970
During screening hours 75% of the customers in the supermarkets and 10% of those in the largest supermarket had their blood-pressures checked. 5653 (23%) of the persons measured were referred to their general practitioner for further evaluation. 3.7% had systolic values > 200, 1-1% > 220 and 0.2% >240 smaller
Hg. 7.3% had diastolic values >110, 2.2% >_120 mm Hg. The campaign showed that it is possible to measure blood-pressure on large numbers of people in an easy, quick, and inexpensive way. Furthermore this unconventional approach was accepted by a public accustomed
mm
and 0.7% >130
free medical care, and the values obtained accord with experience in other investigations using more conventional approaches. We feel that the main purpose of the campaignnamely, to provide information about a common and health-threatening condition-was achieved. The campaign would not have had the same response without the
of the news media. Almost every Dane heard or read about blood-pressure during this "heart week". Since the campaign the Danish Heart Foundation has been asked to measure blood-pressure in several companies and similar institutions, and by the end of April, 1975, another 15 000 persons were screened without any cost at all for the Foundation. After the campaign the health-care system in some areas of Denmark has now agreed to pay for a check-up of blood-pressure by the general practitioner, something that had never been accepted before.
help
to
Medical Education GENERAL PROFESSIONAL TRAINING IN MEDICINE G. M. WILSON
University Department of Medicine, Western Infirmary, Glasgow G11 6NT A programme of general professional training in medicine based on the Royal Commission report has been in operation at the Western Infirmary, Glasgow, and associated hospitals since 1969. It involves a two-year rotation through general medicine, dermatology, psychiatry, pædiatrics, geriatrics, and a variety of medical specialties. A third year is spent as far as possible in one unit of the doctor’s choice. The scheme has been popular with trainees and senior staff. A high pass-rate has been achieved in the M.R.C.P.—23 out of 26 being successful within the three-year period. The trainees have subsequently taken up a wide variety of hospital posts within the broad division of medicine or entered general practice. The concept of a broadly based three-year period of general professional training in medicine has proved both practical and useful.
Summary
INTRODUCTION
THE concept of a period of general professional training to cover the three postgraduate years after the preregistration year was introduced by the Royal Commission on Medical Education in 1968.1 This training was to be
carried out on a wide basis within broad divisions so that the young graduate maintained the greatest opportunity of subsequent choice of career and was not committed to a specialty at too early a stage. Before entry the doctor must decide which field he wishes to choose-medicine, surgery, anaesthetics, laboratory medicine, and so onbut thereafter he should receive a training which is as wide and flexible as possible. Thus general professional training in medicine should be arranged to provide a sound basis not only for a career in general (internal) medicine and associated specialties such as cardiology, neurology, and nephrology but also for entry into less
_
Copies of the pamphlet What about YOUR Blood Pressure? can be obtained from the Danish Heart Foundation, 10 Hauser Plads, DK-1127 Copenhagen K, Denmark. Further results will appear inacta Medica Scandinavica. Requests for reprints should be addressed to P. S.
closely related subjects as dermatology, psychiatry, pxdiatrics, and general practice. The intention of general professional training as defined by the Royal Commission has been much misunderstood, probably because insufficient attention has been given to the numerous examples provided in appendix 5 of the report. Recently the Merrison Committee2reported that it did "not believe that general professional training has turned out to provide the opportunity for obtaining a variety of clinical training appropriate to several specialties". A three-year training programme in medicine was introduced at the Western Infirmary, Glasgow, and associated hospitals along the lines advocated by the Royal Commission. This is a report on the organisation of the scheme, how it has operated to date, and the progress of the doctors who have been involved. ORGANISATION OF POSTS AND TRAINING
The plan inaugurated in 1969 involved starting 4 doctors each year on Aug. 1 and a rotation through general medicine and various specialties as shown under Programme A (see
accompanying table). Periods of three months were spent in four specialties during the first two years together with two sixmonth periods in general medicine. During the first period in general medicine there is a short attachment to the intensivecare unit where special instruction is given in emergency resuscitation. The third year was spent entirely in general medicine. In designing this scheme 12 posts were required over the threeyear period; these were available on the various hospital establishments except for 1 additional post which had to be.created in paediatrics. In the first two years the appointments were in the senior-house-officer grade and for the third year m the registrar grade, but promotion to registrar was granted in the ROTATIONAL PROGRAMMES
971 second year once the M.R.c.P. was obtained. When this rotation had been firmly established and proved extremely popular, a further Programme B (table) was introduced in 1973, likewise
