1390
BRITISH MEDICAL JOURNAL
be asked embarrassing questions without difficulty; (6) they could be asked questions not directly concerned with the reason for the consultation. The doctor/patient relationship is a wonderful theoretical concept; a pity it is not universally applied. However, if a computer terminal can be programmed so that it can be introduced into this dialogue then perhaps the doctor's memory can be jogged, especially when he is tired or rushed and on repetitive routine questions. It appears to leave him time to talk to the patient. The computer interview lasted an average of 30 minutes, not three, which is so often the case in practice, and often asked questions the doctors overlooked about systems not directly related to what the patient came to see the doctor about. Computers can be used in medicine in two ways, either to do the housekeeping or as an intellectual tool as an extension of the doctor's forebrain-for those of us who have any. H C PRICE Fulham Chest Clinic, Western Hospital. London SW6
Abnormal patency of the eustachian tube SIR,-I would like to draw attention to a fairly common ear condition which frequently goes undiagnosed and is managed incorrectly. The condition of a patulous or "over-patent" eustachian tube has been written up in American' and Canadian journals but has had little attention drawn to it in Britain. The patient complains of a sensation of blockage in the ear but paradoxically denies any marked hearing loss. The sensation of blockage disappears on lying down and frequently alters with certain positions of the head, particularly when the head is leant forwards. Patients may comment, or will note if asked directly, that they hear the noise of themselves talking, eating, or breathing in their ears. They have an "echoing" or "hollow" sensation in the ears. The more expansive and neurotic will complain of lightheadedness and a dizzy feeling. Examination shows a normal tympanic membrane and closer examination will occasionally show that the drum moves in and out on respiration when the mouth and opposite nostril are closed. The ENT surgeon will find a normal postnasal space on examination. The condition is frequently managed incorrectly as eustachian tube obstruction and the patient is placed on a decongestant tablet and nose drops. There is, however, no history of a previous cold or barotrauma and nasal symptoms are usually absent. This curious but definite entity is seen in those who have lost weight, usually a relatively rapid and recent loss from dieting, those on the pill, and in pregnancy. I have also seen it in the older patient when placed on diuretics. The symptoms are usually minor and explanation and reassurance suffice as treatment. The management becomes more difficult when the patient is irritated by the failure of nasal decongestants (which, not surprisingly, may accentuate the symptoms) and by a conviction that the problem has not been fully understood. Occasionally symptoms are sufficiently marked to justify insertion of a grommet: this does lessen the ear complaints to a tolerable level. In the very rare instance when the patient is extremely distressed the injection of Teflon
4 DECEMBER 1976
paste into the region of the eustachian cushion Profuse discharge occurs from the drainage to narrow the patulous eustachian tube has site for several days, but a clean and neat been effective.2 suture line generally results. T R BULL A W BANKS Royal National Throat, Nose and
Congleton,
Ear Hospital, London WC1
Cheshire
' Pulek, J L, Laryngoscope, 1964, 74, 257. Pulek, J L, Laryngoscope, 1967, 77, 1542.
2
Management of appendicitis SIR,-The situation with regard to wound drainage and antibiotic prophylaxis in cases of perforated or gangrenous appendicitis is not as clearcut as Mr A W Clark (9 October, p 881) would have us believe. There is a lot of conflicting evidence about the use of wound drainage, as pointed out in a leading article in the Lancet in 1971.' Magarey's study2 was discussed in that article and it was emphasised that he used intraperitoneal drains placed through the wound, not necessarily the best method. Then in 1973 Farrar3 reported a prospective trial of closed suction extraperitoneal wound drainage which failed to demonstrate any reduction in wound infection. In relation to systemic antibiotics, a threedose regimen of cephaloridine failed to reduce the incidence of wound infection in cases of perforated appendicitis, although the overall incidence of wound infection in general surgical wounds was significantly reduced.4 As a result of a recent, as yet unpublished, study5 we are able to provide further information which we hope will help to clarify the situation. In a controlled, prospective, randomised trial we have shown that in patients with a gangrenous or perforated appendix: (1) the use of a 3-day course of cephaloridine, started preoperatively, reduced the wound infection rate from 84.2qo (control) to 40%'; (2) the use of an extraperitoneal wound drain alone significantly reduced the wound infection rate from 84-2%/O to 500,); and (3) the use of both together reduced the wound infection rate even further, from 84 20' to 21 4O00* N W EVERSON J R NASH University Department of Surgery, General Hospital, Leicester ' Lancet, 1971, 2, 195. 2 Magarey, C J, et al, Lancet, 1971, 2, 179. 3 Everson, N W, et al. In press. 4 Evans, C, and Pollock, A V, British Journal of Surgery, 1973, 60, 434. 5 Farrar, D J, et al, British Journal of Clinical Practice, 1973, 27, 63.
