660 Unlike a court of law, hospital inquiries (other than those set up under Section 84 of the National Health Service Act, 1977) have no power to compel witnesses to attend; and the oath cannot be administered. There therefore tends to be talk of attending "to help the committee", as a result of which a witness is often not mentally in tune for what may follow and finds himself in a very different position from that represented to him as an inducement to give evidence. An additional problem is that, when such a closely knit community as a hospital feels itself unfairly attacked, there tends to be a closing of ranks, and allegations of injustices at the hands of the committee will grow as they. are passed from mouth to mouth.
Staff Morale An inquiry inevitably has an emotionally traumatic effect upon some people (if staff have behaved inhumanly towards patients, this may well be deserved, although even here an attempt should be made to discover any possible mitigating circumstances). The unemotional pursuit of truth may easily hurt the deepest feelings of good, genuine people, especially their pride in themselves, in their colleagues, and in their place of work-areas in which emotion often overrules logic. There are, however, ways in which the impact of an inquiry on morale can be buffered. Potential witnesses should be more clearly informed of the terms of reference of a committee of inquiry and the way in which it functions. Witnesses should understand that, when criticism of a hospital has reached a certain threshold, concern over patient-care becomes of paramount importance, and an inquiry becomes inevitable. Future committees of inquiry could point these matters out in the hospital before the inquiry starts, and explain why a more informal investigation would be unand how hurt can best be avoided. They could also advise against the dangers of over-identification with the hospital or with groups within it, so that people may avoid slipping unintentionally into a frame of mind where hurt is nurtured individually and collectively. More time in this kind of preliminary explanation might have prevented the legend that has grown up round the St. Augustine’s Inquiry that witnesses other than the original complainants were not permitted to hear the evidence against them. In fact, the procedure was agreed with all legal and union representatives that witnesses could be present to hear the evidence against them if they so wished. Thereafter there was either a breakdown in communication, or the information was
satisfactory
’
forgotten. The advantages of a private, as opposed to public, hearing are great, provided that the report is published. More informality is possible, and the committee can mingle with the witnesses during tea-breaks, when tentative views can be expressed. If there is general agreement that there is no answer to certain allegations, the committee can avoid subjecting a witness to unnecessary distress. In public it is difficult to do this without risking the comment, "why are they letting him off so lightly?" .
Right of Appeal The right of appeal is desirable in the interests of the individual, but an appeal may prolong the disruption and uncertainty for all concerned. It also raises complex legal problem, unless the appeal is going to be deter-
mined
solely
on
the
transcript of evidence.
There would
have to be a counsel for the person aggrieved and the counsel for the committee, to ensure that the appellate tribunal was guided to all relevant material in the voluminous transcripts and documents. The aggrieved person may want to call further evidence and, instead of the appellate committee pursuing the inquiring function of the original committee, the hearing might become adversarial in character.
elsewhere, prevention is infinitely better than cure. To guard against the risk of unjust criticism witnesses should painstakingly prepare what they want to say -and decide clearly what other witnesses they would like the committee to hear. It is also important not to burden one legal representative with too many clients. It is not easy, for example, for one person to do justice to several doctors, each of whom has patients in several Here,
as
wards. We believe that the improvements which are undoubtedly needed in the inquiry system are more likely to be found along these lines than in the root-and-branch reform sought by some. The grass in the next field is not always greener when one gets there. We thank Mrs Janet Farmer for secretarial
Requests
of Psychiatry, ton
help.
for
reprints should be addressed to J. G. E., Department Royal South Hants Hospital, Graham Rd., Southamp-
S09 4PE.
