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SOCIAL MEDICINE IN THE UNIVERSITIES
1020 be disregarded." And Rapoport had said : " Truth emerges from conflict." Let us hope that it does. Meanwhile, if we feel any doubts about genes we can study the photographs illustrating Darlington’s recent article on genetic
particles.5
mediate examination of the Institute of Medical
Laboratory Technology (or equivalent qualification) or the Inter. B.so., salary to be increased by :í:13per annum at any point on the scale. If no examinations passed, salary to be increased to :í:312 at age 30. Technicians (who must hold
associateship of LM.L.T. or On gaining F.I.M.L.T. (or equivalent).—370-Elo-S435. equivalent) salary to be increased by n5 at any point on the
_________.
REMUNERATION OF MEDICAL LABORATORY TECHNICIANS
scale. Senior technician (who must hold F.I.M.L.T. or equivalent and be in charge of a laboratory or a separate department).L450-:í:20-:í:530. Chief technician (who must be in full charge of laboratory services, or a specialised laboratory of unusual size and importance or a central reference or research laboratory). —E530-E20-650. -
ON April 20 the appropriate technical council of the Whitley Councils for the Health Services agreed to the following salaries for medical laboratory technicians employed in the National Health Service in England,
Wales, and Scotland.
Student and junior ec/MMcaN.—From £ 110 at 16 years of age to E299 at 25 years and over. On passing the inter5.
Darlington, C.
D.
In the Metropolitan Police Area all scales will be to London weighting on the following basis: 16-20, JE10 ; 21-25, ;E20 ; 26 and over, je30.
subject
Endeavour, 1949, 8, 51.
other, and we may put these considering more carefully the which they give rise.
Reconstruction
issues in perspective by two lines of criticism to
SOCIAL MEDICINE IN THE UNIVERSITIES
THOMAS MCKEOWN M.D. Birm., D.Phil. Oxfd, Ph.D. McGill PROFESSOR OF SOCIAL MEDICINE IN THE UNIVERSITY OF BIRMINGHAM
Two conferences on social medicine were arranged at Oxford during April by the Nuffield Foundation, at the request of the medical subcommittee of the University Grants Committee, which " has had under consideration recently the provision made in medical schools for teaching and research in social medicine." No doubt it was the hope of its organisers, as well as of those attending, that the conferences would provide a statement of past achievement, or of plausible intention for the future, which would satisfy a critical observer that the provisions already made in the universities are justified and merit favourable consideration of their extension. Moreover, the answer which the request of the University Grants Committee invited will later have to be given to many other people who take the present claims for social medicine on trust and reserve judgment on its future. Though no direct answer emerged at Oxford, the conferences at least disposed of the confusion between two common grounds for criticism which in part explains the ambiguity of much of recent comment on this subject. It is necessary to remind ourselves that, for many years before the first chair of social medicine was established, far-sighted people had hoped to see an increased emphasis on social and preventive teaching in medicine. They had anticipated that a few clinical teachers would interest themselves, and that their interest would spread to their colleagues. To a limited extent this has happened, and American clinicians, such as Means in medicine at Harvard, and Harvey in surgery at Yale, are examples of such initiative which have their parallel in this country. We should recognise that this work proceeded in the orbit of clinical medicine, without assistance from departments of preventive or social medicine. The creation of whole-time departments of social medicine in several universities entirely changed the position. Naturally these departments inherited responsibility for public-health teaching, to which inevitably was added a special role in relation to the changed attitude to clinical teaching. But what we are now called on to consider is not only whether clinicians can reasonably be asked to extend the range of their interest but also the grounds upon which an appeal can be made to the universities for support for full-time departments. A satisfactory answer for the one will not do for the
TWO
CRITICISMS
The first is the criticism of the practising clinician, who considers that, however worthy the intentions of his colleagues, their preoccupation with the social background of illness is mistaken. He does not question that sometimes the social environment is related to the origin, development, or spread of illness, or that social complications may result from illness ; nor does he question that these matters are so important that someone must make it his business to deal with them. What he does question is the suggestion that it is his business, or that of a sufficient proportion of his students to justify its inclusion in his teaching. It is important to distinguish this criticism from the one which follows. The clinician who hesitates to raise the sights of his teaching is rarely passing a judgment on the claims of social medicine as an academic department. He is usually quick to admit that he does not know what these claims are, and modestly reserves judgment on them. The second criticism is that of the full-time university teacher. The laboratory and the clinical research workers agree that no academic department fulfills its obligations unless it contributes to research as well as to teaching. In their opinion, a subject which justifies the creation of chairs in many universities must demonstrate a field of inquiry with promise of a contribution to medical knowledge which will not suffer by comparison with physiology or medicine. It is in this light that they examine the claims of social medicine, and unlike the clinical teacher pass no judgment on its teaching. The first of these criticisms is entirely reasonable and fully merits a considered reply. But from the point of view of the full-time department it is the less serious of the two, and since it need not disturb the academic status of social medicine it will not be discussed here. To put the claim at its lowest, no-one questions that the traditional public-health course still has a place in teaching, though to many people its solid if undramatic achievement must recently appear to have taken on a great deal of water. Even if unchanged this course could reasonably be considered the teaching complement of a
development justified by
its fruitful research.
