- Email: [email protected]
TEACHING IN NON-TEACHING HOSPITALS
311
psychiatry, education, and some chaps have even got going on politics. It may be a grandiose delusion, but it seems inescapable to me that, as new knowledge is gained, psychiatric and psychological influence will become very widespread and important indeed. Already, it’s a stimulating line, and often very rewarding in many ways. I don’t think the divisions are nearly as deep as the clash of ambitions and personalities often makes them seem, and I believe that before long you will come to accept a surprising incursion of psychiatric activity around diseases you still regard as "organic". Much of it certainly sounds very funny
somatically tuned ears, but at least we are trying (see how that " we keeps slipping out) to push understanding one stage further back. After all, what do you really know about the causes of essential hypertension and ulcerative colitis ? The Physicians and the Psychiatrists are peering at each other across the Hypothalamus; before long they will be shaking hands there. I’m afraid it still seems to be de rigueur round the General Hospitals to make light of our contributions and to
"
PHYSICIAN TO THE COVENTRY GROUP OF HOSPITALS
WHEN he leaves a teaching hospital to join the consultant staff of a " non-teaching hospital ", the senior registrar may think that his teaching days are over and that he will lose the stimulus of regular contact with students. In his new environment, however, he will soon discover that he is a perpetual teacher, or at least may be if he so desires. POSTGRADUATES
Advances in medicine have brought more work for residents, and the physician’s or surgeon’s complement has been increased to a houseman and a registrar (or senior house-officer) instead of a houseman only (or perhaps nobody). In small hospitals registrars still do not abound; but commonly the consultant will have both a recently qualified house-officer, who is seeing a new and often more representative type of hospital practice, and a registrar who is aspiring to a higher qualification or diploma. While he can learn much from these pupils, they can learn more from his years of experience. Every round can be a teaching round, without the boredom of explaining elementary facts to the undergraduate. It is a mutual-benefit society where all contribute-including the ward sister or staff-nurse. In the hospital group in which I work, there are two other types of postgraduate activity. One is a monthly visit from the university professor, the other an aftertea demonstration of interesting cases organised by a senior resident. The professor sees three or four cases, usually with unusual and perhaps perplexing symptoms; or maybe something of which the consultant dreams, such as hypercholesterolasmia " " or chronic meningococcal septicaEmia. Debunking is his prerogative; but some of the patients, to use his own words, These rounds
diagnosed.
not
I remember a long time ago, before I joined this fraternity, I taunted an elderly psychiatrist with the unworthy remark that in his field he understood little and could do less. " May be," he admitted graciously, " but I think we do about as much good as anyone else." He was very right. With all
hitherto reported are
good wishes, Your affectionate nephew, RICHARD COBBLEIGH.
physicians, who have to work hard to pleasure has been enhanced by the professor’s being joined on occasions by other notables, such as the president of the Royal College of Physicians or of the Association of Physicians, the regius professor of physic at Cambridge, and a visiting professor from Boston. With such talent, it is usual to produce at least one patient with a disease
R. E. SMITH M.A., M.B. Cantab., F.R.C.P.
in the disease he has
too rare.
the local
present their
TEACHING IN NON-TEACHING HOSPITALS
"
subjects
enjoyed by
Medical Education
" develop interesting complications
look upon us as a therapeutic last hope if not indeed as for uninhibited mirth. Too many of our patients seem to be sent only when every ketosteroid has been checked and re-checked, radio-opaque material inserted into every conceivable tissue, and almost every expendable organ excised. These words come more from sorrow than anger, and I must add my whisper to the plea for a bit more undergraduate instruction. I reckon it’s the general men that matter most in teaching hospitals, and those with a real appreciation of psychological factors are still to
really
cases.