Women in Medicine A
Campaign to Improve Career Prospects THE percentage of women graduating from medical school in Britain increased from 25% in 1963 to 32% in 1978; by the mid-1980s it is expected to be around 50%. Most women doctors spend a large proportion of their working lives in part-time employment, so, under the present system, they have to forego many of the career prospects and opportunities open to their male colleagues who work full-time. Despite the fact that the percentage of women with higher qualifications is growing, only 14% of senior hospital medical staff (at seniorregistrar grade and above) are women. In 1978 there were only 97 part-time registrar posts out of a total of 4000 full-time posts. The place of women in medicine was discussed by a symposium in London on March 9 at which a campaign was launched to improve their career prospects. The meeting was organised by the Medical Women’s Federation and chaired by Dame JOSEPHINE BARNES, President-elect of the British Medical Association. Prof. MARGOT JEFFERYS (professor of medical sociology, Bedford College, London) described the position of women during the 1960s. She referred to a survey conducted at that time by the Medical Practitioners’ Union which showed that most medical women postponed marriage and childbirth until their training was over. In 1962-63 the majority of young married women wanted part-time work, mainly in family planning or on a sessional basis in schools. Nearly 45% of the married women in the survey wanted to continue with their medical careers, but they were unable to do so because of the traditional organisation of work within and outside the profession. Dr BERENICE BEAUMONT (senior registrar in community medicine, Kensington, Chelsea, and Westminster area health authority) compared this situation with that of medical women
661 doctors in 1976 showed that the profession in the 1970s the problems they faced had not changed significantly. Women in both surveys complained of a lack of posts appropriate to their experience and training, of insufficient postgraduate training facilities for part-time students, and of the unsympathetic attitude of their male colleagues and administrators. In the career grades Dr Beaumont found a higher percentage of women in junior grades than in senior posts, and women tended to occupy consultancies and senior registrarships in pathology, paediatrics, and psychiatry rather than in surgery or general medicine. Nearly two-thirds of the women in the survey experienced difficulties in continuing their careers, particularly since many were unable to take on more than 8 N.H.D. (notional half day) sessions. Another survey conducted last year’ showed that at least 40 women registrars now training would be unable to take up a consultant appointment of as many as 8 clinical sessions. Dr Beaumont suggested that a proportion of consultant posts in every specialty should be advertised for fewer than 10 N.H.D.S. Mrs MARGARET GHILCHICK (consultant surgeon, St Charles’ Hospital, London), describing the position of women consultants, attacked the "appalling and continuous prejudice against women throughout their training" and decried the fact that there were so few women teachers in medical schools and hospitals (there were no female postgraduate deans). She felt that the subconsultant grade was no solution. Dr SUSAN ROBERTS (consultant physician, Newcastle General Hospital) said that women should aim for permanent, senior, and responsible posts and should strongly resist the subconsultant grade. She warned that there was a "grave danger that the profession may buy off the female half of the labour force with the promise of jobs for many at the price of equal opportunities for all". What was needed was a change of attitude from both men and women in the profession. Ways in which action could be taken to improve the status of part-time work might include the payment of full pro-rata benefits for all, paid administrative sessions in part-time contracts, an N.H.S. committment allowance for part-timers in consultant contracts, and an expansion of the consultant grade with reduced hours for all. Dr SALLY JOBLING (general practitioner, Oxford) proposed the establishment of a 24-hour service for all N.H.S. employees and the expansion of deputising services in all major cities. Women should recognise that they needed to be "more professional before competing on equal terms for demanding
today. A although
survey of
women
more women were
entering
sion because of the increasing need for doctors in general practice. The manpower question really arose only at senior-registrar level where the supply of appointments was limited. The profession was now moving towards a situation at the end of the century where 1 in 3 career posts would be occupied by women, most of whom would spend a large proportion of their career working part-time. At the moment there was sufficient leeway to accommodate women in these career posts without upsetting the balance of specialties. Dr GILLIAN FORD (deputy chief medical officer, D.H.S.S.) added that the growth of specialties such as anaesthesia, geriatric medicine, general practice, and psychiatry would create more posts in the consultant
grade. In the discussion many
women
criticised the lack of career
counselling at undergraduate level and the paucity of information on choices of specialty. The suggestion from a male participant that on a cost-effective basis women were not a good return and were "a relatively expensive luxury" aroused great indignation; and another male speaker who referred to the "girls" in the medical profession sent ripples of annoyance through the hall. Many women felt that they were being treated
"pair of hands", the "office temps of mediGpuNEBERG, secretary of the M.W.F., put it. Others declared that they would be setting an "appalling standard" if they insisted on working full-time to the detriment of their children’s wellbeing.
cine",
another
as
as
Dr ANNE
Inevitably, this kind of debate must reach beyond the confines of the medical profession, since it embraces the problems of all women who are committed to both career and family. The prospect that by the end of the century nearly half of Britain’s medical graduates will be women should give planners of medical manpower an opportunity to lead the way in restructuring career grades and training facilities to accommodate not only those women but also the men who wish to work parttime.