SIR,-As an alternative to delayed suture for cases of suppurative appendicitis, as discussed by Mr A W Clark (9 October, p 881) and Mr G Qvist (30 October, p 1074), I have found that the following technique yields satisfactory results. The musculoaponeurotic layers are brought together with a minimum number of interrupted sutures. Several (generally three) deep cutaneous stitches are then inserted, bringing the subcutaneous fat very loosely into apposition but leaving the skin edges gaping. Finally, these edges are brought together with a larger number of fine sutures which do not penetrate deeper than the skin itself; a small subcutaneous drain is inserted into the lower end of the wound. Antibiotic cover is given from the time of operation.
Recruitment to community medicine
SIR,-The inadequate recruitment of young doctors to the specialty of community medicine is currently causing some alarm. Although the quality of those in training is for the most part excellent, their numbers are insufficient even to replace losses due to death and retirement. The report of the Working Party on Medical Administrators, of which I was chairman, stressed that for the foreseeable future one source of recruitment to the specialty would need to be mature entrants. The working party had in mind particularly clinicians with managerial experience gained by membership of Cogwheel committees and, since reorganisation, of district management teams. The report recommended formal arrangements for training and in-service experience for these doctors and emphasised their suitability for particular specialist posts. At present there is no evidence that such formal arrangements exist and I suspect this valuable recruitment pool is largely untapped. In view of the manpower crisis facing community medicine has not the time come for those concerned with the future of the specialty to reassess present policy on recruitment and existing training arrangements ? ROBERT B HUNTER University of Birmingham, Birmingham
Expansion of the medical schools SIR,-Mr F S A Doran (20 November, p 1272) indicates that on the present trend towards 2 9 juniors to each hospital consultant there will never be enough home-produced doctors to staff the hospital service. Parkhouse and McLaughlin' also stressed the impossibility of adequate junior staffing of hospitals, even though enough general practitioners can be provided. Parkhouse' has further suggested that the "cushion of uncommitted junior staff in hospital is not likely to continue indefinitely" and he suggests a redistribution of grades within the hospital service as one possible solution. Traditional methods of working require reexamination from time to time and now may well be the opportune moment to consider whether hospital doctors (physicians, surgeons, paediatricians, geriatricians, and psychiatrists) really need to be supported by junior staff any more than do general practitioners. In many American hospitals, for instance, there are no juniors, and no doubt the same applies in other parts of the world. If the consultant establishment were increased to allow a group of, say, five or six physicians (or paediatricians or geriatricians) to be based on one district general hospital the total number of patients that each would care for would be diminished and each should then be able to provide total care for his own patients. Such numbers would also allow a reasonable on-call rota for each group. Advantages that would accrue from such an arrangement would be not only elimination of
BRITISH MEDICAL JOURNAL
1391
4 DECEMBER 1976
the hospital staffing pyramid which is the cause of so many problems and uncertainties but also the principle of one clinician being entirely responsible for any individual patient -undoubtedly to the mutual benefit and satisfaction of both. It would cut down unnecessary and repetitive examinations and documentation and would lead to better record keeping, to more effective prescribing of treatment, and to more economic use of laboratory and radiological investigations. It would eliminate the "cushion" of junior staff and would cost no more-probably less-than at present. Junior staff provision would then be that required for training-nearer to a ratio of 1: 0 3 than 1: 229 for the replacement of consultants-with whatever further addition would be required for those entering general practice. This would seem to be a question which at least merits discussion and some pilot experiments with the backing of the DHSS.