involving 4 doctors starting on Aug. 1 each year. No additional posts were required for this second programme. The medical specialties were all chosen as relevant to the training of the general physician and the consultants concerned were asked to stress these aspects. In psychiatry particular attention was to be devoted to the assessment of the mental state of a patient and to the psychiatric presentations of organic disease. In dermatology the intention was to afford an opportunity to learn about the common skin disorders and the cutaneous manifestations of systemic disease. In paediatrics the doctor, in addition to general duties, was encouraged to study medical genetics; he was not involved in neonatal care. In Programme B, geriatrics was substituted for dermatology; paediatrics was not included but a period in neurology was a welcome addition. In order to achieve a balance it was arranged that during the course of the three months in psychiatry those in Programme A who had paediatrics but no geriatrics gained some experience in the psychogeriatric unit whereas those in Programme B worked in the adolescent unit. The arrangement of the third year has been left flexible and the wishes of the individuals are met as far as possible. The majority have completed the M.R.C.P. by this time and there is no great educational advantage in further rotation. Indeed a steady period in one unit is appreciated and at this stage many start a research project. The hospitals involved-general, children’s, and psychiatric-lie within about a mile of each other with the exception of the neurological unit which is on the south side of the River Clyde about two miles distant from the Western Infirmary. This means that all the doctors on the training programmes can remain in close contact and organise clinical meetings and discussions amongst themselves in addition to attending the more formal postgraduate educational activities at the various
hospitals.
that withdrawals would probably one-year accessory programme was introduced at the same time as the three-year training programme. This was based on 2 posts involving six months in general medicine and six months in medical oncology and radiotherapy. The doctors completing these annual appointments may be given preference in filling vacancies that might arise in the three-year As it
occur,
was
appreciated
a
programme. SUCCESS IN THE M.R.C.P.
Of the 26 doctors (including the 2 substitutes) who have entered the scheme up to August. 1, 1973, 23 have gained the M.R.C.P. Of the latter, 15 passed both part 1 and part 2 at the first attempt and 20 gained the diploma by the end of the second year. There has been much competition for posts in these training programmes and selection was made mainly on academic ability. Thus the high success-rate in this examination probably depended to a large extent on the innate ability of the candidates. However, many commented on the value of the wide range of experience and particularly on how easy they found questions in both parts which referred to psychiatry, dermatology, and paediatrics if they had rotated through these specialties. No doubt the experience of having to work with a large number of different consultants also afforded confidence in confronting strange examiners in clinical and oral tests.
SUBSEQUENT CAREERS No doctor on completion of general professional training immediately gained a senior-registrar appointment. The 17 doctors (including one substitute) who had entered the programme by August, 1972, and thus have had the opportunity of completing the three years took up a wide variety of careers on leaving the scheme. 2 entered general practice and 2 took up research fellowships. The remainder were placed in N.H.S. registrar posts in a wide variety of medical disciplines, including general medicine, chest diseases, haematology, nephrology, rheumatic diseases, oncology, dermatology, psychiatry, and pa:diatrics.
DURATION OF APPOINTMENTS
COMMENT
doubts were expressed about the three-month Initially in appointments the specialties. In particular it was stated that after this period the junior doctor was only just beginning to contribute effectively to the unit and there was a disadvantage of lack of continuity in the provision of service care to patients. However, in all these special subjects there was a core of junior staff not involved in a rotation. The enthusiasm and manifest. ability of the highly selected doctors in the rotational grammes quickly overcame these theoretical objections and they were accepted and welcomed in all the departments involved. None of the specialties would now at all willingly give up receiving these doctors even though they only come for periods of three months. some
pro-
WITHDRAWALS BEFORE COMPLETION OF TRAINING
A difficulty must arise if a doctor withdraws prematurely as those units involved in the later section of the programme may be deprived of the services of a junior staff member. As they have contributed a post to the training scheme they are understandably resentful. Inevitably during the last half of the third year the doctors are looking for their next posts, and if something attractive is advertised at this stage they naturally apply and may leave a few months early. Excluding those taking up appointments in this way, out of the 24 doctors appointed up to Aug. 1, 1973, 5 left prematurely. 2 left at the end of the first year-one to enter general practice and the other after gaining the M.R.C.P. to enter a MRC research unit. 3 left at the end of the second year-one to go to the U.S.A. for training in clinical pharmacology, one to take up a registrar post in gastroenterology, and one on maternity leave. All 3 had acquired the M.R.C.P. before leaving. 2 substitutes were appointed for two years in the place of those withdrawing at the end of the first year.
