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THE WORK-LOAD IN GENERAL PRACTICE
354 CONCLUSIONS FOR ENGLAND AND WALES
The board’s original proposal would add the equivalent of 5000 whole-time doctors to the staffs of hospitals in five years. The Minister thinks this impracticable. But the foreseeable supply of new graduates, the continued service of some young doctors for longer periods, and the use of the medical-assistant grade can go some way towards it: and the Minister is discussing with the Joint Consultants Committee how the older doctors would continue to give service. HOSPITAL STAFFING IN SCOTLAND
The Secretary of State for Scotland has accepted the recommendations of the Wright Committee.* This committee, which was asked to make recommendations in the light of the Platt report, proposed an increase from 1097 consultant posts in Scotland at the end of 1961 to approximately 1360. The 1961 figure, which had risen to 1179 by the end of last year, includes both wholetime and part-time consultants, whereas the Wright recommendations are on the basis of whole-time or maximum-part-time appointments. Scaling-up of the present part-time posts to the maximum of nine sessions would be equivalent to the creation of approximately 40 further new consultant posts, making a total increase equivalent to about 300 posts. Corresponding increases were recommended in supporting staff. The Committee agreed with the Platt report that a medical-assistant grade, of unlimited tenure, should be created between consultant and registrar.
Views of General Practice THE WORK-LOAD IN GENERAL PRACTICE D. L. CROMBIE M.D. Birm. GENERAL
PRACTITIONER,
BIRMINGHAM
K. W. CROSS Ph.D. Birm. OF THE COLLEGE OF GENERAL PRACTITIONERS’ RECORDS AND STATISTICAL ADVISORY UNIT, 146, HAGLEY ROAD, BIRMINGHAM, 6
SOME general practitioners carry a much heavier workload than others. This load can be related to the " busy" of a practice, and outside Great Britain it is probably ness related directly to remuneration. But in this country, for patients on the National Health Service list, remuneration is based on the number of patients at risk rather than the number of services rendered. The work-load of any practitioner can be measured in terms of the time he spends in the conduct of his practice and also by the number and variety of the consultations which he provides in any given period. Some practitioners work faster than others. TIME SPENT IN GENERAL PRACTICE
This can be considered under the following headings: time spent in effective contact with the patients; travelling time; administrative time; time spent in other medical activities (insurance examinations, &c.); and time spent in contact with patients about matters unconnected with their health. Table I shows the time spent by one of us (D. L. C.) during twelve months’ general practice in 1954 in the suburbs of Birmingham (Crombie and Cross 1956), and table 11 shows the time spent effectively in contact with the patients during November, 1962. In 1962 there had *
Medical Staffing Structure in Scottish Hospitals. Office, 1964. See Lancet, 1964, i, 370.
H.M. Stationery
been little or no change in the relative proportions of total time spent as estimated in 1954. It is probable that time spent in effective contact with the patient is incapable of much reduction in any good general practice. Most general practitioners who run appointment systems allow an average of 5 minutes per patient. The average time spent per consultation in this study was 5-07 minutes. On the other hand, time spent on administration could often be greatly reduced, particularly by delegation to non-medical personnel. In the present study, notwithstanding a determined attempt to delegate everything possible to the secretary, the time spent under this heading was more than a quarter of the time spent in effective contact with patients, and equalled the time spent in travelling. This in turn almost equalled the time spent on effective contact with patients in their own homes. There is also no doubt that every hour spent on administration saved many hours subsequently. The time spent on administration was almost equally divided between services to individual patients, such as letter-writing and arranging appointments, and items which related to the patients as a whole, such as practice organisation. Each week 30 hours were spent effectively in contact with the patients on the National Health Service list while 14 hours were spent on other medical services. The total still does not equal the hours per week during which the doctor was about his business as a general practitioner. These other activities, not specifically measured during the survey but estimated at a later date (1962), included time spent on preventive activities and in contact with
directly concerned with state of the garden, ranged or motor vehicle to weather, philosophical discussions about the doctor-patient relationship within the frame-
patients discussing
matters not
their health. This
from the
work of the health service. All these without doubt are part of good general practice, indirectly benefiting- the patient and the doctor, and cannot be called wasted time, though it was excluded from " effective contact time " in the original survey. In the more recent assessment of the time spent about his practice D. L. C. estimated that on average a further 5 hours of each week were spent in this way. TIME SPENT IN CONTACT WITH THE PATIENT
analysed in table 11: where functions overlapped, the time spent was split equally between them. For instance, a prescription may have been written out while general advice was being given to a patient or while the This is
TABLE II-PERCENTAGE OF TIME SPENT IN CONTACT WITH PATIENT AT
SURGERY AND AT
PATIENT’S
HOME
(1962)
355
practitioner was " therapeutically listening ".