Junior hospital doctors and Europe SIR,-In reply to the Secretary's footnote comments on my previous letter (27 November, p 1326), my apologies for omitting to mention the fact that the BMA has regularly included a junior-as the Secretary says, usually myself-in its delegation to the Standing Committee of Doctors of the EEC. This was unintentional and due to the fact that I was under dire threat about the length of my letter. It is important to mention that the BMA has done this because, of the nine national delegations to the standing committee, only two-UK and Denmark-regularly include juniors, although Ireland has recently begun to do so, and I feel that this once again underlines the fact that a junior voice is needed at a European level. PATRICK MCNALLY Chairman, HJS Committee's EEC Subcommittee
BMA House, London WC1
J C BROCKLEHURST Department of Geriatric Medicine, University Hospital of South
Manchester,
Manchester
Parkhouse, J, and McLaughlin, C, Lancet, 1975, 1, 211. 2Parkhouse, J, Proceedings of the Royal Society of Medicine, 1976, 69, 815.
SIR,-Mr F S A Doran's timely and closely reasoned paper (20 November, p 1272) offers naught for our comfort but much food for thought. As I understand it he is arguing that unless the intake of women medical students approximates to 500) of the annual total by 1995 we shall by then have a surplus of some 15 000 fully trained general practitioners. At present there is a financial disincentive to pursue careers in hospital medicine and its effect on the recruitment of the next generation of surgeons, for instance, is already worrying that royal college. Even if, in the interim, a differential repricing of total earnings potential as between general practice and hospital medicine were to divert enough trainees back to the hospital service to eliminate our dependence on overseas graduates there would still be an overall surplus of doctors. Does anyone seriously believe that in that situation even the meagre increments hitherto reluctantly agreed by successive governments would continue ? The laws of the market place apply as inexorably to medical skills as to merchandise -glut and high prices never co-exist. Most of us are reluctant to use the "ultimate trump" of strike action. The next highest card in our hand is our scarcity value and we are in serious danger of discarding it by being party to the proliferation of medical students. It may be true that "one man's pay rise represents another man's job"; equally one doctor's heavy work load justifies another doctor's pay rise. We simply cannot have it both ways-if no doctor carries an unduly heavy work load no other doctor will be able to expect increases in remuneration. I appreciate that Mr Doran himself was not primarily concerned with the financial effects of the surpluses he forecasts, but it is important that someone draws the appropriate conclusions from his arguments. Matching, Harlow, Essex
Complaints against doctors SIR,-Patients are increasingly encouraged to lodge complaints against their doctors. The latter, on the other hand, appear to have no possibility of redress against patients, except in the case of general practitioners, who can ask the patient to choose another doctor. I feel that far too many doctors are wrongly accused and have to wait anxiously, possibly for months, before the accusation is dropped or an inquiry is held. The inquiry often finds the doctor innocent and that is where the matter ends. I think that in such cases he should have redress. Perhaps the patient should be wamed that in a case of false accusation he will be fined, the money being deducted from his income. I think the BMA should press for legislation along those lines. A doctor has really no redress under the common law. A case of libel, slander, or defamation of character would scarcely succeed. The patient would plead that he is a layman and was unable to assess the doctor's actions and that there was no malicious intent in bringing the action. It seems that accusations against doctors can be made with impunity. If one accused a supermarket of, say, selling rotten food one could find onself in great difficulties. However, anyone can bring a charge against a doctor. The matter will be investigated by the health authority or family practitioner committee and the doctor will have to face the accusation, no matter how unfounded. H A LEIGH Letchworth, Herts
Industrial action
SIR,-I refer to a report in the Sunday Express (31 October, p 17) of the views on industrial action attributed to Dr P A T Wood, the chairman of the Fellowship for Freedom in Medicine. Like him, most of us in the hospital service are sick of the situation which we have been manoeuvred into by force majeure. However, is industrial action a "disease of the National Health Service" rather than a national disease which includes the NHS DONALD V BATEMAN among its victims ? There is no doubt that the present Government fostered this by ignominious surrender to the trade unions and that
