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THE SPECIAL FUNCTION OF THE GENERAL PRACTITIONER
978
Letters
to
in
the Editor
hospital, specialised. specialised.
AFRICA TODAY
SIR,-Your excellent article (April 11) is timely and provocative, especially your sections on postgraduate training, experts, and Britain’s part. Postgraduate Training The present system of bright young graduates going to Europe and America to cram for postgraduate degrees, only to have to return again for further specialist training, is wasteful to the developing countries. It robs the teaching institutions of their best material at a time when these young doctors could help to maintain at a high level the standards of junior appointments so necessary to the efficient running of a good teaching
hospital. To expect the
existing teaching
staff of the
overseas
univer-
sities, with their increasing undergraduate commitments,
to
undertake unaided a postgraduate programme is unrealistic. The obvious solution is for Britain and other developed countries to provide help to achieve the first phase of the postgraduate programme-the trainee specialist stage-abroad; and yet remain the medical epicentre for the second and more important phase of postgraduate education. This approach is not novel in Britain. The Liverpool School of Tropical Medicine has for some years helped to organise and run a diploma in tropical medicine in Thailand and at the same time has provided the opportunity for mature Thai graduates to learn research methods and techniques in Liverpool. The recent announcement of extra lecturers to the Tropical Schools is a step in the right direction, but must be extended to cover other medical schools if the postgraduate teaching programmes in the tropics are to be successfully launched and efficiently maintained.
Experts The expert who is a " doer " is the only one worth having. In Ibadan, we have had excellent examples of such persons. The Nuffield professors have always been a great asset to students and staff. This summer a professor of statistics and an expert in helminth immunology are each spending two months in Ibadan, at the request of the department of preventive medicine. Both are coming under the auspices of the Ford Foundation, both are clear-as to what they propose to do, and both are badly needed as active consultants. Britain’s Part Until the Department of Technical Cooperation can be approached directly, its value to university institutions will be minimal. What interest could a local Ministry have in a request for a medical entomologist by a university department ? Moreover the administrative intricacies of an approach through the local Government are well known. People who are approaching or have reached retiring age have a great part to play. Several such persons are at present working most successfully in the universities of Africa. The following anecdote will illustrate how far opinion in Britain can be from the attitude of mind that-in your final paragraph-you suggest should exist towards British workers overseas. At a recent interview for a provincial consultant appointment an overseas candidate-who incidentally had to pay his own air fare of approximately £ 200-was asked if he realised that coronary disease was very common in Britain. This question was put to a person who had for the past eight years been teaching clinical medicine for the London M.B.
degree. Department of Preventive and Social Medicine, University of Ibadan,
H. M. GILLES.
Nigeria.
THE SPECIAL FUNCTION OF THE GENERAL PRACTITIONER
SiR,-Most consultants see group practice as one doctor doing obstetrics, another geriatrics, another psychiatry, and
so on.
This is
really
an
extension of their
own
work
where medicine is getting But general practice is
more
and
more
essentially
not
In fact, some of the problems are not necessarily finite clinical entities with solutions, but facets of life in continuous change. In a particular family one particular problem may have a bearing on the problems of other members of the family, and the only possible doctor who can assess the nuances of emotion is the general practitioner. I admit that in a practice of two, three, or four doctors there is almost bound to be one who tends to do more obstetrics, one who tends to do more psychiatry, and so on. Nevertheless the initial choice of doctor by a patient depends as much on variable qualities in the doctor (age and sex are obvious examples) as on the doctor’s own interest in a particular medical subject. Why, during busy surgery hours, does a patient choose to wait and see Dr. X when Dr. Y is immediately available ? The following week the roles of Dr. X and Dr. Y may be reversed. A consultation in general practice is much more a two-way exchange between doctor and patient than ever it is in hospital, and this is where the subtle blending of the art and science of medicine
takes
place.
We are approaching a national shortage of doctors. This will not get any better during the next ten years, because there are not enough undergraduate places in medical schools. We will have to be content, therefore, with the same number of doctors in the N.H.S. for the next decade or more.
