Nevertheless they have the highest rate for appendicitis. Liverpool went a little further and engaged a part-time Furthermore, the chief cause of death of adolescents in consultant physician to supervise treatment in hospital Britain is still tuberculosis. Over half the deaths of as well as to examine the medical certincates which the adolescent girls are attributable to this cause, and for incoming freshmen bring from their family doctors (who both sexes 8 times as many die from respiratory tubercuare entitled to a fee of one guinea from the student for losis after leaving school as before. These rates, of course, this examination). are falling but they have not yet reached the same level The three doctors in Cambridge ask freshmen to fill as among American students, where accidents and cancer ina medical questionnaire, awl they also examine are the main causes of death and outnumber those of
drawing
on a
blackboard. SUMMARY
Most
schools would be a practical proposition—the more so as these films can be made entirely factual, and the absence of comment will make them easier to integrate into the programmes of different teachers. The formation of deparmental or central libraries containing such records can be carried out on a restricted budget, and the teacher will find his material near at hand and readv for immediate use without the present cumbersome procedure of having to order films from an outside source several days in advance. AUTOMATIC PROJECTION
unnecessary.
The mechanics of projection can present considerable difficulties. Whilst a piece of chalk and a rag are the only requirements for drawing on the blackboard, a darkened room, a projector, and a projectionist are needed for the showing of films, however short they may be. Attempts are therefore being made to devise means whereby screening can take place in a well-lit room and without a
projectionist.
_
One solution is the use of loop films and back projection with a time-switch. The accompanying figure shows a projector with a device which permits the repeated showing of a length of film whose beginning and end have been joined together. The machine is fixed at right angles to a hollow box which carries a translucent screen at one end and a surface silvered mirror, arranged at 45° to the longitudinal axis, at the other end. The images are projected through a small aperture on to the mirror which reflects them back on to the screen. A brilliant image results, mainly because it is seen by transmitted light. The apparatus can be made to start and stop automatically by operating a variable time switch which breaks the electric circuit after a pre-set time interval. The screen size can be varied in different models, from a television-set type for individual students at a demonstration or seminar, to a much larger one suitable for lecture audiences. This arrangement can be used in a variety of teaching situations : (1) During a formal lecture the speaker can press the switch and show his film for a pre-determined number of times without the presence of a projectionist and without having to darken the lecture-theatre. (2) In set demonstrations and in museums the apparatus can be operated by individual students, when they are ready to study thp film. They press the button, look at the screen, and return to other work when they have seen enough. The projector will switch itself off automatically and is immediately ready for the next student. (3) The same apparatus can be used for group
discussions. The model constructed at Guy’s Hospital has also been fitted with a soundproofing box which fits over the
projector,
so
that noise is reduced to
a
existing medical films are too long and too diffuse to be really useful for teaching. " Animated lanternslides "-that is, films up to three minutes in length demonstrating movements in clinical symptoms, natural phenomena, or experiments--can be designed to satisfy a specific need for a definite audience. Such short films are relatively inexpensive and can therefore be assembled in central or departmental libraries, where they are available for immediate use. During a lecture or demonstration they can be used to illustrate the teacher’s argument or to enrich the students’ visual experience, without taking up too much time. Apparatus and methods are described which make the presence of a projectionist and the darkening of the room
minimum.
We are indebted to Mr. L. V. Hughes of the department of medical illustration, Guy’s Hospital, for building the apparatus. REFERENCES
Cardew, P. N. (1952) Health Education Journal, 10, 1, 21. Heyer, D. (1945) Automatic Projector (International Powermatic Corporation) U.S. patent no. 2568734.