the predilection for the soft option demonstrated by the General Election results of 1974 condoned it. Dr Wood called on his colleagues to become "men of stature" and pave the way for a Health Service completely free from strikes and stoppages. Such freedom has sometimes to be fought for initially. Freedom in medicine is no exception. Can anyone who listened to Mr Ennals recently doubt that there will be no improvements for the professicn, particularly consultants, which are not fought for hard? The Secretary of State deplored industrial action in the NHS in a speech at Blackpool but it became clear that he deplored action by consultants to protect themselves while condoning the activities of the Health Service unions. We will not become "men of stature" by surrendering ignobly to the philosophy which promotes such confrontation. Dr Wood is reported as saying that if people wanted to work in the Health Service they should accept that pay and conditions of service were ultimately dependent on what the community thought was right. This is subject to the philosophy expressed by the Secretary of State at Blackpool on referring to numbers of medical staffs, particularly consultants, relative to other NHS employees. The implication was that it is not the function served that determines worth and influence which can be brought to bear but the numbers you can muster to force your views upon others. Finally Dr Wood says we should not descend to the shop floor. We have not descended to this level; we have been dragged down to it and will be submerged at this level unless we all, as a profession, unite and speak and act with one voice to prevent it. It is against the interests of the nation for any discipline, including medicine, to promote or accept egalitarian principles whereby industry, achievement, and effort will not attract adequate and just differential in reward in their own right. DAVID B MuRRAY Royal Infirmary, Blackburn, Lancs
JHDA SIR,-Dr Elinor Kapp (30 October, p 1076) states that "the delegates who attended the two national conferences of autumn 1975 were elected from regional meetings in all parts of the country." Presumably those who attended the April 1976 conference were similarly elected. Although a member of the JHDA, I am unaware of any meeting called by the association within the South-west Thames Region during the past 12 months. I am equally unaware, having been in contact at various times with mess representatives in all 14 districts in the region, of any mechanism extant whereby the views of junior doctors in the region could be put before the JHDA national executive. Perhaps Dr Kapp could fill in the gaps in my knowledge by supplying me with the dates and places of the regional meetings held by the JHDA in the South-west Thames Region over the past year. I should be particularly gratified to learn at which meeting my regional representative was elected and how many people were in attendance. R A V MILSTED Institute of Cancer Research, Royal Cancer Hospital, Sutton, Surrey
BRITISH MEDICAL JOURNAL
be asked embarrassing questions without difficulty; (6) they could be asked questions not directly concerned with the reason for the consultation. The doctor/patient relationship is a wonderful theoretical concept; a pity it is not universally applied. However, if a computer terminal can be programmed so that it can be introduced into this dialogue then perhaps the doctor's memory can be jogged, especially when he is tired or rushed and on repetitive routine questions. It appears to leave him time to talk to the patient. The computer interview lasted an average of 30 minutes, not three, which is so often the case in practice, and often asked questions the doctors overlooked about systems not directly related to what the patient came to see the doctor about. Computers can be used in medicine in two ways, either to do the housekeeping or as an intellectual tool as an extension of the doctor's forebrain-for those of us who have any. H C PRICE Fulham Chest Clinic, Western Hospital. London SW6
Abnormal patency of the eustachian tube SIR,-I would like to draw attention to a fairly common ear condition which frequently goes undiagnosed and is managed incorrectly. The condition of a patulous or "over-patent" eustachian tube has been written up in American' and Canadian journals but has had little attention drawn to it in Britain. The patient complains of a sensation of blockage in the ear but paradoxically denies any marked hearing loss. The sensation of blockage disappears on lying down and frequently alters with certain positions of the head, particularly when the head is leant forwards. Patients may comment, or will note if asked directly, that they hear the noise of themselves talking, eating, or breathing in their ears. They have an "echoing" or "hollow" sensation in the ears. The more expansive and neurotic will complain of lightheadedness and a dizzy feeling. Examination shows a normal tympanic membrane and closer examination will occasionally show that the drum moves in and out on respiration when the mouth and opposite nostril are closed. The ENT surgeon will find a normal postnasal space on examination. The condition is frequently managed incorrectly as eustachian tube obstruction and the patient is placed on a decongestant tablet and nose drops. There is, however, no history of a previous cold or barotrauma and nasal symptoms are usually absent. This curious but definite entity is seen in those who have lost weight, usually a relatively rapid and recent loss from dieting, those on the pill, and in pregnancy. I have also seen it in the older patient when placed on diuretics. The symptoms are usually minor and explanation and reassurance suffice as treatment. The management becomes more difficult when the patient is irritated by the failure of nasal decongestants (which, not surprisingly, may accentuate the symptoms) and by a conviction that the problem has not been fully understood. Occasionally symptoms are sufficiently marked to justify insertion of a grommet: this does lessen the ear complaints to a tolerable level. In the very rare instance when the patient is extremely distressed the injection of Teflon
4 DECEMBER 1976
paste into the region of the eustachian cushion Profuse discharge occurs from the drainage to narrow the patulous eustachian tube has site for several days, but a clean and neat been effective.2 suture line generally results. T R BULL A W BANKS Royal National Throat, Nose and
Congleton,
Ear Hospital, London WC1
Cheshire
' Pulek, J L, Laryngoscope, 1964, 74, 257. Pulek, J L, Laryngoscope, 1967, 77, 1542.