Round the World
child-minding
jobs". officer, the majority of whom (75% working part-time), was described as a "rag-
The post of clinical medical are women
bag grade" by
Dr KINGSLEY WHITMORE
(research pxdiatri-
c.M.o.s had no and could be promoted only by switching to community medicine. The recommendations of the Court report’ should be accepted as a guide for future child-health services. There should be a proper job description for the C.M.o. grade; training should be compulsory and modular in form to accommodate part-time work; and the service should be organised on a district basis. Dr PETER SUTTON (lecturer in morbid anatomy, University College Hospital Medical School, London) said that since 1970 there had been no discrimination against the selection of women undergraduates in medical schools and that admission procedures tended to favour women. Dr JOHN LISTER (postgraduate dean, North West Thames Region) suggested that postgraduate training programmes could be modified to suit part-time requirements but that this would not solve the problem of reconciling training needs with manpower requirements. Dr ROSEMARY RuE (regional medical officer, Oxford Regional Health Authority) argued that there was no fear of unemployment in the profes-
cian, Thomas Coram Research Unit, London). career structure
1. Beaumont, B., Grüneberg, A.Br.med. J. 1979,i, 359. 2 Whitmore, K., Bax, M., Tyrrell, S.ibid.p. 242. 3.See Lancet, 1977, i, 79.
Canada DEFAMATION OR ACCEPTABLE
CRITICISM?
Although the laws of defamation which operate in the United States and Canada are derived from English law, their application varies widely. A recent judgment handed down by the Supreme Court of Canada has had the Canadian press in a turmoil. The court ruled that the Saskatoon Star Phoenix had libelled a Saskatoon alderman by printing a letter which was defamatory. The ruling was said to be based on a precedent set in a similar British case many years ago, but even the most casual glance at the Letters to the Editor columns of any British newspaper, and not excluding the Lancet and British Medical Journal, makes it evident that there is no reluctance to print critical comments or explicit opinions. A second libel judgment handed down by a British Columbia judge concerned a political cartoon which characterised a British Columbia politician pulling the wings off flies-pretty tame stuff compared to those who were brought up on Gilray or even Thackeray. The problem comes in distinguishing acceptable criticism from defamation. Thus, anything which is spoken or printed and which reflects on the character of another can be regarded as defamatory; even the hint that somebody’s feet are oversize. Such a statement is not actionable, however, if it is true or if it is fair comment or protected by privilege. The important issue in the recent cases, particularly the one involving the Saskatoon paper, is whether the defence of fair comment can be denied in a newspaper which publishes a defamatory letter. Thus, if the editor shares the views of his correspondent he has a defence, but if he does not, then the precedent set by the Supreme Court of Canada would make him liable. It so
.
Staff Morale An inquiry inevitably has an emotionally traumatic effect upon some people (if staff have behaved inhumanly towards patients, this may well be deserved, although even here an attempt should be made to discover any possible mitigating circumstances). The unemotional pursuit of truth may easily hurt the deepest feelings of good, genuine people, especially their pride in themselves, in their colleagues, and in their place of work-areas in which emotion often overrules logic. There are, however, ways in which the impact of an inquiry on morale can be buffered. Potential witnesses should be more clearly informed of the terms of reference of a committee of inquiry and the way in which it functions. Witnesses should understand that, when criticism of a hospital has reached a certain threshold, concern over patient-care becomes of paramount importance, and an inquiry becomes inevitable. Future committees of inquiry could point these matters out in the hospital before the inquiry starts, and explain why a more informal investigation would be unand how hurt can best be avoided. They could also advise against the dangers of over-identification with the hospital or with groups within it, so that people may avoid slipping unintentionally into a frame of mind where hurt is nurtured individually and collectively. More time in this kind of preliminary explanation might have prevented the legend that has grown up round the St. Augustine’s Inquiry that witnesses other than the original complainants were not permitted to hear the evidence against them. In fact, the procedure was agreed with all legal and union representatives that witnesses could be present to hear the evidence against them if they so wished. Thereafter there was either a breakdown in communication, or the information was
satisfactory
’
forgotten. The advantages of a private, as opposed to public, hearing are great, provided that the report is published. More informality is possible, and the committee can mingle with the witnesses during tea-breaks, when tentative views can be expressed. If there is general agreement that there is no answer to certain allegations, the committee can avoid subjecting a witness to unnecessary distress. In public it is difficult to do this without risking the comment, "why are they letting him off so lightly?" .
Right of Appeal The right of appeal is desirable in the interests of the individual, but an appeal may prolong the disruption and uncertainty for all concerned. It also raises complex legal problem, unless the appeal is going to be deter-
mined
solely
on
the
transcript of evidence.
