TRAINED SOCIAL WORKERS

596

In A

England

Now

Running Commentary by Peripatetic Correspondents

HAVE you ever given thought to Abou Ben Adhem ? Why did he awake at night from a deep dream of peace ? And how could he see what the angel was writing and why in a book of gold ? Today the answers came to me. Before I lost consciousness, the speaker was speaking on and on and the projection of lantern slides seemed endless. When I awoke in the night (of the darkened hotel assembly-room) someone was writing beside me in a book of gold. The angel was my host at lunch, from the effects of which I had gained my deep dream of peace. The book in which he was writing was truly of gold in the pale yellow light cast by his latest gadget, a pencil-cum-electric flash for making notes in the darkness. And my name led all the rest of those he was selecting for another committee. All of which leads me to conclude that Abou was a fellow-pathologist. This belief is strengthened by the poet’s exhortation " may his tribe increase!", because there was much talk around me of how good it would be if only there were more of us to share the burden of committees. Poor old Bert suffered from cerebellar degeneration. I suppose that he was neither poor nor old in the strict meaning of those words, but he was never referred to in any other way. Certainly his condition was poor and his appearance old, although his 60th birthday still lay ahead of him. As a young man Bert (for he can hardly have earned his title then) had been taken on as the first employee of an engineering workshop which had just been opened. By the time I first met him he was the oldest member of their staff, and he travelled to and from the factory in a taxi at the firm’s expense. His cerebellum could not get him to work, but his cerebrum was unimpaired and the firm could hardly run without its help. One day the managing director rang me up. Poor old Bert could hardly walk the few yards from the taxi to his place of work. Could I send him to a specialist at the firm’s expense ? The following week Bert’s taxi took him on an unfamiliar route, and a day or two later I was reading a long report from a neurologist whose name was almost as famous as the street from which he wrote. Three pages were devoted to the interesting nature of the case in all its fascinating neurological ramifications. Not until the very last line was treatment even mentioned: I believe this man would benefit greatly from the addition of a rubber tip to his walking-stick ". And so it proved. "

My wife finds dieting difficult, but I have hit on a new psychological aid. This is the use of logarithmic graph paper, plotting weight against time using the logarithmic scale for the weight. Any increase in weight is shown as a steep rise of the curve, whereas a loss of weight appears only as a slight downward slope. My wife is now urging me to find a different kind of graph paper on which she can record a steady weight as a downward sloping curve. Further work is in progress to derive mathematical equations for the slope of the curve from which it is hoped to calculate her day-to-day calorie requirements. The equations are proving to be complex and the calculations time-consuming especially before meals. The concept of a negative meal is a difficult one for her to swallow. As the fifth test moved towards a lugubrious close my only bright thought was that Robert Cowper was about to become a megakaryobat. With the fall of his wicket even this hope was denied. Then my anaesthetist colleague pointed out that Cowper had become a juxta-megakaryobat. *

*

*

Memo to Miss Nancy Mitford-In the brouhaha of the past week I.T.V. kept talking about the " serviette " with which the child wiped her knife and fork; the B.B.C. sniffily called it a " napkin ".

Letters

to

the Editor

MEDICAL STUDENTS AND THEIR EDUCATION

SIR,-Medical education

is

undergoing serious

and we

hope

revolutionary changes. The deliberations of the Royal Commission on Medical Education, under the chairmanship of Lord Todd,I face major problems in the organisation of clinical studies, in the nature and conditions of immediate postgraduate work, in junior hospital posts, and in the three-year B.SC. course. The existence of the Commission is a challenge and an opportunity. It is thus with considerable apprehension that we note Lord receive oral evidence from medical students The Commission will, of course, take into consideration written recommendations, and the British Medical Students’ Association, the National Union of Students, and others are submitting detailed memoranda. But the Commission’s apparent disinterestedness in medical students’ own criticisms and perspectives seems in danger of making its deliberations one-sided and ultimately unhelpful. More than any other discipline, medicine requires, as a positive necessity, effective collaboration between teachers and students. The course must be flexible, and susceptible to change and shifting emphasis. All this ultimately requires face-to-face discussion between academic authorities, teaching staff, and the students themselves. The past ten years has clearly shown the importance and success of this sort of liaison. The B.M.S.A. has had staffstudent curricula committees as a cornerstone of policy. There are at present useful and fruitful s.s.c.c.s in about 80% of British medical schools. The University Grants Committee’s recent report to the University of London Senate, chooses to stress the constructive nature of students’ contribution: " It was very striking that they were not merely content but positively anxious to spend most of the time available in discussion of academic affairs. They were manifestly interested in the teaching methods; in staff student relationships; use of libraries and residential policy; and they discussed these matters sensibly and realistically." I am writing for and on behalf of the students of this union. It is precisely because we are currently students that we can give such a crucial and revealing analysis. We are able to assess and evaluate the impact current medical-school practice is having, and both its strength and omissions. As a union of students in a school with a tradition for innovation we hope very much that the Royal Commission will show increased interest in the analysis presented by medical students themselves. Union of Students, Royal Free Hospital School of Medicine, R. D. WILKINS. London, W.C.1.