2
Management of appendicitis SIR,-The situation with regard to wound drainage and antibiotic prophylaxis in cases of perforated or gangrenous appendicitis is not as clearcut as Mr A W Clark (9 October, p 881) would have us believe. There is a lot of conflicting evidence about the use of wound drainage, as pointed out in a leading article in the Lancet in 1971.' Magarey's study2 was discussed in that article and it was emphasised that he used intraperitoneal drains placed through the wound, not necessarily the best method. Then in 1973 Farrar3 reported a prospective trial of closed suction extraperitoneal wound drainage which failed to demonstrate any reduction in wound infection. In relation to systemic antibiotics, a threedose regimen of cephaloridine failed to reduce the incidence of wound infection in cases of perforated appendicitis, although the overall incidence of wound infection in general surgical wounds was significantly reduced.4 As a result of a recent, as yet unpublished, study5 we are able to provide further information which we hope will help to clarify the situation. In a controlled, prospective, randomised trial we have shown that in patients with a gangrenous or perforated appendix: (1) the use of a 3-day course of cephaloridine, started preoperatively, reduced the wound infection rate from 84.2qo (control) to 40%'; (2) the use of an extraperitoneal wound drain alone significantly reduced the wound infection rate from 84-2%/O to 500,); and (3) the use of both together reduced the wound infection rate even further, from 84 20' to 21 4O00* N W EVERSON J R NASH University Department of Surgery, General Hospital, Leicester ' Lancet, 1971, 2, 195. 2 Magarey, C J, et al, Lancet, 1971, 2, 179. 3 Everson, N W, et al. In press. 4 Evans, C, and Pollock, A V, British Journal of Surgery, 1973, 60, 434. 5 Farrar, D J, et al, British Journal of Clinical Practice, 1973, 27, 63.
SIR,-As an alternative to delayed suture for cases of suppurative appendicitis, as discussed by Mr A W Clark (9 October, p 881) and Mr G Qvist (30 October, p 1074), I have found that the following technique yields satisfactory results. The musculoaponeurotic layers are brought together with a minimum number of interrupted sutures. Several (generally three) deep cutaneous stitches are then inserted, bringing the subcutaneous fat very loosely into apposition but leaving the skin edges gaping. Finally, these edges are brought together with a larger number of fine sutures which do not penetrate deeper than the skin itself; a small subcutaneous drain is inserted into the lower end of the wound. Antibiotic cover is given from the time of operation.
