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that any one symptom may be a manifestation of con-

version, anxiety, or insecurity, and vomiting is an obviousexample. Similarly in any one episode of organic illnessall three types of functional response may show them-selves as in the effects of closed head injury. The patientmay produce a conversion symptom on regaining con-sciousness because of guilty feelings about the accident,he may later produce depression and anxiety as a reactionto his continuing headaches, and he may still later

perpetuate his symptoms in response to the insecurityinvolved in legal delays concerning compensation andreturn to work.

In spite of this I hope a case has been made out for

spending a little more time than is usual in evaluatingthe functional overlay and perhaps we should changeour attitude of vague annoyance and resentment which iscommon among some doctors towards these patients.Faulty diagnosis does not happen because of failingintellectual powers but because thought is not alwaysdirected to the possibility of this peculiar combination oforganic and functional. It seems likely that this particularfield of diagnosis and treatment, lying as it does onthe borderlands of neurology, is well worth cultivating,and I firmly believe that clinical sense will prove to

be just as valuable a tool for this purpose as clinicalscience.

TEMPORARY REGISTRATION AND

REQUALIFICATIONTHIS summer the British Press was much interested in

the efforts of one or two foreign medical graduates tosecure or renew their temporary registration with theGeneral Medical Council, so that they could start or con-tinue to work as hospital doctors in the United Kingdom.Headlines such as " Doctor Ban Starts Change-LawMove " and " Second Foreign Doctor Refused Registra-tion " were to be seen; and The Lancet 1 even went so faras to entitle an editorial comment,

" Marriage and theG.M.C.". Some observers apparently regarded the issueas a simple one-the denial of the right to work (a rightwhich, it was occasionally remarked, finds less restrainedexpression in the Treaty of Rome and its provision for thefree movement of labour). But there is certainly more toit than that.

Concern with the provisions of the Treaty of Rome mayseem a shade academic at present. On the other hand, thedecisions associated with temporary registration by theG.M.C. of doctors who qualified overseas raise day-to-daypractical questions of which the profession and the publicare seldom aware. The Junior Hospital Doctors Associa-tion has lately expressed dissatisfaction with some aspectsof present procedure; and last month the British MedicalAssociation stated:

" A deputation from the British Medical Association hasnow met representatives of the General Medical Council todiscuss the registration of doctors from overseas. It is clearthat the G.M.C. is bound by the provisions of the Medical Act,from which it has no power to depart. It appears that there area number of interests involved, including the Government, theG.M.C. and the B.M.A., but the question whether any changesshould be made in the Act is being actively considered."

Though the procedures and some statistics concerningfull and provisional registration are published annually ina preamble to the Medical Register, the data for temporaryregistration and requalification have been less accessible.This may be one reason for some of the misunderstandingsand the criticisms.

THE MEDICAL REGISTER

The G.M.C. has a duty to protect the British public:and for over a century anyone who requires medical aidhas been able to distinguish a qualified medical prac-titioner from more tenuously accredited individuals byreferring to the statutorily maintained Medical Register(now containing 112,000 names). In practice Parliamenthas, especially by the N.H.S. Acts, so restricted theactivities of an unregistered doctor that this protection is

1. Lancet, Aug. 19, 1967, p. 408.

largely automatic. The G.M.C. maintains standards ofmedical proficiency by supervising medical education (forexample, by visiting medical schools, scrutinising examin-ing bodies, and issuing Recommendations as to theMedical Curriculum); and it publishes a list of qualifica-tions holders of which may be admitted to full or

provisional registration.Before overseas graduates can be granted full or

provisional registration, two conditions must be satisfied:the country, province, or State in which the applicantqualified must have reciprocal arrangements with theU.K.; and the qualification must be recognised by theG.M.C. Reciprocity today covers nearly the whole of theCommonwealth and Burma and South Africa. It is likelyto be extended to more of the developing countries in theCommonwealth. In Canada three provinces are no longerwithin the scope of reciprocity, and so not all her graduatesare directly eligible for registration. On the Indian sub-continent there are some qualifications which have notyet been recognised.