The
of the system on which the visitor is an expert. The after-tea demonstration always produces some surprises and always evokes a good discussion. Cases are demonstrated by the residents or the consultant and postmortem specimens and cases shown a second time often afford salutary
discipline. I have said education is a
enough, perhaps, to show that postgraduate major activity of " non-teaching hospitals. "
THE
FAMILY
DOCTOR
In the past four years, we have had three refresher for general practitioners. We had little idea what the demand would be, but applications for each succeeding course have increased.’,’ It has been said that a clinical lecture should be exhilarating and exhausting. So is a clinical demonstration. A recent course showed that only the seasoned lecturer can go on for more than an hour. Our courses have always been eleven sessions of 21/2 hours with a break of 15-20 minutes for tea in the afternoon, or coffee in the morning. About twenty subjects must be selected. One or two occupy the whole morning or aftercourses
With the help of our patients an expert in gastroenterology or in chest surgery can interest his audience for the whole session; but the local specialists are content with an hour, and if they deal with two aspects of their branch of medicine, they prefer two separate days. All aspects of medicine and surgery are considered but the emphasis is on medical problems. noon.
It is sine-qua-non that all is designed to help the general practitioner in his daily work. Recent advances such as the sulphonamide treatment of diabetics, the use of steroids in the management of haemolytic disease, and the great advances in the treatment of neonatal deformities are examples of the subjects that the general practitioner likes. Certainly one does not want to be too abstruse and too scientific, but it is a worse mistake to suppose that one should talk down to general practitioners. There is much to be learnt about organisation and
method.
312 One of the earliest experiments in postgraduate education undertaken in Edinburgh in 1953, when the course was held on Sunday mornings. Questionnaires at the end suggested that this was the most convenient day and our experience is the same. We have had one course in which people were invited fortnightly on Sunday morning and fortnightly on Thursday afternoons; and the Sunday attendance averaged 24 against 18 on Thursdays. We have tried to have courses in the middle of the week because most doctors take their halfdays then; and it is surprising to me that general practitioners are so often willing to sacrifice their leisure to attend them. was
TEACHING
NURSES
The General Nursing Council holds that lectures on clinical subjects wherever possible be given by doctors, and this is almost always done. Nurses are taught anatomy .and
physiology
on a
theoretical basis because
practical
To classes in medical subjects cannot be arranged. add to the nurse’s difficulties, she has often had no basic training in chemistry, physics, or perhaps in biology. Yet despite all handicaps, nurses are eager to learn the principles of medicine and surgery and of the specialties. Because of these limitations, those who teach nurses should take care to make themselves clear, concise, and factual. Nurses
demonstrations, and some patients are very willing to return thanks to the hospital by coming annually. A mitral stenotic, formerly bedridden, fibrillating, and scattering emboli, will tell nurses how after her operation she returned to work; and a patient with Addison’s disease will relate her improvement after being given salt and deoxycortone but will rise to say that, after a week with cortisone, she told her daily woman that she would not require her any more. Bloodfilms, temperature charts, and photographs all help. Anyone who thinks that he can just walk into a nurses’ lecture-room and speak for an hour should do two things. Firstly, he should take note of his audience at the end, when
appreciate
clinical
he does take preliminary trouble and when he does not, and compare the alertness with the yawns. Secondly, he should He will then find that correct nurses’ examination papers. nurses who have been taught well have a very high standard; and let me say that this reflects much more credit on the sistertutors than on the doctors giving lectures.
Many people think that we are training nurses now on far too scientific a basis. I do not belong to that school; I cannot see how modern medicine and modern nursing can be carried on unless the people practising it understand the reasons. Furthermore, if we are to make nurses good observers, they must know what to look for. In other words, the medical and nursing professions are allies, each with responsibilities; and I, for one, think that the time will come when we shall organise postgraduate training for nurses, which to my mind is grossly neglected. I cannot understand why in one branch of nursing-midwifery-there should be a special course and a special diploma, which carries great weight when nurses are applying for senior posts, whereas in general medicine or general surgery there is The time is no such diploma for the postgraduate nurse.
probably not far distant when children will have the benefit of being nursed by those who have had a special training in paediatrics. If ever a scheme for postgraduate education in general. medicine and surgery evolves, it will probably be started by some enlightened matron, who realises that what is sauce for the midwife is sauce for all other staff nurses and embryonic sisters. MEDICAL
AUXILIARIES
Besides hospitals connected with a university, there a few which have been made responsible for the students of professions ancillary to medicine. In our group, we have schools for orthoptists and for radiographers. The training of radiographers, much of it
are
lasts about 21/2 years. The the lectures (which number about sultants the other half.