The results, the the fact that however, exemplify general practitioner’s main function is that of assessing clinical situations. More than half of his time was spent on fulfilling this function and less than a quarter on giving formal advice. If to this is added the time taken to write out prescriptions and to prevention, this ratio would be increased to a third. In this survey patients above the age of 65 require three times as much time as patients of 15-29, and patients in the age-group 0-4 required twice as much. In addition to the foregoing, time must also be allowed for activities such as attendance at medical meetings, formal postgraduate education, discussions with colleagues, and research. These estimates take no account of the time which is spent on duty waiting for emergencies and of the disturbing effect of out-of-hours calls. The disruption of normal life caused by these is out of all proportion to the actual time spent with the patient.
In our study these variations are seen to be even greater than they believed. Variations of consultation-rates by geographical area, by town and country, and by the age, sex, and social class of the patient all contribute to these differences. Probably the work-load of practitioners would vary as much if measured by the time spent as when measured by consultation-rates-though it must be emphasised that the figures for time spent in general practice given here are for one practitioner only. For instance, Wood (1962), in a study lasting 14 days in a country practice of 2500 patients in October-November, 1956, estimated that he spent only 10 hours a week with his patients in his surgery but over 30 hours a week in rates.
his patients’ homes. This, however, represents only 55% of the 73 hours of his working week compared with the equivalent figure of 46% in the present survey. The smaller proportion may be due to the use of stricter criteria for effective contact time. It is also important to recognise that the variations, as measured CONSULTATION-RATES by consultation-rates, may be confined to as The structure of general practice in Great Britain, based little as 46% of the total working week, and that a higher consultation-rate does not necessarily represent better as it is on defined lists of patients now including some medical care. 98% of the population, has made it possible to measure In this country it is only roughly true that the fewer some of the variations in work-load by differences in the patients for whom the practitioner is responsible the consultation-rates. It must be remembered that conmore he can do under the heading " other professional sultation-rates are confined to activities classified as effective contact time, which in this study accounted for commitments ". In Great Britain there has been little or no examination only 57% of the general practitioner’s total working time, of general practice by work-study specialists. This is or 46% if travelling time was excluded. Consultationprobably because such a study would not pay for itself. rates are expressed here per 1000 patients at risk per year. Variations of consultation-rates with age and sex.-In the Any increase in efficiency which resulted would be National Morbidity Survey (Logan and Cushion 1958) it reflected in more free time for the practitioner or wider services for his patients. was shown that for a given number of patients, females Many of the ways of saving time depend on ancillary have 18% more illnesses than males and all patients over 65 require nearly twice as many consultations in a given help. This in turn can be most economically used where several practitioners work together. Partnerships also time as those aged 15-44. Consultation-rates and social class.-Consultation-rates imply an ability to rationalise surgery and other clinic times with consequent savings in time for a given number per 1000 males aged 15-44 at risk per annum vary from 2165 for social class I to 3701 for social class v. The of items of medical care. On the other hand, too large a corresponding patient consulting-rates, however, are 544 partnership may lead to the loss of the ideal relationship and 579 respectively. The average consultation-rate for of " one patient-one doctor ". Time saved by any all patients in the National Morbidity Survey is 3800. method can be used to develop the elements of medical The equivalent figures in D. L. C.’s practice in a suburb care which involve personal contact between the practitioner and his patients-contact so essential to the cardinal of Birmingham are 3100 for males and 2900 for females. function of primary assessment of clinical situations. It Geographical variations in consultation-rates can also be can also be used to expand the preventive element in the studied in the National Morbidity Survey. The differof his patients. More time will also be availmedical care ences between various regions of Great Britain presumably able for postgraduate study and research, each of which reflect, among other things, a combination of climatic and occupational factors and differences in the age and sex improves the quality of the practitioner’s service. The wide variation in consultation-rates suggest