The second criticism is more serious and requires an immediate answer. It is difficult at this time for new departments, of which the oldest has been active for only a few years, to show the published results which would be the best vindication of their claims. None the less, it is entirely reasonable to expect them to provide
1021
intelligible statement of what they consider their terms of reference, and in brief such a statement follows : (1) The department of social medicine accepts responsibility
an
,
for the continuation of the preventive tradition in teaching, effectively established in a limited field by the earlier departments of public health, and for the initiative in its extension to clinical teaching. it is by no means sufficient justificaof full-time university departments. all, the existing part-time arrangements in public health, with the added interest of far-sighted clinicians in social and preventive teaching, would offer a solution which would easily compensate in economy for any loss in effectiveness.
as this is, (2) Important the creation
tion for If this were
(3)
The department of social medicine recognises that its claim to academic status requires a satisfactory answer to the question : Can it establish a field of medical research inadequately catered for and of sufficient importance to justify a new academic development ?
(4)
This field of research may be indicated as follows: (a) A vast number of medical problems, both curative and preventive, can be investigated only by large-scale inquiry. (b) The problems of collecting observations on large numbers of people have so little in common with experiments on large numbers of laboratory animals, or with observations on small numbers of patients, that a university department may profitably occupy itself with them. CATECHISM
Some
pertinent questions
may be raised and answered
follows :
as
Question..—What
reasons are
social medicine so defined medical knowledge ?
can
there for thinking that add conspicuously to
Answer.-Until now medicine has relied for its advance mainly on two sources : the laboratory, and the Research on man adds to the problems of bedside. variation which are common to the whole of biology the further difficulty that its material is not available for controlled experiment ; it therefore depends especially on research on large numbers. Of its two present sources, the experiments of the laboratory are often conclusive but not entirely relevant, and the observations at the bedside are quite relevant but rarely conclusive.
Q.-Is not this simply the application of statistics to medicine, and will not a well-trained professor of medicine
(for example) expect to use statistical methods in his investigations ? A.--Certainly. He also uses physiological methods, but there is still a place for a department of physiology concerned with the development of methods and with their application to problems beyond the resource, time, or
interest of the clinician.
Q.-Are such problems as tuberculosis, prematurity, incentives, and the human factor (all commonly discussed in relation to social medicine) those with which social medicine is mainly concerned ?z? A.-It will be evident that, as defined, social medicine is by no means limited to such issues, though they are among the more challenging with which its methods
promise advance ; but it would be premature, to say the least, to suggest that answers are readily available for all these, riddles, which havein common their great difficulty as well as their great importance. At present We are not even clear about the kind
of evidence needed for the solution of such problems, and a clarification of For this would be a first considerable contribution. this reason research in a new field is necessarily difficult, since it involves not only the collection of reliable data but also the definition of standards by which their validity may be judged.
Q.-Is
not the
A.-The some
of the
a better place the direction and execution of
public-health department
university for large-scale inquiry ?t
than the
public-health department has at its disposal important sources of raw data, and there is
every reason to encourage its staff to take an interest in field inquiry ; but it is certainly not the only source (the hospital, general practice, and industry are others), and the technical issues arising in the design and execution of these investigations will require more attention and training than the public-health officer can bring to them.