The programme of general professional training in medicine programme described above has been running for six years and has undoubtedly proved popular and successful judging from the large number of applicants of high calibre and their performance in the M.R.C.P. examination. However, there have been a few criticisms both from the consultant staff and the trainees. The periods of only three months in the specialties were at first regarded with apprehension by the senior staff, who commented that they would lose their trainee just when he was becoming useful and were not initially reassured by the comment that educationally this was just the point when he should move on. With only a short period in each specialty it was imperative that the trainee quickly asumed defined clinical duties and was not left as an observer. This was at first a problem, but mutual confidence was soon established as the scheme became established and immediate assumption of responsibility under supervision was quickly accepted. The regular supply of keen young doctors assured by the programme proved an adequate compensation for the high rate of turnover, and when later a proportion sought to come back for further higher training the scheme became even more acceptable. Indeed this has been an encouraging feature since doctors once they have had responsibility for patients have often taken quite a different view of a specialty from that formed during their undergraduate career. They have then chosen on their own accord to come back to it after completion of general professional
training.
972
The problem of withdrawals during the training has been numerically great but is important since those consultants who have contributed posts to the scheme expect to receive junior staff without fail. The flexibility and absence of a fixed rotation in the third year have undoubtedly encouraged completion of the programme. An important aspect of the scheme is that this year should be spent as far as possible in a discipline of the doctor’s tchoice and that at this stage, having completed the M.R.C.P., he should be free to start on a research project or some work in depth. The back-up provided by the one-year rotational training involving general medicine and radiotherapy has been helpful in providing a reserve of doctors some of whom are keen to enter the three-year programme if any vacancy should occur. Experience since 1969 has shown in practice that a not
general professional training programme involving general medicine and several medical specialties as advocated by the Royal Commission can be operated successfully and to the satisfaction of both senior and junior staff despite the statement of the Merrison Committee.
Points of View
provides a good basis for entry both into a wide variety of hospital specialties and into general practice. It
The misfortune has been that no doctor has been able to obtain immediately a senior-registrar post in his chosen career after completing general professional training. He has had to enter a no-man’s land taking a further registrar post which is neither general professional nor higher medical training and hope that in due course he may obtain a senior-registrar post which will enable him to obtain retrospective recognition for at least some of this time. The anomaly is that there are two postgraduate training stages, but three rather than two grades of junior staff in the N.H.S.-senior houseofficer, registrar, and senior registrar. This absurdity requires urgent rectification3 so that training schemes and posts correspond and are fully recognised. REFERENCES
Regulation of the Medical Profession (MerriCommittee). H.M. Stationery Office, 1975. Royal Commission on Medical Education (Todd Report). H.M. Stationery
1. Committee of Inquiry into the son
2.
Office, 1968. 3. Wilson, G. M. Hlth Bull. Scotl. 1975,
5, 189.
junior staff less they be disadvantaged in the rat race to resist inflation. Indeed, anyone who goes on record as saying that he is opposed in principle to some move to better immediate conditions of pay and service is ipso facto a blackleg in the profession now. Consequently, declaration of and practical support for a principle-all-important to maintaining the concept of a profession-tend to be blanketed out by conditions of secure
A PROFESSION DESTROYING ITSELF?
