- Email: [email protected]
THE FUTURE OF CLINICAL TEACHING
389
LETTERS TO THE EDITOR THE G.P. AND THE VOLUNTARY HOSPITAL
SIR,—Recent correspondence in your columns has revealed defects in the voluntary system as we know it. Briefly stated these are: (1) Excessivecentralisation of medical and surgical work. (2) Concentration of all serious illness in the hands of a relatively small section of the profession. (3) Isolation of the
general practitioner from all hospital contacts. (4) Failure to provide for chronic and incurable illness. (5) Tendency to excessive specialisation. And they have had two disastrous consequences: (a) Expensive treatment for all private and non-benefit patients. {b) A general practitioner class which becomes more depressed, spiritually and economically, as the years go by. The remedy proposed by many is a state medical service. Decentralisation of hospitals, multiplication of specialists, and an assured income for all are envisaged in the scheme. Even the general practitioner seems to agree that he has no part in a hospital scheme, judging by the absence of any claims put forward. In my view the public will be very foolish if they agree to such a service. Free choice of doctor is a privilege they should never give up. It is the only check they have on medical autocracy. No section of the community is fit to be trusted with absolute power, our own no more than any other. Is there I no half-way measure between the two extremes? suggest there is. In the first place, the foundation of all services depends upon the general practitioner, and to be a really good practitioner one must have had hospital experience and retain some contact with hospital life. Let us keep our splendid teaching hospitals and staffs, and by decentralisation relieve them of the
congestion per cent.
that is
slowly choking them. Seventy-five of ordinary medical and surgical cases
should be treated in the smaller hospitals. We ought not to be satisfied until the country is covered with a network of hospitals each of about one hundred beds, working in group areas around the great teaching centres. Let these be staffed by general practitioners, and let a body of consultants be available from the big centres when required. Specialisation should be restricted to men attached to teaching schools and large hospitals-incidentally, even specialists should have to spend at least twelve months with an approved general practitioner. It is in practice that the beginnings of disease are seen and the greatest difficulty in diagnosis arises. Further, the specialist would have a far better understanding of the difficulties of
practice. It may be argued that the scheme is impossible. I would reply that there are hospitals in this country where the system is worked successfully, and where the relations between consultants and practitioners are excellent. The private work of the consultant has not suffered. To the practitioner it has meant a level of higher work, a better standard of living, and a firmer hold on the respect of the community. T
Kendal.
am.
Sir.
yours
faithfully
C. M. CRAIG.
THE FUTURE OF CLINICAL TEACHING
SIR,—If my calculations are correct, the remunerasuggested by Professor Ryle for consultants at present attached to the twelve teaching hospitals in London alone would amount to £438,000 per annum. To this would have to be added the salaries of registrars and housemen, who naturally would have to be
tion
more than they are at present; and it is also certain that the state will have to contribute an enormous sum towards the maintenance of the voluntary hospitals. It is true that Professor Ryle envisages a considerable reduction in the proportion of staff to beds, but against this must be set the inevitable and considerable increase in the number of beds which must be provided. When one reflects that similarly gigantic sums would have to be found for Glasgow and Edinburgh, Liverpool and Manchester, and many other places, one begins to wonder if even an Independent Progressive Government would be able to provide the necessary money, appealing though might be the prospect of consultants abandoning their luxury cars and country cottages, elevating their debased ethical and teaching standards, and discussing " service " in the refectory. I am, Sir, vour obedient servant,
paid considerably
MAURICE CASSIDY.
Montagu Square, W.1. A. P. T.
SIR,—The Oxford Dictionary defines " discredited " as " brought into discredit or disrepute " and in this classical work are to be found such terms as: " loss or want of credit; reproach; loss or absence of reputation ; ill repute; disesteem;" dishonour" applied to the words "discredit" and disrepute." On reading the leading article in your issue of Feb. 10 on the prevention of diphtheria two things struck me about the phrase (in parenthesis) "theone shot’ method of administering A.P.T. is now completely discredited." The first of these was the persistence of the expression ‘‘ one shot" and its repetition in a journal like THE LANCET, the second was the use of the word " discredited" and the emphasising effect of its qualifying adjective. Unless I am mistaken, I think TRE LANCET was the first British journal to publish results of the clinical application of A.P.T. so that you must take your share of the various reproachful meanings embraced under the words " completely discredited." I am not quite sure, however, that the single-dose method of administering A.P.T. deserves all these strictures. In the first place it may surely be said that, if it has not achieved repute of itself, it has at least blazed the way for the methods which followed it; nor, secondly, am I quite so certain that it has deserved the discredit which has been attached to it. Wehave records in this department of 2791 children who were treated by the single-dose method between December, 1934, and December, 1936, and of this number seven havesubsequently developed clinical diphtheria, which is approximately 0.25 per cent. I am aware, of course, that there is a considerable volume of experimental work which tends to prove that there is a more rapid elimination of circulating antitoxin with the single-dose method than with multiple injections; but it seems to me that the acid test is actual experience in the field rather than experimental work in the laboratory, and it is difficult to conceivehow any method can show a better result than this; for it must be remembered that there are still carriers in this community and still cases of diphtheria, although the latter have been very considerably reduced—largely, I believe, through the instrumentality of A.P.T. used in single doses. In common with other workers the method of choice here now is the multiple dose, which I believe is probably the correct one; at the same time I think it is quite incorrect to assume that the older method has
LETTERS TO THE EDITOR THE G.P. AND THE VOLUNTARY HOSPITAL
SIR,—Recent correspondence in your columns has revealed defects in the voluntary system as we know it. Briefly stated these are: (1) Excessivecentralisation of medical and surgical work. (2) Concentration of all serious illness in the hands of a relatively small section of the profession. (3) Isolation of the
general practitioner from all hospital contacts. (4) Failure to provide for chronic and incurable illness. (5) Tendency to excessive specialisation. And they have had two disastrous consequences: (a) Expensive treatment for all private and non-benefit patients. {b) A general practitioner class which becomes more depressed, spiritually and economically, as the years go by. The remedy proposed by many is a state medical service. Decentralisation of hospitals, multiplication of specialists, and an assured income for all are envisaged in the scheme. Even the general practitioner seems to agree that he has no part in a hospital scheme, judging by the absence of any claims put forward. In my view the public will be very foolish if they agree to such a service. Free choice of doctor is a privilege they should never give up. It is the only check they have on medical autocracy. No section of the community is fit to be trusted with absolute power, our own no more than any other. Is there I no half-way measure between the two extremes? suggest there is. In the first place, the foundation of all services depends upon the general practitioner, and to be a really good practitioner one must have had hospital experience and retain some contact with hospital life. Let us keep our splendid teaching hospitals and staffs, and by decentralisation relieve them of the
congestion per cent.