TEMPORARY REGISTRATION

Under the Medical Act 1956, the G.M.C. may granttemporary registration to a doctor with whose country ofqualification the U.K. has no reciprocal arrangements orwhose qualification is not otherwise recognised for

permanent registration, or to a doctor who, thougheligible for registration, requires time to obtain docu-mentary evidence or wishes to take up an approved hospitalappointment to acquire experience for full registration.Applicants must satisfy the Council, each time they askfor a certificate, that they intend to reside only temporarilyin this country. Certificates are given for a limited periodand for named hospital appointments: change of jobnecessitates reregistration.

It is not widely known how the G.M.C. screens medicaldegrees and diplomas for this purpose. The WorldDirectory of Medical Schools 2 lists well over six hundredcolleges in 1960-61, and there will be many more by now;and graduates of 60 countries are today working in thiscountry on temporary registration. Clearly the Councilcannot scrutinise in depth by examining curricula andvisiting medical schools, as it can for permanent registra-tion. And outside the terms of reciprocity, detaileddependable sources of information are not readily avail-able to the G.M.C. The Council’s task in this respect isnot made easier by the variation of standards within acountry and at different times. It is believed that thereare certain qualifications which the Council feels it cannotaccept, at least for the time being. These include

2. World Directory of Medical Schools 1963. Geneva.

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No. of certificates of temporary registration 1955-66 (and estimatedfigure for 1967) and no. of doctors (not eligible for full or provis-ional registration) requalifying 1957-66.

some degrees granted in the Far East-in Indonesia,and, since 1953, in the Chinese People’s Republic,for example.An answer of " acceptable " or " unacceptable

"

(or theunmasking of the very rare bogus diploma) does not coverall the G.M.C.’s decisions. Some borderline cases remainand the G.M.C. copes with these by limiting the firstcertificate to posts in hospitals approved for preregistrationpurposes or by asking for evidence of postgraduatetraining.

Certificates are not granted indefinitely. Moreover,temporary registration will not be granted if the applicantannounces his intention to stay in the United Kingdommore than " temporarily " or if, for some other reason,the G.M.C. is not convinced that he is still here tem-

porarily (the taking-up of British nationality may be apointer). But a certificate of registration is allowed to runits full course: it cannot be withdrawn simply becausecircumstances change. After 21/2 to 3 years a holder maybe sent an " early warning " letter reiterating the tem-porary nature of his registration. Anyone who has residedor is intending to reside in the U.K. for more than 4 orat most 5 years will find reregistration on a temporarybasis extremely difficult. Lord Cohen of Birkenhead putthe limit at 4 or 41/2 years,3 but the Council is not inflexible.Neurosurgery is recognised as requiring lengthy post-graduate training, and temporary registration, for this

purpose, of 61/2 years is not unknown; the M.CH.ORTH.Lpool, taken after an F.R.c.s., is similarly placed.Rare in 1949, certificates of temporary registration are

being issued more and more (see figure). In 1966, a totalof 3551 certificates were granted (two-thirds to doctorsnot eligible for full or provisional registration) to about2400 doctors; and on Sept. 30 of that year 1041 doctorsholding hospital appointments were on temporary regis-tration (the majority as registrars or S.H.O.S).4 Certificatesmay be given for periods of from under 2 months to overa year. The average is just over 6 months. Since fees areE3 10s. for periods of 2 months or less and E10 thereafter

3. See Lancet, 1965, ii, 1179.4. ibid. Nov. 25, 1967, p. 1143.

the process may be fairly expensive: a doctor who is giventhree certificates or more than 2 months’ duration willhave paid E30 in fees, and this is more than a fully regis-tered practitioner pays in a lifetime (so long as an annualretention fee is not introduced).

Geographically, of the 708 doctors not eligible for fullregistration who were temporarily registered for the firsttime in 1966, 245 qualified in Europe, 251 in Asia, 104 inAfrica, and 108 obtained their degrees in the Americas.The leading countries and blocs in these areas in 1965and 1966 are as follows:Doctors not eligible for full registration temporarily registered for the

first timp

* Including U.S.S.R. and Yugoslavia; excluding Poland.

It is worth noting that any proposals for the freemovement of labour within the Common Market (orwithin the European Free Trade Association for that

matter) would not affect the status of the majority ofnon-British European doctors now working here on

temporary certificates.