Sociologists and others define a profession
in different ways. To those with a Machiavellian turn of mind it is a grouping of individuals largely if not solely concerned with preserving its own status.’ More idealistically, it is a collection of people who, while recognising their individuality, still think that there are some binding principles that transcend self-interest. Predominantly, these features will favour society in some way, either through the Benthamite principle of the greatest good for the greatest number, or by providing for some one person a service which preserves or enhances his position in society as a whole and by so doing sustains that society. Medicine qualifies on all counts to be provisionally called a profession. It has strong self-interest; at the same time it is firmly lashed to the ship of society if not to the barque of State. Yet because of these two allegiances it is making fair to destroy itself. Self-interest has two corollaries. First, it generates a desire to preserve or improve upon the status quo. We all share this and we all tend to assess it relative to ourselves as we are or were rather than to the world at large. Thus, consultants find it difficult to accept that they might have to do things for their patients which were formerly delegated to junior staff and junior staff find it impossible to believe that because they may in some ways have been feather-bedded by overtime payments they should now contemplate detrimental redistribution of the pool. Second, self-concern corrupts debate away from any long-term consideration of the principles on which social institutions such as the N.H.S. are based, towards the short-term expedients of what is good for you or me in our condition now. In hospital medicine we have seen this particularly in relation to overtime payments where, though most of us reject the principle of overtime, few if any oppose it as a practice for our 1.
Millar, S J. Prescription for Leadership. Chicago, 1970.
expediency. Part of a profession’s self-maintenance lies in its public image. True it is that overall the public view of professions has declined in this rationalist and debunking age. Nevertheless, medicine has in the past enjoyed a unique position because of the naked power it was credited with in relation to life or death, sickness or health, work or idleness. Its quasi-magical and certainly unrational authority in these fields has given it a useful if illogical credibility which, however, cannot be sustained if in the market-place its individuals are seen to behave in a way which shows they have or can be regarded as having feet of clay. The declining standards of which many of the leaders of medicine loudly complain are partly the result of a loss of confidence by the public, the Press, and the politician in the profession’s rectitude and personal disinterest. Medicine is no longer quite the nonpareil. It receives less support than before, and being what it is cannot understand that this then becomes part of the problem it finds in fulfilling its role. The decline in public confidence and a crumbling of the professional image have been accelerated by a further characteristic of professions-their axiomatic if paradoxical amateurism when it comes to tackling any thing new. The very existence of a professional body and its corporate expression as an institution is opposed to change. When society changes, either through natural or political forces, a profession is likely to be left behind because of the inward-lookingness of its thought. Once it belatedly recognises change, there is a violent reaction, usually accompanied by rhetorical statements about ill-defined principles. If negotiation is required to meet the needs of change, this stance is usually unproductive because compromise is seen as erosion and
During screening hours 75% of the customers in the supermarkets and 10% of those in the largest supermarket had their blood-pressures checked. 5653 (23%) of the persons measured were referred to their general practitioner for further evaluation. 3.7% had systolic values > 200, 1-1% > 220 and 0.2% >240 smaller
Hg. 7.3% had diastolic values >110, 2.2% >_120 mm Hg. The campaign showed that it is possible to measure blood-pressure on large numbers of people in an easy, quick, and inexpensive way. Furthermore this unconventional approach was accepted by a public accustomed
mm
and 0.7% >130
free medical care, and the values obtained accord with experience in other investigations using more conventional approaches. We feel that the main purpose of the campaignnamely, to provide information about a common and health-threatening condition-was achieved. The campaign would not have had the same response without the
of the news media. Almost every Dane heard or read about blood-pressure during this "heart week". Since the campaign the Danish Heart Foundation has been asked to measure blood-pressure in several companies and similar institutions, and by the end of April, 1975, another 15 000 persons were screened without any cost at all for the Foundation. After the campaign the health-care system in some areas of Denmark has now agreed to pay for a check-up of blood-pressure by the general practitioner, something that had never been accepted before.
help
to
Medical Education GENERAL PROFESSIONAL TRAINING IN MEDICINE G. M. WILSON
University Department of Medicine, Western Infirmary, Glasgow G11 6NT A programme of general professional training in medicine based on the Royal Commission report has been in operation at the Western Infirmary, Glasgow, and associated hospitals since 1969. It involves a two-year rotation through general medicine, dermatology, psychiatry, pædiatrics, geriatrics, and a variety of medical specialties. A third year is spent as far as possible in one unit of the doctor’s choice. The scheme has been popular with trainees and senior staff. A high pass-rate has been achieved in the M.R.C.P.—23 out of 26 being successful within the three-year period. The trainees have subsequently taken up a wide variety of hospital posts within the broad division of medicine or entered general practice. The concept of a broadly based three-year period of general professional training in medicine has proved both practical and useful.