SELECTION OF FUTURE DOCTORS LESSONS FROM THE PAST
P. W. NATHAN M.D. Lond., M.R.C.P. OF THE NEUROLOGICAL RESEARCH
UNIT,
HOSPITAL, QUEEN SQUARE,
THE
NATIONAL
LONDON
THE question of how to choose the most suitable students to become future doctors has, in the past few years, become more important and more difficult ; for the guardians of the entrances to our profession are today faced by a glut of young people eager to be doctors. Those who have to choose the best material from the large number of candidates probably rely on their ability to judge character. and on a picture in their mind’s eye of a perfect doctor, capable of being a general practitioner, a pathologist, surgeon, physician, biochemist, or medical officer of health. It may be helpful to the selectors of future doctors to examine the characteristics and personalities of doctors who, in the past, added lustre to our profession. Yet to investigate the characters of a hundred or more meritorious doctors who have recently died would be a formidable task ; and it might throw more light on the prejudices of the investigator than on the characteristics of the investigated. Some Characters from
Neurology
There has
lately been published in the United States a very interesting book called (L’he Founclers of Neurology, edited by Haymaker (1953). Here are set out 133 short biographies of those doctors who contributed to neurology, written by 84 of their living colleagues. All these 133 people were outstandingly successful in their chosen fields, and therefore, judging by results, they were all suitable candidates for admission to the medical pro-
408 fession. One wonders if each of them, presenting himself to a selection board today, would have been chosen for a place in a medical school. Rather than imagine an answer to this question, it may be rewarding to examine some of the characteristics of these successful contributors to medicine, to see if we can learn how to evaluate the eminent doctor of the future, when seen as a young man. It is clearly not the purpose of the selectors of medical students to find future neurologists ; indeed, I am ready to believe that the rest of my profession may not regard neurologists as typical doctors, or even as a desirable type. But my argument is that all these neurologists were outstanding men who added to knowledge, so they should have been admitted to medical schools when they presented themselves as unknown candidates. As these biographies are contributed by so many writers, a certain objectivity is gained ; for ’the prejudices of the various contributors to some extent cancel each other out. And many of the biographers come from the same country as their subjects ; so national antipathies tend to be eliminated. Of these 133 short biographies, 100 are of some use to us in assessing the personality of the subject; for in this 100 at least some features of character, personality, and habits are recounted. No doubt many interesting characteristics have been omitted from the 100 useful biographies : one writer, for instance, will record that his subject is irascible and good at drawing, whereas another will not mention these features, although they may be more developed in his subject than in the previous one. Owing to such inadequacies, any kind of statistical examination of the material would be meaningless : the data are inadequate. An
Imaginary Interview
If we now imagine a candidate with some of the characteristics of these famous neurologists presenting himself for admission to a medical school, what would the selector think of him Perhaps the first question put to him would be about his school career. There should be no need for the young man or women to try to conceal the fact that it was highly unsatisfactory ; for it was probably no worse than that of Cajal, Clarke (the neuroanatomist), von Monakow, Spielmeyer, or Weir Mitchell. The selector might have a bias in favour of the young man who has always wanted to be a doctor ; yet there is an impressive list of great neurologists who were not interested in medicine before they came to study it, and who started out on other careers at the university : Charcot, Marie, Claude Bernard, Vulpian, Purkinje, Liepmann, and several others. Literature was the original choice of Claude Bernard, Brown-Sequard, and Magnus. And the following not only wrote poetry, but had it published : Purkinje, Bechterev, Meynert, Foix, and Weir Mitchell. (Sherrington, of course, springs to mind ; but he is not included in the book, for he was still living when the list of subjects was compiled.) As the selector is likely to be thinking of future general practitioners, ready to face the dull realities of everyday life, he may not think of finding out if the young person before him is artistic or not ; but this was a prominent feature in the personalities of 16 of these neurologists, including Gowers, Charcot, and Cajal. In Britain, the selector is likely to want to know if the young man is good at games. If he is, he will be in the company- of Pavlov, Weir Mitchell, Wagner, von Jauregg, Argyll Robertson, Campbell, who made the first architectonic maps of the cortex, and many others. But our imaginary candidate may prefer more studious pursuits and he now thinks that he has blotted his copybook by not concealing his lack of enthusiasm for sport ; he tends to withdraw into his shell. The selector notices this, and thinks that it will never do to have a doctor who is reserved and retiring ; but these characteristics were mentioned prominently in the biographies of Brodmann,