practical,
UNDERGRADUATE
physicist gives half 100) and the con-
STUDENTS
From what has been said, it is evident that in the nonteaching hospital one teaches almost every type of student except undergraduates; and even this exception is a little doubtful. For several years we have had applications from students at teaching hospitals, who have been advised to go and get experience elsewhere. In hospitals where the houseman takes a holiday doing his 6 months’ residence, a student working under supervision, may temporarily take his place; but for most of his 2-3 months’ stay he is acting as a clinical clerk-
taking histories, making examinations, taking blood, and, under his senior’s eye, doing perhaps his first lumbar puncture or pleural tap. Sometimes these students go to a particular hospital because it is near their home. But then they may tell their friends about it; and so the tradition grows up that it is a good place to go to.
In our group, the only consultant who has students sent him from the university is the obstetrician and gynaecologist, who is recognised as a clinical tutor. Two students go to him regularly, and they get infinitely more experience than they would in their teaching hospital. To come to us is much simpler and cheaper for them than going to faraway Dublin, as was formerly done by so many students from the London hospitals; and, just as postgraduate training of nurses in midwifery sets an example for postgraduate training of nurses in other medical specialties, so I think that this training of gynaecological students points the way to a better training of students in other branches of medicine-particularly in general medicine, which will probably always remain the basis of medical education.
In the teaching hospitals, in a clinical course of about 3 years, a student spends only 6 months in general medical clerking, and sometimes with only one group of physicians. The objection to sending him out into neighbouring hospitals within the region is that he misses lectures, which are often designed to complete his formal training. But on balance, he would probably learn more in 3 months’ clerking to a general physician in a large peripheral hospital where the clinical material is abundant and interesting, besides giving a better idea of the commoner diseases. Moreover, a steadily increasing proof portion physicians in these hospitals have served a teaching apprenticeship as registrars in teaching hospitals. MEDICAL
SOCIETIES
Medical societies are on the increase, and the temptation is to join too many. To be a member of the local medical society is a privilege and responsibility. It brings one in contact with one’s fellows in the same town; but the consultant usually contributes more than the general practitioner and is often asked to go to other towns. Then there are the regional societies, and my experience of these is of growing prosperity. The East Midlands Association of Physicians is the oldest and carries on at a steady tempo. The West Midlands Association of Physicians is only 7 years old and often has to refuse communications. Although the audience might resent the suggestion that it is being taught, and the speaker that he is teaching, in fact that is what is happening, and most people come away saying that they have learnt much. Furthermore, the man who has to present a paper at any of these meetings learns much himself.
313 TEACHING
ONESELF
There are so many ways of teaching onself that it is difficult to know what to single out. Regular reading of the journals is essential, although very often the summary of an article suffices to tell one if there is anything new in it. Attendance at medical meetings serves two purposes -the advancement of knowledge and the promotion of friendship; and certainly it is much easier to read articles if one knows the authors of them. Perhaps the consultant learns most by pursuing one particular subject, as he has to do if he is writing a paper. Some regional boards are
Public Health THE WORK OF W.H.O. THE record1 of the activities of the World Health Organisation in 1956 gives a vivid picture of the remarkable scope of the Organisation’s work and the magnificent results that are being achieved. CONTROL OF INFECTIOUS DISEASES
Mass
campaigns against leprosy with sulphone drugs have reduced the need for long and expensive hospital treatment and lifelong segregation in leprosaria. Much attention is being paid to finding an effective long-acting drug. In Nigeria treatment is based on temporary segregation and outpatient supervision by both fixed and mobile units responsible for the oral administration of the drug, whereas in French territories mass treatment consists of a fortnightly injection of an oily suspension of dapsone-a scheme easily adaptable to rural areas. Of the 150,000 leprosy patients in French
Equatorial Africa, 100,000 are now under regular treatment; and a similar project has been initiated with the Government of French West Africa, where the number of patients is estimated to be 500,000. Case-finding by examination of contacts and health education of the public to dispel centuriesold fear follow the lines of campaigns against tuberculosis and
treponematosis. Spectacular results have been achieved against the disfiguring yaws. By the end of 1956 more than 55 million people had been examined and 16 million treated with long-acting penicillin in W.H.O./UNICEF-assisted campaigns. Serious reactions to procainebenzylpenicillin in oil with aluminium monostearate have been reported from urban areas and have directed research towards new preparations which may be free from side-effects; but it is interesting to learn that little evidence of reactions has come from underdeveloped rural areas, children not previously exposed to antibiotics being particularly free from trouble. The splendid results after only one injection are a little-known triumph of penicillin and a tribute to those in UNICEF and W.H.O. who have organised such rewarding campaigns against treponematosis. Some thirty national and other laboratories all over the world are now helping in the search for a practicable method of serum diagnosis in the treponematoses. Mass treatment of trachoma has for long been difficult because of the need for repeated daily application of antibiotics to the eye and the strict control of personal and domestic hygiene. In North Africa much of the treatment is now left to teachers and schoolchildren who have been instructed in the common rules of cleanliness and in the application of antibiotic ointment to the eyes of their schoolmates. The W.H.O. report has impressive photographs to illustrate this promising scheme. The attack on malaria has continued over vast areas of the globe, and the report’s comprehensive maps show the extent 1. Annual
Report for 1956 of the Director-General of W.H.O. Official Records of the World Health Organisation, no. 75, March, 1957. Obtainable from H.M. Stationery Office, P.O. Box 569, London, S.E.1. 10s.