Summary
INTRODUCTION
THE concept of a period of general professional training to cover the three postgraduate years after the preregistration year was introduced by the Royal Commission on Medical Education in 1968.1 This training was to be
carried out on a wide basis within broad divisions so that the young graduate maintained the greatest opportunity of subsequent choice of career and was not committed to a specialty at too early a stage. Before entry the doctor must decide which field he wishes to choose-medicine, surgery, anaesthetics, laboratory medicine, and so onbut thereafter he should receive a training which is as wide and flexible as possible. Thus general professional training in medicine should be arranged to provide a sound basis not only for a career in general (internal) medicine and associated specialties such as cardiology, neurology, and nephrology but also for entry into less
_
Copies of the pamphlet What about YOUR Blood Pressure? can be obtained from the Danish Heart Foundation, 10 Hauser Plads, DK-1127 Copenhagen K, Denmark. Further results will appear inacta Medica Scandinavica. Requests for reprints should be addressed to P. S.
closely related subjects as dermatology, psychiatry, pxdiatrics, and general practice. The intention of general professional training as defined by the Royal Commission has been much misunderstood, probably because insufficient attention has been given to the numerous examples provided in appendix 5 of the report. Recently the Merrison Committee2reported that it did "not believe that general professional training has turned out to provide the opportunity for obtaining a variety of clinical training appropriate to several specialties". A three-year training programme in medicine was introduced at the Western Infirmary, Glasgow, and associated hospitals along the lines advocated by the Royal Commission. This is a report on the organisation of the scheme, how it has operated to date, and the progress of the doctors who have been involved. ORGANISATION OF POSTS AND TRAINING
The plan inaugurated in 1969 involved starting 4 doctors each year on Aug. 1 and a rotation through general medicine and various specialties as shown under Programme A (see
accompanying table). Periods of three months were spent in four specialties during the first two years together with two sixmonth periods in general medicine. During the first period in general medicine there is a short attachment to the intensivecare unit where special instruction is given in emergency resuscitation. The third year was spent entirely in general medicine. In designing this scheme 12 posts were required over the threeyear period; these were available on the various hospital establishments except for 1 additional post which had to be.created in paediatrics. In the first two years the appointments were in the senior-house-officer grade and for the third year m the registrar grade, but promotion to registrar was granted in the ROTATIONAL PROGRAMMES
971 second year once the M.R.c.P. was obtained. When this rotation had been firmly established and proved extremely popular, a further Programme B (table) was introduced in 1973, likewise
involving 4 doctors starting on Aug. 1 each year. No additional posts were required for this second programme. The medical specialties were all chosen as relevant to the training of the general physician and the consultants concerned were asked to stress these aspects. In psychiatry particular attention was to be devoted to the assessment of the mental state of a patient and to the psychiatric presentations of organic disease. In dermatology the intention was to afford an opportunity to learn about the common skin disorders and the cutaneous manifestations of systemic disease. In paediatrics the doctor, in addition to general duties, was encouraged to study medical genetics; he was not involved in neonatal care. In Programme B, geriatrics was substituted for dermatology; paediatrics was not included but a period in neurology was a welcome addition. In order to achieve a balance it was arranged that during the course of the three months in psychiatry those in Programme A who had paediatrics but no geriatrics gained some experience in the psychogeriatric unit whereas those in Programme B worked in the adolescent unit. The arrangement of the third year has been left flexible and the wishes of the individuals are met as far as possible. The majority have completed the M.R.C.P. by this time and there is no great educational advantage in further rotation. Indeed a steady period in one unit is appreciated and at this stage many start a research project. The hospitals involved-general, children’s, and psychiatric-lie within about a mile of each other with the exception of the neurological unit which is on the south side of the River Clyde about two miles distant from the Western Infirmary. This means that all the doctors on the training programmes can remain in close contact and organise clinical meetings and discussions amongst themselves in addition to attending the more formal postgraduate educational activities at the various
hospitals.
that withdrawals would probably one-year accessory programme was introduced at the same time as the three-year training programme. This was based on 2 posts involving six months in general medicine and six months in medical oncology and radiotherapy. The doctors completing these annual appointments may be given preference in filling vacancies that might arise in the three-year As it
occur,
was
appreciated
a
programme. SUCCESS IN THE M.R.C.P.