There would
have to be a counsel for the person aggrieved and the counsel for the committee, to ensure that the appellate tribunal was guided to all relevant material in the voluminous transcripts and documents. The aggrieved person may want to call further evidence and, instead of the appellate committee pursuing the inquiring function of the original committee, the hearing might become adversarial in character.
elsewhere, prevention is infinitely better than cure. To guard against the risk of unjust criticism witnesses should painstakingly prepare what they want to say -and decide clearly what other witnesses they would like the committee to hear. It is also important not to burden one legal representative with too many clients. It is not easy, for example, for one person to do justice to several doctors, each of whom has patients in several Here,
as
wards. We believe that the improvements which are undoubtedly needed in the inquiry system are more likely to be found along these lines than in the root-and-branch reform sought by some. The grass in the next field is not always greener when one gets there. We thank Mrs Janet Farmer for secretarial
Requests
of Psychiatry, ton
help.
for
reprints should be addressed to J. G. E., Department Royal South Hants Hospital, Graham Rd., Southamp-
S09 4PE.
Women in Medicine A
Campaign to Improve Career Prospects THE percentage of women graduating from medical school in Britain increased from 25% in 1963 to 32% in 1978; by the mid-1980s it is expected to be around 50%. Most women doctors spend a large proportion of their working lives in part-time employment, so, under the present system, they have to forego many of the career prospects and opportunities open to their male colleagues who work full-time. Despite the fact that the percentage of women with higher qualifications is growing, only 14% of senior hospital medical staff (at seniorregistrar grade and above) are women. In 1978 there were only 97 part-time registrar posts out of a total of 4000 full-time posts. The place of women in medicine was discussed by a symposium in London on March 9 at which a campaign was launched to improve their career prospects. The meeting was organised by the Medical Women’s Federation and chaired by Dame JOSEPHINE BARNES, President-elect of the British Medical Association. Prof. MARGOT JEFFERYS (professor of medical sociology, Bedford College, London) described the position of women during the 1960s. She referred to a survey conducted at that time by the Medical Practitioners’ Union which showed that most medical women postponed marriage and childbirth until their training was over. In 1962-63 the majority of young married women wanted part-time work, mainly in family planning or on a sessional basis in schools. Nearly 45% of the married women in the survey wanted to continue with their medical careers, but they were unable to do so because of the traditional organisation of work within and outside the profession. Dr BERENICE BEAUMONT (senior registrar in community medicine, Kensington, Chelsea, and Westminster area health authority) compared this situation with that of medical women
661 doctors in 1976 showed that the profession in the 1970s the problems they faced had not changed significantly. Women in both surveys complained of a lack of posts appropriate to their experience and training, of insufficient postgraduate training facilities for part-time students, and of the unsympathetic attitude of their male colleagues and administrators. In the career grades Dr Beaumont found a higher percentage of women in junior grades than in senior posts, and women tended to occupy consultancies and senior registrarships in pathology, paediatrics, and psychiatry rather than in surgery or general medicine. Nearly two-thirds of the women in the survey experienced difficulties in continuing their careers, particularly since many were unable to take on more than 8 N.H.D. (notional half day) sessions. Another survey conducted last year’ showed that at least 40 women registrars now training would be unable to take up a consultant appointment of as many as 8 clinical sessions. Dr Beaumont suggested that a proportion of consultant posts in every specialty should be advertised for fewer than 10 N.H.D.S. Mrs MARGARET GHILCHICK (consultant surgeon, St Charles’ Hospital, London), describing the position of women consultants, attacked the "appalling and continuous prejudice against women throughout their training" and decried the fact that there were so few women teachers in medical schools and hospitals (there were no female postgraduate deans). She felt that the subconsultant grade was no solution. Dr SUSAN ROBERTS (consultant physician, Newcastle General Hospital) said that women should aim for permanent, senior, and responsible posts and should strongly resist the subconsultant grade. She warned that there was a "grave danger that the profession may buy off the female half of the labour force with the promise of jobs for many at the price of equal opportunities for all". What was needed was a change of attitude from both men and women in the profession. Ways in which action could be taken to improve the status of part-time work might include the payment of full pro-rata benefits for all, paid administrative sessions in part-time contracts, an N.H.S. committment allowance for part-timers in consultant contracts, and an expansion of the consultant grade with reduced hours for all. Dr SALLY JOBLING (general practitioner, Oxford) proposed the establishment of a 24-hour service for all N.H.S. employees and the expansion of deputising services in all major cities. Women should recognise that they needed to be "more professional before competing on equal terms for demanding