Golgi, Claude Bernard, Friedreich, Erb, Wernicke, Hughlings Jackson, Berger, who discovered electroencephalography, and others. Indeed, Erb, Landouzy, Goltz, Hitzig, Brodmann, Flechsig, Meynert, and others are described as unfriendly, though it is to be admitted that in this respect they were definitely in a minority; most of these eminent neurologists lived an active social life. Meanwhile, the candidate has become embarrassed by the long silence, when the selector was remembering these facts about the eminent neurologists ; the selector observes this, and thinks that he must not choose as a future doctor someone who is so easily upset. But it is recorded that Hitzig, Mingazzini, and Remak were also
easily upset ; Wernicke, Mingazzini, Hitzig, Goltz, Remak, Meynert, Brodmann, Claude Bernard, and others were difficult to get on with ; and Erb, von Monakow, Brodmann, and Berger were all liable to To hide his embarrassment, the lose their tempers. now started blowing his own candidate has young trumpet ; he is obviously a conceited young man. So were Cajal, Hammond, Mingazzini, and Hitzig. Conceit, however, is unusual among eminent neurologists : 17 of the subjects of these biographies are described as being modest and lacking in all conceit. The atmosphere is now rather tense, so the selector turns to more general topics ; he is interested to note that the candidate is versatile, and has many interests outside medicine. But he may not know whether to favour this trait or not ; he should know that it was present in 16 of the famous neurologists. The conversation turns to music ; this turns out to be a passion of the young man’s ; and so it was of 15 of the neurologists. But, unfortunately the candidate’s views of what is good and what is bad in music are extremely dogmatic ; surely this will never do in a man who should have an objective scientific approach. Yet it did not hamper the careers of many of our neurologists. Now that the candidate has warmed up a little in giving his views on music, it becomes apparent that he is an impulsive young man ; surely impulsiveness is to be avoided in any kind of doctor ; one must look for an ability to weigh evidence coolly and to give a balanced judgment in all things. Yet impulsive " is used in describing von Monakow, Elsberg, who contributed largely to the surgery of the spinal cord, von Gudden, Remak, Mingazzini, Henschen, and BrownSequard. The young man now mentions politics. The selector feels he is on firm ground here : an interest in politics is deplorable. Yet twice as many of the neurologists were active in politics as were active in sport, and their names include those of Sir Victor H.orsley, Forel, Virchow, and Barany. The candidate now sees that he has spoilt his chance of entering a medical school and becoming a doctor ; he lets fall one or two sarcastic remarks ; here he is again in good company among famous neurologists, several of whom were said to be sarcastic. "
Energy is the Key
By now, may have come to the conclusion that it takes all sorts to make neurologists, and that probably the same applies to the rest of the profession. Is there, then, no single characteristic or trait, common to the majority of these successful men who laid the basis of neurology, which we should look for in the suitable candidate ? There is one characteristic which appears over and over again in these biographies and is far commoner than any other single feature : these men had an unusual amount of energy. They were capable of doing an exceptional amount of hard work ; and many of them spent a lot of energy in activities other than medicine. And so it might be suggested that somehow the examiner of young people who want to become doctors should try and find out if the candidate is full of energy or not. It is perhaps necessary to add, for an extroverted culture like ours, that this is not the same thing as we
409 for exuberance and joie de 1Jivre. A quiet girl living a very full life, looking after her invalid mother, coaching her fellow students to make some money, and learning German in her spare moments, because she had to do biology at school ; none of this information may be obtained in the interview. A young man may like to spend most of his time wandering in the country, and it is not readily discovered that he has acquired a great knowledge of bird-cries and the habits of badgers, and that he knows a lot about the geological basis of scenery ; yet much work and energy has gone into learning all this. Energy will be dealt with differently by different types : the more manic will scatter it over others will concentrate it on a wide field of interests ; one or two subjects. I suggest that it is more important to find out if the candidate commands a large supply of energy than if he is neurotic or not. The neurotic to be rejected is he whose energy is consumed in fruitless conflicts and who is too inhibited to be able to cope with the world around him. The neurotic who escapes from internal conflict into what is called reality, and the obsessional with a drive for work, these may be welcomed into the profession with open arms. It seems, then, that those selecting the doctors of the future should reject the candidate who is lazy, lacking in energy, and incapable of achievement in the world. How he finds this out is another question. lvheii he has rejected an obvious example of such a type, he may well learn later than this shut-in and asocial young man has become the chess champion of the world.
looking
may be
REFERENCE of
Haymaker, W. (1953) The Founders Ill.; see Lancet, 1953, ii, 763.
Neurology.