Recruitment to community medicine
SIR,-The inadequate recruitment of young doctors to the specialty of community medicine is currently causing some alarm. Although the quality of those in training is for the most part excellent, their numbers are insufficient even to replace losses due to death and retirement. The report of the Working Party on Medical Administrators, of which I was chairman, stressed that for the foreseeable future one source of recruitment to the specialty would need to be mature entrants. The working party had in mind particularly clinicians with managerial experience gained by membership of Cogwheel committees and, since reorganisation, of district management teams. The report recommended formal arrangements for training and in-service experience for these doctors and emphasised their suitability for particular specialist posts. At present there is no evidence that such formal arrangements exist and I suspect this valuable recruitment pool is largely untapped. In view of the manpower crisis facing community medicine has not the time come for those concerned with the future of the specialty to reassess present policy on recruitment and existing training arrangements ? ROBERT B HUNTER University of Birmingham, Birmingham
Expansion of the medical schools SIR,-Mr F S A Doran (20 November, p 1272) indicates that on the present trend towards 2 9 juniors to each hospital consultant there will never be enough home-produced doctors to staff the hospital service. Parkhouse and McLaughlin' also stressed the impossibility of adequate junior staffing of hospitals, even though enough general practitioners can be provided. Parkhouse' has further suggested that the "cushion of uncommitted junior staff in hospital is not likely to continue indefinitely" and he suggests a redistribution of grades within the hospital service as one possible solution. Traditional methods of working require reexamination from time to time and now may well be the opportune moment to consider whether hospital doctors (physicians, surgeons, paediatricians, geriatricians, and psychiatrists) really need to be supported by junior staff any more than do general practitioners. In many American hospitals, for instance, there are no juniors, and no doubt the same applies in other parts of the world. If the consultant establishment were increased to allow a group of, say, five or six physicians (or paediatricians or geriatricians) to be based on one district general hospital the total number of patients that each would care for would be diminished and each should then be able to provide total care for his own patients. Such numbers would also allow a reasonable on-call rota for each group. Advantages that would accrue from such an arrangement would be not only elimination of
BRITISH MEDICAL JOURNAL
1391
4 DECEMBER 1976
the hospital staffing pyramid which is the cause of so many problems and uncertainties but also the principle of one clinician being entirely responsible for any individual patient -undoubtedly to the mutual benefit and satisfaction of both. It would cut down unnecessary and repetitive examinations and documentation and would lead to better record keeping, to more effective prescribing of treatment, and to more economic use of laboratory and radiological investigations. It would eliminate the "cushion" of junior staff and would cost no more-probably less-than at present. Junior staff provision would then be that required for training-nearer to a ratio of 1: 0 3 than 1: 229 for the replacement of consultants-with whatever further addition would be required for those entering general practice. This would seem to be a question which at least merits discussion and some pilot experiments with the backing of the DHSS.
Junior hospital doctors and Europe SIR,-In reply to the Secretary's footnote comments on my previous letter (27 November, p 1326), my apologies for omitting to mention the fact that the BMA has regularly included a junior-as the Secretary says, usually myself-in its delegation to the Standing Committee of Doctors of the EEC. This was unintentional and due to the fact that I was under dire threat about the length of my letter. It is important to mention that the BMA has done this because, of the nine national delegations to the standing committee, only two-UK and Denmark-regularly include juniors, although Ireland has recently begun to do so, and I feel that this once again underlines the fact that a junior voice is needed at a European level. PATRICK MCNALLY Chairman, HJS Committee's EEC Subcommittee
BMA House, London WC1
J C BROCKLEHURST Department of Geriatric Medicine, University Hospital of South
Manchester,
Manchester
Parkhouse, J, and McLaughlin, C, Lancet, 1975, 1, 211. 2Parkhouse, J, Proceedings of the Royal Society of Medicine, 1976, 69, 815.
