403
buying pigs in pokes. When, therefore, an August 1989 article in the New England Journal of Medicine suggested that additional yellow page listings by board certification could lick the problem, the American Board of Medical Specialties (ABMS) quickly followed through. The new programme will begin with the March distribution of this year’s phone books in about 2000 communities. It is more controversial than might be supposed. For one thing, the ABMS is charging from$200 to $400-depending on the locality-for a board-certified specialist to be listed as such and it can cost these practitioners multiples of that if, as often happens, there are several classified directories for their communities. The ABMS says the hefty fees are needed to pay both for the added listings and for a toll-free phone number the public can call for further guidance; it promises that, if there is a money surplus this year, the price tags will go down in 1991. Still, it has been muttered that, in doing good, the ABMS may also be doing well. Indeed, its annual take would exceed $80 million were all the 375 000 or so US board-certified practitioners to buy into the programme at its present rates. That is unlikely if only because what board-certified specialists do is not always obvious to the public from the name of their credentialling board. The Otolaryngology Board, for example, has vigorously objected to the programme. At least part of the reason: many of its members stick mostly to facial plastic surgery. To be listed as board-certified otolaryngologists would put them at a competitive disadvantage with surgeons listed as certified by the American Board of Plastic Surgery. The ABMS counters that subspecialty listings can solve such overlapping problems and that the names of boarded physicians and surgeons choosing not to be listed-thus far the majority-will, nonetheless, be provided to callers using the toll-free phone number. Not given, of course, will be the names of the more than half the nation’s doctors who are not board-certified. Such exclusions may not be wholly publicspirited. It is possible to imagine, for instance, that a general practitioner who has been skilfully delivering babies for decades may lose business to obstetricians who have only recently been board-certified. Well intentioned the ABMS programme surely is. Just as surely, and whether or not it turns a profit, it is also in the self-interest of the ABMS’s constituency. Yellow page listings for physicians and surgeons are more consulted than any other. Washington, DC
Judith Randal
USA: Nomination for Assistant Secretary for Defense The Senate is balking at President George Bush’s nomination of Victor Stello, Jr, to head the nation’s nuclear weapons programme. So long as this resistance continues, Mr Stello, the former senior civil-service executive at the Nuclear Regulatory Commission, cannot have the job, for presidential appointments require Senate confirmation. Approval of Stello’s appointment is being withheld because he has acquired enemies in and out of Congress for a bias favouring the regulated industry. One incident cited against him concerned an inquiry in 1985 by NRC investigator Ben B. Hayes into the private advice that Mr Stello gave to a reactor licence applicant on how to cope with an agency complaint about violating safety regulations. At an NRC management meeting, Mr Stello shook his fist in Mr Hayes’
face and warned him: "I don’t care how long it takes. I’m going to get you". All this is recorded in Congressional hearing transcripts. Still, Energy Secretary James Watkins wants Mr Stello to direct the bomb factories as his Assistant Secretary for Defense. On the basis of Mr Stello’s resume, Mr Watkins can make a good case. Mr Stello has regulated the nuclear power industry at the NRC for more than 20 years, the last 3 as executive director of operations. Long experience is needed. The plants are in such severe disrepair that some have been forced to close. Populations around some plants are at risk of severe radiological pollution. Such dangers have not, however, been high on Mr Stello’s agenda. In fact, in 1988, he approved a secret investigation of a high level NRC colleague, Roger Fortuna, who did concern himself with such matters. Mr Fortuna had discussed the NRC’s less-than-impressive regulatory record in telephone calls with an anti-nuclear activist. The attempt to show that Mr Fortuna was acting illegally was unsuccessful, and the Senate Committee on Governmental Operations called the investigation "unfair" and a waste of government funds. The committee expressed particular concern that the man paid$6000 to tape the conversations had a record of being a child molester. It is awaiting further details from the NRC about the investigation of Mr Fortuna before making a final decision on Mr Stello’s nomination. The unpleasantness over Mr Stello’s nomination comes at an otherwise propitious time for radiation research scientists. For the first time national security will no longer be cited as a reason for the department of energy to deny independent scientists access to the data base of about 300 000 men and women who have worked in nuclear weapons plants. Until now only scientists under contract to the government could see this information. Whatever the Senate does, it is entirely possible that Mr Stello will be involved in the decisions regarding this file. He already holds an important post in the weapons programme that does not require Senate confirmation. J. B. Sibbison
