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medical faculty to arrange for its members to be brought upto date in, and kept abreast of, teaching techniques (as sug-gested by the delegates’ to an informal seminar held at

Makerere University College last June).Awareness of modern teaching methods and what can be

done by them is a prerequisite for their use. It may be thateach undergraduate school could not make its own arrange-ments, and courses of this kind might be one of the earlyresponsibilities of the Association of Medical Schools in

Africa.! tThe second approach, more easily stated than achieved,

is to persuade more young men to become teachers,especially in the basic sciences, where the shortage isacute.

By far the greatest number of academic staff, both clinicaland preclinical, are drawn from the small group (about 10%of students) who spend an extra year taking a science degree,or whose interest in these subjects has been sustained duringthe clinical years by the interest of a particular teacher fromone of the preclinical departments. The average medical

This organisation was founded last December by the Universitiesof East Africa, Ibadan, Khartoum, Lagos, Lovanium, HaileSelassie I University, and the University College of Rhodesiaand Nyasaland.

student has little idea of the exciting developments in the

preclinical sciences. It should be possible to give him a betteridea of their potentialities, by designing his course so as toallow him to find out things for himself instead of confirmingpast experiment, to give him the opportunity to take part inresearch and, above all, by exposing him to enthusiastic teachersusing good teaching methods.Of the twenty or so countries of whose medical

educational systems I have sufficient knowledge, onlyPakistan has an excess of preclinical teachers, and therea two-year training school, leading to a graduate diplomain one of the basic sciences, is sponsored by Americanaid with expatriate help from the University of Indiana.This produces 18 graduates a year trained to teach basicmedical sciences. A project of this type in Africa on aninternational basis might be well worth the support ofthe World Health Organisation or the new Association ofMedical Schools in Africa.

CONCLUSION

These thoughts are tentative, but I hope they will actas additional yeast to the already fermenting brew ofmedical educational ideas in the youngest continent.

Special Articles

A CASUALTY APPOINTMENT SYSTEM

D. P. MANNING M.B. Lpool

FORMERLY SENIOR CASUALTY OFFICER

W. V. N. PUGHM.B. Lpool

SENIOR CASUALTY OFFICER

ROYAL SOUTHERN HOSPITAL, LIVERPOOL

THE casualty department of the Royal Southern Hos-pital, Liverpool, is very small and there is a grave shortageof space. Each year there are about 45,000 attendances,28,000 of which are for review and re-dressing. Abouttwo-thirds of total attendances are handled by the twofull-time casualty-officers.The patients for review are seen, together with any new

patients that may arrive, between 9 A.M. and 11 A.M.

This arrangement came about because the casualtydepartment did not have permanent nurses and sharedits staff with the outpatient department, which needed alarge number of nurses for afternoon clinics.There was no method of controlling numbers or rates

of arrival for reattendance, and the patients were simply

asked to return between 9 A.M. and 11 A.M. on the day oftheir subsequent visit. At 9 A.M. about 7 patients wouldbe waiting to see the doctors, and the number sometimesrose to 40 by 11 A.M.

In addition, the dressing facilities were " swamped."Patients needing dressings only often had a protracted waitwhilst the nurses were occupied with patients passingdirectly from the consulting-room. The total numberdealt with in a morning has been as high as 160, and underthese conditions the doctors and nurses worked under

great pressure and with a feeling of urgency and some-times of desperation. There were many complaints bypatients who had been missed and complaints that somewere being treated out of their turn.

THE NEW SYSTEM

The first change made was to devise a simple systemenabling patients to receive treatment in the correct

sequence. The casualty clerk pinned a numbered ticketto the casualty card of each patient on arrival. The

casualty card was placed in numbered sequence in one oftwo racks-one rack for patients to be seen by the doctor,the other rack for redressings only. After attention by thedoctor or on completion of any investigations the patientswere directed to a waiting area for treatment. Smallwounds were covered with a temporary sterile gauze

EFFECT OF APPOINTMENT SYSTEM ON NO. OF PATIENTS AND WAITING TIME

*The casualty X-ray department is shared with outpatient clinics.