With increased clerical and nursing help the present number could cope with practically all the day-to-day work in their own premises. Well-trained, well-housed, adequately assisted general practitioners with access to laboratory facilities could run a vastly improved domiciliary health service. West Drayton, Middlesex.
A. D. BOWMAN.
TRAUMA AND MULTIPLE SCLEROSIS
SIR,-Dr. Miller’s suggestion (April 18) that trauma previously silent multiple sclerosis into an overt disease is borne out by three necropsies in my experience. The first patient died within 48 hours of craniotomy for division of the sensory root of a trigeminal nerve, and the second within a similar period after removal of an acoustic-nerve tumour. In neither was multiple sclerosis suspected, nor was the postoperative collapse explained at necropsy by haemorrhage or by any other surgical mishap. But examination of the brain revealed numerous old plaques in the cerebral white matter and can convert
brain-stem in both. The third patient, a middle-aged woman, sustained a head injury which resulted in slight coup and contre-coup contusions of the temporal lobes. Consciousness was never regained, and the patient died about three weeks after the accident. Since this course of events was clinically inexplicable I was asked to seek for a complication. Again, examination disclosed a large number of old plaques in both cerebral hemispheres.
It was disappointing to find no microscopic evidence of reactivation of the multiple sclerosis in these three cases: the modus operandi of the trauma remains a mystery, but I regard cranial injury as potentially lethal in this disease. DOROTHY S. RUSSELL Dorking, Surrey,
SIR,-Dr. Miller’s article prompts me to report a moderately advanced case of multiple sclerosis in a woman, aged forty-six, seen just ten days ago. This patient was symptom-free until a spinal anaesthetic for cxsarean section performed nine and a half years ago. Three days after the lumbar puncture she experienced recurring flashes of light in her left eye, followed by dimness of vision. Low-back pain and weakness came on about the same time, to e a degree that seemed out of proportion to expected postoperative influences. The patient and her husband are both quite cate-
Letters
to
in
the Editor
hospital, specialised. specialised.
AFRICA TODAY
SIR,-Your excellent article (April 11) is timely and provocative, especially your sections on postgraduate training, experts, and Britain’s part. Postgraduate Training The present system of bright young graduates going to Europe and America to cram for postgraduate degrees, only to have to return again for further specialist training, is wasteful to the developing countries. It robs the teaching institutions of their best material at a time when these young doctors could help to maintain at a high level the standards of junior appointments so necessary to the efficient running of a good teaching
hospital. To expect the
existing teaching
staff of the
overseas
univer-
sities, with their increasing undergraduate commitments,
to
undertake unaided a postgraduate programme is unrealistic. The obvious solution is for Britain and other developed countries to provide help to achieve the first phase of the postgraduate programme-the trainee specialist stage-abroad; and yet remain the medical epicentre for the second and more important phase of postgraduate education. This approach is not novel in Britain. The Liverpool School of Tropical Medicine has for some years helped to organise and run a diploma in tropical medicine in Thailand and at the same time has provided the opportunity for mature Thai graduates to learn research methods and techniques in Liverpool. The recent announcement of extra lecturers to the Tropical Schools is a step in the right direction, but must be extended to cover other medical schools if the postgraduate teaching programmes in the tropics are to be successfully launched and efficiently maintained.
Experts The expert who is a " doer " is the only one worth having. In Ibadan, we have had excellent examples of such persons. The Nuffield professors have always been a great asset to students and staff. This summer a professor of statistics and an expert in helminth immunology are each spending two months in Ibadan, at the request of the department of preventive medicine. Both are coming under the auspices of the Ford Foundation, both are clear-as to what they propose to do, and both are badly needed as active consultants. Britain’s Part Until the Department of Technical Cooperation can be approached directly, its value to university institutions will be minimal. What interest could a local Ministry have in a request for a medical entomologist by a university department ? Moreover the administrative intricacies of an approach through the local Government are well known. People who are approaching or have reached retiring age have a great part to play. Several such persons are at present working most successfully in the universities of Africa. The following anecdote will illustrate how far opinion in Britain can be from the attitude of mind that-in your final paragraph-you suggest should exist towards British workers overseas. At a recent interview for a provincial consultant appointment an overseas candidate-who incidentally had to pay his own air fare of approximately £ 200-was asked if he realised that coronary disease was very common in Britain. This question was put to a person who had for the past eight years been teaching clinical medicine for the London M.B.