liberal in giving study leave, which is another way of saying that they know that the consultant is still a student. Travelling clubs, visits abroad, visits from others of one’s own standing, or perhaps visits from professorsall help to widen one’s interests and advance one’s knowledge. Some people will get most from preparing a paper; others from watching or listening. But all will notice that in their teaching they introduce things that they have learnt elsewhere, and they will find increasingly that, as J. H. Sheldon said, work in a nonteaching hospital can be fully satisfying. of eradication already achieved and where campaigns are still in progress. A new project has begun in Mexico, where it is estimated that there are 2 million cases a year, and where districts potentially the richest in agriculture, livestock, fisheries, petroleum, and sulphur mining are the worst affected. UNICEF is sending supplies and equipment worth nearly S8’/a million, the Mexican Government is investing more than $12 million, and W.H.O. has awarded fellowships to train more than 1300 specialists. Wherever possible W.H.O. malaria teams are now testing the susceptibility of local vectors to different insecticides. Where anopheles has become resistant to dicophane (D.D.T.) it can often still be controlled by gammexane (B.H.c.), but some strains are resistant to both. Another method of malaria control is the distribution for human consumption of table salt containing pyrimethamine or chloroquine. The first results in volunteers inoculated with malaria have been encouraging. An interesting sideline of malaria control is reported from South-East Asia: spraying, " particularly patch-dusting ", seems to combat the rat flea, and has thus diminished the incidence of plague. Smallpox still persists in some areas where vaccination programmes have been carried out. Rapid loss of potency of the lymph under tropical conditions has been the principal cause of failure, even where dried vaccines were used. During 1956 a freeze-dried vaccine became available with which, in the Latin Americas, eradication programmes were started. Pertussis vaccine became the first bacterial vaccine to be internationally standardised, " a unique achievement in the history of vaccine control ". An estimated 40,000 children in Syria were affected with favus. This fungus infection of the scalp is a serious social and medical problem, particularly because it interferes with education. Under a new project started in 1956 30,000 children were examined and 7000 treated. TUBERCULOSIS
In the report’s comments on the several B.c.. campaigns which were completed, it is frankly admitted that in some mass campaigns vaccines were of poor quality and techniques and organisation defective. A new plan for anti-tuberculosis drug trial projects has been put into operation, and in 1956 one such project began in Madras in association with the. British and Indian Medical Research Councils. (The preventive value of p-aminosalicylic acid and isoniazid was demonstrated in the W.H.O.UNICEF Thailand scheme.2) From the Madras project, which is conducted by clinical and laboratory experts from this country, much valuable information on simplification of treatment schemes and on resistance and virulence of the tubercle bacillus under oral chemotherapy is expected during the five years for which this project is planned. SANITATION
An environmental sanitation project, which may be of world-wide importance, was organised in Japan. In Asian countries traditional methods of collection, disposal, and utilisation of organic wastes have always been unsatisfactory. It has been estimated, the report says, that the health of over 500 million persons is affected by undesirable sanitation practices. In Japan the use of human excrement as fertiliser has 2.
Benatt,
A.
