- Email: [email protected]
THE GENERAL PRACTITIONER AS REGISTRAR
1238
Letters
to
the Editor
F.R.C.S.
SIR,-As a fellow or honorary fellow of all four Royal Colleges in the British Isles, but with responsibility for none, I wish to express a strong plea for unification of the fellowship examination. There are historic and practical reasons for maintaining the identity of the four colleges, for each has important responsibilities in its own territory, but I know no justification for continuing the practice of conferring diplomas which are the passport to surgical appointments in many overseas countries, as well as in our National Health Service, on the basis of four separate examinations under four sets of conditions. The matter should be capable of agreement. The four Royal Colleges already admit reciprocity in respect of the primary examinations and the arrangements have worked well, and to general satisfaction, over a number of years. Representatives of the four colleges meet regularly to confer on these and other matters and their relations are extremely cordial. I suggest that they should now set up a Joint Examination Board, to conduct both primary and final examinations (probably in each of the four centres in some sort of rotation) on a non-profit basis. Successful candidates would be required to seek admission to the college of their choice and would then be entitled to the description F.R.C.S. without qualification. The
desirability of some such plan has been expressed in
your columns
would
on
many occasions.
I have
no
doubt it
emphatic support from all those who are now merely apprentices but will be leading members of the profession in the years to come. I have no doubt it meet
with
would enhance the influence of British surgery in the world
at
large.
University
of
Glasgow.
CHARLES ILLINGWORTH.
THE GENERAL PRACTITIONER AS REGISTRAR
experience of working with G.P. registrars (six all) in three specialties—paediatrics, and obstetrics, dermatology-over a period of ten years, SIR,-From
our
in
would endorse the conclusions of Dr. Keable-Elliot and his colleagues (Nov. 7) that these appointments play a valuable part in the hospital service. We speak primarily from the point of view of the consultant or hospital. we
Many hospitals now depend on Commonwealth or foreign registrars. The quality is uneven and the choice increasingly restricted. Although willing, they are often of little assistance during their first months, and only towards the end of their limited appointment do they become really useful. The cycle then begins again. The G.P. registrar not only provides continuity, but, by reason of his accumulated experience, becomes an increasingly valuable member of the staff. This is especially so with urgency work. Their intimate knowledge of local services and the social and economic conditions of the area means that the patient gets better overall care. This side of the patients’ welfare is often neglected or inadequately dealt with by a registrar with a different cultural background. And, in addition, the turnover of beds is increased. The G.P. registrar, by reason of his maturity, is more aware of the importance of human relations in and out of hospital. He can quickly anticipate, and often settle, minor difficulties which otherwise might easily assume exaggerated importance and occupy a disproportionate amount of the time of a consultant or
administrator.
A consultant working in a provincial hospital tends to be isolated in his specialty. Other members of his staff are much junior in age and experience. Discussion is, of necessity, limited, and he may find himself living almost in an ivory tower. A G.P. registrar is more likely to be of a similar N.H.S. seniority and, with his wider general experience, can make suggestions or offer advice which can serve as a salutary reminder to the consultant that the fount of wisdom is deeper than he thought. One criticism (Dr. Meadow, Nov. 21) is that a G.P. registrar may not be available for urgencies. He has, by his terms of service, to be readily available for his list-patients and has organised his work accordingly. We have found G.P. registrars at least as available as a full-time registrar, who may be on the staff of several hospitals, and is now often non-resident. Other practitioners welcome these appointments, because they realise that their patients thereby get a higher standard of care than they would otherwise, and the liaison between hospital and G.P. services is improved. Our G.P. registrars are in partnerships (not, as it happens, with each other). This is probably essential. The appointments should be for several sessions weekly, and should include both outpatient and inpatient responsibilities. The G.P. registrar then feels himself a full member of the firm and is accepted as such by the hospital staff. The amount of responsibility that a G.P. registrar can reasonably accept is limited because, under the present system, he has no long-term security of tenure for his hospital work. This, we think, is primarily the reason why Dr. Meadow has found a conflict of interests ". The new intermediate grade of medical assistant is permanent and seems to fill this need, and we hope that the G.P. registrars will be given due credit for their years of service and insecurity. The Gillie report showed that in September, 1962, the number of practitioners working in paid appointments in hospitals, excluding these attending patients in general-practitionerhospital units, was 3408. Very many of these would be of registrar status or above. The chief medical officer of the Ministry of Health has estimated that the proportion of doctors engaged in general practice who carried out some kind of hospital appointment was about one in four. Unless quick action is taken on this recommendation of the Platt report, the hospital service may well lose many of these men wholly to general practice, where the terms and conditions of service are being reviewed and improved. If this happens there will be a rapid falling off in the standard of hospital work which in very many areas is already limited by staff difficulties. The Ministry of Health has given a lead in Circular H.M.