Temporary registration may not be granted if the Councildoubts whether an applicant’s English is sufficient for thejob he is proposing to do. A substantial proportion ofdoctors do present themselves at the London office of theG.M.C. at some point during their stay; but the G.M.C.need not necessarily be in verbal touch with an applicant,and written applications are not always a reliable guide.Moreover, an understaffed hospital in the North of

England is not likely to complain about a houseman’sEnglish unless this is quite intolerable. The Council alsomakes use of other safeguards-such as scrutinising withparticular care the application of a man who has qualifiedfairly recently and who may be aiming at a post of toohigh a level. In general terms, temporary registration isat the sole discretion of the G.M.C.: it is not a right.The procedure works. That is to say, the majority of

the holders of temporary registration return, post-graduate diploma in hand, to their own country, havingacquired valuable experience and given important help tothe British hospital service. But the plight of the smallnumber of overseas graduates who, because they havemarried here, or because they are at daggers drawn withthe regime at home, or simply because they prefer it, wishto stay here and practise medicine, is worth investigatingfurther. So too is the case, also rare, of the foreign doctorwho, lacking guile or guidance, admits from the start anintention to stay here indefinitely and is therefore in-

eligible for temporary registration.Temporary registration was never intended as a short

cut to the Medical Register. The only course at present fortemporarily registered doctors who want to stay inBritain is to requalify; and however this is done it is liableto be a lengthy or otherwise inconvenient process.

REQUALIFICATIONThe Polish graduate who became ineligible for further

registration after marrying a British citizen and settlingdown in this country 1 could take a full university courseof 5 or 6 years or (more likely) sit one of the other qualify-ing exams. With exemptions granted on the basis of

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courses of study and examinations taken at institutionsoverseas, a candidate may be admitted to the final examina-tions of the English and Scottish (but not the Irish)Conjoints, the L.M.S.S.A., and the L.A.H. Dublin.

Exemption may depend on the candidate completing somefurther years of hospital experience: this may be 1,2, or 3 years.Examination returns for 1966 show that only 4 out of 31overseas candidates for the English Conjoint Board final wererequired to pursue further hospital practice before sitting theexamination-they were graduates of the Universities of

Freiburg (2) and Teheran (1) and a holder of the licence of theState Medical Faculty, East Pakistan. For the Scottish

Conjoint Board final all but 1 out of 17 candidates had to

complete 1 extra year of hospital practice. For the L.M.S.S.A.only 5 candidates-graduates of Chung San, Freiburg (2),Sun-Yat-Sen, and Teheran-out of 58 had to obtain furtherhospital experience (3 years). Before granting admission to itsfinal examination, Apothecaries’ Hall, Dublin, required 2 yearsof further hospital practice or study for all 30 exemptedcandidates in 1966.

Clearly the position must be confusing for any foreigngraduate embarking on requalification. It has been

suggested that the quickest route, given enough money, isto fly to Canada and take without delay the L.M.C.C. in oneof the provinces: this device seems to be based on a

misconception, since the qualification will not be recog-nised when an applicant had lived in the U.K. within the5 years up to equipping himself with the licence of theMedical Board of Canada. Of the 568 doctors who have

requalified between 1957 and 1966, 35% took theL.A.H. Dublin, 33% took the L.M.S.S.A., and 19% and 12%took the English and Scottish Conjoints, respectively.

These doctors were roughly equally divided between Asia,Europe, and the Middle East in country of originalqualification.The total cost of taking such examinations can be very

high. To travel to Dublin and stay there to take the shortcourse in pharmacy required for admission to the L.A.H.final could well cost over E250. It must come as a surpriseto most local education authorities when a once-qualifieddoctor seeks a grant to requalify: but tenacity and knowingthe ropes may help in getting financial assistance. Sincethe candidate may well be rusty on some of the subjectsfor the final exam, and since he or she may also be studyingfor a higher diploma at the same time, the strain to pocket,brain, and family can be considerable.