J. Lancet, 1956, i, 736.
psychiatry, education, and some chaps have even got going on politics. It may be a grandiose delusion, but it seems inescapable to me that, as new knowledge is gained, psychiatric and psychological influence will become very widespread and important indeed. Already, it’s a stimulating line, and often very rewarding in many ways. I don’t think the divisions are nearly as deep as the clash of ambitions and personalities often makes them seem, and I believe that before long you will come to accept a surprising incursion of psychiatric activity around diseases you still regard as "organic". Much of it certainly sounds very funny
somatically tuned ears, but at least we are trying (see how that " we keeps slipping out) to push understanding one stage further back. After all, what do you really know about the causes of essential hypertension and ulcerative colitis ? The Physicians and the Psychiatrists are peering at each other across the Hypothalamus; before long they will be shaking hands there. I’m afraid it still seems to be de rigueur round the General Hospitals to make light of our contributions and to
"
PHYSICIAN TO THE COVENTRY GROUP OF HOSPITALS
WHEN he leaves a teaching hospital to join the consultant staff of a " non-teaching hospital ", the senior registrar may think that his teaching days are over and that he will lose the stimulus of regular contact with students. In his new environment, however, he will soon discover that he is a perpetual teacher, or at least may be if he so desires. POSTGRADUATES
Advances in medicine have brought more work for residents, and the physician’s or surgeon’s complement has been increased to a houseman and a registrar (or senior house-officer) instead of a houseman only (or perhaps nobody). In small hospitals registrars still do not abound; but commonly the consultant will have both a recently qualified house-officer, who is seeing a new and often more representative type of hospital practice, and a registrar who is aspiring to a higher qualification or diploma. While he can learn much from these pupils, they can learn more from his years of experience. Every round can be a teaching round, without the boredom of explaining elementary facts to the undergraduate. It is a mutual-benefit society where all contribute-including the ward sister or staff-nurse. In the hospital group in which I work, there are two other types of postgraduate activity. One is a monthly visit from the university professor, the other an aftertea demonstration of interesting cases organised by a senior resident. The professor sees three or four cases, usually with unusual and perhaps perplexing symptoms; or maybe something of which the consultant dreams, such as hypercholesterolasmia " " or chronic meningococcal septicaEmia. Debunking is his prerogative; but some of the patients, to use his own words, These rounds
diagnosed.
not
I remember a long time ago, before I joined this fraternity, I taunted an elderly psychiatrist with the unworthy remark that in his field he understood little and could do less. " May be," he admitted graciously, " but I think we do about as much good as anyone else." He was very right. With all
hitherto reported are
good wishes, Your affectionate nephew, RICHARD COBBLEIGH.
physicians, who have to work hard to pleasure has been enhanced by the professor’s being joined on occasions by other notables, such as the president of the Royal College of Physicians or of the Association of Physicians, the regius professor of physic at Cambridge, and a visiting professor from Boston. With such talent, it is usual to produce at least one patient with a disease
R. E. SMITH M.A., M.B. Cantab., F.R.C.P.
in the disease he has
too rare.
the local
present their
TEACHING IN NON-TEACHING HOSPITALS
"
subjects
enjoyed by
Medical Education
" develop interesting complications
look upon us as a therapeutic last hope if not indeed as for uninhibited mirth. Too many of our patients seem to be sent only when every ketosteroid has been checked and re-checked, radio-opaque material inserted into every conceivable tissue, and almost every expendable organ excised. These words come more from sorrow than anger, and I must add my whisper to the plea for a bit more undergraduate instruction. I reckon it’s the general men that matter most in teaching hospitals, and those with a real appreciation of psychological factors are still to
really
cases.
The
of the system on which the visitor is an expert. The after-tea demonstration always produces some surprises and always evokes a good discussion. Cases are demonstrated by the residents or the consultant and postmortem specimens and cases shown a second time often afford salutary
discipline. I have said education is a
enough, perhaps, to show that postgraduate major activity of " non-teaching hospitals. "
THE
FAMILY
DOCTOR
In the past four years, we have had three refresher for general practitioners. We had little idea what the demand would be, but applications for each succeeding course have increased.’,’ It has been said that a clinical lecture should be exhilarating and exhausting. So is a clinical demonstration. A recent course showed that only the seasoned lecturer can go on for more than an hour. Our courses have always been eleven sessions of 21/2 hours with a break of 15-20 minutes for tea in the afternoon, or coffee in the morning. About twenty subjects must be selected. One or two occupy the whole morning or aftercourses
With the help of our patients an expert in gastroenterology or in chest surgery can interest his audience for the whole session; but the local specialists are content with an hour, and if they deal with two aspects of their branch of medicine, they prefer two separate days. All aspects of medicine and surgery are considered but the emphasis is on medical problems. noon.