(64)94. The need for action is urgent. We suggest that decisions on this grade should be made only after full consultation locally, and not on "
an arbitrary " optimum " national or regional basis by assessors unfamiliar with local conditions. Most of our G.P. registrars were previously on the hospital staff as house-officers and/or registrars with postgraduate diplomas. Some, after completing their resident appointments, were encouraged and helped to settle in practice locally with a view to retaining their services for the hospital. This is an arrangement that could be more widely adopted. There must be many occasions when a hospital would like to retain the services of a good middle-grade resident. At the same time there may well be in the hospital catchment area a G.P. looking for help whose practice would not sustain a full partner. By this arrangement the G.P. could obtain his partner; the hospital would continue to have the part-time services of a trained ex-resident of proved ability; and the resident would be able to continue in the specialty of his choice.
Many hospitals which wish to employ part-time G.P. registrars may not be able to keep staff in this manner. Instead, they could employ a promising untrained G.P. in the clinical-assistant grade-normally a limited appointment. If this proved a success he could then be promoted to the permanent grade of medical assistant. It seems to us that the medical-assistant grade will be of greater value to the hospital service when used in this manner than as a
1239
grade
for
time-expired
senior
registrars
or
Royal Infirmary, Huddersfield, Yorks.
MEDIC-ALERT
perennial
S.H.M.O.S.
W. P. SWEETNAM E. GLEDHILL A. J. E. BARLOW.
CLINICAL TRIAL OF FRUSEMIDE SIR,-Iread with interest the reports of Dr. Robson and his coworkers and Dr. Verel and his coworkers
(Nov. 21). They have
substantiated the claim that frusemide is an effective oral diuretic, but it is difficult from their papers to learn much of the side-effects. In the paper by Dr. Verel and his colleagues, table I shows levels of electrolytes and urea which presumably correspond to the start of treatment. No
change in these levels is shown as the result of the treatment, either with frusemide or with the alternative diuretics. One would certainly expect a change, for example, in the level of serum-potassium when triamterene was given in a dose of 200 mg. daily together with 1 g. of potassium bicarbonate daily; this seems to have happened in cases 11 and 12. One would also expect many of the diuretics used to cause a rise in the level of blood-urea. The average urinary excretion of potassium in cases 11 and 12 was two to three times as great with frusemide as with triamterene, as is seen in table n, I find this difficult to reconcile with the statement in the discussion: " After administration of triamterene there is a slightly greater loss of potassium compared with the loss after frusemide." Finally, Dr. Verel and his colleagues say in their summary that frusemide in a dose of 80 mg. is a more potent diuretic than triamterene in a dose of 100 mg., yet both cases 11 and 12 were given 200 mg. of triamterene. Edgware General Hospital, G. S. C. SOWRY. Edgware, Middlesex.
SiR,—We should like to comment on the article by Dr. Verel and his colleagues (Nov. 21). They state: Chlorthalidone, on the other hand, conserves potassium better than does frusemide, but it is a much less efficient diuretic. This poor performance is still evident if 48hour excretion periods are compared." These statements appear to be based on results obtained in two patients, one of whom had a blood-urea of 116 mg. per 100 ml. which might reasonably haveexcluded participation in a comparative diuretic trial. The results in the other patient are derived from a mean "
of four 24-hour urinary output values after chlorthalidone and five 24-hour values after frusemide administration. The unqualified statements of Dr. Verel and his colleagues seem quite unjustified in view of the evidence that (1) neither sodium nor fluid intake was accurately measured; (2) chlorthalidone acts for between 48 and 72 hours, and frusemide for 4 hours, after administration; and (3) an individual patient’s sensitivity to different diuretics varies. In addition, the article does not state which of the two drugs was given first (when the biggest diuresis would be expected). 48-hour excretion periods " are said to have been compared, but no evidence of this is given. In any event they would also be without real significance in comparing diuretic efficacy, unless either weight change or the findings of totalbalance studies were included.
