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I am grateful for the advice of several colleagues, particularly MissL. 0. Morris, Prof. T. P. Whitehead, and Dr P. Wilding, who allassisted in the design of the reporting system in the Queen ElizabethHospital.

REFERENCES

1. The Standardisation of Hospital Medical Records. H.M. Stationery Office,1965.

2. Sunderman, F. W. Clin Chem. 1975, 21, 1873.3. Hems, G. Lancet, 1969, i, 267.4. Murphy, E A., Abbey, H. J. chron. Dis. 1967, 20, 79.5. Flynn, F. V. Ann. Clin. Biochem. 1969, 6, 1.6. Bold, A. M., Wilding, P. Clinical Chemistry: Conversion Scales with Adult

Normal (Reference) Values. Oxford, 1975.7. Grasbeck, R., Fellman, J Scand. J. clin. Lab. Invest. 1968, 21, 193.8. Lennox, B., Lancet, 1975, ii, 1085.9. Wright, B. M. ibid. p. 1261.

10. Gerbstem, W. H., Ledener, H. L. J. Am. med. Ass 1974, 227, 325.11. Gräsbeck, R. Lancet, 1976, i, 244.12. Hrgovciv, M., Tessmer, C. F., Brown, B. W., Wilbur, J. R., Mumford,

D. M., Thomas, F. B., Shullenberger, C. C., Taylor, G. Prog. Clin.

Cancer, 1973, 5, 121.13 Young, D. S., Pestaner, L. C., Gibberman, V. Clin Chem. 1975, 21, 1D.14. McGowan, G. K. J. clin Path. 1974, 27, 42715. Memorandum Concerning the Signing of Pathology Reports. Medical

Defence Union, 1971.

Occasional Book

UNIVERSITY MEDICINE

A RECENT publication, Anesthesiology and the University, 1is unlikely to be noticed by many academic or non-academicgeneral practitioners, gastroenterologists, surgeons, or patho-logists. This is a pity because the contents of this monographbear examination by any doctor and also because, if its generalmessage is ignored, the whole of the British medical professionis doomed.

It is directed to the anaesthesiologists of America and, insummary, the author, himself an academic, argues persua-sively’for the place of academic doctors within the university.Academics are different from clinicians even though both maywork in university hospitals; academics are, or should be,appointed because they possess evidence of academic ability inteaching and research. They should not be appointed on thebasis of administrative ability, political skill, or clinical pro-wess though it is likely that these estimable qualities may alsobe present. The high level of scholarship which is a feature ofWestern civilisation stems from the academic activity predom-inantly found in the universities. It is clear that academicsin medicine must not only themselves be trained in the disci-pline of scholarship but must also be able to foster scholarshipin the young.Governmental, not to say public, pressure is now operative

in Britain to remove or reduce the influence of the universityin the education of our doctors. The opinion is sometimes

expressed that "X is a good physician" and the non-sequitur"I am confident he can teach our students" follows. No doubtsuch a person can teach the technology of medicine, becausethat is what he does superbly, but will the lessons of scientificthought, hypothesis, experiment, observation, deduction, becarefully and conscientiously demonstrated so that the studentlearns in a manner which will last him throughout his profes-sional career? Clinical decisions must often, in the best in-terests of the patient, be prompt, and even to some extent,empiric, whereas the academic approach in instruction must beslower and may involve more investigation. We are in dangerof forgetting that consultants are appointed to consult; if theyhappen to teach or conduct clinical research, they do so as asideline to their main activity which is clinical work. Thosewhose primary function is an academic one are likely to be bet-ter at that than those whose primary function is something dif-

1. Anesthesiology and the University. N. M. GRFENE. Philadelphia: Lippincott.Oxford: Blackwell. 1975. Pp. 164. £7.

ferent. The student is the one who suffers-but the signs of hisillness will not be manifest immediately; he will become a doc-tor who is unable to modify his practice in relation to advancesin knowledge, if his training has been anti-academic or if anon-intellectual and non-critical approach has been engen-dered.