It is sine-qua-non that all is designed to help the general practitioner in his daily work. Recent advances such as the sulphonamide treatment of diabetics, the use of steroids in the management of haemolytic disease, and the great advances in the treatment of neonatal deformities are examples of the subjects that the general practitioner likes. Certainly one does not want to be too abstruse and too scientific, but it is a worse mistake to suppose that one should talk down to general practitioners. There is much to be learnt about organisation and
method.
312 One of the earliest experiments in postgraduate education undertaken in Edinburgh in 1953, when the course was held on Sunday mornings. Questionnaires at the end suggested that this was the most convenient day and our experience is the same. We have had one course in which people were invited fortnightly on Sunday morning and fortnightly on Thursday afternoons; and the Sunday attendance averaged 24 against 18 on Thursdays. We have tried to have courses in the middle of the week because most doctors take their halfdays then; and it is surprising to me that general practitioners are so often willing to sacrifice their leisure to attend them. was
TEACHING
NURSES
The General Nursing Council holds that lectures on clinical subjects wherever possible be given by doctors, and this is almost always done. Nurses are taught anatomy .and
physiology
on a
theoretical basis because
practical
To classes in medical subjects cannot be arranged. add to the nurse’s difficulties, she has often had no basic training in chemistry, physics, or perhaps in biology. Yet despite all handicaps, nurses are eager to learn the principles of medicine and surgery and of the specialties. Because of these limitations, those who teach nurses should take care to make themselves clear, concise, and factual. Nurses
demonstrations, and some patients are very willing to return thanks to the hospital by coming annually. A mitral stenotic, formerly bedridden, fibrillating, and scattering emboli, will tell nurses how after her operation she returned to work; and a patient with Addison’s disease will relate her improvement after being given salt and deoxycortone but will rise to say that, after a week with cortisone, she told her daily woman that she would not require her any more. Bloodfilms, temperature charts, and photographs all help. Anyone who thinks that he can just walk into a nurses’ lecture-room and speak for an hour should do two things. Firstly, he should take note of his audience at the end, when
appreciate
clinical
he does take preliminary trouble and when he does not, and compare the alertness with the yawns. Secondly, he should He will then find that correct nurses’ examination papers. nurses who have been taught well have a very high standard; and let me say that this reflects much more credit on the sistertutors than on the doctors giving lectures.
Many people think that we are training nurses now on far too scientific a basis. I do not belong to that school; I cannot see how modern medicine and modern nursing can be carried on unless the people practising it understand the reasons. Furthermore, if we are to make nurses good observers, they must know what to look for. In other words, the medical and nursing professions are allies, each with responsibilities; and I, for one, think that the time will come when we shall organise postgraduate training for nurses, which to my mind is grossly neglected. I cannot understand why in one branch of nursing-midwifery-there should be a special course and a special diploma, which carries great weight when nurses are applying for senior posts, whereas in general medicine or general surgery there is The time is no such diploma for the postgraduate nurse.
probably not far distant when children will have the benefit of being nursed by those who have had a special training in paediatrics. If ever a scheme for postgraduate education in general. medicine and surgery evolves, it will probably be started by some enlightened matron, who realises that what is sauce for the midwife is sauce for all other staff nurses and embryonic sisters. MEDICAL
AUXILIARIES
Besides hospitals connected with a university, there a few which have been made responsible for the students of professions ancillary to medicine. In our group, we have schools for orthoptists and for radiographers. The training of radiographers, much of it
are
lasts about 21/2 years. The the lectures (which number about sultants the other half.
practical,
UNDERGRADUATE
physicist gives half 100) and the con-
STUDENTS
From what has been said, it is evident that in the nonteaching hospital one teaches almost every type of student except undergraduates; and even this exception is a little doubtful. For several years we have had applications from students at teaching hospitals, who have been advised to go and get experience elsewhere. In hospitals where the houseman takes a holiday doing his 6 months’ residence, a student working under supervision, may temporarily take his place; but for most of his 2-3 months’ stay he is acting as a clinical clerk-
taking histories, making examinations, taking blood, and, under his senior’s eye, doing perhaps his first lumbar puncture or pleural tap. Sometimes these students go to a particular hospital because it is near their home. But then they may tell their friends about it; and so the tradition grows up that it is a good place to go to.