SiR,-The Medic-Alert Foundation (International), which is sponsored in the United Kingdom and the Republic of Ireland by the Lions Clubs, has announced the extension of its services to these two countries. It is already operating successfully in the United States, Canada, New Zealand and several European countries. The Foundation provides immediate information about patients who are at some specific risk, when casualty officers, or doctors treating them in their homes, or on the streets in emergencies, would benefit from the warning as to the risk involved in giving normal emergency treatment. There are a number of instances in which a patient suffers from some disorder, or is aware of some potential danger to his health, or even his life, for which special precautions need to be taken. But if such a patient is unconscious when he arrives at hospital, or has to be dealt with by a doctor at the scene of an accident or a seizure, he himself is unable to tell the doctor about his disorder or particular danger. The Medic-Alert organisation provides for such people a bracelet which is worn on the wrist, and gives particulars, either of the specific danger concerned, or an indication that this information-perhaps too complicated to be engraved on the bracelet-can be obtained by telephone from the Central Reference Bureau in London. All that the doctor has to do is to telephone the number of this Bureau, with reverse charges, and the information will be supplied immediately on quoting the patient’s reference number, which is engraved on the bracelet. The types of danger most frequently met with and covered by the service include allergy to horse-serum or penicillin, diabetes, epilepsy, a bleeding tendency, and the taking of anticoagulants. It may also be importantto know that the person concerned has had tetanus toxoid. A pamphlet which gives full particulars can be obtained from the Medic-Alert offices in London. Practitioners may wish to keep a small stock so that any patient, who wants to avail himself of the service by becoming a member, can be assisted to do so. It is necessary for any patient’s application to join the organisation to be countersigned by his doctor to ensure that the right information is recorded at the Central Bureau. The scheme will come into operation on Jan. 1, 1965.
This system is organised by an independent non-profitmaking foundation and is not part of the Government Health Services, although its aims and objects have the sympathy and encouragement of the Ministry of Health, and are supported and endorsed by the British Medical Association and other representative bodies, such as the British Epilepsy Association and the British Diabetic Association. Medic-Alert Foundation,
43a, Wigmore St., London, W.1.
Telephone: WELbeck 5995.
Respiratory Diseases , Unit, Northern General Hospital, Edinburgh.
I. W. B. GRANT.
Chest
Unit, City Hospital, Greenbank Drive,
Edinburgh.
N. W. HORNE W. J. H. LECKIE.
Advisory Council.
EPSOM SALTS FOR HYALINE-MEMBRANE DISEASE
"
As with mersalyl, " free-water clearance " plays an important part in diuresis after frusemide; and clinical evaluation of this type of diuretic action, which evokes thirst and rapid restoration of water-loss, can only be made either by carefully controlled balance studies or by estimation of weight change.
BRAIN Chairman
SIR,-Your annotation (Nov. 21) states that alteration or absence of a surface-active alveolar lining in hyalinemembrane disease of the newborn is an important clue to further elucidation of this disorder. There is no evidence to show whether this deficiency starts before or after birth, and I suggest that it is secondary to pulmonary oedema. One possible explanation may be of interest, since evidence is accumulating that the mammalian foetal trachea contains a viscid fluid, and that a foetus does not inhale in utero in the absence of distress.2 The tracheal contents are normally forcibly expelled by intrauterine pressure the moment an infant’s face appears at the vulva. If the contents are not expelled, dilute mucin is drawn 1. 2.
Adams, F. H., Fujiwara, T., Rowshan, G. J. Pediat. 1963, 63, 881. Carter, W. A., Becker, R. F., King, E. J., Barry, W. F. Amer. J. Obstet. Gynec. 1964, 90, 247.
