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population enclosed by the post-1965 boundaries is about1,130,000; the 1968 Essex list contains the names of 526general practitioners (excluding 195 Greater Londondoctors on the Essex list). The population of Birminghamis about 1,100,000, with 603 general practitioners on thelist. The table shows the average annual recruitment tothe Essex and Birmingham lists, and the percentage ofthese recruits who were: (1) graduates of universities inEngland, Wales, or Scotland, (2) qualified less than tenyears at the end of the period during which they joinedthe list, and (3) English, Welsh, or Scottish graduatesqualified less than ten years or who had qualified outsideGreat Britain.

In both areas the proportion of mainland graduates rosefrom about 50% in 1951-54 to over 80%, Birminghamreaching its highest proportion in 1958-61 with a fall in1961-63 and a further, sharper, fall in 1963-67. In Essexthe rise was more gradual, the peak was reached later, andthe fall has not yet reached a level as low as that for

Birmingham. The proportion of young doctors rose

steadily in Birmingham until a very high level in 1961-63was followed by a sharp fall. Essex achieved its highestproportion of young doctors in 1954-57 and never

reached the highest Birmingham level but showed a

much more gradual decline to a similar proportion. Forthe past ten years Essex has recruited a higher proportionthan Birmingham of older mainland graduates, many ofwhom have been in industrial practice in the midlands ornorth. The Birmingham proportion of young English,Welsh, and Scottish graduates started higher than that ofEssex, rose less swiftly, but continued to rise for longer,reaching a higher level from which it has suddenlyfallen by almost half.The proportion of recruits who qualified outside

England, Wales, and Scotland was quite high in the early’50s, diminished gradually, and then rose again, the Birm-ingham level being higher than that of Essex in everyperiod and showing an earlier rise. These doctors canbe divided into four categories on the basis of the countryin which they first qualified:

(1) Qualified in Ireland.-Irish doctors have alwaysplayed an important part in staffing the medical servicesof the mainland. Both areas show a fairly steady levelof Irish recruiting with a higher level at Birmingham. Ofthe Essex recruits 20 had degrees and 3 had diplomas.Of the Birmingham recruits 31 had degrees and 19 haddiplomas.

(2) Qualified in Continental Europe.-Most of thesedoctors came as refugees during the ’30s or ’40s. Noneof them is young now and most are long settled in theirpresent employment; many have retired. The numbersfor the successive periods have been 3, 2, 1, 1, and 1 in

Essex, and 9, 4, 1, 3, and 0 in Birmingham.(3) Qualified in Australia, Canada, New Zealand, or

South Africa.-Figures for Essex were 1, 1, 0, 2, and 3;figures for Birmingham were 0, 1, 0, 0, and 0 in the fiveperiods, respectively.

(4) Qualified in Asia and the Middle East.-Almost allthese doctors qualified in India or Pakistan. The per-centage of these Asian recruits was tiny up to 1960; sincethen the numbers have increased strikingly in both areas.

DISCUSSION

The most important conclusions to be drawn from thisinvestigation are that among recruits to general practice in

both Essex and Birmingham the proportion of youngEnglish, Welsh, and Scottish graduates has fallen sharplyand that the proportion of Asian qualified doctors hasincreased. This trend could reflect a change in fashionin the choice of candidates for vacancies or a lack ofcandidates of the sort previously chosen.

Change of fashion is a possible, but rather unlikely,explanation. Surviving partners have, de facto at least,an absolute right to choose the person who will fill a

partnership vacancy. When there is a vacancy in single-handed practice, or when no partner survives, the choiceis made by the executive council, but even then theinfluence of the medical members is probably large. Adoctor tries to choose someone with whom he can agreeand one who will, he hopes, please the patients. It israther likely that he will have a preconception in favourof his own kind. In 1951, 78% of Essex and 68% ofBirmingham general practitioners had English, Welsh, orScottish degrees or the English Conjoint diploma. For adozen years they chose or helped to choose people likethemselves, but much younger if they could get them. Itseems improbable that they have suddenly changed theirminds.

The other possibility is that there is a lack of supplyof the sort of candidate who used to be chosen and that

general practice has begun to join transport, nursing,public works, catering, and junior hospital doctoring asone of the industries which cannot recruit enough nativelabour even to fill the gaps left by normal wastage,let alone to expand with the needs of an increasingpopulation.

