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TEACHING OF EVERYDAY PSYCHIATRY
312 in a morbid anxiety about my car, and here was a man who would indulge my fears. Time showed that he took pleasure in doing so. It was a disappointment to us both when I had nothing to complain of. Squeaks and rattles were patiently investigated, cured where possible, alleviated sometimes, and always I was offered reassurance. Vi-beration is a favourite explanation of Walter’s, and there is no doubt he is right. From rest, up through the gears to 70 m.p.h., one word adequately describes the mechanism of a popular car-viberation. What a relief to be free from dependence on a garage where comment varied from the merely irritating, "Well, sir, I saw the boy working on it. He’s gone to lunch now. Try it out, anyway. It should be all right", to a real death sentence, " You’ll have to be careful with that halfshaft, sir; it might go at any time." Walter subjects all parts of the car to a regular check, and never shrinks from a major engine overhaul. Using wooden planks and blocks, he lifts the front of the car, puts on his reading-glasses, and slowly goes to work. Occasionally I help. The intensity of Walter’s concentration equals that of a brain surgeon. " A little further over with the lamp, sister. 3/8 spanner. Hammer and chisel, please. Quick, get the tin under here." *
*
*
I have never enjoyed syringing ears, and the ancient syringe with which the surgery was equipped did not add to the pleasure. It delivered a very poor jet and was always liable to backfire. Softening the way with oil was undoubtedly a useful preliminary measure. When the end of my locum appointment was only five days away, I began to advise patients to put the drops in their ears for six days before coming back. As the days passed, the course of preliminary treatment with the oildrops did not need to be so long and, by my last day, I was advising just two days’ treatment. Saturday night came and the last patient of the last surgery walked in. I asked him what he was complaining about, and he replied, " I have wax in my ears, Doctor." My spirits rose as I wrote a prescription for ear-drops, advised him to return on the Monday for syringing, and rose to show him to the door. To my dismay, he looked at the prescription and said, " I’ve often had my ears syringed out and Dr. X told me all about the routine. I got these drops from my chemist three days ago and I’ve been using them since. The wax should be soft enough for you to go ahead right away." *
*
*
Letters to the Editor TEACHING OF EVERYDAY PSYCHIATRY
SIR,-Ishould like to recommend the articles by Prof. Romano (July 8) and Dr. Kehoe (July 15) to the attention of physicians interested in medical education. These articles describe some of the philosophy and activities of the department of psychiatry and the psychiatricmedical liaison department of the University of Rochester School of Medicine-widely esteemed in the U.S.A. for its education of students, particularly in the psychiatric aspects of medicine and in those qualities which quicken the doctor’s perception of the humanity of his patients. The Rochester school is a model which United Kingdom and Commonwealth medical schools could study with benefit. Prof. Romano states that, in his view, we are seeing a major reorientation (of medical attitudes and practice), as great perhaps as that which took place in the 16th century in Padua with the beginning of systematic instruction in bedside teaching. Having seen the expressions of this reorientation in the U.S.A., I agree; and I think the same awareness of the nature of man and disease is not manifest in practical changes in the curriculum of many United Kingdom and Commonwealth medical schools. Most of your readers are aware of the considerable need to improve medical education in its psychiatric aspects and to improve the training and number of psychiatrists. To bring some aspects of the English situation into the perspective of American developments, I should like to emphasise certain
points: (1) The department of psychiatry at the University of Rochester is allotted more of the teaching time of medical students than any other department in the medical school with the exception of the department of internal medicine-that is, it occupies more time than, individually, the departments of surgery, obstetrics The and gynaecology, physiology, anatomy, biochemistry, &c. department of psychiatry is allotted a substantial portion of the teaching time in all four years of the undergraduate medical course.