Professor Greene makes other points which will be echoedby many British academics. The demands of clinical serviceare such that if they are not resisted academic growth is stran-gled. He also, somewhat as an aside, fires a broadside at cur-riculum committees by asking the fundamental, and alwaysunanswered, question "What is the ultimate objective of medi-cal education and how does it relate to the future needs of the

community"? and he states how amateur, non-scientific, andconjectural is the scrutiny currently applied to both old andnew teaching methods.

These are matters for all medical and dental academics toconsider. They will learn from reading this book somethingabout modern anaesthesia which itself is a valuable benefit;but, more importantly, they may question themselves abouttheir own specialties. Clinicians practising in university hospi-tals should also read it in order to reassess their ideas abouttheir own position and, furthermore, they will perhaps cometo understand those who have misgivings about the extensionof the involvement of district general hospitals in undergrad-uate medical education and desire to see this carefully regu-lated.

j. N. LUNN

Commentary from Westminster

Preventive Medicine and Health Education

FROM A CORRESPONDENT

FOR a country which is a world leader in so manyspheres of medicine Britain is disappointingly low in theinternational league in preventive medicine. Preventionhas received little of the resources and not much atten-tion. But now at least part of this is changing. Preven-tion still may not be due for the resources it deserves,but it is beginning to get the attention. In March we hadthe Government’s consultative document, Preventionand Health: Everybody’s Business, which was meant tostimulate public discussion on the issues. If the nationaldebate seems sluggish in getting under way, thenanother document due later this year may stir up some-

thing. This is the report of the inquiry into preventivemedicine which a subcommittee of the all-Party Com-mons Expenditure Committee has been conducting for thepast few months.The nine-member committee, under the chairmanship

of Mrs Renee Short, has been collecting evidence, bothoral and written, from a wide range of medical and non-medical experts. The result is expected to be a numberof recommendations designed to correct the imbalancebetween cure and prevention; and the controversialissues involved may be just what is needed to get thepublic debate going. For what the committee has beeninvestigating goes to the very heart of many of the mostdivisive problems which face a democratic country. Howfar should we rely solely on education and persuasionand how far on measures of compulsion through legisla-tion ?

1. See Lancet, March 20, 1976, p. 621.

956

As Mrs Short admitted at the outset, the committee’s

wide-ranging terms of reference have made it impossiblefor the M.p.s to look at every area of preventive medi-cine. But "we want if possible to get some ideas of howpreventive medicine might replace some of the work thatis now done and we hope save some money too, althoughperhaps that is being too ambitious". The M.p.s even-tually found themselves concentrating on four areas-nutrition, exercise, smoking, and alcohol. And as the evi-dence unfolded over the months it clearly showed thatinterest in these matters in Britain, particularly in thenation’s diet, was far less than in other countries. Prof.J. N. Morris, of the department of community health atthe London School of Hygiene and Tropical Medicine,contrasted the low interest here with the "tremendousdebate" going on in the United States between the medi-cal lobby and agricultural and commercial interestsabout the levels of consumption of saturated fats and theeffect which this debate has had on consumption. Hereferred to steps being taken in Finland to reduce thehigh rate of coronary heart-disease following publicdemand for community and Government action. Prof.E. M. Backett, professor of community health at Nott-ingham, said the Finns were switching their subsidiesfrom butter to margarine. And the interest taken in thismove by the committee suggests that the M.p.s mightrecommend something along these lines in this country.From the dietary point of view witnesses and committeewere agreed that too often the wrong foods were beingsubsidised, making it virtually impossible to achieve Pro-fessor Morris’s aim of bringing about radical changes inour diet.

Prof. John Yudkin, professor of nutrition in the Uni-versity of London, who believes that sugar is the maindietary cause of ischaemic heart-disease, declared thatwhat was required was intensive research into methodsof persuading people to change their eating habits. Thiscall for more research, echoed by most witnesses, is some-thing on which the committee’s final report is bound todwell. Professor Backett believed that the greatest needof all was for research ’into ways of preventing the pro-gression of disease already present. He wanted to seelarge population studies to examine different methods ofpersuading people to alter their behaviour. He wouldfind the money be reallocating funds from curativemedicine.