I thank the clerks to the Essex and Birmingham executive councilsfor lending me copies of their medical lists and for answeringquestions; and to the medical officer of health for Essex for givingme population figures for the area covered by the " new County ".Population figures for Birmingham are from the Registrar General’sStatistical Review.

Requests for reprints should be addressed to D. C., 24 HighStreet, Maldon, Essex.

Intercepted Letter

INTRAPROFESSIONAL MISADVENTUREDEAR SANDY,Thank you for your get-well card.I arrived at the hospital on a Monday morning and went

through the admission procedure at the hands of an accom-plished filler-in of hospital-activity-analysis (H.A.A.) forms.There is much to be said for H.A.A. because it presents facts,not fiction, until, that is, errors and opinions creep in. Anyonecan spot the obvious mistake of a woman being recorded ashaving had a prostatectomy; and it is unlikely that a man reallydid undergo a curettage. More careful examination of theH.A.A. returns will reveal that a patient apparently had anoperation five days before admission or five days after discharge.The year of birth of a patient can be verified by showing, inaddition, the present age of the patient. In this way it is

possible to check that, with a person aged 48 years, the date ofbirth should have been shown as 2.1.21, instead of 2.1.12. Theobvious mistakes can be rectified. The hidden mistakes are theones that worry me. I have seen emphysema and empyemainterchanged between case-sheet and H.A.A. form.But the major problem is when facts are left for the realm of

opinions. An entry under the section on diagnosis on dischargeof condition causing admission is fine-any consultant can tell

671

his houseman to tell his secretary what to say as a matter of fact.When one comes to the section on principal other conditions orcomplications and on chronic disabling conditions, things getmore difficult. Is the blood-pressure reading sufficient to

warrant an entry of hypertension and, if so, under whichheading ? Is that smoker’s cough enough to write chronicbronchitis ? It is all far too nebulous and one must think hardabout the possibility of removing opinion from such a statisticalmatter as hospital activity analysis. There is already enoughroom for mistakes among the facts.

But I digress. Knowing that I had to enter hospital for alaparotomy, I was interested to read Birley’s 1 mention of thev.i.p. syndrome. Such patients upset the usual mechanism of ahospital-they are generally well favoured, more liberal visitingis allowed, and senior registrars are asked to perform the tasksnormally performed by housemen. By no stretch of the

imagination could I be termed a v.i.p. I am a K.A.F. V.I.P.I know a few v.i.p.s.

I went to see the surgeon on the old-boy net and myadmission was arranged to suit my diary. Theatre was con-vened on a normally fallow afternoon and the full first xi wasin the field, all in clean flannels. Postoperatively, I luxuriatedin a single room, was fed on a special diet, was allowed toreceive visitors as they appeared, and was generally a completenuisance to the ward routine. I being a doctor, minor compli-cations of course arose. I had a prolonged ileus with distensionof the abdomen and very minor linear atelectasis in both lowerlobes. This kind of picture is clinically to be expected of doctorpatients, and of two other classes, and if no one has yet puta name to it, let us formulate the hypothesis of intraprofessionalmisadventure thus: " Despite meticulous attention, the medicalcare of doctors, of doctors’ wives, and of nurses will be fraughtwith crises, so that the hospital staff will always be pleased, andrelieved, when such patients go home."The registrar who tended to my needs was sympathetic

and friendly. The fact that he referred to his chief by hischristian name (when out of earshot) and informed me of what" we " found at the operation shows that he was altogethera friendly soul. Unfortunately he owned a motor car and, asa budding surgeon, used to practise on the engine. I am surethat the oil around his cuticles was scrubbed to the point ofsterility, but it used to make me wonder occasionally about thesocial, let alone surgical, graces of clean (-looking) hands.There must come a time in the life of a mechanically mindedsurgeon when he has to take the decision to wear gloves in thepresence either of his patient or of his car.When I was a houseman, with a consultant the same age as

me on the firm, I vowed that I would never tell a housemanabout " my

" day, but, avoiding " my " and " his " day, I mustquery modern teaching. It was necessary for this young doctorto perform rectal examinations; I was taught that the procedureshould end with the use of a gauze swab to save the patientremaining uncomfortable in a patch of jelly for the rest of thenight. My friend scored 50%-one gauze, one no gauze, in twoexaminations. He joined others I have met in telling me that itis more painful to have a local anaesthetic than to have a dispos-able dripset needle plunged directly through the skin and,eventually, into a vein. I stuck to my guns and, on the secondrequest, duly had a local anaesthetic. Perhaps every medicalstudent should experience the insertion of an intravenous drip-set needle. But, these are the tiny criticisms of a well-cared-forspell as a patient.