Well, holiday 1961 is over, and after a fortnight of mumps and chickenpox almost forgotten. It was fun, though, flying to the Channel Isles, hardly marred by the unexpected reunion with two of my patients staying at the same hotel. A third had apparently missed me by one day, while a fourth, warned of my arrival, sent me a picture postcard together with an invitation to tea. Anyhow no-one in my immediate neighbourhood died, was drowned, or needed urgent medical care. Thus began a fortnight of sun, sea, and sketching, with watch forgotten and time unmentioned. Back in the plane the voice of our local dispenser, sitting directly behind me, brought me up with a jolt on the job to hand. Guernsey 10.30 A.M., surgery 2 P.M. with locum gone and waiting-room bulging. And what have I got to show for it all ? The best tan ever and the pharyngitis of a lifetime, and it’s small consolation that the highest in the land seem to be affected with the latter. But, cheerful thought, it is high time I started planning summer holiday 1962. summer
*
*
*
The candidate had difficulty in recognising a cystoscope, which she identified as biopsy forceps. Demonstration of the " Well," said the optical system seemed to help little. " examiner, to make the hint broader, it has to be used under water." Light dawned. A periscope, Sir." *
" Thou shalt
Officiously
*
not kill, but to keep alive "
*
need’st
not
Was once the call. But now, with crowded roads to drive, To keep alive, thou should’st not strive -at all.
strive
(2) The department of psychiatry at the University of Rochester was developed out of a gift of 3 million dollars fifteen years ago, the department’s benefactions being further increased by substantial gifts since. To build and organise a comparable department of psychiatry in a London teaching hospital today would possibly cost Ll-1 ’/, million. This gives some idea of the need for imaginative and foresighted spending in developing a first-class department of psychiatry within the framework of the teaching hospital. Perhaps this need can be seen alongside the fact that only recently have the teaching hospitals of the London medical schools begun to establish chairs of psychiatry and most are still without such chairs. (3) One of the dominant attitudes in departments of psychiatry in the U.S.A., such as the Rochester department, is the attitude that psychiatry is concerned not only with madness and neurosis but particularly with the humanisation of medical practice. Associated with this, there is a considerable emphasis on so-called " dynamic " psychiatry and on understanding human beings, their major psychosocial stresses, and how they handle them. In Britain, for complex reasons, psychiatrists are still in the main concerned with gross psychiatric illness, a " phenomenological, rather descriptive, organic " approach to and to of collected patients aspects psychiatry roughly together " as social psychiatry ". If psychiatrists in Britain are to contribute, with more profit, to the ordinary physician’s understanding of what is really happening to his patient, there must develop,
in every
teaching hospital, departments
of
psychiatry
somewhat after the Rochester model-namely, departments which are well staffed and financed, where there are many experienced, dynamically oriented psychiatrists to give close personal supervision to trainee psychiatrists and students, and
313 where the staff is allowed the luxury of treating limited numbers of patients in some depth. This type of training widens the perception of the psychiatrist and he becomes a more suitable model and instructor for the medical student. In the past, Britain has produced practical, skilled clinicians, and in the U.S.A. today British physicians are valued for their clinical judgment and sound bedside
diagnostic skill, particularly their skill in detecting and evaluating physical signs. While I esteem the clinical standards of the British physician, I believe that many schools in the U.S.A., such as the Rochester school, are today graduating a type of clinician more appropriate to the treatment of patients than that produced in Britain, not perhaps as skilled in some areas of organic medicine, but far more sophisticated in interviewing and in enabling patients to elaborate into awareness what is really troubling them. Maudsley Hospital, London, S.E.5.
ORCHARD. WILLIAM WILLIAM ORCHARD.