Letters
to
the Editor
F.R.C.S.
SIR,-As a fellow or honorary fellow of all four Royal Colleges in the British Isles, but with responsibility for none, I wish to express a strong plea for unification of the fellowship examination. There are historic and practical reasons for maintaining the identity of the four colleges, for each has important responsibilities in its own territory, but I know no justification for continuing the practice of conferring diplomas which are the passport to surgical appointments in many overseas countries, as well as in our National Health Service, on the basis of four separate examinations under four sets of conditions. The matter should be capable of agreement. The four Royal Colleges already admit reciprocity in respect of the primary examinations and the arrangements have worked well, and to general satisfaction, over a number of years. Representatives of the four colleges meet regularly to confer on these and other matters and their relations are extremely cordial. I suggest that they should now set up a Joint Examination Board, to conduct both primary and final examinations (probably in each of the four centres in some sort of rotation) on a non-profit basis. Successful candidates would be required to seek admission to the college of their choice and would then be entitled to the description F.R.C.S. without qualification. The
desirability of some such plan has been expressed in
your columns
would
on
many occasions.
I have
no
doubt it
emphatic support from all those who are now merely apprentices but will be leading members of the profession in the years to come. I have no doubt it meet
with
would enhance the influence of British surgery in the world
at
large.
University
of
Glasgow.
CHARLES ILLINGWORTH.
THE GENERAL PRACTITIONER AS REGISTRAR
experience of working with G.P. registrars (six all) in three specialties—paediatrics, and obstetrics, dermatology-over a period of ten years, SIR,-From
our
in
would endorse the conclusions of Dr. Keable-Elliot and his colleagues (Nov. 7) that these appointments play a valuable part in the hospital service. We speak primarily from the point of view of the consultant or hospital. we
Many hospitals now depend on Commonwealth or foreign registrars. The quality is uneven and the choice increasingly restricted. Although willing, they are often of little assistance during their first months, and only towards the end of their limited appointment do they become really useful. The cycle then begins again. The G.P. registrar not only provides continuity, but, by reason of his accumulated experience, becomes an increasingly valuable member of the staff. This is especially so with urgency work. Their intimate knowledge of local services and the social and economic conditions of the area means that the patient gets better overall care. This side of the patients’ welfare is often neglected or inadequately dealt with by a registrar with a different cultural background. And, in addition, the turnover of beds is increased. The G.P. registrar, by reason of his maturity, is more aware of the importance of human relations in and out of hospital. He can quickly anticipate, and often settle, minor difficulties which otherwise might easily assume exaggerated importance and occupy a disproportionate amount of the time of a consultant or
administrator.
A consultant working in a provincial hospital tends to be isolated in his specialty. Other members of his staff are much junior in age and experience. Discussion is, of necessity, limited, and he may find himself living almost in an ivory tower. A G.P. registrar is more likely to be of a similar N.H.S. seniority and, with his wider general experience, can make suggestions or offer advice which can serve as a salutary reminder to the consultant that the fount of wisdom is deeper than he thought. One criticism (Dr. Meadow, Nov. 21) is that a G.P. registrar may not be available for urgencies. He has, by his terms of service, to be readily available for his list-patients and has organised his work accordingly. We have found G.P. registrars at least as available as a full-time registrar, who may be on the staff of several hospitals, and is now often non-resident. Other practitioners welcome these appointments, because they realise that their patients thereby get a higher standard of care than they would otherwise, and the liaison between hospital and G.P. services is improved. Our G.P. registrars are in partnerships (not, as it happens, with each other). This is probably essential. The appointments should be for several sessions weekly, and should include both outpatient and inpatient responsibilities. The G.P. registrar then feels himself a full member of the firm and is accepted as such by the hospital staff. The amount of responsibility that a G.P. registrar can reasonably accept is limited because, under the present system, he has no long-term security of tenure for his hospital work. This, we think, is primarily the reason why Dr. Meadow has found a conflict of interests ". The new intermediate grade of medical assistant is permanent and seems to fill this need, and we hope that the G.P. registrars will be given due credit for their years of service and insecurity. The Gillie report showed that in September, 1962, the number of practitioners working in paid appointments in hospitals, excluding these attending patients in general-practitionerhospital units, was 3408. Very many of these would be of registrar status or above. The chief medical officer of the Ministry of Health has estimated that the proportion of doctors engaged in general practice who carried out some kind of hospital appointment was about one in four. Unless quick action is taken on this recommendation of the Platt report, the hospital service may well lose many of these men wholly to general practice, where the terms and conditions of service are being reviewed and improved. If this happens there will be a rapid falling off in the standard of hospital work which in very many areas is already limited by staff difficulties. The Ministry of Health has given a lead in Circular H.M.