Surgeons and HIV infection

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Surgeons and HIV infection SIR,-During operations even the best surgeons occasionally cut or puncture themselves or their assistants. If the patient is HIVpositive the surgeon may become infected through such wounds. If the surgeon knows before the operation that the patient has HIV antibodies, he might well be more careful. Some surgeons are therefore unhappy about the 1988 General Medical Council guidance on HIV testing, which restricts testing without express

all rather embarrassing. My second piece was concerned with the health hazards of British beaches. Not only was I invited to lecture on the subject, but also I received a largish correspondence on sewage outfalls. Of course my experience may be unique, but in future I shall think very carefully before I agree to write another signed editorial. Department of Microbiology, St Thomas’ Hospital, London SE1 7EH, UK

SUSANNAH J. EYKYN

consent.

In your note (May 19, p 1211) you say that the Royal College of Surgeons of Edinburgh is aware of surgeons’ responsibilities not only to their patients but also to their colleagues, their families, and themselves. Because of this responsibility the surgeons would have preferred that all patients suspected of being infected with HIV

should

consent to a test.

I can well understand this attitude. There is, however, one additional step that would also prevent infection with HIV. This is HIV testing of all surgeons-for example, once a year. When an HIV-positive surgeon cuts a finger while it is in the patient’s wound, he might very well pass on the virus. The prevalence of HIV in surgeons is not known, but it is probably not less than in the general population. Apart from the risk of contracting HIV while operating, some surgeons will necessarily be high-risk individuals because of sexual promiscuity, use of drugs, or intimacy with friends who are

drug users. If the RCSE demands that all members submit themselves

to

regular HIV testing it would be much easier to recommend compulsory HIV testing of all patients before surgery. Rikshospitalet, PER STAVEM

Oslo, Norway

SIR,—The General Medical Council’s attitude towards testing for AIDS illustrates the dangers of a professional body having statutory, even arbitrary powers. The GMC is now, reluctantly and only under irresistible pressure from various respected medical bodies, emerging into reality, although it remains shackled to the view that the psychological and social interests of the patient should take precedence over the public interest, including the welfare and safety of health professionals and their families. According to your May 19 note "... The new RCSE [Royal College of Surgeons of Edinburgh] guidelines state that if a patient is suspected of being infected with HIV he or she should be asked to consent to a test". Unlike the GMC, the RCSE is not a statutory body, so where does this leave us? Is the GMC then not infallible? By what criteria should one suspect a person of being infected? AIDS is on the increase, and what point must we reach before every patient is tested as I believe is increasingly the case in hospitals in the USA? I wonder also what are the medicolegal implications of a health worker’s being accidentally infected by an unsuspected carrier. It is debatable whether, to most people, routine testing for everyone having a surgical procedure is more offensive than the implied suggestion that the patient or his or her partner look the type to acquire AIDS. The GMC’s duty is to the larger public not to the minority. 20 Hocroft Avenue, London NW2 2EH, UK

Ethics of healthy subjects in nuclear

medicine SIR,-In quantitative nuclear medicine abnormality has to be gauged against the established normal range. This poses difficulties. The dose of radiation used in testing has a small but finite risk, and it can be argued that this is not ethically acceptable for healthy subjects being examined solely to establish a normal reference range.1 Nuclear medicine departments are faced with the need to reappraise their normal ranges when technology, techniques, or radiopharmaceuticals change. If they cannot examine healthy subjects, they have to look for alternative laboratory methods to establish normality. We encountered such difficulties when we replaced our gamma camera and computer, and we asked others what they did under these circumstances. Our survey of fourteen nuclear medicine departments in the UK showed that five relied on published data from other laboratories; five used age-matched patients who had had the test under consideration and had been shown by other investigations to be "normal" (two had ethical approval); eight used symptom-free age-matched subjects (all with ethical approval); six used healthy volunteers (five with ethical approval); and one used staff. All fourteen believed there was value in the use of a simulator or "phantom" but none did so. Thus the approach for establishing normal ranges in nuclear medicine varies between and even within hospitals. Perhaps surprisingly ethical committees are still willing to approve the investigation of healthy volunteers, but with recent publicity on radiation topics this may not be the case for long and it may prove difficult to obtain informed consent from such subjects. The extrapolation from published data is of doubtful validity and the use of age-matched healthy controls is dubious. Although an initial normal series would still need to be examined, there seems to be a case for the use of phantoms, and we recommend that this approach should be explored and organised on a national basis (by the Department of Health and the Scottish Home and Health Department or possibly by the British Nuclear Medicine Society). There would be two clear benefits-improved quality assurance and a reduction in the number of healthy subjects required to be examined in order to establish a new technique. R. RAILTON C. J. HOSIE J. C. RODGER

Medical Physics Department and Medical Unit, Monklands District General Hospital,

Airdrie ML6 0JS, UK J, Sumner D. Irradiation of normal volunteers Med 1989; 30: 2062-63.

1. Paterson

m

Nucl

ALAN GILSTON

Consumer, customer, client,

Signed editorials otherwise of signed editorials have recently been aired in your columns (Dr McManus, April 14, p 916; Dr Stredder, May 12, p 1163); one result of declaring one’s identity has not been mentioned-that of subsequent requests to lecture on the subject of the piece. Organisers of postgraduate lectures are always trawling for "experts" to fill their schedules and a quick scan of signed editorials in the major general journals provides a ready

SIR,—The merits

nuclear medicine. J

or

source. Beware he or she who signs; you will be amazed at how popular you have become. My experience (albeit with a rival weekly journal) may be of interest. My first offering addressed the toxic shock syndrome. At the time I wrote the editorial I had never seen a case (and still have only seen one). Gynaecologists were quick to invite me to enlighten them on this fascinating "new" disease. It was

or

patient

SIR,-In the UK patients

are increasingly recognised to be clients. We felt that such consumers’ views about this redesignation should be sought. 100 people under hospital care were asked to answer anonymously the question: Did they wish to be called consumers, customers, clients, or patients? 48 men replied,

customers or

(age range 25-91 years, mean 48); 43 were English, 2 Gujarati, 2 German, and 1 Punjabi. Of the 52 women (age range 21-87, mean 58), 48 were English, 3 Gujarati, and 1 Egyptian. Women were but the English/non-English case mix older than men (p<0-01), was similar. 96 wished still to be called patients; 2 women and 1 man thought of themselves as customers, and 1 woman wished to be known as a client. Health service jargon in the 1990s has become that of the commercial world. Success in that area means the satisfaction of