Springfield,
MEDICAL CARE OF STUDENTS BIRMINGHAM BATTERY OR MANCHESTER
QUESTIONNAIRE ? R. F. L. LOGAN M.D. Belf., M.R.C.P., D.I.H. PHYSICIAN IN CHARGE OF THE UNIVERSITY HEALTH MANCHESTER
SERVICE,
volunteers ; but treatment can be given only by the practitioners in the town, with whom the undergraduate is temporarily registered. Wales, Glasgow, Manchester, North Staffordshire, and probably in future the London School of Economics and St. Andrews, whilst advising the student to register with a local practitioner, also their own consultant and advisory services and run provide treatment-rooms staffed by nursing sisters. This arrangement is basically similar to the industrial medical services in large and progressive factories, and in fact two of the university medical officers are also part-time industrial medical officers. Sheffield, Bristol, Nottingham, Leeds, and Belfast largely oblige students who live away from home to register with the university medical officer as their temporary N.H.S. practitioner (as do most boardingschools ; but the reduced capitation fee of about 14s. is perhaps unfair in the case of universities). Edinburgh in 1929, and later Aberdeen, were the first universities to establish health services, and as pioneers gained valuable experience for the others to use after the war. Oxford and Birmingham began in 1946. Belfast, Bristol, Sheffield, and Cambridge followed. Leeds began in 1949, Liverpool in 1950, and Manchester in 1951. Whilst not so dependent on N.H.S. registrations and with a sick-bay (as have Leeds, Sheffield, and Birmingham also) the Scottish universities have other aspects similar to industrial medical services. University College, London, is uliique in that it was largely sponsored by the students themselves : six of the teaching staff and six students are the committee, but all officers except the treasurer are students. A student contributes 5s. each year (in contrast to the ;S5 often paid in the U.S.A.). They are the only ones in Britain to do so, but their organisation is really democratic. The type of service and medical care given, and the ratio of doctors employed, vary considerably between the universities ; so it does not follow that where the student medical officer is also the N.H.S. doctor to students in hall or in lodgings the service is less expensive to the university. In fact, with 11/2 doctors to 6000 students and staff in Manchester, the annual total cost is only 12s. per head. In contrast, despite the N.H.S. capitation fees in Leeds, Birmingham, Sheffield, Bristol, Aberdeen, and London, the cost may rise to 30s. per head. Much of this, however, is due to the varying requirements for medical examination by the university. For example, Belfast and Leeds make it compulsory for all freshmen to be medically examined, while Liverpool and Leeds require an annual chest X-ray examination. Again, some medical officers also supervise the health of nurses in the neighbouring teaching hospitals (as in Sheffield), which needs two or three full-time doctors for 2000 students and 700 nurses. It is thus seen that, although there is usually one doctor per 1000 students, there are variations in the ratio and in the scope of medical examination and care.
ALMOST every university in Britain has now a health These services, however, differ service for students. considerably in their organisation, which may depend on their history, or whether they were founded before or after the National Health Service in 1948, or how far the university is residential, or on the local customs. Not enough thought, perhaps, has been given to these differences. Perhaps, too, the minds of doctors, like the tools of craftsmen, contain their own resistance to the work they have to do. It therefore may be worth while, after glancing at some of the variations, to examine the medical needs of university students in Britain today and then see how these are already met by the N.I.S. Some Characteristics of a University Population and how the university services may fill any gaps. Since 1948, every student has been entitled to compreThe university population is highly selected by hensive medical care under the N.H.S. (including free intelligence and comprises less than 2% of its narrow dental treatment up to the age of 21). If the student has age-group in the community. This age-group, moreover, to live away from home in hall or in lodgings, he is entitled makes the lowest demands on the medical services. to register temporarily with a local general practitioner. Young people have the lowest rates for attendance at the In theory, therefore, in Durham and several of the surgeries of general practitioners (Pemberton 1949) or London colleges where there is still no student health as outpatients and inpatients of hospitals (Nuffield 1949), service, a sick student can obtain medical treatment and enjoy better health than those of any other age. from a general practitioner whose list lie joins. In 1951 Nevertheless they have the highest rate for appendicitis. Liverpool went a little further and engaged a part-time Furthermore, the chief cause of death of adolescents in consultant physician to supervise treatment in hospital Britain is still tuberculosis. Over half the deaths of as well as to examine the medical certincates which the adolescent girls are attributable to this cause, and for incoming freshmen bring from their family doctors (who both sexes 8 times as many die from respiratory tubercuare entitled to a fee of one guinea from the student for losis after leaving school as before. These rates, of course, this examination). are falling but they have not yet reached the same level The three doctors in Cambridge ask freshmen to fill as among American students, where accidents and cancer ina medical questionnaire, awl they also examine are the main causes of death and outnumber those of