Of the 26 doctors (including the 2 substitutes) who have entered the scheme up to August. 1, 1973, 23 have gained the M.R.C.P. Of the latter, 15 passed both part 1 and part 2 at the first attempt and 20 gained the diploma by the end of the second year. There has been much competition for posts in these training programmes and selection was made mainly on academic ability. Thus the high success-rate in this examination probably depended to a large extent on the innate ability of the candidates. However, many commented on the value of the wide range of experience and particularly on how easy they found questions in both parts which referred to psychiatry, dermatology, and paediatrics if they had rotated through these specialties. No doubt the experience of having to work with a large number of different consultants also afforded confidence in confronting strange examiners in clinical and oral tests.
SUBSEQUENT CAREERS No doctor on completion of general professional training immediately gained a senior-registrar appointment. The 17 doctors (including one substitute) who had entered the programme by August, 1972, and thus have had the opportunity of completing the three years took up a wide variety of careers on leaving the scheme. 2 entered general practice and 2 took up research fellowships. The remainder were placed in N.H.S. registrar posts in a wide variety of medical disciplines, including general medicine, chest diseases, haematology, nephrology, rheumatic diseases, oncology, dermatology, psychiatry, and pa:diatrics.
DURATION OF APPOINTMENTS
COMMENT
doubts were expressed about the three-month Initially in appointments the specialties. In particular it was stated that after this period the junior doctor was only just beginning to contribute effectively to the unit and there was a disadvantage of lack of continuity in the provision of service care to patients. However, in all these special subjects there was a core of junior staff not involved in a rotation. The enthusiasm and manifest. ability of the highly selected doctors in the rotational grammes quickly overcame these theoretical objections and they were accepted and welcomed in all the departments involved. None of the specialties would now at all willingly give up receiving these doctors even though they only come for periods of three months. some
pro-
WITHDRAWALS BEFORE COMPLETION OF TRAINING
A difficulty must arise if a doctor withdraws prematurely as those units involved in the later section of the programme may be deprived of the services of a junior staff member. As they have contributed a post to the training scheme they are understandably resentful. Inevitably during the last half of the third year the doctors are looking for their next posts, and if something attractive is advertised at this stage they naturally apply and may leave a few months early. Excluding those taking up appointments in this way, out of the 24 doctors appointed up to Aug. 1, 1973, 5 left prematurely. 2 left at the end of the first year-one to enter general practice and the other after gaining the M.R.C.P. to enter a MRC research unit. 3 left at the end of the second year-one to go to the U.S.A. for training in clinical pharmacology, one to take up a registrar post in gastroenterology, and one on maternity leave. All 3 had acquired the M.R.C.P. before leaving. 2 substitutes were appointed for two years in the place of those withdrawing at the end of the first year.
The programme of general professional training in medicine programme described above has been running for six years and has undoubtedly proved popular and successful judging from the large number of applicants of high calibre and their performance in the M.R.C.P. examination. However, there have been a few criticisms both from the consultant staff and the trainees. The periods of only three months in the specialties were at first regarded with apprehension by the senior staff, who commented that they would lose their trainee just when he was becoming useful and were not initially reassured by the comment that educationally this was just the point when he should move on. With only a short period in each specialty it was imperative that the trainee quickly asumed defined clinical duties and was not left as an observer. This was at first a problem, but mutual confidence was soon established as the scheme became established and immediate assumption of responsibility under supervision was quickly accepted. The regular supply of keen young doctors assured by the programme proved an adequate compensation for the high rate of turnover, and when later a proportion sought to come back for further higher training the scheme became even more acceptable. Indeed this has been an encouraging feature since doctors once they have had responsibility for patients have often taken quite a different view of a specialty from that formed during their undergraduate career. They have then chosen on their own accord to come back to it after completion of general professional
training.
972
The problem of withdrawals during the training has been numerically great but is important since those consultants who have contributed posts to the scheme expect to receive junior staff without fail. The flexibility and absence of a fixed rotation in the third year have undoubtedly encouraged completion of the programme. An important aspect of the scheme is that this year should be spent as far as possible in a discipline of the doctor’s tchoice and that at this stage, having completed the M.R.C.P., he should be free to start on a research project or some work in depth. The back-up provided by the one-year rotational training involving general medicine and radiotherapy has been helpful in providing a reserve of doctors some of whom are keen to enter the three-year programme if any vacancy should occur. Experience since 1969 has shown in practice that a not
general professional training programme involving general medicine and several medical specialties as advocated by the Royal Commission can be operated successfully and to the satisfaction of both senior and junior staff despite the statement of the Merrison Committee.