(64)94. The need for action is urgent. We suggest that decisions on this grade should be made only after full consultation locally, and not on "
an arbitrary " optimum " national or regional basis by assessors unfamiliar with local conditions. Most of our G.P. registrars were previously on the hospital staff as house-officers and/or registrars with postgraduate diplomas. Some, after completing their resident appointments, were encouraged and helped to settle in practice locally with a view to retaining their services for the hospital. This is an arrangement that could be more widely adopted. There must be many occasions when a hospital would like to retain the services of a good middle-grade resident. At the same time there may well be in the hospital catchment area a G.P. looking for help whose practice would not sustain a full partner. By this arrangement the G.P. could obtain his partner; the hospital would continue to have the part-time services of a trained ex-resident of proved ability; and the resident would be able to continue in the specialty of his choice.
Many hospitals which wish to employ part-time G.P. registrars may not be able to keep staff in this manner. Instead, they could employ a promising untrained G.P. in the clinical-assistant grade-normally a limited appointment. If this proved a success he could then be promoted to the permanent grade of medical assistant. It seems to us that the medical-assistant grade will be of greater value to the hospital service when used in this manner than as a
1239
grade
for
time-expired
senior
registrars
or
Royal Infirmary, Huddersfield, Yorks.
MEDIC-ALERT
perennial
S.H.M.O.S.
W. P. SWEETNAM E. GLEDHILL A. J. E. BARLOW.
CLINICAL TRIAL OF FRUSEMIDE SIR,-Iread with interest the reports of Dr. Robson and his coworkers and Dr. Verel and his coworkers
(Nov. 21). They have
substantiated the claim that frusemide is an effective oral diuretic, but it is difficult from their papers to learn much of the side-effects. In the paper by Dr. Verel and his colleagues, table I shows levels of electrolytes and urea which presumably correspond to the start of treatment. No
change in these levels is shown as the result of the treatment, either with frusemide or with the alternative diuretics. One would certainly expect a change, for example, in the level of serum-potassium when triamterene was given in a dose of 200 mg. daily together with 1 g. of potassium bicarbonate daily; this seems to have happened in cases 11 and 12. One would also expect many of the diuretics used to cause a rise in the level of blood-urea. The average urinary excretion of potassium in cases 11 and 12 was two to three times as great with frusemide as with triamterene, as is seen in table n, I find this difficult to reconcile with the statement in the discussion: " After administration of triamterene there is a slightly greater loss of potassium compared with the loss after frusemide." Finally, Dr. Verel and his colleagues say in their summary that frusemide in a dose of 80 mg. is a more potent diuretic than triamterene in a dose of 100 mg., yet both cases 11 and 12 were given 200 mg. of triamterene. Edgware General Hospital, G. S. C. SOWRY. Edgware, Middlesex.
SiR,—We should like to comment on the article by Dr. Verel and his colleagues (Nov. 21). They state: Chlorthalidone, on the other hand, conserves potassium better than does frusemide, but it is a much less efficient diuretic. This poor performance is still evident if 48hour excretion periods are compared." These statements appear to be based on results obtained in two patients, one of whom had a blood-urea of 116 mg. per 100 ml. which might reasonably haveexcluded participation in a comparative diuretic trial. The results in the other patient are derived from a mean "
of four 24-hour urinary output values after chlorthalidone and five 24-hour values after frusemide administration. The unqualified statements of Dr. Verel and his colleagues seem quite unjustified in view of the evidence that (1) neither sodium nor fluid intake was accurately measured; (2) chlorthalidone acts for between 48 and 72 hours, and frusemide for 4 hours, after administration; and (3) an individual patient’s sensitivity to different diuretics varies. In addition, the article does not state which of the two drugs was given first (when the biggest diuresis would be expected). 48-hour excretion periods " are said to have been compared, but no evidence of this is given. In any event they would also be without real significance in comparing diuretic efficacy, unless either weight change or the findings of totalbalance studies were included.