degree. Department of Preventive and Social Medicine, University of Ibadan,
H. M. GILLES.
Nigeria.
THE SPECIAL FUNCTION OF THE GENERAL PRACTITIONER
SiR,-Most consultants see group practice as one doctor doing obstetrics, another geriatrics, another psychiatry, and
so on.
This is
really
an
extension of their
own
work
where medicine is getting But general practice is
more
and
more
essentially
not
In fact, some of the problems are not necessarily finite clinical entities with solutions, but facets of life in continuous change. In a particular family one particular problem may have a bearing on the problems of other members of the family, and the only possible doctor who can assess the nuances of emotion is the general practitioner. I admit that in a practice of two, three, or four doctors there is almost bound to be one who tends to do more obstetrics, one who tends to do more psychiatry, and so on. Nevertheless the initial choice of doctor by a patient depends as much on variable qualities in the doctor (age and sex are obvious examples) as on the doctor’s own interest in a particular medical subject. Why, during busy surgery hours, does a patient choose to wait and see Dr. X when Dr. Y is immediately available ? The following week the roles of Dr. X and Dr. Y may be reversed. A consultation in general practice is much more a two-way exchange between doctor and patient than ever it is in hospital, and this is where the subtle blending of the art and science of medicine
takes
place.
We are approaching a national shortage of doctors. This will not get any better during the next ten years, because there are not enough undergraduate places in medical schools. We will have to be content, therefore, with the same number of doctors in the N.H.S. for the next decade or more.
With increased clerical and nursing help the present number could cope with practically all the day-to-day work in their own premises. Well-trained, well-housed, adequately assisted general practitioners with access to laboratory facilities could run a vastly improved domiciliary health service. West Drayton, Middlesex.
A. D. BOWMAN.
TRAUMA AND MULTIPLE SCLEROSIS
SIR,-Dr. Miller’s suggestion (April 18) that trauma previously silent multiple sclerosis into an overt disease is borne out by three necropsies in my experience. The first patient died within 48 hours of craniotomy for division of the sensory root of a trigeminal nerve, and the second within a similar period after removal of an acoustic-nerve tumour. In neither was multiple sclerosis suspected, nor was the postoperative collapse explained at necropsy by haemorrhage or by any other surgical mishap. But examination of the brain revealed numerous old plaques in the cerebral white matter and can convert
brain-stem in both. The third patient, a middle-aged woman, sustained a head injury which resulted in slight coup and contre-coup contusions of the temporal lobes. Consciousness was never regained, and the patient died about three weeks after the accident. Since this course of events was clinically inexplicable I was asked to seek for a complication. Again, examination disclosed a large number of old plaques in both cerebral hemispheres.
It was disappointing to find no microscopic evidence of reactivation of the multiple sclerosis in these three cases: the modus operandi of the trauma remains a mystery, but I regard cranial injury as potentially lethal in this disease. DOROTHY S. RUSSELL Dorking, Surrey,
SIR,-Dr. Miller’s article prompts me to report a moderately advanced case of multiple sclerosis in a woman, aged forty-six, seen just ten days ago. This patient was symptom-free until a spinal anaesthetic for cxsarean section performed nine and a half years ago. Three days after the lumbar puncture she experienced recurring flashes of light in her left eye, followed by dimness of vision. Low-back pain and weakness came on about the same time, to e a degree that seemed out of proportion to expected postoperative influences. The patient and her husband are both quite cate-