that distribution of the population. For instance consultationmore study should be made of the characteristics of the rates vary between 2640 per year for East Anglia and practitioners and the patients which are the cause of these 4000 for Wales. The figures so far given reflect the averages from several differences. Also, in view of the current interest in all practices and therefore reflect the differences of morbidity aspects of general practitioners’ work, including their experienced by the community as a whole. When the remuneration, it seems advisable to have a great deal more figures from individual practices are considered, the varia- information about the way in which they spend their tions from 963 consultations to 9152 consultations per professional time. SUMMARY 1000 patients at risk are much greater (Logan and Cushion 1958). The work-load of a general practice in a Birmingham It is fair, from these figures, to assume that there are suburb in 1954 is analysed. greater variations between different practices, and thereOf 44-5 hours per week working as a general practitioner, fore different practitioners, than between different areas was spent in effective contact with patients, 11-5% 0 456°,o in the country, great though the latter may be. on travelling, 11-5% on administration, and 31-4% on DISCUSSION medical commitments outside the National Health SerLees and Cooper (1963) have shown that there are great vice. To this basic 44-5 hours must be added a further variations between general practitioners in their consulting5 hours spent just talking.
356 The National
Morbidity Survey (Logan and Cushion
1958) showed wide variation in the number of doctorpatient contacts (consultations). The average per 1000 patients, per year, varied from 2640 in East Anglia, to 4000 in Wales. The highest and lowest rates for individual practices were 963 and 9162 respectively, a ratio of nearly 10 to 1. More study should be made of the characteristics of the practitioners and the patients which are the cause of these differences. More information is needed about the way in which practitioners spend their professional time. REFERENCES
Crombie, D. L., Cross, K. W. (1956) Brit. J. soc. prev. Med. 10, 141. Lees, D. S., Cooper, M. H. (1963) J. Coll. gen. Pract. 6, 233. Logan, W. P. D., Cushion, A. A., General Register Office Studies on Medical and Population Subjects no. 14, Morbidity Statistics from General Practice. H.M. Stationery Office 1958, vol. I. Wood, L. A. C. (1962) J. Coll. gen. Pract. 5. 379.
Conferences DIABETES FROM A CORRESPONDENT
The 5th Congress of the International Diabetes Federation was held at Toronto, the birthplace of insulin, from July 20 to 24 under the presidency of Dr. H. F. ROOT. It was attended by 1600 medical and scientific delegates and 1000 lay delegates from 44 countries. Islet Cells M. F. SAK (Boston) and his colleagues described the successful homotransplantation of neonatal pancreas into alloxan diabetic golden hamsters, with temporary improvement in the diabetes. Other original papers described the permissive role of the vagus nerves in allowing increased release of insulin-like activity into the pancreaticoduodenal vein of dogs, into whose pancreatic arteries mesoxalate, ethylenediamine tetra-acetate (E.D.T.A.), L-histidine, or glycine had been injected (R. NINOMIYA et al. [Tokyo]). H. ELRICK and colleagues (Denver) provided evidence for a gastrointestinal hormone that stimulates the secretion of insulin in man, for they found a greater and more sustained rise in plasma-insulin by an immuno assay procedure when 20 g. glucose was given orally than when it was given intravenously. Other contributions supported the hypothesis that the blood-sugar level of the pancreatic arterial blood did not provide an adequate explanation for the level of insulin release in the pancreatic venous effluent blood. Thus A. R. COLwELL, Jr., and his two namesakes (Chicago) found that the insulin release provoked by pancreatic arterial hyperglycaemia was insufficient in the ansesthetised dog to produce peripheral hypoglycasmia, and F. C. GoETZ and his colleagues (Minneapolis) found that glucose or galactose injected into the portal vein of dogs produced a striking rise in insulin output without, in most cases, any rise in arterial glucose concentration. This work suggested the presence of receptor sites along the course of the portal vein or in the liver. Other papers described effects of insulin on the transport not only of glucose and aminoacids but also of potassium and inorganic phosphate. Insulin also stimulates pinocytosis and increases the electric potential of cell membranes even in the absence of glucose. Metabolic Characteristics of Selected Tissues M. J. WHICHELOow and other workers at Guy’s Hospital, London, described a significant correlation between glucose uptake in the deep forearm tissues and skinfold thickness, as an index of obesity. Several other workers have found high plasma-insulin levels in obese subjects with or without carbohydrate intolerance. A. WINEGRAD (Philadelphia) illustrated the importance of direct metabolic studies of vascular tissues by his work on the aorta of diabetic and non-diabetic rabbits.