Not unnaturally, the Health Education Council

agrees, saying that the arguments for diverting resourcesfrom cure to prevention are overwhelming. Mr A. C. L.Mackie, the Council’s director-general, used the occa-sion of his appearance before the committee to attackthe "extremely faint-hearted support" his Councilreceived from the Department of Health and Social

Security and the "absolutely massive inertia" in otherGovernment departments. He protested at the enormoussum of money being poured unnecessarily into thera-peutic medicine, for want of attention to the educativepart of preventive medicine. At least one witness, Prof.C. E. Stroud, of the department of child health at King’sCollege Hospital Medical School, thought that doublingthe Health Education Council’s incorre from 1 millionto C,2 million would probably be one of the best invest-ments of [1 million in health that could be made in thiscountry.

Letters to the Editor

CONSULTANTS’ WORK LOADSIR,-Your issue of Apnl 3 contains contributions from Dr

Loudon (p. 736), Mr Norcross (p. 737), and Dr Strube (p.740): the important message in these contributions is that thesupply of medical endeavour should be more clearly related tomorbidity, that unnecessary work and expense should be

avoided, and that this more economical matching of supplyand demand can only be accomplished by doctors themselves.But how much "work" do consultants have to do? The

prevalence of diseases withm a specialty and the referral-ratesof patients will indicate some of a consultant’s work. In neuro-logy, for example, I can calculate the rough probability of see-ing a patient with any diagnosis. In the table I have used Kur-land’s figures’ for neurological diseases. Consulting-rates wereobtained from the O.P.C.S. morbidity survey2 and referral-rates were had from the same source. The average populationserved by a general practitioner in England, is 2398.3 Theaverage population served by one whole-time equivalent(W.T.E.) neurologist is 428 000.3 I do not suggest that all thosereferred with cerebrovascular disease, for example, will be seenby a neurologist rather than a physician. The point of the tableis to give some indication of the relative frequency of variousdiseases, and the relative frequency of referral to hospital.Multiple sclerosis is generally considered to be.one of the com-moner neurological diseases, yet a, neurologist will see aboutone new case a month. A neurologist will see about a quarterof all prevalent cases each year. Huntington’s chorea is a dis-ease known by name to many, but a G.P. would have to prac-tise for over 80 years before seeing a new case. The incidenceof myasthenia gravis and syringomyelia, disorders which

figure prominently in undergraduate medical texts, is even

lower. z

.

Referred patients with non-specific symptoms such as head-ache are very numerous. For every new case of multiplesclerosis in the community there will be about 100 referrals fornon-specific headache and migraine. Our department at St.Bartholomew’s Hospital, supported by the Department ofHealth and Social Security, is attempting to analyse the expec-tations of patients with headaches, and of their general practi-tioners, on referral to hospital, but a further interesting areafor research would be a study of how a young doctor, taughtin terms of the pathology and management of specific. diseases,learns to cope with the non-specific complaints encountered ingeneral practice and hospital clinics. One way in which he

copes seems to be by limiting new outpatient attendances. Con-sultants may remain confident that they will be asked to seeas an "urgent" or "extra" case those patients who are "really"ill. The M.P. for Essex (South East) told. the House of Com-mons that "In one district general hospital patients have towait as long as 12 or .13 weeks for an urgent outpatientappointment, and routine new patient appointments are notavailable at all [my italics] in ,the general surgery, E.N.T. andorthopaedic departments"." This means that consultants at thishospital will only see a patient if the G.P. considers it reallynecessary-and that should be the basis of all referrals.

In support of the hypothesis of limitation by consultants ofthe supply of their time, I have examined the numbers of new

outpatient attendances and discharges and deaths per W,T.f,consultant in various specialties in England (figs. 1 and 2).The numbers in the left-hand part of fig. 1 have been calcu-lated by dividing the numbers of new patients attending out-patient clinics in various specialties in 1963 and 1973 by the

1. Kurland, L. Epidemiology of Neurologic and Sense Organ Disorders. Cam-bridge, Mass., 1973.

2 Office of Population Censuses and Surveys Morbidity Statistics from GeneralPractice, Second National Study 1970-1971. H.M. Stationery Office,1974; and personal communication with O.P.C.S.

3. Department of Health and Social Security Health and Personal Social Ser-vices Statistics for England. H.M. Stationery Office, 1974.

4. Hansard, 1975, 898, no. 186. col. 1089.