SiR,-The Medic-Alert Foundation (International), which is sponsored in the United Kingdom and the Republic of Ireland by the Lions Clubs, has announced the extension of its services to these two countries. It is already operating successfully in the United States, Canada, New Zealand and several European countries. The Foundation provides immediate information about patients who are at some specific risk, when casualty officers, or doctors treating them in their homes, or on the streets in emergencies, would benefit from the warning as to the risk involved in giving normal emergency treatment. There are a number of instances in which a patient suffers from some disorder, or is aware of some potential danger to his health, or even his life, for which special precautions need to be taken. But if such a patient is unconscious when he arrives at hospital, or has to be dealt with by a doctor at the scene of an accident or a seizure, he himself is unable to tell the doctor about his disorder or particular danger. The Medic-Alert organisation provides for such people a bracelet which is worn on the wrist, and gives particulars, either of the specific danger concerned, or an indication that this information-perhaps too complicated to be engraved on the bracelet-can be obtained by telephone from the Central Reference Bureau in London. All that the doctor has to do is to telephone the number of this Bureau, with reverse charges, and the information will be supplied immediately on quoting the patient’s reference number, which is engraved on the bracelet. The types of danger most frequently met with and covered by the service include allergy to horse-serum or penicillin, diabetes, epilepsy, a bleeding tendency, and the taking of anticoagulants. It may also be importantto know that the person concerned has had tetanus toxoid. A pamphlet which gives full particulars can be obtained from the Medic-Alert offices in London. Practitioners may wish to keep a small stock so that any patient, who wants to avail himself of the service by becoming a member, can be assisted to do so. It is necessary for any patient’s application to join the organisation to be countersigned by his doctor to ensure that the right information is recorded at the Central Bureau. The scheme will come into operation on Jan. 1, 1965.
This system is organised by an independent non-profitmaking foundation and is not part of the Government Health Services, although its aims and objects have the sympathy and encouragement of the Ministry of Health, and are supported and endorsed by the British Medical Association and other representative bodies, such as the British Epilepsy Association and the British Diabetic Association. Medic-Alert Foundation,
43a, Wigmore St., London, W.1.
Telephone: WELbeck 5995.
Respiratory Diseases , Unit, Northern General Hospital, Edinburgh.
I. W. B. GRANT.
Chest
Unit, City Hospital, Greenbank Drive,
Edinburgh.
N. W. HORNE W. J. H. LECKIE.
Advisory Council.
EPSOM SALTS FOR HYALINE-MEMBRANE DISEASE
"
As with mersalyl, " free-water clearance " plays an important part in diuresis after frusemide; and clinical evaluation of this type of diuretic action, which evokes thirst and rapid restoration of water-loss, can only be made either by carefully controlled balance studies or by estimation of weight change.
BRAIN Chairman
SIR,-Your annotation (Nov. 21) states that alteration or absence of a surface-active alveolar lining in hyalinemembrane disease of the newborn is an important clue to further elucidation of this disorder. There is no evidence to show whether this deficiency starts before or after birth, and I suggest that it is secondary to pulmonary oedema. One possible explanation may be of interest, since evidence is accumulating that the mammalian foetal trachea contains a viscid fluid, and that a foetus does not inhale in utero in the absence of distress.2 The tracheal contents are normally forcibly expelled by intrauterine pressure the moment an infant’s face appears at the vulva. If the contents are not expelled, dilute mucin is drawn 1. 2.
Adams, F. H., Fujiwara, T., Rowshan, G. J. Pediat. 1963, 63, 881. Carter, W. A., Becker, R. F., King, E. J., Barry, W. F. Amer. J. Obstet. Gynec. 1964, 90, 247.