that is
slowly choking them. Seventy-five of ordinary medical and surgical cases
should be treated in the smaller hospitals. We ought not to be satisfied until the country is covered with a network of hospitals each of about one hundred beds, working in group areas around the great teaching centres. Let these be staffed by general practitioners, and let a body of consultants be available from the big centres when required. Specialisation should be restricted to men attached to teaching schools and large hospitals-incidentally, even specialists should have to spend at least twelve months with an approved general practitioner. It is in practice that the beginnings of disease are seen and the greatest difficulty in diagnosis arises. Further, the specialist would have a far better understanding of the difficulties of
practice. It may be argued that the scheme is impossible. I would reply that there are hospitals in this country where the system is worked successfully, and where the relations between consultants and practitioners are excellent. The private work of the consultant has not suffered. To the practitioner it has meant a level of higher work, a better standard of living, and a firmer hold on the respect of the community. T
Kendal.
am.
Sir.
yours
faithfully
C. M. CRAIG.
THE FUTURE OF CLINICAL TEACHING
SIR,—If my calculations are correct, the remunerasuggested by Professor Ryle for consultants at present attached to the twelve teaching hospitals in London alone would amount to £438,000 per annum. To this would have to be added the salaries of registrars and housemen, who naturally would have to be
tion
more than they are at present; and it is also certain that the state will have to contribute an enormous sum towards the maintenance of the voluntary hospitals. It is true that Professor Ryle envisages a considerable reduction in the proportion of staff to beds, but against this must be set the inevitable and considerable increase in the number of beds which must be provided. When one reflects that similarly gigantic sums would have to be found for Glasgow and Edinburgh, Liverpool and Manchester, and many other places, one begins to wonder if even an Independent Progressive Government would be able to provide the necessary money, appealing though might be the prospect of consultants abandoning their luxury cars and country cottages, elevating their debased ethical and teaching standards, and discussing " service " in the refectory. I am, Sir, vour obedient servant,
paid considerably
MAURICE CASSIDY.
Montagu Square, W.1. A. P. T.
SIR,—The Oxford Dictionary defines " discredited " as " brought into discredit or disrepute " and in this classical work are to be found such terms as: " loss or want of credit; reproach; loss or absence of reputation ; ill repute; disesteem;" dishonour" applied to the words "discredit" and disrepute." On reading the leading article in your issue of Feb. 10 on the prevention of diphtheria two things struck me about the phrase (in parenthesis) "theone shot’ method of administering A.P.T. is now completely discredited." The first of these was the persistence of the expression ‘‘ one shot" and its repetition in a journal like THE LANCET, the second was the use of the word " discredited" and the emphasising effect of its qualifying adjective. Unless I am mistaken, I think TRE LANCET was the first British journal to publish results of the clinical application of A.P.T. so that you must take your share of the various reproachful meanings embraced under the words " completely discredited." I am not quite sure, however, that the single-dose method of administering A.P.T. deserves all these strictures. In the first place it may surely be said that, if it has not achieved repute of itself, it has at least blazed the way for the methods which followed it; nor, secondly, am I quite so certain that it has deserved the discredit which has been attached to it. Wehave records in this department of 2791 children who were treated by the single-dose method between December, 1934, and December, 1936, and of this number seven havesubsequently developed clinical diphtheria, which is approximately 0.25 per cent. I am aware, of course, that there is a considerable volume of experimental work which tends to prove that there is a more rapid elimination of circulating antitoxin with the single-dose method than with multiple injections; but it seems to me that the acid test is actual experience in the field rather than experimental work in the laboratory, and it is difficult to conceivehow any method can show a better result than this; for it must be remembered that there are still carriers in this community and still cases of diphtheria, although the latter have been very considerably reduced—largely, I believe, through the instrumentality of A.P.T. used in single doses. In common with other workers the method of choice here now is the multiple dose, which I believe is probably the correct one; at the same time I think it is quite incorrect to assume that the older method has