1028 ANATOMY AND MEDICINE 1975
SIR,-In his valedictory article (April 19, p. 875) Professor Sinclair clearly sets out the staffing problems which now afflict anatomy departments and which if not overcome will inevitably reduce the efficiency and effectiveness of both undergraduate and postgraduate medical education. Not all his colleagues would, however, agree that there are two anatomies, since many now adopt a holistic attitude to the subject believing that the term " anatomy " has, over the past fifty years throughout the world, come to mean form and structure, and not, as some of the wellknown critics aver, dissection. In the holistic concept structure is continuous from molecular to gross and with This concept is applicable to functional interactions. embryology and growth, to neuroanatomy, as well as system and regional anatomy. Histology, histochemistry, electron microscopy, which have been developed primarily by anatomists and pathologists, are technologies essential to the main themes: structure (and its correlation with function) and development. If one accepts the holistic concept it is clearly important particularly in light of post-war advances in medicine to ensure that a balanced presentation of the subject matter is achieved. Hence normal cell and tissue structure and their modifications under different functional conditions are essential components of a course which accompanies or precedes biochemistry, physiology, and pathology, and clinical medicine. In some centres anatomy and pathology are already presented together in relation to appropriate topics. Structure from the molecular to the gross is a continuum and must be thought of as such in the fields of both teaching and research. Where possible integrated classes on particular topics should be conducted with an emphasis which is relevant to the educational brief-the scientific and/or vocational training of undergraduate
adequate complement of medically qualified anatomists, who carry the major burden in vocational training and organisation at both undergraduate and postgraduate stages in anatomy departments. The presence of medical graduates who have previous postgraduate clinical and biological science experience, and who hopefully retain a close link with a clinical discipline is absolutely essential in selecting what is appropriate and is
to
maintain
how much in
an
terms
of the immediate and of the whole
course.
Modern anatomy, as practised in most centres in Britain during the past 15 years, is not the dead subject implied in your leader (April 19, p. 903). It is unfortunate that your knowledge of the research contributions of anatomists to neurology should end in the 1830s-or was it deliberate The international reputations of distortion of facts ? departments and individual anatomists in fields of endocrinology, neuroanatomy, and haematology, to mention only a few, is, however, sufficiently high to cast serious doubts about the veracity of either statements or
conclusions.
-
During the past 20 years I, in common with many senior colleagues, have had responsibility for, and personally participated extensively in, the anatomical and scientific training of thousands of medical students and hundreds of dental, , postgraduate medical, and medical ancillary students. Many of the medical graduates who have held short-term appointments in the department have indicated that, given a different financial climate, they would have liked to have obtained permanent posts. Admittedly the close clinical links which this department enjoys assists in this matter, but since anatomy, which should where possible be taught on the living, forms the only logical scientific basis for physical examination and diagnosis, and staff retain much of, and even extend, their diagnostic competence, they feel an integral part of medicine as a medical, dental, postgraduate surgical, postgraduate whole. psychiatric, or of medical ancillary workers. The barrier to recruitment is first and foremost financial, David Sinclair rightly stresses the possible value of a the staff of preclinical anatomy departments are on since shift in time of anatomical presentations with a reduction general university pay scales. As a result, even before the in preclinical time and a definite commitment at the recent pay award to the N.H.S., medical anatomists undergraduate clinical and postgraduate phases of educasuffered a career loss of E80,000-E100,000 as compared tion. Ideally at the undergraduate stage a shorter introwith those (including anatomy demonstrators and lecturers) ductory course should be followed by system and regional who entered general practice, or those who made a success courses integrated with specific hospital attachments to in academic clinical work, including pathology. A further general and special clinical departments. This should be recent complication is that the technicians’ salary scale followed by postgraduate courses relevant to the medical now exceeds that of senior lecturers, while the pay scales specialties, as already occurs in some regions. The major of the staff of polytechnics have overtaken those of univerproblem at the undergraduate phase relates to the logistics sities. Differentials are now so small that senior lecturers of organisation and presentation and staff shortages. may not be able to afford to accept chairs in other centres, with with to short-term respect integration Timetabling and professors who elect to move by invitation do so at a clinical attachments, such as E.N.T., ophthalmology, and very considerable financial loss, as a number know to dermatology, is a nightmare to both anatomists and their cost. clinicians. The answer is most definitely not the delegation Barriers to retention of staff are primarily financial, but of these classes to specialist clinicians, since