SIR,-Mr F S A Doran's timely and closely reasoned paper (20 November, p 1272) offers naught for our comfort but much food for thought. As I understand it he is arguing that unless the intake of women medical students approximates to 500) of the annual total by 1995 we shall by then have a surplus of some 15 000 fully trained general practitioners. At present there is a financial disincentive to pursue careers in hospital medicine and its effect on the recruitment of the next generation of surgeons, for instance, is already worrying that royal college. Even if, in the interim, a differential repricing of total earnings potential as between general practice and hospital medicine were to divert enough trainees back to the hospital service to eliminate our dependence on overseas graduates there would still be an overall surplus of doctors. Does anyone seriously believe that in that situation even the meagre increments hitherto reluctantly agreed by successive governments would continue ? The laws of the market place apply as inexorably to medical skills as to merchandise -glut and high prices never co-exist. Most of us are reluctant to use the "ultimate trump" of strike action. The next highest card in our hand is our scarcity value and we are in serious danger of discarding it by being party to the proliferation of medical students. It may be true that "one man's pay rise represents another man's job"; equally one doctor's heavy work load justifies another doctor's pay rise. We simply cannot have it both ways-if no doctor carries an unduly heavy work load no other doctor will be able to expect increases in remuneration. I appreciate that Mr Doran himself was not primarily concerned with the financial effects of the surpluses he forecasts, but it is important that someone draws the appropriate conclusions from his arguments. Matching, Harlow, Essex
Complaints against doctors SIR,-Patients are increasingly encouraged to lodge complaints against their doctors. The latter, on the other hand, appear to have no possibility of redress against patients, except in the case of general practitioners, who can ask the patient to choose another doctor. I feel that far too many doctors are wrongly accused and have to wait anxiously, possibly for months, before the accusation is dropped or an inquiry is held. The inquiry often finds the doctor innocent and that is where the matter ends. I think that in such cases he should have redress. Perhaps the patient should be wamed that in a case of false accusation he will be fined, the money being deducted from his income. I think the BMA should press for legislation along those lines. A doctor has really no redress under the common law. A case of libel, slander, or defamation of character would scarcely succeed. The patient would plead that he is a layman and was unable to assess the doctor's actions and that there was no malicious intent in bringing the action. It seems that accusations against doctors can be made with impunity. If one accused a supermarket of, say, selling rotten food one could find onself in great difficulties. However, anyone can bring a charge against a doctor. The matter will be investigated by the health authority or family practitioner committee and the doctor will have to face the accusation, no matter how unfounded. H A LEIGH Letchworth, Herts
Industrial action
SIR,-I refer to a report in the Sunday Express (31 October, p 17) of the views on industrial action attributed to Dr P A T Wood, the chairman of the Fellowship for Freedom in Medicine. Like him, most of us in the hospital service are sick of the situation which we have been manoeuvred into by force majeure. However, is industrial action a "disease of the National Health Service" rather than a national disease which includes the NHS DONALD V BATEMAN among its victims ? There is no doubt that the present Government fostered this by ignominious surrender to the trade unions and that
the predilection for the soft option demonstrated by the General Election results of 1974 condoned it. Dr Wood called on his colleagues to become "men of stature" and pave the way for a Health Service completely free from strikes and stoppages. Such freedom has sometimes to be fought for initially. Freedom in medicine is no exception. Can anyone who listened to Mr Ennals recently doubt that there will be no improvements for the professicn, particularly consultants, which are not fought for hard? The Secretary of State deplored industrial action in the NHS in a speech at Blackpool but it became clear that he deplored action by consultants to protect themselves while condoning the activities of the Health Service unions. We will not become "men of stature" by surrendering ignobly to the philosophy which promotes such confrontation. Dr Wood is reported as saying that if people wanted to work in the Health Service they should accept that pay and conditions of service were ultimately dependent on what the community thought was right. This is subject to the philosophy expressed by the Secretary of State at Blackpool on referring to numbers of medical staffs, particularly consultants, relative to other NHS employees. The implication was that it is not the function served that determines worth and influence which can be brought to bear but the numbers you can muster to force your views upon others. Finally Dr Wood says we should not descend to the shop floor. We have not descended to this level; we have been dragged down to it and will be submerged at this level unless we all, as a profession, unite and speak and act with one voice to prevent it. It is against the interests of the nation for any discipline, including medicine, to promote or accept egalitarian principles whereby industry, achievement, and effort will not attract adequate and just differential in reward in their own right. DAVID B MuRRAY Royal Infirmary, Blackburn, Lancs
JHDA SIR,-Dr Elinor Kapp (30 October, p 1076) states that "the delegates who attended the two national conferences of autumn 1975 were elected from regional meetings in all parts of the country." Presumably those who attended the April 1976 conference were similarly elected. Although a member of the JHDA, I am unaware of any meeting called by the association within the South-west Thames Region during the past 12 months. I am equally unaware, having been in contact at various times with mess representatives in all 14 districts in the region, of any mechanism extant whereby the views of junior doctors in the region could be put before the JHDA national executive. Perhaps Dr Kapp could fill in the gaps in my knowledge by supplying me with the dates and places of the regional meetings held by the JHDA in the South-west Thames Region over the past year. I should be particularly gratified to learn at which meeting my regional representative was elected and how many people were in attendance. R A V MILSTED Institute of Cancer Research, Royal Cancer Hospital, Sutton, Surrey