Amherst, MA
Medicine and the Law Benzodiazepine
sex
fantasies:
acquittal of
dentist On Feb 5, 1990, Mr George Larah, a dentist, was acquitted of sexually assaulting seven women who had been given diazepam for dental treatment. The judge, Mr Justice Hodgson, directed the jury to a verdict of not guilty. At the conclusion of the prosecution case and having heard medical evidence from Prof Thomas Healey (University of Manchester), counsel for the defence had applied for the charges to be dismissed. Professor Healey’s evidence accepted the findings of Prof J. W. Dundee that 1 woman in 200 given large doses of benzodiazepines experiences sexual fantasies, including fantasies of sexual assault in circumstances where this could not have happened. 1-4 The first case of benzodiazepine-induced sexual fantasy to be recorded in the UK was in 1981. Since then Dundee has been notified of 43 such cases, and the number is mounting.5 The judge was impressed by this evidence. The women gave what they believed to be accurate accounts. The danger, the judge said, is that they are mistaken"that their recollection honestly believed in is of an unreal and not a real experience ... It is clear that there is a mounting body of
404
evidence that patients under sedation from this class of drugs do sometimes experience erotic fantasies". The assaults were alleged to have taken place over a period of more than two years, but none of the attacks was corroborated or confirmed and some of the complaints were not made until months or years afterwards. This made it impossible for the dentist to recollect individual patients and left the defendant with no defence other than a straight denial. Current guidelines from the General Dental Council require dentists using such sedatives to administer them only when a third, qualified person is present to monitor the patient’s condition. Failure to arrange this renders a dentist liable to a charge of serious professional misconduct. At another criminal trial heard a few months ago, another dentist, Mr Stuart Allen, was charged with sexually assaulting four female patients who had been sedated with benzodiazepines. Dundee gave evidence for the defence. The jury convicted on two charges. An appeal is due to be heard shortly. No charge of sexual assault has been brought by a male patient against dentists or doctors, male or female. There are several possible explanations for the low incidence of recorded fantasies and/or complaints reported by men sedated by benzodiazepines.There may be fewer occasions when men receive benzodiazepine sedation from a dentist; benzodiazepines may not prompt hallucinations or fantasies in men as readily as they do in women; or such fantasies may be experienced as enjoyable. According to Dr Malcolm Weller, a consultant psychiatrist at Friern Hospital, London, a person who represses sexual yearnings and awareness will have greater propensity to release sexual fantasies under the effects of a disinhibiting drug. Thus, argues Weller, since most men regularly indulge in sexual fantasies, fewer repressed urges will be available for release. It is women who have the greatest defences against their underlying sexuality who are likely to experience release with benzodiazepines and to be most disturbed and embarrassed by them. The disinhibiting effects of benzodiazepine apart, it should not be forgotten that sexual fondling of patients by medical staff may happen occasionally, and it may not always be male to female. A consultant told me that some thirty years ago, when homosexuality was still a crime in the UK, he had observed a very senior male doctor fondling an anaesthetised man. Others apparently had seen the doctor do this many times. My informant was told to mind his own business-the patient did not know and no harm was done. One wonders whether the patient awoke with any fantasies or memories and what he made of them. I hope that such behaviour today, if observed, would not be tolerated, but would a junior doctor or nurse feel free to speak out?
Diana Brahams 1. Dundee JW. Do fantasies occur with intravenous benzodiazepines? SAAD Dig 1986; 6: 173-76. 2. Dundee JW. Further data on sexual fantasies during benzodiazepine sedation. SAAD Dig 1989; 7: 171-72. 3. Brahams D. Benzodiazepine sedation and allegations of sexual assault. Lancet 1989; i: 1339. 4. Brahams D. Benzodiazepine and sexual fantasies. Lancet 1990; 335: 157. 5. Sapsted D. Judge clears dentist of sex assault after drug-fantasy evidence.