their experience in primary medical education and the scientific aspects of secondly due to statements and publications containing inaccuracies and distortions like your leader, which basic medical sciences is usually limited, and the fact that, emanate from a vocal minority of individuals who, in the from past experience, coverage of what each specialist context of current scientific medical education, can only considers essential would double the anatomical discipline be termed wreckers. course content; quite apart from the fact that the clinical In some centres during the past eight years, notably throughput of the units would be greatly reduced. where the new medical schools have been established, Apart from its vocational aspects the scientific discipline of modern anatomy has proved of great value to many medical anatomists have played a prominent role in the medical graduates now practising as consultants and medical community as a whole in the hospital service, and in regional and area health authority activities. In congeneral practitioners. This is best obtained during an honours course, but should always be included along with sequence some hold honorary (unpaid) regional and area the vocational in the normal curriculum. Many individuals consultant contracts. In established centres many would from such diverse fields as paediatrics, neurology, general become similarly involved if they were encouraged to do surgery, and general practice believe that the most valuable so, though others would question the sense of suffering a educational experience of their undergraduate medical further increase in workload without financial return. The course was the honours year spent in anatomy departments. time has now come when the profession at large, the The best cost-effective answer to the present problems University Grants Committee and the Department of
1029 Health
decide whether
must
they
wish the activities of
medically qualified anatomists, as set out above, to continue by ensuring a reasonable financial return, possibly derived in part from University and partly from N.H.S., or whether the rearguard action of British anatomists to maintain a medical presence must finally end and the departments become staffed by non-medical individuals who quite reasonably put science first and second, and vocational training a poor third; a balanced staff provides a balanced course. Both Vice-Chancellors and the U.G.C. have been aware of the deteriorating situation for the past The seven years, but have chosen to remain inactive. crisis in staffing is now, and with the current exodus of career anatomists overseas and into general practice, the new schools, and even some long established schools, may fail to meet their teaching commitments during the next 12 months. Virtually all the older establishments will be past the point of no-return so far as medical staff is concerned within 5 years. Department of Human Morphology, University Park, Nottingham NG7 2RD.
lower or not in an Open University medical course. Possibly not, but we would have to try the experiment on a small scale to find out. What is likely, however, is that his estimate of 2 years’ preclinical and 22 years’ clinical period is too short. It is frightening to expect even mature students to learn " anatomy, physiology, biochemistry, pharmacology, behavioural sciences, general pathology and microbiology, medical statistics and epidemiology, and
genetics",
as
suggested by Professor Acheson,
R. E. COUPLAND.
138
MEDICAL COURSE AT THE OPEN UNIVERSITY
SiR,—Iam an admirer of the Open University and I am full of praise for its achievements in developing new techniques in education and in enabling 10,000 of our citizens to achieve its degrees since its start only a few years ago. However, I do not accept the case made by the Dean of the Medical Faculty at Southampton University, Prof. Donald Acheson, for an undergraduate medical course for the Open University (April 26, p. 965). The chief reason for developing the idea must be the need for more doctors in the United Kingdom. No sound case has been made for this in spite of the fact that the Governments, U.G.C., and our medical schools are planning to double the annual intake of medical schools to over 4000 (compared with 1970 intakes). Even allowing for a 2-3% annual increase I believe that we need approximately 2600 new medical students each year to meet our own requirements. I believe that we may be creating medical unemployment within 10-15 years if we go ahead with present projections.l There is therefore no good reason for accepting that we need a new Open University Medical School to take in 600 students annually in order to produce 300, as Professor Acheson suggests. Professor Acheson seeks to show that the Open University course would be cheaper than setting up a traditional medical school for 100 students. Surely it is wrong to make such comparisons. It would be crazy for us to build such a It would be much fairer if he had comof increasing the intake of existing medical schools by 100 each year with those of an Open University course. We must realise also that each new medical student who graduates will be responsible for a national capital expenditure of up to Elmillion in his or her professional lifetime.1 Another reason given by Professor Acheson is that it would make it easier for mature students to gain entry to a medical school. If there is a strong case for taking in more mature students into medicine, then why do not Professor Acheson and his fellow deans agree to allocate a higher proportion of places in their existing medical schools for this purpose and convince the Treasury and the Department of Education of the need to support such students with
school
pared the
part-time
University. Croydon Road. Beckenham,
JOHN FRY.