SIR,-Dr. Klauber’s interesting article (July 22), illustrating history-taking in the light of knowledge of unconscious mental processes, concludes that training in these methods is virtually lacking. Having attended a seminar at the Tavistock Clinic for three years, while working as a G.P., I have been trained to be sensitive to the undertones that he describes, as is illustrated in the following case. A married woman of 27 complained that she had not had normal period for 4 months, though she had had intermittent bleeding at intervals of never more than 4 weeks. She had not felt well during this time, but had not had any pain or other symptoms. I had attended her only a dozen times in the 6 years she had been a patient, the main reason being for infertility after 6 years of marriage some 4 years ago. She conceived the next year, and bore a son within a year of the a
investigation. She appeared fit, she was not pregnant, and nothing abnormal was found in the pelvis. I told her of my negative findings and waited. She then volunteered that in fact she was constantly worried about her child, and that this had been worse during the past 4 months, though the trouble had been present ever since his birth, but she had never been able to tell anyone because it sounded so silly. I had certainly never suspected this, and had always thought her a sensible and uncomplaining woman. I suggested that she might like to tell me all about it and gave an appointment for a long interview. At this interview a few days later she told me that she always felt nervous whenever her child was not with her, and resented anyone else looking after him, even her husband, her sister, or her mother. This feeling was intense enough for her to prefer to carry him about as a baby rather than push him in a pram. The feeling always became worse towards nightfall, and she had not been out of an evening since he was born, because she would not trust any baby-sitter whatsoever. I asked her if she had any idea what might be the reason for her fears, and she told me how she was admitted to hospital in labour in the midst of a terrific thunderstorm towards nightfall, when it was found that the baby was presenting as a breech, and that in her confused state after the delivery she gathered that he was jaundiced, and had to be taken away to the nursery immediately. (I do not want to make an issue of the facts of the confinement, but merely to recount her views.) She felt that his life was in danger and that his separation from her a further hazard, and that this feeling had remained with her ever since, especially in circumstances mimicking the time and meteorological conditions. Discussion of her childhood and marital relationships did not reveal anything very striking at this interview, but thinking that this was a latent postpartum depression, and not being able to give her a further appointment for a fortnight, I gave her an
anti-depressant (mono-amine oxidase).
She next appeared exactly a week early for her appointment, but I was unfortunately deaf to the significance of this at the time. On the correct day she appeared half-an-hour late, apologetic and wreathed in smiles, but thus limiting our talk to under half-an-hour. She told me that she felt very much better, and had been out in the evening six times since our last interview, four of them since our abortive encounter the previous week. The improvement had occurred 2 days after the interview, and had been sudden. On the intervening day, however, a dramatic incident had occurred. A neighbour had given her child a sweet which he had inadvertently inhaled, and while he turned blue with open mouth before her eyes, she was incapable of action, but could only call her sister, who happened to be at her flat. The latter promptly turned him upside down and hooked the sweet out with her finger. She ascribes the improvement she has made to the realisation that she is not essential to her son’s wellbeing-but would this history have been obtained at all by orthodox history-taking, and would she. have improved without it ?
MICHAEL COURTENAY.
London, S.W.11.
THE N.H.S. UNNECESSARY?
SIR,-We are sorry that your leader of July 22 on The Genesis of the British National Health Service thought fit to charge us with a lack of objectivity; for, if there are good points to be made against us, it is a pity to employ such a poor one. May we, however, add something on the two matters of substance you raise ? We agree, and we said so in the pamphlet, that the efficiency of a medical system cannot be judged uniquely to it, that there is by the economic resources devoted " something vaguely described as quality " which ought to be taken into account. But has anyone the slightest idea how to measure this " quality " ? If so, we should like to know about it. Why then neglect quantity which, after all, is relevant and can be measured ? In the meantime, and particularly in the light of recent revelations of defects at so many points in our medical arrangements, to assume that the quality of our medical services is superior to that in other Western countries would be just one further instance of British complacency. As for the second matter, that of the concentration of consultants in the London area, we have looked at the figures again and we cannot accept the correction you proffered. Even when a more restricted definition of the Metropolitan Area is taken, what we said is broadly correct. We knew about Wessex! It has further to be kept in mind that, in order to be on the safe side in our comparison, we made no allowance for post-war private practice, and we imagine that private practice is fairly heavily concentrated in the London area. Our original statement stands that " the National Health Service has not changed greatly the distribution of consultants as between London and the provinces ". JOHN JEWKES SYLVIA JEWKES.