Times, Feb 6, 1990. JW. Fantasies during sedation with intravenous midazolam diazepam. Med Leg J (in press).
6. Dundee
or
Obituary George
Komrower
The detection of metabolic disease at a stage where its treatment can prevent irreversible damage, particularly to the brain, is now a widespread and routine procedure. It was not always so and George Komrower, who died in December, was one of the pioneers of "screening" for inborn metabolic disease. Komrower
set up
in Manchester
a
service, later adopted and
expanded by the Regional Health Authority, phenylketonuria. In a characteristic fashion he
to screen for chose not the
standard "Guthrie" technique with blood spotted on filter paper but one-dimensional paper chromatography with blood in a capillary tube. This enabled him and his co-workers in the laboratory at the Royal Manchester Children’s Hospital to study several other metabolic disorders not detectable with the monospecific Guthrie test-an advantage he exploited to the full, thus establishing an international reputation. He had been appointed a consultant paediatrician in 1947-48 in Manchester, one of a small handful of paediatricians in the city at that time. He quickly became associated with Aron Holzel, another paediatrician, and with Vera Wilson and Victor Schwarz, both biochemists; together they did some outstanding work defining the enzyme deficiency in galactosaemia and developing an assay to measure it. He studied congenital adrenal hyperplasia, renal tubular acidosis, diabetes mellitus, and other diseases with a "metabolic" basis-always with an eye to improving the clinical care of children with these disorders. His skills did not stop with research for he became President of the Manchester Paediatric Club and ultimately President (1979-82) of the British Paediatric Association. He did all this and ran a first-class paediatric service, despite indifferent health-at one point having to conduct his ward rounds and clinics from a wheelchair. Later he suffered distressingly from parkinsonism, a disease he fought to overcome: if not successful in that, at least he succeeded in ignoring to a large extent the handicaps it imposed upon him. He will be remembered by his junior staff as a hard but fair task master and a concerned mentor not averse to plain talking when it was needed. Ian B. Houston
Geoffrey H. Watson adds: "George’s professional contacts with physicians in the UK and abroad tended to become lifelong friendships. Patients and their parents also liked him and many of them organised a large retirement party for him. He was always ready to discuss problems, whether clinical or personal, with colleagues and juniors and had a useful ability to apply a wide background of knowledge and experience. This would be done with firmness tempered with a puckish humour. These aspects were noted by the presenter at his honorary degree ceremony, when he was said to be tough with colleagues, but tender with children."
Gordon Beckett Dr Beckett, consultant physician to the Royal Free Hospital from 1965 to 1986, died on Oct 12, aged 69. After Oxford and The London Hospital Gordon undertook research at the Royal Free Hospital on the retinal and renal lesions in diabetes. His interest in diabetes continued throughout his career as a consultant physician, and he published several original papers on the subject. He was appointed physician to Moorfields Eye Hospital and was one of the founders of the Eye Physic Club in London. He was also one of the first to report on the value of corticotropin in the treatment of ulcerative colitis, and played an important part in the development of needle biopsy of the liver and kidney. In a paper published in 1961, he was the first to describe acute alcoholic hepatitis. He took endless trouble with his patients, who thought the world of him. He had a gentle and loving nature and was much liked and highly regarded by all who knew him. He had many interests outside medicine, including literature and the arts, science and technology, cricket and soccer; and he was an accomplished pianist. He was justifiably proud of being winner of the Times crossword puzzle on three occasions. In Gordon’s final years before retirement he was stricken by a severe and debilitating illness, which he faced with great courage, overcoming his physical difficulties and taking much interest in the scientific problems related to it. Throughout this long and trying period until his death he was lovingly looked after by his devoted wife, Dorothy. R. T. D. Emond