Kent BR3 4DG.
new
as
home students. In spite of my uncertainty of the need for an undergraduate medical course I am certain that there is much that the Open University can contribute to postgraduate medical education. There are great opportunities for Open University involvement and cooperation in specialist training and continuing education. The methods and techniques of teaching and learning that it has developed would add greatly to the current programmes. It is in the postgraduate medical field that I see the greatest scope for the Open
now.
costs
BIOLOGY, ABORTION,
AND ETHICS
SIR,-As one who, like Dr Potts (April 19, p. 913), is interested in the relationship between the natural law and resistance to disease, I believe that biological evidence favours the natural law. For example, there is evidence that oestriol plays a significant anticarcinogenic role in the human female, accounting for the reduced expectancy of mammary cancer in women with multiple pregnancies in their early childbearing years.l It has also been suggested that pregnancy at a young age is associated with the formation of favourable cestrogen ratios and decreased breast-cancer risk later.2 On the other hand, there is an association between changes in adrenocortical function and mental disturbances.3 It has been found that excretion of urinary ketosteroid levels and levels of circulating lymphocytes may be modified by emotional stress.44 It has been affirmed that emotional stress results in increased adrenocortical activity.5 There is also much evidence to suggest that depressed emotional states decrease resistance to tuberculosis, rheumatoid arthritis, and cancer, diseases to which immunity is cell-mediated. It is well known that plasmaoestrogen levels are increased in pregnancy. Should not the exponents of a liberal policy towards abortion be asked to quote objective evidence of urinary and plasma steroid assays in support of their contention that terminations are justified on account of psychological stress ? Plymouth Road, Buckfastleigh, Devon TQ110DH.
72
MICHAEL WILKINSON.
MEDICAL AUDIT
.
government
grants ?
It is difficult 1.
to
theorise whether standards would be
Fry, J. Update (in the press).
SIR,-It is apparent that a myth called Medical Audit is being promoted in Great Britain. Having wasted countless hours during the past twenty years on meetings of the so-called medical audit and tissue committee, I feel obliged to sound an alarm. The myth of medical audit was invented by the Council ,
1. 2. 3. 4.
5.
Lemon, H. M. Cancer, 1970, 25, 423. Cole, P., McMahon, B. Lancet, 1969, i, 604. Beck, J. C., McGarry, E. E. Br. med. Bull. 1962, 18, 134. Hill, S. R., Goetz, F. C., Fox, H. M., Murawski, B. J., Krakauer, L. J., Reifenstein, R. W., Gray, S. J., Reddy, W. J., Hadberg, S. E., St. Marc, J. R., Thorn, G. W. Archs intern. Med. 1956, 97, Greenwood, F. C., Landon, J. Nature, 1966, 210, 540.
no.
3.
SIR,-In his valedictory article (April 19, p. 875) Professor Sinclair clearly sets out the staffing problems which now afflict anatomy departments and which if not overcome will inevitably reduce the efficiency and effectiveness of both undergraduate and postgraduate medical education. Not all his colleagues would, however, agree that there are two anatomies, since many now adopt a holistic attitude to the subject believing that the term " anatomy " has, over the past fifty years throughout the world, come to mean form and structure, and not, as some of the wellknown critics aver, dissection. In the holistic concept structure is continuous from molecular to gross and with This concept is applicable to functional interactions. embryology and growth, to neuroanatomy, as well as system and regional anatomy. Histology, histochemistry, electron microscopy, which have been developed primarily by anatomists and pathologists, are technologies essential to the main themes: structure (and its correlation with function) and development. If one accepts the holistic concept it is clearly important particularly in light of post-war advances in medicine to ensure that a balanced presentation of the subject matter is achieved. Hence normal cell and tissue structure and their modifications under different functional conditions are essential components of a course which accompanies or precedes biochemistry, physiology, and pathology, and clinical medicine. In some centres anatomy and pathology are already presented together in relation to appropriate topics. Structure from the molecular to the gross is a continuum and must be thought of as such in the fields of both teaching and research. Where possible integrated classes on particular topics should be conducted with an emphasis which is relevant to the educational brief-the scientific and/or vocational training of undergraduate
adequate complement of medically qualified anatomists, who carry the major burden in vocational training and organisation at both undergraduate and postgraduate stages in anatomy departments. The presence of medical graduates who have previous postgraduate clinical and biological science experience, and who hopefully retain a close link with a clinical discipline is absolutely essential in selecting what is appropriate and is
to
maintain
how much in
an
terms
of the immediate and of the whole
course.
Modern anatomy, as practised in most centres in Britain during the past 15 years, is not the dead subject implied in your leader (April 19, p. 903). It is unfortunate that your knowledge of the research contributions of anatomists to neurology should end in the 1830s-or was it deliberate The international reputations of distortion of facts ? departments and individual anatomists in fields of endocrinology, neuroanatomy, and haematology, to mention only a few, is, however, sufficiently high to cast serious doubts about the veracity of either statements or
conclusions.