Oxford.
APPROVED NAMES
SIR,-One
approved of trade
answer to
names are to
Dr. Edwards’ query (July 15) why preferred is the superabundance
be
names.
Here are 2 examples from the British National Formulary: phenoxymethylpenicillin:’Calcipen V ’, ’Compocillin V ’, Crystapen V ’, ’Distaquaine V ’, ’Eskacillin V ’,Icipen V ’, ’
*
*
I have never enjoyed syringing ears, and the ancient syringe with which the surgery was equipped did not add to the pleasure. It delivered a very poor jet and was always liable to backfire. Softening the way with oil was undoubtedly a useful preliminary measure. When the end of my locum appointment was only five days away, I began to advise patients to put the drops in their ears for six days before coming back. As the days passed, the course of preliminary treatment with the oildrops did not need to be so long and, by my last day, I was advising just two days’ treatment. Saturday night came and the last patient of the last surgery walked in. I asked him what he was complaining about, and he replied, " I have wax in my ears, Doctor." My spirits rose as I wrote a prescription for ear-drops, advised him to return on the Monday for syringing, and rose to show him to the door. To my dismay, he looked at the prescription and said, " I’ve often had my ears syringed out and Dr. X told me all about the routine. I got these drops from my chemist three days ago and I’ve been using them since. The wax should be soft enough for you to go ahead right away." *
*
*
Letters to the Editor TEACHING OF EVERYDAY PSYCHIATRY
SIR,-Ishould like to recommend the articles by Prof. Romano (July 8) and Dr. Kehoe (July 15) to the attention of physicians interested in medical education. These articles describe some of the philosophy and activities of the department of psychiatry and the psychiatricmedical liaison department of the University of Rochester School of Medicine-widely esteemed in the U.S.A. for its education of students, particularly in the psychiatric aspects of medicine and in those qualities which quicken the doctor’s perception of the humanity of his patients. The Rochester school is a model which United Kingdom and Commonwealth medical schools could study with benefit. Prof. Romano states that, in his view, we are seeing a major reorientation (of medical attitudes and practice), as great perhaps as that which took place in the 16th century in Padua with the beginning of systematic instruction in bedside teaching. Having seen the expressions of this reorientation in the U.S.A., I agree; and I think the same awareness of the nature of man and disease is not manifest in practical changes in the curriculum of many United Kingdom and Commonwealth medical schools. Most of your readers are aware of the considerable need to improve medical education in its psychiatric aspects and to improve the training and number of psychiatrists. To bring some aspects of the English situation into the perspective of American developments, I should like to emphasise certain
points: (1) The department of psychiatry at the University of Rochester is allotted more of the teaching time of medical students than any other department in the medical school with the exception of the department of internal medicine-that is, it occupies more time than, individually, the departments of surgery, obstetrics The and gynaecology, physiology, anatomy, biochemistry, &c. department of psychiatry is allotted a substantial portion of the teaching time in all four years of the undergraduate medical course.
Well, holiday 1961 is over, and after a fortnight of mumps and chickenpox almost forgotten. It was fun, though, flying to the Channel Isles, hardly marred by the unexpected reunion with two of my patients staying at the same hotel. A third had apparently missed me by one day, while a fourth, warned of my arrival, sent me a picture postcard together with an invitation to tea. Anyhow no-one in my immediate neighbourhood died, was drowned, or needed urgent medical care. Thus began a fortnight of sun, sea, and sketching, with watch forgotten and time unmentioned. Back in the plane the voice of our local dispenser, sitting directly behind me, brought me up with a jolt on the job to hand. Guernsey 10.30 A.M., surgery 2 P.M. with locum gone and waiting-room bulging. And what have I got to show for it all ? The best tan ever and the pharyngitis of a lifetime, and it’s small consolation that the highest in the land seem to be affected with the latter. But, cheerful thought, it is high time I started planning summer holiday 1962. summer
*
*
*
The candidate had difficulty in recognising a cystoscope, which she identified as biopsy forceps. Demonstration of the " Well," said the optical system seemed to help little. " examiner, to make the hint broader, it has to be used under water." Light dawned. A periscope, Sir." *
" Thou shalt
Officiously
*
not kill, but to keep alive "
*
need’st
not
Was once the call. But now, with crowded roads to drive, To keep alive, thou should’st not strive -at all.