buying pigs in pokes. When, therefore, an August 1989 article in the New England Journal of Medicine suggested that additional yellow page listings by board certification could lick the problem, the American Board of Medical Specialties (ABMS) quickly followed through. The new programme will begin with the March distribution of this year’s phone books in about 2000 communities. It is more controversial than might be supposed. For one thing, the ABMS is charging from$200 to $400-depending on the locality-for a board-certified specialist to be listed as such and it can cost these practitioners multiples of that if, as often happens, there are several classified directories for their communities. The ABMS says the hefty fees are needed to pay both for the added listings and for a toll-free phone number the public can call for further guidance; it promises that, if there is a money surplus this year, the price tags will go down in 1991. Still, it has been muttered that, in doing good, the ABMS may also be doing well. Indeed, its annual take would exceed $80 million were all the 375 000 or so US board-certified practitioners to buy into the programme at its present rates. That is unlikely if only because what board-certified specialists do is not always obvious to the public from the name of their credentialling board. The Otolaryngology Board, for example, has vigorously objected to the programme. At least part of the reason: many of its members stick mostly to facial plastic surgery. To be listed as board-certified otolaryngologists would put them at a competitive disadvantage with surgeons listed as certified by the American Board of Plastic Surgery. The ABMS counters that subspecialty listings can solve such overlapping problems and that the names of boarded physicians and surgeons choosing not to be listed-thus far the majority-will, nonetheless, be provided to callers using the toll-free phone number. Not given, of course, will be the names of the more than half the nation’s doctors who are not board-certified. Such exclusions may not be wholly publicspirited. It is possible to imagine, for instance, that a general practitioner who has been skilfully delivering babies for decades may lose business to obstetricians who have only recently been board-certified. Well intentioned the ABMS programme surely is. Just as surely, and whether or not it turns a profit, it is also in the self-interest of the ABMS’s constituency. Yellow page listings for physicians and surgeons are more consulted than any other. Washington, DC
Judith Randal
USA: Nomination for Assistant Secretary for Defense The Senate is balking at President George Bush’s nomination of Victor Stello, Jr, to head the nation’s nuclear weapons programme. So long as this resistance continues, Mr Stello, the former senior civil-service executive at the Nuclear Regulatory Commission, cannot have the job, for presidential appointments require Senate confirmation. Approval of Stello’s appointment is being withheld because he has acquired enemies in and out of Congress for a bias favouring the regulated industry. One incident cited against him concerned an inquiry in 1985 by NRC investigator Ben B. Hayes into the private advice that Mr Stello gave to a reactor licence applicant on how to cope with an agency complaint about violating safety regulations. At an NRC management meeting, Mr Stello shook his fist in Mr Hayes’
face and warned him: "I don’t care how long it takes. I’m going to get you". All this is recorded in Congressional hearing transcripts. Still, Energy Secretary James Watkins wants Mr Stello to direct the bomb factories as his Assistant Secretary for Defense. On the basis of Mr Stello’s resume, Mr Watkins can make a good case. Mr Stello has regulated the nuclear power industry at the NRC for more than 20 years, the last 3 as executive director of operations. Long experience is needed. The plants are in such severe disrepair that some have been forced to close. Populations around some plants are at risk of severe radiological pollution. Such dangers have not, however, been high on Mr Stello’s agenda. In fact, in 1988, he approved a secret investigation of a high level NRC colleague, Roger Fortuna, who did concern himself with such matters. Mr Fortuna had discussed the NRC’s less-than-impressive regulatory record in telephone calls with an anti-nuclear activist. The attempt to show that Mr Fortuna was acting illegally was unsuccessful, and the Senate Committee on Governmental Operations called the investigation "unfair" and a waste of government funds. The committee expressed particular concern that the man paid$6000 to tape the conversations had a record of being a child molester. It is awaiting further details from the NRC about the investigation of Mr Fortuna before making a final decision on Mr Stello’s nomination. The unpleasantness over Mr Stello’s nomination comes at an otherwise propitious time for radiation research scientists. For the first time national security will no longer be cited as a reason for the department of energy to deny independent scientists access to the data base of about 300 000 men and women who have worked in nuclear weapons plants. Until now only scientists under contract to the government could see this information. Whatever the Senate does, it is entirely possible that Mr Stello will be involved in the decisions regarding this file. He already holds an important post in the weapons programme that does not require Senate confirmation. J. B. Sibbison