In our group, the only consultant who has students sent him from the university is the obstetrician and gynaecologist, who is recognised as a clinical tutor. Two students go to him regularly, and they get infinitely more experience than they would in their teaching hospital. To come to us is much simpler and cheaper for them than going to faraway Dublin, as was formerly done by so many students from the London hospitals; and, just as postgraduate training of nurses in midwifery sets an example for postgraduate training of nurses in other medical specialties, so I think that this training of gynaecological students points the way to a better training of students in other branches of medicine-particularly in general medicine, which will probably always remain the basis of medical education.
In the teaching hospitals, in a clinical course of about 3 years, a student spends only 6 months in general medical clerking, and sometimes with only one group of physicians. The objection to sending him out into neighbouring hospitals within the region is that he misses lectures, which are often designed to complete his formal training. But on balance, he would probably learn more in 3 months’ clerking to a general physician in a large peripheral hospital where the clinical material is abundant and interesting, besides giving a better idea of the commoner diseases. Moreover, a steadily increasing proof portion physicians in these hospitals have served a teaching apprenticeship as registrars in teaching hospitals. MEDICAL
SOCIETIES
Medical societies are on the increase, and the temptation is to join too many. To be a member of the local medical society is a privilege and responsibility. It brings one in contact with one’s fellows in the same town; but the consultant usually contributes more than the general practitioner and is often asked to go to other towns. Then there are the regional societies, and my experience of these is of growing prosperity. The East Midlands Association of Physicians is the oldest and carries on at a steady tempo. The West Midlands Association of Physicians is only 7 years old and often has to refuse communications. Although the audience might resent the suggestion that it is being taught, and the speaker that he is teaching, in fact that is what is happening, and most people come away saying that they have learnt much. Furthermore, the man who has to present a paper at any of these meetings learns much himself.
313 TEACHING
ONESELF
There are so many ways of teaching onself that it is difficult to know what to single out. Regular reading of the journals is essential, although very often the summary of an article suffices to tell one if there is anything new in it. Attendance at medical meetings serves two purposes -the advancement of knowledge and the promotion of friendship; and certainly it is much easier to read articles if one knows the authors of them. Perhaps the consultant learns most by pursuing one particular subject, as he has to do if he is writing a paper. Some regional boards are
Public Health THE WORK OF W.H.O. THE record1 of the activities of the World Health Organisation in 1956 gives a vivid picture of the remarkable scope of the Organisation’s work and the magnificent results that are being achieved. CONTROL OF INFECTIOUS DISEASES
Mass
campaigns against leprosy with sulphone drugs have reduced the need for long and expensive hospital treatment and lifelong segregation in leprosaria. Much attention is being paid to finding an effective long-acting drug. In Nigeria treatment is based on temporary segregation and outpatient supervision by both fixed and mobile units responsible for the oral administration of the drug, whereas in French territories mass treatment consists of a fortnightly injection of an oily suspension of dapsone-a scheme easily adaptable to rural areas. Of the 150,000 leprosy patients in French
Equatorial Africa, 100,000 are now under regular treatment; and a similar project has been initiated with the Government of French West Africa, where the number of patients is estimated to be 500,000. Case-finding by examination of contacts and health education of the public to dispel centuriesold fear follow the lines of campaigns against tuberculosis and
treponematosis. Spectacular results have been achieved against the disfiguring yaws. By the end of 1956 more than 55 million people had been examined and 16 million treated with long-acting penicillin in W.H.O./UNICEF-assisted campaigns. Serious reactions to procainebenzylpenicillin in oil with aluminium monostearate have been reported from urban areas and have directed research towards new preparations which may be free from side-effects; but it is interesting to learn that little evidence of reactions has come from underdeveloped rural areas, children not previously exposed to antibiotics being particularly free from trouble. The splendid results after only one injection are a little-known triumph of penicillin and a tribute to those in UNICEF and W.H.O. who have organised such rewarding campaigns against treponematosis. Some thirty national and other laboratories all over the world are now helping in the search for a practicable method of serum diagnosis in the treponematoses. Mass treatment of trachoma has for long been difficult because of the need for repeated daily application of antibiotics to the eye and the strict control of personal and domestic hygiene. In North Africa much of the treatment is now left to teachers and schoolchildren who have been instructed in the common rules of cleanliness and in the application of antibiotic ointment to the eyes of their schoolmates. The W.H.O. report has impressive photographs to illustrate this promising scheme. The attack on malaria has continued over vast areas of the globe, and the report’s comprehensive maps show the extent 1. Annual
Report for 1956 of the Director-General of W.H.O. Official Records of the World Health Organisation, no. 75, March, 1957. Obtainable from H.M. Stationery Office, P.O. Box 569, London, S.E.1. 10s.