strive
(2) The department of psychiatry at the University of Rochester was developed out of a gift of 3 million dollars fifteen years ago, the department’s benefactions being further increased by substantial gifts since. To build and organise a comparable department of psychiatry in a London teaching hospital today would possibly cost Ll-1 ’/, million. This gives some idea of the need for imaginative and foresighted spending in developing a first-class department of psychiatry within the framework of the teaching hospital. Perhaps this need can be seen alongside the fact that only recently have the teaching hospitals of the London medical schools begun to establish chairs of psychiatry and most are still without such chairs. (3) One of the dominant attitudes in departments of psychiatry in the U.S.A., such as the Rochester department, is the attitude that psychiatry is concerned not only with madness and neurosis but particularly with the humanisation of medical practice. Associated with this, there is a considerable emphasis on so-called " dynamic " psychiatry and on understanding human beings, their major psychosocial stresses, and how they handle them. In Britain, for complex reasons, psychiatrists are still in the main concerned with gross psychiatric illness, a " phenomenological, rather descriptive, organic " approach to and to of collected patients aspects psychiatry roughly together " as social psychiatry ". If psychiatrists in Britain are to contribute, with more profit, to the ordinary physician’s understanding of what is really happening to his patient, there must develop,
in every
teaching hospital, departments
of
psychiatry
somewhat after the Rochester model-namely, departments which are well staffed and financed, where there are many experienced, dynamically oriented psychiatrists to give close personal supervision to trainee psychiatrists and students, and
313 where the staff is allowed the luxury of treating limited numbers of patients in some depth. This type of training widens the perception of the psychiatrist and he becomes a more suitable model and instructor for the medical student. In the past, Britain has produced practical, skilled clinicians, and in the U.S.A. today British physicians are valued for their clinical judgment and sound bedside
diagnostic skill, particularly their skill in detecting and evaluating physical signs. While I esteem the clinical standards of the British physician, I believe that many schools in the U.S.A., such as the Rochester school, are today graduating a type of clinician more appropriate to the treatment of patients than that produced in Britain, not perhaps as skilled in some areas of organic medicine, but far more sophisticated in interviewing and in enabling patients to elaborate into awareness what is really troubling them. Maudsley Hospital, London, S.E.5.
ORCHARD. WILLIAM WILLIAM ORCHARD.