602

dressing for this period. The treatment ’cards were placedin a rack in the dressing-room, the patient with the lowestnumbered card being treated first. At the discretion ofthe casualty officers patients were treated out of turn ifthere was priority of a medical or social nature.The correct sequence for treatment was now obvious,

and all complaints about treatment out of turn ceased.Next, with a view to establishing an appointment system,the time spent by patients waiting to consult the doctorswas assessed. The patient’s time of arrival and the timehe was seen by the doctor were recorded.Method

For convenience, patients were identified by their ticketnumbers. The appointments clerk recorded the numbersand time of arrival of all patients going to the casualty-officers. The doctor recorded the numbers and the timeof arrival in the consulting-room. Watches were syn-chronised each morning. The average waiting-time wascalculated. Other information, such as the number of

Fig. I-Appointment ticket.

emergencies and additional waiting time spent in the

X-ray department, was noted.After six weeks the information shown in the accom-

panying table was obtained. The significant figure wasthe average number of patients seen by the doctors ineach half-hour period of the morning, and this figure-15-was the basis for the appointment system, which wasthe subject of the second part of the investigation.

Pads of 70 appointment slips were printed. A separatepad of different colour was produced for each weekdayand was divided into five sections. The first four sectionscontained 15 tickets for each half-hour period beginningat 9 A.M. The fifth section contained 10 reserve tickets.Appointment slips were numbered through the pads;hence the numbers already issued could be seen at a

glance. The six pads, measuring 4 x 3 in., were clippedto the stationery box, which was within easy reach ofthe two doctors, who were screened from each other.After the consultation the appropriate appointment slipwas torn from a pad and handed to the patient. Each

morning the pad for that particular day was replaced bya new pad for the same day of the following week. Whenthe patient arrived for his appointment the casualty clerkdestroyed the slip to avoid duplication.

Shortly after the introduction of the appointment sys-tem minor adjustments were made. Monday pads werereduced to 14 for each half-hour period because of aslight excess of new patients on that morning and becausea higher proportion of cases required investigation; the

10 reserve

tickets weretimed for11.15 A.M. to11.30 A.M. toallow a shortbreak forcoffee.One casu-

alty officer

usually at-

tended on

Saturdaymornings,and the padswere there-fore reduced to 15 slips and 5 in reserve on that day,An appointment ticket and the sheet separating off thereserve tickets are reproduced in figs. 1 and 2.An identical time study was undertaken for a compar-

able period of six weeks, and the results are shown in theaccompanying table.Results

The average waiting time was reduced from sixteenminutes to ten minutes with no ambulance cases, andfrom twenty-one and a half to twelve and a half withambulance cases. The spread of average waiting timeswas also reduced (fig. 3).When the appointment system was operating, the aver-

age number of patients seen per half-hour was 13, ofwhom 3 were new patients. About 5 patients failed toreturn in each half-hour period. Pressure of work wasreduced from 14 to 13 patients per half-hour.

DISCUSSION

The appointment system was an obvious success.

Many people remarked how quiet the casualty departmenthad become, although the numbers of new patients in thetwo six-week timed trials were about the same-1673before and 1697 after the appointment system came intouse.

Patients with trivial complaints seemed to prefer to

treat themselves rather than attend at a particular time,and this was shown in the reduction of total attendances.

Fig. 3-Total numbers of patients arriving before 11 a.m. to seethe doctors: before and after introduction of appointments system.

Fig. 2-heet separating appointment ticketsfrom reserve tickets.

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Few patients attended after 11 A.M., and late arrivals-a feature of the pre-appointment days-were almosteliminated. The reduction of rate of arrival did not resultin later finishing as had been expected, but in a muchearlier completion of the morning clinic. Few patientsrequested an alternative appointment time.Three waiting benches, of 12 ft. length each, were

seldom more than half full, and there was never an overspillfrom them. This reduction in the number waiting wasthe most striking feature of the system, and is not reflectedin the statistical results.The half-hourly averages show a significant reduction

in work from 9 A.M. to 10 A.M., and this prevented a build-up of waiting patients. Other advantages (not seen in thestatistics) are that each patient is given strict instructionsover reattendance with the following benefits:

1. The patient does not have to remember his instructions.2. Patients do not fail to attend through uncertainty. This

fact has medicolegal significance.3. Patients do not return in the afternoon or at night with

the excuse that they did not know the time for reattendance.Fresh cases therefore receive more time and attention, andthe junior casualty officers are not troubled in the eveningswith patients wanting routine reassessment or removal ofsutures.

With a regular steady flow of patients through theconsulting-room there is no build-up of patients waitingfor treatment in the re-dressing rooms. The system is so

simple that it can be subjected to many variations. Byusing pads of 10 tickets per half-hour period it was pos-sible for one doctor to see all the patients in an extendedclinic, and the system was found equally successful

during periods of leave without locums or during courtattendances.