Amherst, MA
Medicine and the Law Benzodiazepine
sex
fantasies:
acquittal of
dentist On Feb 5, 1990, Mr George Larah, a dentist, was acquitted of sexually assaulting seven women who had been given diazepam for dental treatment. The judge, Mr Justice Hodgson, directed the jury to a verdict of not guilty. At the conclusion of the prosecution case and having heard medical evidence from Prof Thomas Healey (University of Manchester), counsel for the defence had applied for the charges to be dismissed. Professor Healey’s evidence accepted the findings of Prof J. W. Dundee that 1 woman in 200 given large doses of benzodiazepines experiences sexual fantasies, including fantasies of sexual assault in circumstances where this could not have happened. 1-4 The first case of benzodiazepine-induced sexual fantasy to be recorded in the UK was in 1981. Since then Dundee has been notified of 43 such cases, and the number is mounting.5 The judge was impressed by this evidence. The women gave what they believed to be accurate accounts. The danger, the judge said, is that they are mistaken"that their recollection honestly believed in is of an unreal and not a real experience ... It is clear that there is a mounting body of
404
evidence that patients under sedation from this class of drugs do sometimes experience erotic fantasies". The assaults were alleged to have taken place over a period of more than two years, but none of the attacks was corroborated or confirmed and some of the complaints were not made until months or years afterwards. This made it impossible for the dentist to recollect individual patients and left the defendant with no defence other than a straight denial. Current guidelines from the General Dental Council require dentists using such sedatives to administer them only when a third, qualified person is present to monitor the patient’s condition. Failure to arrange this renders a dentist liable to a charge of serious professional misconduct. At another criminal trial heard a few months ago, another dentist, Mr Stuart Allen, was charged with sexually assaulting four female patients who had been sedated with benzodiazepines. Dundee gave evidence for the defence. The jury convicted on two charges. An appeal is due to be heard shortly. No charge of sexual assault has been brought by a male patient against dentists or doctors, male or female. There are several possible explanations for the low incidence of recorded fantasies and/or complaints reported by men sedated by benzodiazepines.There may be fewer occasions when men receive benzodiazepine sedation from a dentist; benzodiazepines may not prompt hallucinations or fantasies in men as readily as they do in women; or such fantasies may be experienced as enjoyable. According to Dr Malcolm Weller, a consultant psychiatrist at Friern Hospital, London, a person who represses sexual yearnings and awareness will have greater propensity to release sexual fantasies under the effects of a disinhibiting drug. Thus, argues Weller, since most men regularly indulge in sexual fantasies, fewer repressed urges will be available for release. It is women who have the greatest defences against their underlying sexuality who are likely to experience release with benzodiazepines and to be most disturbed and embarrassed by them. The disinhibiting effects of benzodiazepine apart, it should not be forgotten that sexual fondling of patients by medical staff may happen occasionally, and it may not always be male to female. A consultant told me that some thirty years ago, when homosexuality was still a crime in the UK, he had observed a very senior male doctor fondling an anaesthetised man. Others apparently had seen the doctor do this many times. My informant was told to mind his own business-the patient did not know and no harm was done. One wonders whether the patient awoke with any fantasies or memories and what he made of them. I hope that such behaviour today, if observed, would not be tolerated, but would a junior doctor or nurse feel free to speak out?
Diana Brahams 1. Dundee JW. Do fantasies occur with intravenous benzodiazepines? SAAD Dig 1986; 6: 173-76. 2. Dundee JW. Further data on sexual fantasies during benzodiazepine sedation. SAAD Dig 1989; 7: 171-72. 3. Brahams D. Benzodiazepine sedation and allegations of sexual assault. Lancet 1989; i: 1339. 4. Brahams D. Benzodiazepine and sexual fantasies. Lancet 1990; 335: 157. 5. Sapsted D. Judge clears dentist of sex assault after drug-fantasy evidence.