Points of View
provides a good basis for entry both into a wide variety of hospital specialties and into general practice. It
The misfortune has been that no doctor has been able to obtain immediately a senior-registrar post in his chosen career after completing general professional training. He has had to enter a no-man’s land taking a further registrar post which is neither general professional nor higher medical training and hope that in due course he may obtain a senior-registrar post which will enable him to obtain retrospective recognition for at least some of this time. The anomaly is that there are two postgraduate training stages, but three rather than two grades of junior staff in the N.H.S.-senior houseofficer, registrar, and senior registrar. This absurdity requires urgent rectification3 so that training schemes and posts correspond and are fully recognised. REFERENCES
Regulation of the Medical Profession (MerriCommittee). H.M. Stationery Office, 1975. Royal Commission on Medical Education (Todd Report). H.M. Stationery
1. Committee of Inquiry into the son
2.
Office, 1968. 3. Wilson, G. M. Hlth Bull. Scotl. 1975,
5, 189.
junior staff less they be disadvantaged in the rat race to resist inflation. Indeed, anyone who goes on record as saying that he is opposed in principle to some move to better immediate conditions of pay and service is ipso facto a blackleg in the profession now. Consequently, declaration of and practical support for a principle-all-important to maintaining the concept of a profession-tend to be blanketed out by conditions of secure
A PROFESSION DESTROYING ITSELF?
Sociologists and others define a profession
in different ways. To those with a Machiavellian turn of mind it is a grouping of individuals largely if not solely concerned with preserving its own status.’ More idealistically, it is a collection of people who, while recognising their individuality, still think that there are some binding principles that transcend self-interest. Predominantly, these features will favour society in some way, either through the Benthamite principle of the greatest good for the greatest number, or by providing for some one person a service which preserves or enhances his position in society as a whole and by so doing sustains that society. Medicine qualifies on all counts to be provisionally called a profession. It has strong self-interest; at the same time it is firmly lashed to the ship of society if not to the barque of State. Yet because of these two allegiances it is making fair to destroy itself. Self-interest has two corollaries. First, it generates a desire to preserve or improve upon the status quo. We all share this and we all tend to assess it relative to ourselves as we are or were rather than to the world at large. Thus, consultants find it difficult to accept that they might have to do things for their patients which were formerly delegated to junior staff and junior staff find it impossible to believe that because they may in some ways have been feather-bedded by overtime payments they should now contemplate detrimental redistribution of the pool. Second, self-concern corrupts debate away from any long-term consideration of the principles on which social institutions such as the N.H.S. are based, towards the short-term expedients of what is good for you or me in our condition now. In hospital medicine we have seen this particularly in relation to overtime payments where, though most of us reject the principle of overtime, few if any oppose it as a practice for our 1.
Millar, S J. Prescription for Leadership. Chicago, 1970.
expediency. Part of a profession’s self-maintenance lies in its public image. True it is that overall the public view of professions has declined in this rationalist and debunking age. Nevertheless, medicine has in the past enjoyed a unique position because of the naked power it was credited with in relation to life or death, sickness or health, work or idleness. Its quasi-magical and certainly unrational authority in these fields has given it a useful if illogical credibility which, however, cannot be sustained if in the market-place its individuals are seen to behave in a way which shows they have or can be regarded as having feet of clay. The declining standards of which many of the leaders of medicine loudly complain are partly the result of a loss of confidence by the public, the Press, and the politician in the profession’s rectitude and personal disinterest. Medicine is no longer quite the nonpareil. It receives less support than before, and being what it is cannot understand that this then becomes part of the problem it finds in fulfilling its role. The decline in public confidence and a crumbling of the professional image have been accelerated by a further characteristic of professions-their axiomatic if paradoxical amateurism when it comes to tackling any thing new. The very existence of a professional body and its corporate expression as an institution is opposed to change. When society changes, either through natural or political forces, a profession is likely to be left behind because of the inward-lookingness of its thought. Once it belatedly recognises change, there is a violent reaction, usually accompanied by rhetorical statements about ill-defined principles. If negotiation is required to meet the needs of change, this stance is usually unproductive because compromise is seen as erosion and