Relation of Angiopathy to Diabetic Control M. K. MACDONALD and J. T. IRELAND (Edinburgh) reported significant thickening of the basement membrane of the glomerular capillaries even before development of carbohydrate intolerance. Yet these electron microscopic studies revealed no qualitative difference between the glomerular lesions of idiopathic and secondary diabetes. Some experimental support for the well-known views of the Joslin Clinic on the importance of diabetic control in limiting complications was given by W. R. HARTROFT (Toronto), who showed the effect of a diet high in unsaturated fat (corn oil) in protecting against atherosclerosis in partly pancreatectomised diabetic rats. Treatment of Diabetic Retinopathy by
Pituitary Ablation Reducing the function of the pituitary has encouraging effects on vision in diabetic retinopathy; but renal function is not improved, and significant renal impairment is one of the important common contraindications to ablative procedures. In the long-term assessment of various treatments on the progress of diabetic retinopathy the value of an untreated control group was described by R. FRASER (London) in relation to yttrium90 implantation of the pituitary, in abstracts submitted by L. J. P. Durrcarr and colleagues (Edinburgh) in relation to the use of ’Atromid’, and by two groups at the Joslin Clinic (Boston) in relation to pituitary ablation and to various medicinal treatments. Good results of the treatment of diabetic retinopathy with anabolic steroids were reported by, among others, A. J. HOUTSMULLER and H. E. HENKES
(Rotterdam). Insulin Immunochemistry and Blood-levels P. H. WRIGHT (Indianapolis) contributed a paper describing the rapid diabetogenic effects of insulin antiserum injected into rabbits. Although he obtained no good evidence of direct damage to the &bgr;-cells he did see inflammatory lesions in the exocrine pancreas. G. M. GRODSKY (San Francisco) was able to show in both rabbits and man that exogenous insulin can produce circulating antibodies that bind and retain large amounts of the endogenous hormone. J. VALLANCE-OWEN (Newcastle upon Tyne) reviewed the synalbumin insulin antagonist which may represent the p-chain of the insulin molecule, and cited evidence for its inheritance as a Mendelian dominant character. There was some disagreement between those doing similar work which only further work is likely to resolve. L. POWER and co-workers (Ann Arbor) described the results of their work on the mechanism of the higher insulin assay levels obtained from diluted than from whole serum. In the past this feature has usually been attributed to a dilutingout effect on physiological insulin antagonists, but the work of Power et al. showed that the insulin added to undiluted serum was recovered quantitatively. This suggested that a more plausible explanation was the release by dilution of a factor which augments insulin activity. I. MAGYAR (Budapest) has measured insulin resistance in diabetic subjects by determining in vitro the glucose consumption of small pieces of excised muscle. In some cases the resistance to insulin appeared to be localised in the muscle itself rather than in the plasma. R. M. EHRLICH and his colleagues (Toronto) had performed plasma-insulin assays in patients with infantile hypoglycaemia and found no evidence of unusually high values. Hormonal and Other Influences on Metabolic Processes Dr. A. SIREK and her colleagues (Toronto) showed very neatly that the hyperglycasmic substance released by growth hormone in dogs was very probably serotonin. R. H. UNGER (Dallas) gave convincing evidence of the physiological role of glucagon. In this connection K. J. WEINGES (Homburg-Saar) delivered a valuable paper describing the part played by glucagon in mobilising the energy from
The board’s original proposal would add the equivalent of 5000 whole-time doctors to the staffs of hospitals in five years. The Minister thinks this impracticable. But the foreseeable supply of new graduates, the continued service of some young doctors for longer periods, and the use of the medical-assistant grade can go some way towards it: and the Minister is discussing with the Joint Consultants Committee how the older doctors would continue to give service. HOSPITAL STAFFING IN SCOTLAND
The Secretary of State for Scotland has accepted the recommendations of the Wright Committee.* This committee, which was asked to make recommendations in the light of the Platt report, proposed an increase from 1097 consultant posts in Scotland at the end of 1961 to approximately 1360. The 1961 figure, which had risen to 1179 by the end of last year, includes both wholetime and part-time consultants, whereas the Wright recommendations are on the basis of whole-time or maximum-part-time appointments. Scaling-up of the present part-time posts to the maximum of nine sessions would be equivalent to the creation of approximately 40 further new consultant posts, making a total increase equivalent to about 300 posts. Corresponding increases were recommended in supporting staff. The Committee agreed with the Platt report that a medical-assistant grade, of unlimited tenure, should be created between consultant and registrar.