liberal in giving study leave, which is another way of saying that they know that the consultant is still a student. Travelling clubs, visits abroad, visits from others of one’s own standing, or perhaps visits from professorsall help to widen one’s interests and advance one’s knowledge. Some people will get most from preparing a paper; others from watching or listening. But all will notice that in their teaching they introduce things that they have learnt elsewhere, and they will find increasingly that, as J. H. Sheldon said, work in a nonteaching hospital can be fully satisfying. of eradication already achieved and where campaigns are still in progress. A new project has begun in Mexico, where it is estimated that there are 2 million cases a year, and where districts potentially the richest in agriculture, livestock, fisheries, petroleum, and sulphur mining are the worst affected. UNICEF is sending supplies and equipment worth nearly S8’/a million, the Mexican Government is investing more than $12 million, and W.H.O. has awarded fellowships to train more than 1300 specialists. Wherever possible W.H.O. malaria teams are now testing the susceptibility of local vectors to different insecticides. Where anopheles has become resistant to dicophane (D.D.T.) it can often still be controlled by gammexane (B.H.c.), but some strains are resistant to both. Another method of malaria control is the distribution for human consumption of table salt containing pyrimethamine or chloroquine. The first results in volunteers inoculated with malaria have been encouraging. An interesting sideline of malaria control is reported from South-East Asia: spraying, " particularly patch-dusting ", seems to combat the rat flea, and has thus diminished the incidence of plague. Smallpox still persists in some areas where vaccination programmes have been carried out. Rapid loss of potency of the lymph under tropical conditions has been the principal cause of failure, even where dried vaccines were used. During 1956 a freeze-dried vaccine became available with which, in the Latin Americas, eradication programmes were started. Pertussis vaccine became the first bacterial vaccine to be internationally standardised, " a unique achievement in the history of vaccine control ". An estimated 40,000 children in Syria were affected with favus. This fungus infection of the scalp is a serious social and medical problem, particularly because it interferes with education. Under a new project started in 1956 30,000 children were examined and 7000 treated. TUBERCULOSIS
In the report’s comments on the several B.c.. campaigns which were completed, it is frankly admitted that in some mass campaigns vaccines were of poor quality and techniques and organisation defective. A new plan for anti-tuberculosis drug trial projects has been put into operation, and in 1956 one such project began in Madras in association with the. British and Indian Medical Research Councils. (The preventive value of p-aminosalicylic acid and isoniazid was demonstrated in the W.H.O.UNICEF Thailand scheme.2) From the Madras project, which is conducted by clinical and laboratory experts from this country, much valuable information on simplification of treatment schemes and on resistance and virulence of the tubercle bacillus under oral chemotherapy is expected during the five years for which this project is planned. SANITATION
An environmental sanitation project, which may be of world-wide importance, was organised in Japan. In Asian countries traditional methods of collection, disposal, and utilisation of organic wastes have always been unsatisfactory. It has been estimated, the report says, that the health of over 500 million persons is affected by undesirable sanitation practices. In Japan the use of human excrement as fertiliser has 2.
Benatt,
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J. Lancet, 1956, i, 736.