Q.-Is the work of the epidemiologist diseases
an
example
on the infectious of social medical research ?
A.-It is an excellent example, and the department of social medicine which does effective work on this subject calls for comment rather than criticism. The case for social medicine in the universities now rests on the assumption that similar inquiries may be extended fruitfully to other fields ; this view can scarcely be supported by further demonstrations of their effectiveness in epidemiology, which no-one questions.
Q.-Since the department of social medicine is concerned with observations on people, should not its staff be recruited from practising clinicians ? A.-It would be as unreasonable to deny a professor of social medicine the use of clinical methods as to deny a professor of surgery the use of a calculating machine ; but the professor of surgery who works mainly with a calculating machine is likely to persuade his faculty that it has appointed him to the wrong chair. In short, the professor of social medicine who proposes chiefly to exploit clinical methods would be more comfortable in a clinical department. His business, essentially, is to bring together the observations of many clinicians, to which on occasion he may find it useful to add his. ’
own.
then are the essential of social medicine’?
Q.—What
requirements
in
a
professor A.-Experience industrial hygiene,
of many years in public health, and clinical medicine would be most useful; it would also be practical if university teachers had four lives instead of one. In practice, until the new departments have had time to train staff specifically for this work, it will be difficult enough to make appointments if requirements are restricted to the
following : (1) An acquaintance with the standards of competent scientific work, acquired preferably in one of the fields of research. (2) An imaginative grasp of the possibilities of large-scale research in medicine, and some experience in the conduct of fleld inquiry. (3) Sufficient common sense to recognise that as his department will inherit responsibility for instruction in many subjects which his own experience does not include, he will require the support of a staff selected with an eye to his own deficiencies. Until universities have in sight candidates who at least satisfy these minimal requirements, they would do well to delay appointments to full-time chairs. They need not delay consideration of their arrangements for social and preventive teaching, and may be encouraged to realise that much
can be done through alternatives, intelligently adapted to local circumstances, which do not commit them prematurely to an ambitious adventure in a new department. It is equally important that they should recognise that the full-time department is not necessary for advance in teaching, and that
success
in
department.
teaching
will not alone
justify
a
full-time
particles.5
mediate examination of the Institute of Medical
Laboratory Technology (or equivalent qualification) or the Inter. B.so., salary to be increased by :í:13per annum at any point on the scale. If no examinations passed, salary to be increased to :í:312 at age 30. Technicians (who must hold
associateship of LM.L.T. or On gaining F.I.M.L.T. (or equivalent).—370-Elo-S435. equivalent) salary to be increased by n5 at any point on the
_________.
REMUNERATION OF MEDICAL LABORATORY TECHNICIANS
scale. Senior technician (who must hold F.I.M.L.T. or equivalent and be in charge of a laboratory or a separate department).L450-:í:20-:í:530. Chief technician (who must be in full charge of laboratory services, or a specialised laboratory of unusual size and importance or a central reference or research laboratory). —E530-E20-650. -
ON April 20 the appropriate technical council of the Whitley Councils for the Health Services agreed to the following salaries for medical laboratory technicians employed in the National Health Service in England,
Wales, and Scotland.
Student and junior ec/MMcaN.—From £ 110 at 16 years of age to E299 at 25 years and over. On passing the inter5.
Darlington, C.
D.
In the Metropolitan Police Area all scales will be to London weighting on the following basis: 16-20, JE10 ; 21-25, ;E20 ; 26 and over, je30.
subject
Endeavour, 1949, 8, 51.
other, and we may put these considering more carefully the which they give rise.