Times, Feb 6, 1990. JW. Fantasies during sedation with intravenous midazolam diazepam. Med Leg J (in press).
6. Dundee
or
Obituary George
Komrower
The detection of metabolic disease at a stage where its treatment can prevent irreversible damage, particularly to the brain, is now a widespread and routine procedure. It was not always so and George Komrower, who died in December, was one of the pioneers of "screening" for inborn metabolic disease. Komrower
set up
in Manchester
a
service, later adopted and
expanded by the Regional Health Authority, phenylketonuria. In a characteristic fashion he
to screen for chose not the
standard "Guthrie" technique with blood spotted on filter paper but one-dimensional paper chromatography with blood in a capillary tube. This enabled him and his co-workers in the laboratory at the Royal Manchester Children’s Hospital to study several other metabolic disorders not detectable with the monospecific Guthrie test-an advantage he exploited to the full, thus establishing an international reputation. He had been appointed a consultant paediatrician in 1947-48 in Manchester, one of a small handful of paediatricians in the city at that time. He quickly became associated with Aron Holzel, another paediatrician, and with Vera Wilson and Victor Schwarz, both biochemists; together they did some outstanding work defining the enzyme deficiency in galactosaemia and developing an assay to measure it. He studied congenital adrenal hyperplasia, renal tubular acidosis, diabetes mellitus, and other diseases with a "metabolic" basis-always with an eye to improving the clinical care of children with these disorders. His skills did not stop with research for he became President of the Manchester Paediatric Club and ultimately President (1979-82) of the British Paediatric Association. He did all this and ran a first-class paediatric service, despite indifferent health-at one point having to conduct his ward rounds and clinics from a wheelchair. Later he suffered distressingly from parkinsonism, a disease he fought to overcome: if not successful in that, at least he succeeded in ignoring to a large extent the handicaps it imposed upon him. He will be remembered by his junior staff as a hard but fair task master and a concerned mentor not averse to plain talking when it was needed. Ian B. Houston
Geoffrey H. Watson adds: "George’s professional contacts with physicians in the UK and abroad tended to become lifelong friendships. Patients and their parents also liked him and many of them organised a large retirement party for him. He was always ready to discuss problems, whether clinical or personal, with colleagues and juniors and had a useful ability to apply a wide background of knowledge and experience. This would be done with firmness tempered with a puckish humour. These aspects were noted by the presenter at his honorary degree ceremony, when he was said to be tough with colleagues, but tender with children."
Gordon Beckett Dr Beckett, consultant physician to the Royal Free Hospital from 1965 to 1986, died on Oct 12, aged 69. After Oxford and The London Hospital Gordon undertook research at the Royal Free Hospital on the retinal and renal lesions in diabetes. His interest in diabetes continued throughout his career as a consultant physician, and he published several original papers on the subject. He was appointed physician to Moorfields Eye Hospital and was one of the founders of the Eye Physic Club in London. He was also one of the first to report on the value of corticotropin in the treatment of ulcerative colitis, and played an important part in the development of needle biopsy of the liver and kidney. In a paper published in 1961, he was the first to describe acute alcoholic hepatitis. He took endless trouble with his patients, who thought the world of him. He had a gentle and loving nature and was much liked and highly regarded by all who knew him. He had many interests outside medicine, including literature and the arts, science and technology, cricket and soccer; and he was an accomplished pianist. He was justifiably proud of being winner of the Times crossword puzzle on three occasions. In Gordon’s final years before retirement he was stricken by a severe and debilitating illness, which he faced with great courage, overcoming his physical difficulties and taking much interest in the scientific problems related to it. Throughout this long and trying period until his death he was lovingly looked after by his devoted wife, Dorothy. R. T. D. Emond