Todd’s refusal

at

to

present undergoing medical education.

TRAINED SOCIAL WORKERS SIR,-May I comment from the point of view of a medical social worker on a paragraph in Question Time in Parliament

(Feb. 26). The Chancellor of the Duchy of Lancaster appears to have spoken with some complacency in reply to Mr. Geoffrey Lloyd’s question about " the numbers of trained social workers required in the public services other than those controlled by the local authorities ". We know that the Ministry of Health wants to attract qualified social workers into local-authority

health and welfare services. It seems that one of its ways of doing this is to force medical social workers with upwards of 5 or 10 years’ experience to move out of the hospital service by applying financial pressure. The circular on salaries for medical and psychiatric social workers published on Feb. 24, 1966,2 does, it is true, offer 1. See Lancet, 1965, ii, 71. 2. Whitley Council for the Health Services: Professional and Technical Council " A ". P.T.A. Circular No. 125.

597 the future and gives better eventual grades. The rulings given on assimilation, however, can only be described as appalling. To cite one example: a head of department, grade ill (with 6-9 professional staff under her), already at the top of her salary scale, receives, apart from the 3% rise awarded to everyone, an immediate increase of Elper annum. She may have been at the top of her grade for many years, and be too near retiring to have any appreciable hope of improvement. We are a graduate profession; all of us have spent at least 3 years in training, and some as much as 5 years. Is it surprising that the younger group in the middle of the profession, on whom we depend for the future, is looking elsewhere for employment ? Yet they are needed in the larger hospitals to keep up a high standard of service by guiding new comers to the profession, and in the smaller hospitals to take charge of departments. The Chancellor is anxious to increase facilities for training. On the experienced staff depends, in fact, both the calibre of the work carried out and the quality of training opportunities that can be offered to future hospital and localauthority social-worker staff. Surely there is still a place for medical social work in hospital, even if some departments must be smaller in the future. As the head of the social-work department of a teaching hospital I am concerned at the Ministry’s way of approaching the problem of recruitment from hospitals to local-authority services, and at the growing bitterness in my own profession. I wonder whether the medical profession are as satisfied as the Chancellor that all is well. Department of Social Work, King’s College Hospital, HELEN A. BATE. London, S.E.5.