Reconstruction
issues in perspective by two lines of criticism to
SOCIAL MEDICINE IN THE UNIVERSITIES
THOMAS MCKEOWN M.D. Birm., D.Phil. Oxfd, Ph.D. McGill PROFESSOR OF SOCIAL MEDICINE IN THE UNIVERSITY OF BIRMINGHAM
Two conferences on social medicine were arranged at Oxford during April by the Nuffield Foundation, at the request of the medical subcommittee of the University Grants Committee, which " has had under consideration recently the provision made in medical schools for teaching and research in social medicine." No doubt it was the hope of its organisers, as well as of those attending, that the conferences would provide a statement of past achievement, or of plausible intention for the future, which would satisfy a critical observer that the provisions already made in the universities are justified and merit favourable consideration of their extension. Moreover, the answer which the request of the University Grants Committee invited will later have to be given to many other people who take the present claims for social medicine on trust and reserve judgment on its future. Though no direct answer emerged at Oxford, the conferences at least disposed of the confusion between two common grounds for criticism which in part explains the ambiguity of much of recent comment on this subject. It is necessary to remind ourselves that, for many years before the first chair of social medicine was established, far-sighted people had hoped to see an increased emphasis on social and preventive teaching in medicine. They had anticipated that a few clinical teachers would interest themselves, and that their interest would spread to their colleagues. To a limited extent this has happened, and American clinicians, such as Means in medicine at Harvard, and Harvey in surgery at Yale, are examples of such initiative which have their parallel in this country. We should recognise that this work proceeded in the orbit of clinical medicine, without assistance from departments of preventive or social medicine. The creation of whole-time departments of social medicine in several universities entirely changed the position. Naturally these departments inherited responsibility for public-health teaching, to which inevitably was added a special role in relation to the changed attitude to clinical teaching. But what we are now called on to consider is not only whether clinicians can reasonably be asked to extend the range of their interest but also the grounds upon which an appeal can be made to the universities for support for full-time departments. A satisfactory answer for the one will not do for the
TWO
CRITICISMS
The first is the criticism of the practising clinician, who considers that, however worthy the intentions of his colleagues, their preoccupation with the social background of illness is mistaken. He does not question that sometimes the social environment is related to the origin, development, or spread of illness, or that social complications may result from illness ; nor does he question that these matters are so important that someone must make it his business to deal with them. What he does question is the suggestion that it is his business, or that of a sufficient proportion of his students to justify its inclusion in his teaching. It is important to distinguish this criticism from the one which follows. The clinician who hesitates to raise the sights of his teaching is rarely passing a judgment on the claims of social medicine as an academic department. He is usually quick to admit that he does not know what these claims are, and modestly reserves judgment on them. The second criticism is that of the full-time university teacher. The laboratory and the clinical research workers agree that no academic department fulfills its obligations unless it contributes to research as well as to teaching. In their opinion, a subject which justifies the creation of chairs in many universities must demonstrate a field of inquiry with promise of a contribution to medical knowledge which will not suffer by comparison with physiology or medicine. It is in this light that they examine the claims of social medicine, and unlike the clinical teacher pass no judgment on its teaching. The first of these criticisms is entirely reasonable and fully merits a considered reply. But from the point of view of the full-time department it is the less serious of the two, and since it need not disturb the academic status of social medicine it will not be discussed here. To put the claim at its lowest, no-one questions that the traditional public-health course still has a place in teaching, though to many people its solid if undramatic achievement must recently appear to have taken on a great deal of water. Even if unchanged this course could reasonably be considered the teaching complement of a
development justified by
its fruitful research.
The second criticism is more serious and requires an immediate answer. It is difficult at this time for new departments, of which the oldest has been active for only a few years, to show the published results which would be the best vindication of their claims. None the less, it is entirely reasonable to expect them to provide
1021
intelligible statement of what they consider their terms of reference, and in brief such a statement follows : (1) The department of social medicine accepts responsibility
an
,
for the continuation of the preventive tradition in teaching, effectively established in a limited field by the earlier departments of public health, and for the initiative in its extension to clinical teaching. it is by no means sufficient justificaof full-time university departments. all, the existing part-time arrangements in public health, with the added interest of far-sighted clinicians in social and preventive teaching, would offer a solution which would easily compensate in economy for any loss in effectiveness.
as this is, (2) Important the creation
tion for If this were
(3)
The department of social medicine recognises that its claim to academic status requires a satisfactory answer to the question : Can it establish a field of medical research inadequately catered for and of sufficient importance to justify a new academic development ?