Before I left, I thanked the hospital secretary for all theattention I had had from so many members of the staff;I suggested that he had earned a day off, but he replied, " No.Now we have to work to keep up these standards and toimprove on them." There can’t be much wrong with sucha service, can there ?

Yours,ToNY

1. Birley, J. L. T. Lancet, 1968, ii, 1181.

In England Now

A Running Commentary by Peripatetic Correspondents

I am not much at home with horses, but when my veteri-narian friend rang me to discuss a thoroughbred foal who hadsyncope on exertion, I was intrigued and immediately agreedto have a look at it. At the stud farm the foal and its mare were

together in a loose-box, and there was a rather exciting strugglewhile the patient was being separated from her wide-eyedmother. I stayed outside at a respectful and apprehensivedistance, and the elderly stable-lad, who waited with me, didnothing to help my confidence. " Shouldn’t go in there if I wasyou. If she don’t bite, she’ll kick you " he cheerfully assuredme. It is difficult in a bad light to be sure whether a black foalis cyanosed or not, but auscultation has its particular hazards.I found that listening to a foal’s chest using a stethoscope withthe usual length of tubing involves bending right under thebeast with one’s bottom high in the air. The slow tempo ofthe beat needs special concentration, and this was not helped bythe restlessness of the mare close behind. One cannot be sureof an ejection click when the chief thought in one’s mind is," Will the bite come before the kick or vice versa ?". Eventuallythe mare could bear it no longer, and further help was neededto control her. A shout, meant to summon my old friend thestable-lad, was greeted with, " Not bloody likely, I won’t comein there. My insurance doesn’t cover that sort of thing ". Idoubted if mine did either and decided it was time to finish theexamination. I think vets probably earn their money. I haveseldom been bitten or kicked by my usual patients.

*’ *’ *’

It is a common experience to read or hear a strange word,and then to come across it again a short time later. Coincidence ?Some Higher Educational Power at work ? More likely, onehas seen the word often before but could never be bothered tofind out what it meant and skipped quickly past it; only whenthe will-power is strong or the dictionary to hand does the wordreally register, and from then on the eye or ear takes it inproperly. But an experience the other evening has made methink again. I’ve never read Middlemarch (I know, I shouldhave done) nor did I see it on T.v. Tertius Lydgate meantnothing to me when my wireless warmed up for Music at Nightto the sound of his name on that evening’s Book at Bedtime.The music didn’t satisfy, so I turned to book at bedside. Crime ?Biography ? Science ? My hand hovered uncertainly, and then,almost unwillingly, reached for a book on molecular biology atthe bottom (naturally) of the pile. I don’t know why (it cannothave been a voluntary act, for I read science books methodically;I have to) but I found myself starting at a late page, well beyondwhere I had got to. And what did I see at the foot of the thirdpage in this book about a very much 20th-century subject ? Ofcourse, you’ve guessed by now-a quotation from Middlemarchabout the ambitious Dr. Lydgate. I’ll stick to Late Night Extraand crime thrillers in future.

*’ * *

It was heartening to hear from a general-practitioner friendthat, despite assertions to the contrary, the doctor-patientrelationship still flourishes with a modicum of intimacy. Onreceipt of the following letter, my friend had no difficulty intaking appropriate action: " Dear Doctor, Wind. Car in dock.Cdtton wool. The usual. Sincerely..." He of course realisedat once that this sufferer from a lower-limb muscular dystrophywas unable to attend his surgery as she was habitually mal-steering her Ministry vehicle, so he sent by return (first-classmail) the E.C. 10 for the wool and soothing cream needed for thecalliper, together with Mist. Mag. Carb. for the chronic milddyspepsia.

......... *

The Plight of the MesiatriciansWe could not face the Old, which being knownFate led us to them, hoodwinked and forlorn.