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that taken in the University of New South Wales, Aus-tralia, where students learn to understand patients bybecoming them; they are admitted with simulated mala-dies to the wards of their own teaching hospital. 7As Byrne and Long remark, doctors are consulted

about an enormous variety of problems, from thestraight medical-"Have I got pneumonia, doc-tor?"-to what may be termed the straight bizarre-"What make of gas cooker ought I to buy, doctor?"Somewhere in their training, and we would rather see itearly in medical school than late in established practice,doctors must be taught how to understand their pa-tients, even if they cannot learn to pronounce on themerits of gas cookers.

WHAT EVERY WOMAN NEEDS TO KNOW

DISCUSSIONS in the New England Journal of Medi-cine about elective hysterectomy8 record some of theissues of choice in medical care and highlight one oftenoverlooked distinction between private and State medi-cine-namely, who does the choosing. As with manyother elective surgical procedures, the rate of hysterec-tomy in the United States is much higher than in Bri-tain. Although there seems to have been no increase inthe incidence of "clinical" indications for hysterectomy,the operation-rate in the U.S.A. has risen from 6.8 per1000 women aged 15 or more in 1968 to 8.6 in.1973-at least twice the British rate, which is falling. Itis even higher among the wives of American physicians,9and the signs are that hysterectomy is increasingly beingchosen, by women who are well-informed and who canafford it, as an investment against cancer, pregnancy,menstruation, and menopausal disturbances of uterinefunction. If this is so, the information and advice avail-able to these women must suggest that for them theexpected benefits outweigh the temporary incon-venience, the operative risks, and the further risks ofpost-hysterectomy depression and other symptoms as-sociated with low oestrogen levels. 10 The nature of choicesdiffers from that in Britain; although in the U.S.A. eachwoman must include in her personal cost-benefit assess-ment the cost of the operation, at present the Americanhospitals or Government feel no urge to weigh up thenational costs and benefits of making hysterectomyavailable to all who wish to invest in it. Despite this, var-ious estimates have been presented in the New EnglandJournal of the costs and benefits for the country as awhole. As with most such exercises, they disagree mainlyon three values-the proportion of women for whom thequality of life is improved after hysterectomy (aboutwhich sufficient data do not exist); technical details ofcosting procedure; and the value which can be attachedto each year of life saved.

In Britain, the Health Service rather than the patientis responsible for rationing and the broad selection ofwho shall have what. Even more important than "whoshall have" is "who shall not have"-the "opportunitycost" of treating one patient to the exclusion of another.While many doctors feel that such decisions increasinglyare pre-empted by Government policy in allocating

7. Lancet, 1974, ii, 1433.8. Bunker, J. P. New Engl. J. Med. 1976, 295, 264.9. Bunker, J. P., Brown, B. W. ibid. 1974, 290, 1051.

10. Richards, D. H. Lancet, 1973, ii, 430.

resources, the final allocation still rests with the clinicianwho must take two distinct judgments-on the net ben-efit to each patient and on the opportunity cost of usinghis (or her) own limited resources to treat one type ofproblem rather than another. While his views of the ben-efits to different patients will depend largely on existingclinical and epidemiological knowledge, his judgment ofwhom to exclude, based on the weights that he attachesto different benefits, is likely to favour treatment of con-ditions where there is a prospect of immediate andobvious clinical relief. If this is so, the Health Service is

likely to exclude an increasing proportion of preventiveand discomfort-relieving interventions. Thus, howeverhighly the British Health Service patient may judge thebenefit to herself of elective hysterectomy, her chancesof obtaining it are small when she has to compete withmore demonstrably ill patients. But does the informa-tion exist on which the pros and cons can be realisticallyassessed? The position with hysterectomy today isreminiscent of that of cervical cytology when it was in-troduced as a national preventive service in the expan-sive early days of State medicine. Then, too, the clinicalmeasures of benefit were missing-and they still are. Itshould be possible now to obtain both subjective andobjective information about the long-term outcomes inhysterectomy patients compared with those in similarpatients who keep their uterus. Subjective, armchairestimates are not sufficient grounds either for nationalpolicy or for allocation of scarce resources to individualpatients. In State medicine the bases of choice must beas objective as possible, because those who pay, thosewho choose, and those who consume do not all have thesame set of values.

DIABETIC FOOT ULCERS

FOOT lesions are common in middle-aged and elderlydiabetics. The various combinations of sepsis, neuro-

pathy, and ischaemia may demand long spells of treat-ment in hospital. Peripheral neuropathy causes not onlysensory impairment (and thus increased risk of trauma)but also weakness of the intrinsic muscles of the foot,leading to toe deformities.1 Neuro-arthropathy is a com-plication of longstanding diabetes, the most commonlyaffected joints being the tarsal and tarsometatarsals, fol-lowed by the metatarsophalangeal and (infrequently)the ankles.2 Trauma, often ligamentous, is an impor-tant factor in tarsometatarsal disease but when the

metatarsophalangeal joints are involved there is usuallyno story of injury. Disease in these joints tends to pres-ent as skin ulceration, and chronic ulcers most com-monly arise on the sole of the foot, in the region of themetatarsal heads. The earliest change is a callus whichrecurs despite regular foot care. (Many ulcers are dis-covered when a callus is debrided.3) The ulcer can

become a source of chronic infection and discharge,penetrating to the metatarsal bones and communicatingwith the metatarsophalangeal joint. Although the lesionmay follow a benign course over months or years it is

always a potential cause of spreading foot infection. OnX-ray, feet affected by neurophathy may show resorptive

1. Catterall, R. C. F in Clinical Diabetes and its Biochemical Basis (edited byW. G. Oakley, D. A. Pyke, and K. W. Taylor); p. 557. Oxford, 1968.

2. Sinha, S , Munichodappa, C. S., Kozak, G. P. Medicine, 1972, 51, 191.3. Swallow, A. W. Br J. Hosp. Med. 1976, 16, 235.