-
During the past 20 years I, in common with many senior colleagues, have had responsibility for, and personally participated extensively in, the anatomical and scientific training of thousands of medical students and hundreds of dental, , postgraduate medical, and medical ancillary students. Many of the medical graduates who have held short-term appointments in the department have indicated that, given a different financial climate, they would have liked to have obtained permanent posts. Admittedly the close clinical links which this department enjoys assists in this matter, but since anatomy, which should where possible be taught on the living, forms the only logical scientific basis for physical examination and diagnosis, and staff retain much of, and even extend, their diagnostic competence, they feel an integral part of medicine as a medical, dental, postgraduate surgical, postgraduate whole. psychiatric, or of medical ancillary workers. The barrier to recruitment is first and foremost financial, David Sinclair rightly stresses the possible value of a the staff of preclinical anatomy departments are on since shift in time of anatomical presentations with a reduction general university pay scales. As a result, even before the in preclinical time and a definite commitment at the recent pay award to the N.H.S., medical anatomists undergraduate clinical and postgraduate phases of educasuffered a career loss of E80,000-E100,000 as compared tion. Ideally at the undergraduate stage a shorter introwith those (including anatomy demonstrators and lecturers) ductory course should be followed by system and regional who entered general practice, or those who made a success courses integrated with specific hospital attachments to in academic clinical work, including pathology. A further general and special clinical departments. This should be recent complication is that the technicians’ salary scale followed by postgraduate courses relevant to the medical now exceeds that of senior lecturers, while the pay scales specialties, as already occurs in some regions. The major of the staff of polytechnics have overtaken those of univerproblem at the undergraduate phase relates to the logistics sities. Differentials are now so small that senior lecturers of organisation and presentation and staff shortages. may not be able to afford to accept chairs in other centres, with with to short-term respect integration Timetabling and professors who elect to move by invitation do so at a clinical attachments, such as E.N.T., ophthalmology, and very considerable financial loss, as a number know to dermatology, is a nightmare to both anatomists and their cost. clinicians. The answer is most definitely not the delegation Barriers to retention of staff are primarily financial, but of these classes to specialist clinicians, since their experience in primary medical education and the scientific aspects of secondly due to statements and publications containing inaccuracies and distortions like your leader, which basic medical sciences is usually limited, and the fact that, emanate from a vocal minority of individuals who, in the from past experience, coverage of what each specialist context of current scientific medical education, can only considers essential would double the anatomical discipline be termed wreckers. course content; quite apart from the fact that the clinical In some centres during the past eight years, notably throughput of the units would be greatly reduced. where the new medical schools have been established, Apart from its vocational aspects the scientific discipline of modern anatomy has proved of great value to many medical anatomists have played a prominent role in the medical graduates now practising as consultants and medical community as a whole in the hospital service, and in regional and area health authority activities. In congeneral practitioners. This is best obtained during an honours course, but should always be included along with sequence some hold honorary (unpaid) regional and area the vocational in the normal curriculum. Many individuals consultant contracts. In established centres many would from such diverse fields as paediatrics, neurology, general become similarly involved if they were encouraged to do surgery, and general practice believe that the most valuable so, though others would question the sense of suffering a educational experience of their undergraduate medical further increase in workload without financial return. The course was the honours year spent in anatomy departments. time has now come when the profession at large, the The best cost-effective answer to the present problems University Grants Committee and the Department of
1029 Health
decide whether
must
they
wish the activities of
medically qualified anatomists, as set out above, to continue by ensuring a reasonable financial return, possibly derived in part from University and partly from N.H.S., or whether the rearguard action of British anatomists to maintain a medical presence must finally end and the departments become staffed by non-medical individuals who quite reasonably put science first and second, and vocational training a poor third; a balanced staff provides a balanced course. Both Vice-Chancellors and the U.G.C. have been aware of the deteriorating situation for the past The seven years, but have chosen to remain inactive. crisis in staffing is now, and with the current exodus of career anatomists overseas and into general practice, the new schools, and even some long established schools, may fail to meet their teaching commitments during the next 12 months. Virtually all the older establishments will be past the point of no-return so far as medical staff is concerned within 5 years. Department of Human Morphology, University Park, Nottingham NG7 2RD.