Views of General Practice THE WORK-LOAD IN GENERAL PRACTICE D. L. CROMBIE M.D. Birm. GENERAL
PRACTITIONER,
BIRMINGHAM
K. W. CROSS Ph.D. Birm. OF THE COLLEGE OF GENERAL PRACTITIONERS’ RECORDS AND STATISTICAL ADVISORY UNIT, 146, HAGLEY ROAD, BIRMINGHAM, 6
SOME general practitioners carry a much heavier workload than others. This load can be related to the " busy" of a practice, and outside Great Britain it is probably ness related directly to remuneration. But in this country, for patients on the National Health Service list, remuneration is based on the number of patients at risk rather than the number of services rendered. The work-load of any practitioner can be measured in terms of the time he spends in the conduct of his practice and also by the number and variety of the consultations which he provides in any given period. Some practitioners work faster than others. TIME SPENT IN GENERAL PRACTICE
This can be considered under the following headings: time spent in effective contact with the patients; travelling time; administrative time; time spent in other medical activities (insurance examinations, &c.); and time spent in contact with patients about matters unconnected with their health. Table I shows the time spent by one of us (D. L. C.) during twelve months’ general practice in 1954 in the suburbs of Birmingham (Crombie and Cross 1956), and table 11 shows the time spent effectively in contact with the patients during November, 1962. In 1962 there had *
Medical Staffing Structure in Scottish Hospitals. Office, 1964. See Lancet, 1964, i, 370.
H.M. Stationery
been little or no change in the relative proportions of total time spent as estimated in 1954. It is probable that time spent in effective contact with the patient is incapable of much reduction in any good general practice. Most general practitioners who run appointment systems allow an average of 5 minutes per patient. The average time spent per consultation in this study was 5-07 minutes. On the other hand, time spent on administration could often be greatly reduced, particularly by delegation to non-medical personnel. In the present study, notwithstanding a determined attempt to delegate everything possible to the secretary, the time spent under this heading was more than a quarter of the time spent in effective contact with patients, and equalled the time spent in travelling. This in turn almost equalled the time spent on effective contact with patients in their own homes. There is also no doubt that every hour spent on administration saved many hours subsequently. The time spent on administration was almost equally divided between services to individual patients, such as letter-writing and arranging appointments, and items which related to the patients as a whole, such as practice organisation. Each week 30 hours were spent effectively in contact with the patients on the National Health Service list while 14 hours were spent on other medical services. The total still does not equal the hours per week during which the doctor was about his business as a general practitioner. These other activities, not specifically measured during the survey but estimated at a later date (1962), included time spent on preventive activities and in contact with
directly concerned with state of the garden, ranged or motor vehicle to weather, philosophical discussions about the doctor-patient relationship within the frame-
patients discussing
matters not
their health. This
from the
work of the health service. All these without doubt are part of good general practice, indirectly benefiting- the patient and the doctor, and cannot be called wasted time, though it was excluded from " effective contact time " in the original survey. In the more recent assessment of the time spent about his practice D. L. C. estimated that on average a further 5 hours of each week were spent in this way. TIME SPENT IN CONTACT WITH THE PATIENT
analysed in table 11: where functions overlapped, the time spent was split equally between them. For instance, a prescription may have been written out while general advice was being given to a patient or while the This is
TABLE II-PERCENTAGE OF TIME SPENT IN CONTACT WITH PATIENT AT
SURGERY AND AT
PATIENT’S
HOME
(1962)
355
practitioner was " therapeutically listening ".