SIR,-Dr. Klauber’s interesting article (July 22), illustrating history-taking in the light of knowledge of unconscious mental processes, concludes that training in these methods is virtually lacking. Having attended a seminar at the Tavistock Clinic for three years, while working as a G.P., I have been trained to be sensitive to the undertones that he describes, as is illustrated in the following case. A married woman of 27 complained that she had not had normal period for 4 months, though she had had intermittent bleeding at intervals of never more than 4 weeks. She had not felt well during this time, but had not had any pain or other symptoms. I had attended her only a dozen times in the 6 years she had been a patient, the main reason being for infertility after 6 years of marriage some 4 years ago. She conceived the next year, and bore a son within a year of the a
investigation. She appeared fit, she was not pregnant, and nothing abnormal was found in the pelvis. I told her of my negative findings and waited. She then volunteered that in fact she was constantly worried about her child, and that this had been worse during the past 4 months, though the trouble had been present ever since his birth, but she had never been able to tell anyone because it sounded so silly. I had certainly never suspected this, and had always thought her a sensible and uncomplaining woman. I suggested that she might like to tell me all about it and gave an appointment for a long interview. At this interview a few days later she told me that she always felt nervous whenever her child was not with her, and resented anyone else looking after him, even her husband, her sister, or her mother. This feeling was intense enough for her to prefer to carry him about as a baby rather than push him in a pram. The feeling always became worse towards nightfall, and she had not been out of an evening since he was born, because she would not trust any baby-sitter whatsoever. I asked her if she had any idea what might be the reason for her fears, and she told me how she was admitted to hospital in labour in the midst of a terrific thunderstorm towards nightfall, when it was found that the baby was presenting as a breech, and that in her confused state after the delivery she gathered that he was jaundiced, and had to be taken away to the nursery immediately. (I do not want to make an issue of the facts of the confinement, but merely to recount her views.) She felt that his life was in danger and that his separation from her a further hazard, and that this feeling had remained with her ever since, especially in circumstances mimicking the time and meteorological conditions. Discussion of her childhood and marital relationships did not reveal anything very striking at this interview, but thinking that this was a latent postpartum depression, and not being able to give her a further appointment for a fortnight, I gave her an
anti-depressant (mono-amine oxidase).
She next appeared exactly a week early for her appointment, but I was unfortunately deaf to the significance of this at the time. On the correct day she appeared half-an-hour late, apologetic and wreathed in smiles, but thus limiting our talk to under half-an-hour. She told me that she felt very much better, and had been out in the evening six times since our last interview, four of them since our abortive encounter the previous week. The improvement had occurred 2 days after the interview, and had been sudden. On the intervening day, however, a dramatic incident had occurred. A neighbour had given her child a sweet which he had inadvertently inhaled, and while he turned blue with open mouth before her eyes, she was incapable of action, but could only call her sister, who happened to be at her flat. The latter promptly turned him upside down and hooked the sweet out with her finger. She ascribes the improvement she has made to the realisation that she is not essential to her son’s wellbeing-but would this history have been obtained at all by orthodox history-taking, and would she. have improved without it ?
MICHAEL COURTENAY.
London, S.W.11.
THE N.H.S. UNNECESSARY?
SIR,-We are sorry that your leader of July 22 on The Genesis of the British National Health Service thought fit to charge us with a lack of objectivity; for, if there are good points to be made against us, it is a pity to employ such a poor one. May we, however, add something on the two matters of substance you raise ? We agree, and we said so in the pamphlet, that the efficiency of a medical system cannot be judged uniquely to it, that there is by the economic resources devoted " something vaguely described as quality " which ought to be taken into account. But has anyone the slightest idea how to measure this " quality " ? If so, we should like to know about it. Why then neglect quantity which, after all, is relevant and can be measured ? In the meantime, and particularly in the light of recent revelations of defects at so many points in our medical arrangements, to assume that the quality of our medical services is superior to that in other Western countries would be just one further instance of British complacency. As for the second matter, that of the concentration of consultants in the London area, we have looked at the figures again and we cannot accept the correction you proffered. Even when a more restricted definition of the Metropolitan Area is taken, what we said is broadly correct. We knew about Wessex! It has further to be kept in mind that, in order to be on the safe side in our comparison, we made no allowance for post-war private practice, and we imagine that private practice is fairly heavily concentrated in the London area. Our original statement stands that " the National Health Service has not changed greatly the distribution of consultants as between London and the provinces ". JOHN JEWKES SYLVIA JEWKES.
Oxford.
APPROVED NAMES
SIR,-One
approved of trade
answer to
names are to
Dr. Edwards’ query (July 15) why preferred is the superabundance
be
names.
Here are 2 examples from the British National Formulary: phenoxymethylpenicillin:’Calcipen V ’, ’Compocillin V ’, Crystapen V ’, ’Distaquaine V ’, ’Eskacillin V ’,Icipen V ’, ’