(4)
This field of research may be indicated as follows: (a) A vast number of medical problems, both curative and preventive, can be investigated only by large-scale inquiry. (b) The problems of collecting observations on large numbers of people have so little in common with experiments on large numbers of laboratory animals, or with observations on small numbers of patients, that a university department may profitably occupy itself with them. CATECHISM
Some
pertinent questions
may be raised and answered
follows :
as
Question..—What
reasons are
social medicine so defined medical knowledge ?
can
there for thinking that add conspicuously to
Answer.-Until now medicine has relied for its advance mainly on two sources : the laboratory, and the Research on man adds to the problems of bedside. variation which are common to the whole of biology the further difficulty that its material is not available for controlled experiment ; it therefore depends especially on research on large numbers. Of its two present sources, the experiments of the laboratory are often conclusive but not entirely relevant, and the observations at the bedside are quite relevant but rarely conclusive.
Q.-Is not this simply the application of statistics to medicine, and will not a well-trained professor of medicine
(for example) expect to use statistical methods in his investigations ? A.--Certainly. He also uses physiological methods, but there is still a place for a department of physiology concerned with the development of methods and with their application to problems beyond the resource, time, or
interest of the clinician.
Q.-Are such problems as tuberculosis, prematurity, incentives, and the human factor (all commonly discussed in relation to social medicine) those with which social medicine is mainly concerned ?z? A.-It will be evident that, as defined, social medicine is by no means limited to such issues, though they are among the more challenging with which its methods
promise advance ; but it would be premature, to say the least, to suggest that answers are readily available for all these, riddles, which havein common their great difficulty as well as their great importance. At present We are not even clear about the kind
of evidence needed for the solution of such problems, and a clarification of For this would be a first considerable contribution. this reason research in a new field is necessarily difficult, since it involves not only the collection of reliable data but also the definition of standards by which their validity may be judged.
Q.-Is
not the
A.-The some
of the
a better place the direction and execution of
public-health department
university for large-scale inquiry ?t
than the
public-health department has at its disposal important sources of raw data, and there is
every reason to encourage its staff to take an interest in field inquiry ; but it is certainly not the only source (the hospital, general practice, and industry are others), and the technical issues arising in the design and execution of these investigations will require more attention and training than the public-health officer can bring to them.
Q.-Is the work of the epidemiologist diseases
an
example
on the infectious of social medical research ?
A.-It is an excellent example, and the department of social medicine which does effective work on this subject calls for comment rather than criticism. The case for social medicine in the universities now rests on the assumption that similar inquiries may be extended fruitfully to other fields ; this view can scarcely be supported by further demonstrations of their effectiveness in epidemiology, which no-one questions.
Q.-Since the department of social medicine is concerned with observations on people, should not its staff be recruited from practising clinicians ? A.-It would be as unreasonable to deny a professor of social medicine the use of clinical methods as to deny a professor of surgery the use of a calculating machine ; but the professor of surgery who works mainly with a calculating machine is likely to persuade his faculty that it has appointed him to the wrong chair. In short, the professor of social medicine who proposes chiefly to exploit clinical methods would be more comfortable in a clinical department. His business, essentially, is to bring together the observations of many clinicians, to which on occasion he may find it useful to add his. ’
own.
then are the essential of social medicine’?
Q.—What
requirements
in
a
professor A.-Experience industrial hygiene,
of many years in public health, and clinical medicine would be most useful; it would also be practical if university teachers had four lives instead of one. In practice, until the new departments have had time to train staff specifically for this work, it will be difficult enough to make appointments if requirements are restricted to the
following : (1) An acquaintance with the standards of competent scientific work, acquired preferably in one of the fields of research. (2) An imaginative grasp of the possibilities of large-scale research in medicine, and some experience in the conduct of fleld inquiry. (3) Sufficient common sense to recognise that as his department will inherit responsibility for instruction in many subjects which his own experience does not include, he will require the support of a staff selected with an eye to his own deficiencies. Until universities have in sight candidates who at least satisfy these minimal requirements, they would do well to delay appointments to full-time chairs. They need not delay consideration of their arrangements for social and preventive teaching, and may be encouraged to realise that much
can be done through alternatives, intelligently adapted to local circumstances, which do not commit them prematurely to an ambitious adventure in a new department. It is equally important that they should recognise that the full-time department is not necessary for advance in teaching, and that
success
in
department.
teaching
will not alone
justify
a
full-time