The results, the the fact that however, exemplify general practitioner’s main function is that of assessing clinical situations. More than half of his time was spent on fulfilling this function and less than a quarter on giving formal advice. If to this is added the time taken to write out prescriptions and to prevention, this ratio would be increased to a third. In this survey patients above the age of 65 require three times as much time as patients of 15-29, and patients in the age-group 0-4 required twice as much. In addition to the foregoing, time must also be allowed for activities such as attendance at medical meetings, formal postgraduate education, discussions with colleagues, and research. These estimates take no account of the time which is spent on duty waiting for emergencies and of the disturbing effect of out-of-hours calls. The disruption of normal life caused by these is out of all proportion to the actual time spent with the patient.
In our study these variations are seen to be even greater than they believed. Variations of consultation-rates by geographical area, by town and country, and by the age, sex, and social class of the patient all contribute to these differences. Probably the work-load of practitioners would vary as much if measured by the time spent as when measured by consultation-rates-though it must be emphasised that the figures for time spent in general practice given here are for one practitioner only. For instance, Wood (1962), in a study lasting 14 days in a country practice of 2500 patients in October-November, 1956, estimated that he spent only 10 hours a week with his patients in his surgery but over 30 hours a week in rates.
his patients’ homes. This, however, represents only 55% of the 73 hours of his working week compared with the equivalent figure of 46% in the present survey. The smaller proportion may be due to the use of stricter criteria for effective contact time. It is also important to recognise that the variations, as measured CONSULTATION-RATES by consultation-rates, may be confined to as The structure of general practice in Great Britain, based little as 46% of the total working week, and that a higher consultation-rate does not necessarily represent better as it is on defined lists of patients now including some medical care. 98% of the population, has made it possible to measure In this country it is only roughly true that the fewer some of the variations in work-load by differences in the patients for whom the practitioner is responsible the consultation-rates. It must be remembered that conmore he can do under the heading " other professional sultation-rates are confined to activities classified as effective contact time, which in this study accounted for commitments ". In Great Britain there has been little or no examination only 57% of the general practitioner’s total working time, of general practice by work-study specialists. This is or 46% if travelling time was excluded. Consultationprobably because such a study would not pay for itself. rates are expressed here per 1000 patients at risk per year. Variations of consultation-rates with age and sex.-In the Any increase in efficiency which resulted would be National Morbidity Survey (Logan and Cushion 1958) it reflected in more free time for the practitioner or wider services for his patients. was shown that for a given number of patients, females Many of the ways of saving time depend on ancillary have 18% more illnesses than males and all patients over 65 require nearly twice as many consultations in a given help. This in turn can be most economically used where several practitioners work together. Partnerships also time as those aged 15-44. Consultation-rates and social class.-Consultation-rates imply an ability to rationalise surgery and other clinic times with consequent savings in time for a given number per 1000 males aged 15-44 at risk per annum vary from 2165 for social class I to 3701 for social class v. The of items of medical care. On the other hand, too large a corresponding patient consulting-rates, however, are 544 partnership may lead to the loss of the ideal relationship and 579 respectively. The average consultation-rate for of " one patient-one doctor ". Time saved by any all patients in the National Morbidity Survey is 3800. method can be used to develop the elements of medical The equivalent figures in D. L. C.’s practice in a suburb care which involve personal contact between the practitioner and his patients-contact so essential to the cardinal of Birmingham are 3100 for males and 2900 for females. function of primary assessment of clinical situations. It Geographical variations in consultation-rates can also be can also be used to expand the preventive element in the studied in the National Morbidity Survey. The differof his patients. More time will also be availmedical care ences between various regions of Great Britain presumably able for postgraduate study and research, each of which reflect, among other things, a combination of climatic and occupational factors and differences in the age and sex improves the quality of the practitioner’s service. The wide variation in consultation-rates suggest