today. A although
survey of
women
more women were
entering
sion because of the increasing need for doctors in general practice. The manpower question really arose only at senior-registrar level where the supply of appointments was limited. The profession was now moving towards a situation at the end of the century where 1 in 3 career posts would be occupied by women, most of whom would spend a large proportion of their career working part-time. At the moment there was sufficient leeway to accommodate women in these career posts without upsetting the balance of specialties. Dr GILLIAN FORD (deputy chief medical officer, D.H.S.S.) added that the growth of specialties such as anaesthesia, geriatric medicine, general practice, and psychiatry would create more posts in the consultant
grade. In the discussion many
women
criticised the lack of career
counselling at undergraduate level and the paucity of information on choices of specialty. The suggestion from a male participant that on a cost-effective basis women were not a good return and were "a relatively expensive luxury" aroused great indignation; and another male speaker who referred to the "girls" in the medical profession sent ripples of annoyance through the hall. Many women felt that they were being treated
"pair of hands", the "office temps of mediGpuNEBERG, secretary of the M.W.F., put it. Others declared that they would be setting an "appalling standard" if they insisted on working full-time to the detriment of their children’s wellbeing.
cine",
another
as
as
Dr ANNE
Inevitably, this kind of debate must reach beyond the confines of the medical profession, since it embraces the problems of all women who are committed to both career and family. The prospect that by the end of the century nearly half of Britain’s medical graduates will be women should give planners of medical manpower an opportunity to lead the way in restructuring career grades and training facilities to accommodate not only those women but also the men who wish to work parttime.
Round the World
child-minding
jobs". officer, the majority of whom (75% working part-time), was described as a "rag-
The post of clinical medical are women
bag grade" by
Dr KINGSLEY WHITMORE
(research pxdiatri-
c.M.o.s had no and could be promoted only by switching to community medicine. The recommendations of the Court report’ should be accepted as a guide for future child-health services. There should be a proper job description for the C.M.o. grade; training should be compulsory and modular in form to accommodate part-time work; and the service should be organised on a district basis. Dr PETER SUTTON (lecturer in morbid anatomy, University College Hospital Medical School, London) said that since 1970 there had been no discrimination against the selection of women undergraduates in medical schools and that admission procedures tended to favour women. Dr JOHN LISTER (postgraduate dean, North West Thames Region) suggested that postgraduate training programmes could be modified to suit part-time requirements but that this would not solve the problem of reconciling training needs with manpower requirements. Dr ROSEMARY RuE (regional medical officer, Oxford Regional Health Authority) argued that there was no fear of unemployment in the profes-
cian, Thomas Coram Research Unit, London). career structure
1. Beaumont, B., Grüneberg, A.Br.med. J. 1979,i, 359. 2 Whitmore, K., Bax, M., Tyrrell, S.ibid.p. 242. 3.See Lancet, 1977, i, 79.
Canada DEFAMATION OR ACCEPTABLE
CRITICISM?
Although the laws of defamation which operate in the United States and Canada are derived from English law, their application varies widely. A recent judgment handed down by the Supreme Court of Canada has had the Canadian press in a turmoil. The court ruled that the Saskatoon Star Phoenix had libelled a Saskatoon alderman by printing a letter which was defamatory. The ruling was said to be based on a precedent set in a similar British case many years ago, but even the most casual glance at the Letters to the Editor columns of any British newspaper, and not excluding the Lancet and British Medical Journal, makes it evident that there is no reluctance to print critical comments or explicit opinions. A second libel judgment handed down by a British Columbia judge concerned a political cartoon which characterised a British Columbia politician pulling the wings off flies-pretty tame stuff compared to those who were brought up on Gilray or even Thackeray. The problem comes in distinguishing acceptable criticism from defamation. Thus, anything which is spoken or printed and which reflects on the character of another can be regarded as defamatory; even the hint that somebody’s feet are oversize. Such a statement is not actionable, however, if it is true or if it is fair comment or protected by privilege. The important issue in the recent cases, particularly the one involving the Saskatoon paper, is whether the defence of fair comment can be denied in a newspaper which publishes a defamatory letter. Thus, if the editor shares the views of his correspondent he has a defence, but if he does not, then the precedent set by the Supreme Court of Canada would make him liable. It so
.