This appointment system has considerably increasedthe efficiency of the department by reducing the strainon all the staff, reducing the time wasted by patients, andincreasing the time available to the medical staff for theassessment of patients.

SUMMARY

An appointment system was thought to be necessary,because of overcrowding, in a busy casualty departmentrun by two full-time day casualty officers.A timed investigation was carried out for six.weeks to

assess a practicable rate of arrival for patients, and fromthe data an appointment system was devised.

After the appointment system began, a further sixweeks’ study was carried out to estimate the advantagesof the system.The pressure of work was reduced, and consequently

the time available for assessment of patients was increased.The waiting times of patients were also considerablyreduced.We wish to thank Mr. R. W. Doyle, Mr. J. W. Fitzpatrick, Mr.

E. G. McClean, Miss 0. M. Jones, Miss T. Powell, and Miss D.Hunt for help in this study.

Conferences

EAST AFRICA

DESPITE the recent troubles in East Africa, events in themedical calendar have proceeded with remarkably littleinterruption, and two important conferences have beenheld. The first, on Diseases of the Gastrointestinal Tract,was sponsored by the East African Council for MedicalResearch and occupied the four days Jan. 22-25, whilethe second, on International Support for Research inEast Africa, was sponsored by the East African CommonServices Organisation and took place on Feb. 20-21.

GASTROINTESTINAL DISEASE

Dr. T. C. HUNT (St. Mary’s Hospital, London), whopresided over the first conference, said that the epidemiologyof gastrointestinal disease can give clues to the aetiology ofmany disorders. The curiously high prevalence of lympho-reticular tumours (Burkitt’s sarcoma) in yellow-fever areas hasgiven rise to the suggestion that they are caused by virusestransmitted by mosquitoes, and related work is going on inseveral East African centres. On the other hand, the lowincidence of certain diseases, such as cholecystitis and gall-stones, can be equally instructive.Dr. NJOROGE MUNGAI, Minister of Health for Kenya, in

opening the conference, emphasised that Kenya recognises theimportance of research to developing countries, even thosewith difficulties in maintaining essential services, and accord-ingly in the next six-year development programme " funds forthe continuation of research as a top priority " have beenincluded. Expatriate research workers, he said, will bewelcomed.

Diets rich in banana (matoke) are consumed by many tribesin East Africa, and it has been suggested that the serotonin inthem may cause endomyocardial fibrosis in much the same wayas serotonin has been held responsible for a similar conditionin the right side of the heart in carcinoid disease. An extensionto this work was reported by Dr. M. A. CRAWFORD, who

showed that adult intussussception is unusually commonamong matoke-eating peoples and can similarly be explained byingestion of excessive amounts of serotonin.

In his concluding remarks, Dr. Hunt spoke of the need foran African association of gastroenterologists.

RESEARCH IN EAST AFRICA

In opening the second conference, Mr. BRUCE McKENzrE,Minister of Agriculture, Kenya, again laid stress on theimportance which East African Governments attach to

research. He pointed out that they are not merely asking foraid, but are themselves prepared to make great sacrifices inorder to sustain research.Mr. MWAI KIBAKI, parliamentary secretary of the Kenya

Ministry of Finance, said that the East African CommonServices Organisation annually spend El million sterling onresearch and that half of this comes from Britain. Funds are

needed, however, for still more research, and it is unfortunatethat donor organisations usually prefer to finance new projectsrather than contribute to existing programmes. They alsoprefer to finance completely a small project rather than con-tribute to a large one. Research requires staff as well as money,and secondment is probably the best means of providing it;but secondment arrangements need to be more flexible thanin the past.Mr. W. A. C. MATHIESON, of the Department of Technical

Cooperation, London, said that, whereas many Governmentprogrammes include only award of training facilities or givingtechnical advice, his Department, bearing in mind the vulner-ability of research expenditure in national budgets, is preparedto assist with cash. It is willing to support existing programmesand does not limit its aid to new projects or to projects that itfinances completely. An extensive fellowship and educationalprogramme has also been developed.

Secondment of personnel from Britain and other countries,and a need for collaboration between universities in Britain,Europe, and the United States, as well as the University ofEast Africa and the local research teams, were constantlyrecurring themes in the conference, and it was stated that moremoney is wanted to support such collaboration. The repre-sentatives of Continental European institutes indicated thatthey were particularly anxious to participate in such collaborative