lower or not in an Open University medical course. Possibly not, but we would have to try the experiment on a small scale to find out. What is likely, however, is that his estimate of 2 years’ preclinical and 22 years’ clinical period is too short. It is frightening to expect even mature students to learn " anatomy, physiology, biochemistry, pharmacology, behavioural sciences, general pathology and microbiology, medical statistics and epidemiology, and
genetics",
as
suggested by Professor Acheson,
R. E. COUPLAND.
138
MEDICAL COURSE AT THE OPEN UNIVERSITY
SiR,—Iam an admirer of the Open University and I am full of praise for its achievements in developing new techniques in education and in enabling 10,000 of our citizens to achieve its degrees since its start only a few years ago. However, I do not accept the case made by the Dean of the Medical Faculty at Southampton University, Prof. Donald Acheson, for an undergraduate medical course for the Open University (April 26, p. 965). The chief reason for developing the idea must be the need for more doctors in the United Kingdom. No sound case has been made for this in spite of the fact that the Governments, U.G.C., and our medical schools are planning to double the annual intake of medical schools to over 4000 (compared with 1970 intakes). Even allowing for a 2-3% annual increase I believe that we need approximately 2600 new medical students each year to meet our own requirements. I believe that we may be creating medical unemployment within 10-15 years if we go ahead with present projections.l There is therefore no good reason for accepting that we need a new Open University Medical School to take in 600 students annually in order to produce 300, as Professor Acheson suggests. Professor Acheson seeks to show that the Open University course would be cheaper than setting up a traditional medical school for 100 students. Surely it is wrong to make such comparisons. It would be crazy for us to build such a It would be much fairer if he had comof increasing the intake of existing medical schools by 100 each year with those of an Open University course. We must realise also that each new medical student who graduates will be responsible for a national capital expenditure of up to Elmillion in his or her professional lifetime.1 Another reason given by Professor Acheson is that it would make it easier for mature students to gain entry to a medical school. If there is a strong case for taking in more mature students into medicine, then why do not Professor Acheson and his fellow deans agree to allocate a higher proportion of places in their existing medical schools for this purpose and convince the Treasury and the Department of Education of the need to support such students with
school
pared the
part-time
University. Croydon Road. Beckenham,
JOHN FRY.
Kent BR3 4DG.
new
as
home students. In spite of my uncertainty of the need for an undergraduate medical course I am certain that there is much that the Open University can contribute to postgraduate medical education. There are great opportunities for Open University involvement and cooperation in specialist training and continuing education. The methods and techniques of teaching and learning that it has developed would add greatly to the current programmes. It is in the postgraduate medical field that I see the greatest scope for the Open
now.
costs
BIOLOGY, ABORTION,
AND ETHICS
SIR,-As one who, like Dr Potts (April 19, p. 913), is interested in the relationship between the natural law and resistance to disease, I believe that biological evidence favours the natural law. For example, there is evidence that oestriol plays a significant anticarcinogenic role in the human female, accounting for the reduced expectancy of mammary cancer in women with multiple pregnancies in their early childbearing years.l It has also been suggested that pregnancy at a young age is associated with the formation of favourable cestrogen ratios and decreased breast-cancer risk later.2 On the other hand, there is an association between changes in adrenocortical function and mental disturbances.3 It has been found that excretion of urinary ketosteroid levels and levels of circulating lymphocytes may be modified by emotional stress.44 It has been affirmed that emotional stress results in increased adrenocortical activity.5 There is also much evidence to suggest that depressed emotional states decrease resistance to tuberculosis, rheumatoid arthritis, and cancer, diseases to which immunity is cell-mediated. It is well known that plasmaoestrogen levels are increased in pregnancy. Should not the exponents of a liberal policy towards abortion be asked to quote objective evidence of urinary and plasma steroid assays in support of their contention that terminations are justified on account of psychological stress ? Plymouth Road, Buckfastleigh, Devon TQ110DH.
72
MICHAEL WILKINSON.
MEDICAL AUDIT
.
government
grants ?
It is difficult 1.
to
theorise whether standards would be
Fry, J. Update (in the press).
SIR,-It is apparent that a myth called Medical Audit is being promoted in Great Britain. Having wasted countless hours during the past twenty years on meetings of the so-called medical audit and tissue committee, I feel obliged to sound an alarm. The myth of medical audit was invented by the Council ,
1. 2. 3. 4.
5.
Lemon, H. M. Cancer, 1970, 25, 423. Cole, P., McMahon, B. Lancet, 1969, i, 604. Beck, J. C., McGarry, E. E. Br. med. Bull. 1962, 18, 134. Hill, S. R., Goetz, F. C., Fox, H. M., Murawski, B. J., Krakauer, L. J., Reifenstein, R. W., Gray, S. J., Reddy, W. J., Hadberg, S. E., St. Marc, J. R., Thorn, G. W. Archs intern. Med. 1956, 97, Greenwood, F. C., Landon, J. Nature, 1966, 210, 540.
no.
3.