that distribution of the population. For instance consultationmore study should be made of the characteristics of the rates vary between 2640 per year for East Anglia and practitioners and the patients which are the cause of these 4000 for Wales. The figures so far given reflect the averages from several differences. Also, in view of the current interest in all practices and therefore reflect the differences of morbidity aspects of general practitioners’ work, including their experienced by the community as a whole. When the remuneration, it seems advisable to have a great deal more figures from individual practices are considered, the varia- information about the way in which they spend their tions from 963 consultations to 9152 consultations per professional time. SUMMARY 1000 patients at risk are much greater (Logan and Cushion 1958). The work-load of a general practice in a Birmingham It is fair, from these figures, to assume that there are suburb in 1954 is analysed. greater variations between different practices, and thereOf 44-5 hours per week working as a general practitioner, fore different practitioners, than between different areas was spent in effective contact with patients, 11-5% 0 456°,o in the country, great though the latter may be. on travelling, 11-5% on administration, and 31-4% on DISCUSSION medical commitments outside the National Health SerLees and Cooper (1963) have shown that there are great vice. To this basic 44-5 hours must be added a further variations between general practitioners in their consulting5 hours spent just talking.
356 The National
Morbidity Survey (Logan and Cushion
1958) showed wide variation in the number of doctorpatient contacts (consultations). The average per 1000 patients, per year, varied from 2640 in East Anglia, to 4000 in Wales. The highest and lowest rates for individual practices were 963 and 9162 respectively, a ratio of nearly 10 to 1. More study should be made of the characteristics of the practitioners and the patients which are the cause of these differences. More information is needed about the way in which practitioners spend their professional time. REFERENCES
Crombie, D. L., Cross, K. W. (1956) Brit. J. soc. prev. Med. 10, 141. Lees, D. S., Cooper, M. H. (1963) J. Coll. gen. Pract. 6, 233. Logan, W. P. D., Cushion, A. A., General Register Office Studies on Medical and Population Subjects no. 14, Morbidity Statistics from General Practice. H.M. Stationery Office 1958, vol. I. Wood, L. A. C. (1962) J. Coll. gen. Pract. 5. 379.
Conferences DIABETES FROM A CORRESPONDENT
The 5th Congress of the International Diabetes Federation was held at Toronto, the birthplace of insulin, from July 20 to 24 under the presidency of Dr. H. F. ROOT. It was attended by 1600 medical and scientific delegates and 1000 lay delegates from 44 countries. Islet Cells M. F. SAK (Boston) and his colleagues described the successful homotransplantation of neonatal pancreas into alloxan diabetic golden hamsters, with temporary improvement in the diabetes. Other original papers described the permissive role of the vagus nerves in allowing increased release of insulin-like activity into the pancreaticoduodenal vein of dogs, into whose pancreatic arteries mesoxalate, ethylenediamine tetra-acetate (E.D.T.A.), L-histidine, or glycine had been injected (R. NINOMIYA et al. [Tokyo]). H. ELRICK and colleagues (Denver) provided evidence for a gastrointestinal hormone that stimulates the secretion of insulin in man, for they found a greater and more sustained rise in plasma-insulin by an immuno assay procedure when 20 g. glucose was given orally than when it was given intravenously. Other contributions supported the hypothesis that the blood-sugar level of the pancreatic arterial blood did not provide an adequate explanation for the level of insulin release in the pancreatic venous effluent blood. Thus A. R. COLwELL, Jr., and his two namesakes (Chicago) found that the insulin release provoked by pancreatic arterial hyperglycaemia was insufficient in the ansesthetised dog to produce peripheral hypoglycasmia, and F. C. GoETZ and his colleagues (Minneapolis) found that glucose or galactose injected into the portal vein of dogs produced a striking rise in insulin output without, in most cases, any rise in arterial glucose concentration. This work suggested the presence of receptor sites along the course of the portal vein or in the liver. Other papers described effects of insulin on the transport not only of glucose and aminoacids but also of potassium and inorganic phosphate. Insulin also stimulates pinocytosis and increases the electric potential of cell membranes even in the absence of glucose. Metabolic Characteristics of Selected Tissues M. J. WHICHELOow and other workers at Guy’s Hospital, London, described a significant correlation between glucose uptake in the deep forearm tissues and skinfold thickness, as an index of obesity. Several other workers have found high plasma-insulin levels in obese subjects with or without carbohydrate intolerance. A. WINEGRAD (Philadelphia) illustrated the importance of direct metabolic studies of vascular tissues by his work on the aorta of diabetic and non-diabetic rabbits.