At the instance of the G.M.C. the 1956 Medical Actwas amended in 1958. Before this amendment came intoforce success in a second final examination did not markthe end of the road, and in some cases it may still not.Formerly a twice-qualified doctor (no matter if he hadbeen a professor of surgery in his own country) had to do12 months as a house-officer before he could be fullyregistered. Latterly, previous clinical experience may betaken into account. But this experience must be equiva-lent to that gained by newly qualified doctors in house-officer posts; an Icelandic doctor who, after 5 years inthis country (including an appointment as senior registrarin pathology), had requalified, still had to take up a house-officer appointment before he could obtain full registra-tion. In 1962-66, 321 doctors requalified; in the sameperiod 283 such doctors were admitted to full registrationunder the terms of the 1958 Amendment Act.

Round the World

CanadaThe third week of November marked the tenth anniversary of

the Gairdner awards in biological sciences by a gathering ofdistinguished scientists. The Foundation, which was startedby Mr. J. A. Gairdner of Toronto, this year distributed$80,000to 9 scientists selected from 70 nominations representing almostevery part of the globe. 3 of the 1967-awardees were Canadians,4 came from United States, 1 from Belgium, and 1 from England.The special awards of$20,000 apiece went to Christian

Deduve, of the University of Louvain and the RockefellerUniversity, N.Y., for his concept of lysosomes and to Dr.George Palade, of Rockefeller, for his pioneer contributions inelectron microscopy. Dr. Harold Copp of British Columbia(calcitonin), Dr. Peter Maloney of Toronto (immuno chemistryof insulin), and Dr. Fraser Mustard of McMaster University,Hamilton, and formerly of the University of Toronto (plateletthrombi) were the three Canadians who each received awardsof$5000. The Americans were Marshall Nirenberg (proteinsynthesis), and Julius Axelrod and Sidney Udenfriend

(noradrenaline), who all work at Bethesda. lain MacIntyrefrom England was recognised- for his demonstration that theultimobranchial body is the source of Copp’s calcitonin.

In a sense these awards are Canadian-style, albeit modest,Nobel prizes. But the atmosphere of the three days of academicexercises associated with the awards is informal. Each awardee

gives a short lecture at a time and place easily accessible to themedical students of the university as well as its faculty. Thisyear six were given in weekday lunch hours and the remain-ing three on Saturday morning. With the lecture room of theUniversity of Toronto’s General Hospital crowded with studentssitting on the steps of the amphitheatre and standing at theback, the lectures achieved an air of excitement rather than ofpomp and circumstance. This was reflected in many of thedissertations which sparkled with wit and humour as well aserudition. It seems fitting that this flavour of colonial informal-ity predominates at colonial academic occasions.

New GuineaWe lead an interesting life in our highland retreat, but

naturally our experiences may not apply to the rest of NewGuinea. Only fifteen years ago our people were still engagedin fighting and eating each other. Now the local M.p. goes toPort Moresby several times each year at the public expensefor sittings of the new House of Assembly, and locally ownedtrade-stores are springing up in many of the villages. Coffeeis the only cash crop, and, though the people have easilymastered the art of producing the sun-dried bean, the

vagaries of the world coffee market are regarded with

suspicion.Sweet potato (now unfortunately in short supply) is the

staple food, and the diet is marginal in protein, which probablyexplains the slow growth of children after weaning. Some

depigmentation of the hair in toddlers is common, but frankkwashiorkor is rare. Leprosy is coming under control, whilealtitude and inaccessibility have hitherto largely protected usfrom malaria and tuberculosis. Obstetrics can present all the

complications we used to hear about from ageing professorswhen we were students. A recent measles epidemic providedus with 7 cases of infant myocarditis-although the 3 babieswho died never developed a rash. Several other deaths latelyhave been due to pig-bel, or enteritis necroticans, the effectof eating poorly cooked meat at pig feasts. Our epidemic hasmainly affected children from one isolated population pocket,but we have heard of outbreaks in other parts of the highlands.

Despite a well-equipped subdistrict hospital to serve an

indigenous population of 40,000, most of our patients comefrom nearby villages. Belief in sorcery is still universal, butfor some diseases, such as pneumonia, the village people areprepared to concede that our magic is stronger. Earlier this

year one sorcery victim baffled us for a few days until wediagnosed disseminated lupus erythematosus. Our steroidmagic produced enough improvement to allow him to gohome to die from his urxmia. New Guinea, with its com-bination of primitive disease patterns among a populationserved by a nucleus of skilled doctors, offers opportunities formuch exciting research.