hope for new

entrants in

prospects for

some

MYOCARDIAL VASCULAR REACTIVITY SIR,-Dr. Parratt and Professor Grayson (Feb. 12) gave propranolol to dogs on a weight basis 3-7 times greater than the pro-rata dosage given in man, an found a decrease in myocardial blood-flow as measured the method of Grayson and Dennis MendeU Dr. Parratt a d Professor Grayson suggest that there may be dangers inherent in the use of propranolol in clinical practice. If this decrease in blood-flow occurs in men, it might well be dangerous, and would certainly be precisely the opposite effect to that which the clinician is seeking in patients with angina or myocardial infarction, unless the decrease in flow was paralleled by as great or even greater decrease in the myocardial requirement for oxygen. Dr. Parratt and Professor Grayson examine this hypothesis and reject it on the grounds that -blockade causes minimal decrease in cardiac output and the mean blood-pressure does not change, and that hence " there should theoretically be little effect on cardiac work ". The mean blood-pressure is a curious relic of the past which is used because it allows a rather dubious calculation of " external work " of the heart to be made. The mean pressure is profoundly affected by changes in the heart-rate and if the mean is to be used-which in my opinion is doubtful-it should only be used when the heart-rate is unchanged. -blockade reduces the heart-rate and the systolic pressure in the left ventricle, both of which reduce the work of the heart. Blockade also reduces the rate at which that pressure changes, decreasing the maximum rate of change of pressure (dp/dt) by about 30%, and causing much larger changes in the rate of acceleration of that pressure. Thus I found that before p-blockade the pulserate was 86 per minute, left-ventricular pressure 120/0 mm. Hg, and dp/dt 2340 mm. Hg per second, with the differentiated tracing tall and peaked during contraction. After p-blockade the pulse-rate was 74 per minute, left-ventricular pressure 100/0 mm. Hg, and dp/dt 1400 mm. Hg per second, with the differentiated tracing shorter and squatter during contraction but almost unchanged in relaxation. Since the cardiac output is little changed, it is possible that the heart, in contracting less often and more slowly, may put out a larger stroke-volume for less expenditure of energy, and hence its blood-flow require-

b

1.

Grayson, J., Mendel,

Dennis Am.

J. Physiol. 1961, 200, 968.

be less because its energy-wasting exuberance is curbed. The pharmacological basis for the research into the P-blocking drugs was that adrenaline increased the cost of heart work which might be reduced by its antagonist, and the therapeutic effect of the drugs in some patients with angina suggests that this in fact may be the case. The cardiac failure reported during use of the drug may have occurred in patients who were unable to increase their stroke-volume and in whom adequate output could not be maintained with a reduced pulse-rate, rather than " as the result of a reduced myocardial irrigation ". St. Thomas’s Hospital, DAVID MENDEL. London, S.E.1. ments may

A HOSPITAL PLAN FOR 1966

SIR,-" Consultant " (Feb. 26) is to be congratulated detailed knowledge of planning matters and on the

his many

on

examples he cites of bad planning of hospitals. He does, however, allow his article to degenerate into an attack on administrators, without reservation. This I consider to be unfortunate, and as a practical hospital administrator I must protest. Even if he has not been fortunate himself, I feel sure that his colleagues can recall instances when an administrator has been able to furnish some guidance on matters affecting the planning of a medical department, albeit that such assistunobtrusive. Can I go so far as to say that in some medical men are the laymen? Hospital administrators are not interested only in their own comfort and office accommodation, as is hinted by one of the examples cited, and they have been known to have fairly sound overall knowledge of the working of the many departments in what can be a very complex organisation. Nobody in their right mind would suggest the exclusion of representative views of senior medical staff when planning a hospital, any more than those of all staff concerned with the working of the proposed unit. The point is, surely, whether the nation can afford the luxury of indulging individual members of the staff, whatever their status or grade. When the basic factors are approximately the same-e.g., site, and service required-how can it be defended that what is suitable in area A is basically unsuitable in area B, so that a completely different design is adopted at much greater cost ? Every hospital administrator has his limitations, and as those at hospital level know to their cost, there is no such thing as good administration, for if a patient has fault to find with any aspect of this treatment this is invariably attributed to bad administration, whereas if all proceeds satisfactorily praise is extended to the medical and nursing staffs. By all means shoot the bad pianist, but please do not advocate replacement of all pianists by wood-wind instrumentalists. ance was

matters

R. N. HUMPHERSON. "

Consultant " about hospital SiR,łThe opinions of buildings are no doubt correct. It is not clear, however, whether he waxes indignant because of his exclusion from the planning of his own new hospital or because of exclusion from hospital planning as a whole. The statement of " Administrator " (Feb. 5) must be in essence completely valid. We are a small, highly industrialised country. In order to achieve the best possible value for public money spent, there simply must be standardisation-and there is no need for this to be of poor aesthetic, functional, or constructional quality. New buildings can be erected so that the minimum of effort is needed if expansion becomes necessary. All essential services-electrical wiring, telephone cables, water, oxygen lines-are piped beneath the floors. Administrator’s assumption that there are 70 separate groups working on building programmes is disturbing. What is needed is a central group with functional (medical) as well as structural advisers to provide a very few designs for basic hospitals, and a standard flexible design for specialised units that can be added