Relation of Angiopathy to Diabetic Control M. K. MACDONALD and J. T. IRELAND (Edinburgh) reported significant thickening of the basement membrane of the glomerular capillaries even before development of carbohydrate intolerance. Yet these electron microscopic studies revealed no qualitative difference between the glomerular lesions of idiopathic and secondary diabetes. Some experimental support for the well-known views of the Joslin Clinic on the importance of diabetic control in limiting complications was given by W. R. HARTROFT (Toronto), who showed the effect of a diet high in unsaturated fat (corn oil) in protecting against atherosclerosis in partly pancreatectomised diabetic rats. Treatment of Diabetic Retinopathy by
Pituitary Ablation Reducing the function of the pituitary has encouraging effects on vision in diabetic retinopathy; but renal function is not improved, and significant renal impairment is one of the important common contraindications to ablative procedures. In the long-term assessment of various treatments on the progress of diabetic retinopathy the value of an untreated control group was described by R. FRASER (London) in relation to yttrium90 implantation of the pituitary, in abstracts submitted by L. J. P. Durrcarr and colleagues (Edinburgh) in relation to the use of ’Atromid’, and by two groups at the Joslin Clinic (Boston) in relation to pituitary ablation and to various medicinal treatments. Good results of the treatment of diabetic retinopathy with anabolic steroids were reported by, among others, A. J. HOUTSMULLER and H. E. HENKES
(Rotterdam). Insulin Immunochemistry and Blood-levels P. H. WRIGHT (Indianapolis) contributed a paper describing the rapid diabetogenic effects of insulin antiserum injected into rabbits. Although he obtained no good evidence of direct damage to the &bgr;-cells he did see inflammatory lesions in the exocrine pancreas. G. M. GRODSKY (San Francisco) was able to show in both rabbits and man that exogenous insulin can produce circulating antibodies that bind and retain large amounts of the endogenous hormone. J. VALLANCE-OWEN (Newcastle upon Tyne) reviewed the synalbumin insulin antagonist which may represent the p-chain of the insulin molecule, and cited evidence for its inheritance as a Mendelian dominant character. There was some disagreement between those doing similar work which only further work is likely to resolve. L. POWER and co-workers (Ann Arbor) described the results of their work on the mechanism of the higher insulin assay levels obtained from diluted than from whole serum. In the past this feature has usually been attributed to a dilutingout effect on physiological insulin antagonists, but the work of Power et al. showed that the insulin added to undiluted serum was recovered quantitatively. This suggested that a more plausible explanation was the release by dilution of a factor which augments insulin activity. I. MAGYAR (Budapest) has measured insulin resistance in diabetic subjects by determining in vitro the glucose consumption of small pieces of excised muscle. In some cases the resistance to insulin appeared to be localised in the muscle itself rather than in the plasma. R. M. EHRLICH and his colleagues (Toronto) had performed plasma-insulin assays in patients with infantile hypoglycaemia and found no evidence of unusually high values. Hormonal and Other Influences on Metabolic Processes Dr. A. SIREK and her colleagues (Toronto) showed very neatly that the hyperglycasmic substance released by growth hormone in dogs was very probably serotonin. R. H. UNGER (Dallas) gave convincing evidence of the physiological role of glucagon. In this connection K. J. WEINGES (Homburg-Saar) delivered a valuable paper describing the part played by glucagon in mobilising the energy from