1292
tice, part time in community care (group practice, health centre, domiciliary). The consultant could then revert to
consulting, and the primary-care physician would benefit by his closer contact, and by continuing to work in the milieu where he was trained. The hospital would be in reality a part of the community. Such a change in roles and functions would ease the hospital-practitioner shortage and benefit the training of junior hospital doctors, the majority of whom eventually become primary-care practitioners. It would, however, exacerbate the shortage within primary care. To overcome this shortage, the primary-care physician would become much more a referral point in the group or health-centre practice, with more of his present functions More job being assumed by nurse-practitioners, &c. satisfaction would result all round. Such a redefining of the role of the primary-care physician would do more to integrate care and to promote community care than any structural reorganisation. Reorganisation must be made at the periphery, within the community. The rest of the reorganisation services would flow from this first step. It is quite apparent that the attempt to supply a physicianmanned service-both primary and referral-is beyond the economic and social capacity of any nation, developed or not. This is at last achieving recognition, and many stratagems are being adopted throughout the world-the medical assistant in Africa and elsewhere, the feldsher in the U.S.S.R., the Medex and physician’s assistant in the U.S.A., the expanded role of nurses in Canada and the U.S.A., the rural health technician in Guatemala, and so on. With expanding need deriving from population growth, new programmes such as family planning, the vast accumulation of medical knowledge of this century, and the critical necessity to apply such knowledge effectively and rapidly, The joint U.N.C.F./ new stratagems must be applied. W.H.O. proposals now being adopted by the executive board of U.N.C.F. recognises this need as urgent. For the United Kingdom I believe that a devolution of functions is probably the best to nurses, pharmacists, midwives, &c., route. It is not, however, likely to be an easy route, and your leader should have remarked Department of Tropical Community Health, School of Tropical Medicine, Liverpool L3 5QA.
on
the difficulties.
REX FENDALL.
THE CONSULTANTS’ INCREASE
SIR,-The B.M.A. has now advised consultants to stop working to contract, and extra pay has been awarded to them. All doctors, of course, know that the dispute has been on much more than pay and that many other matters are still at stake. But many lay people do not realise this and think (helped by misrepresentation of our case) that yet another body of people, who are already well-off, have used their power to make others suffer, and have thus demanded more money for this than the country can afford. Can nothing be done to show (as I believe is true) that many doctors are more concerned with the state of the N.H. S. than with our own earnings ? May I return to a proposal which had little support in the bitterness of January, but which might get more sympathy now ? This is that any senior consultant willing to do so should relinquish part of his increase, not to the Government but to his own hospital, where it could form a fund for maintenance and development to be used at the discretion of the Medical Committee. It would, of course, be easier to decide to give this back before we have actually got it. I would not press younger consultants, for they have had to suffer a good deal of hardship, but perhaps anyone drawing over E8000 a year from the N.H.S. might
consider contributing 1 % of it, with higher rates for higher salaries. The total would not be impressive; the gesture might be. If the idealistic reason does not appeal, some might prefer a more material one. As far as I can see the only hope to help the country’s financial position is that some groups should give up something. Could the doctors give a lead here ? Who knows but that it might be followed by senior Civil Servants and even Cabinet Ministers ? If so, it might in the long run make the money we actually do get worth more.
Department of Psychological Medicine, University College Hospital, Gower Street, London WC1E 6AU.
R. F. TREDGOLD.
DOES T4-TOXICOSIS EXIST ?
SIR,-We
were
very interested in the
and his
reply by Dr
colleagues (April 12, p. 868). The
Kirkegaard thyrotoxic patient they described was a 70-year-old woman with " serum T3 within 95% normal range and serum T4 exceeding 95% normal range ". It has been shown that serum-T3 levels fall with age, and we assume that the rather low normal range (35-153 ng. per 100 ml.) Dr Kirkegaard quoted is adjusted for the geriatric population. If this is the case their patient truly has T4-toxicosis. In the Canterbury area of New Zealand, thyrotoxicosis is most prevalent in the 50 + age-group, and a previous report by Dr Kirkegaard2 indicates a similar situation in Denmark. It is therefore essential, before the estimation of total serum-triiodothyronine becomes a routine thyroid-function test, that each laboratory establishes a normal range for different age-groups. Dr Hadden and his colleagues (March 29, p. 754) show a good correlation between serum-T3 and the free-thyroxine index in both euthyroid and thyrotoxic patients. These results are similar to our initial experience3 in a group of 137 patients representing a wide range of thyroid disease, where we correlated total serum-T3 and total serum-T4 levels (r=0-866). However, widely discordant serum-T3 and serum-T4 results do occur in patients with nonthyroidal illness, in patients with thyroidal enzyme defects,5 and in other clinical situations where there is an increased thyroid-stimulating-hormone effect upon the thyroid gland-e.g., after iodine-131 therapy.In relapse of thyrotoxicosis, too, serum-T3 and serum-T4 may be discordant. In this situation the serum-T3 may rise before the serum-T4, but occasionally the reverse may occur. We have one such example, a 22-year-old woman who showed clinical evidence of relapse after a course of antithyroid drugs (serum-T4=12-3 µg. per 100 ml. (normal 3-5-10-0 fg. per 100 ml.), serum-T3=118 ng. per 100 ml. (75-175 ng. per 100 ml.). Although triiodothyronine is thought to be the physiologically more important thyroid hormone, the estimation of the free-thyroxine index at present seems to be the best screening test for thyroid dysfunction. The discordant T3 and T4 results found in many conditions indicates that serum-T3 levels should not be interpreted in isolation. This is particularly important in patients with non-thyroidal illness. We believe that both T3 and T4 toxicosis exist and 1. 2. 3. 4.
5. 6. 7.
Rubenstein, H. A., Butler, V. P., Werner, S. C. J. clin. Endocr. 1973, 37, 247. Ronnov-Jessen, V., Kirkegaard, C. Br. med. J. 1973, i, 41. Sadler, W. A., Brownlie, B. E. W. N.Z. med. J. 1975, 81, 328. Carter, J. N., Eastman, C. J., Corcoran, J. M., Lazarus, L. Lancet, 1974, ii, 971. Gomez-Pan, A., Evered, D. C., Hall, R. Br. med. J. 1974, ii, 152. Sterling, K., Brenner, M. A., Newman, E. S., Odell, W. D., Bellabarba, D. J. clin. Endocr. 1971, 33, 729. Marsden, P., Howorth, P. J. M., Chalkley, S., Acosta, M., Leatherdale, B., McKerron, C. G. Lancet, 1975, i, 944.
tice, part time in community care (group practice, health centre, domiciliary). The consultant could then revert to
consulting, and the primary-care physician would benefit by his closer contact, and by continuing to work in the milieu where he was trained. The hospital would be in reality a part of the community. Such a change in roles and functions would ease the hospital-practitioner shortage and benefit the training of junior hospital doctors, the majority of whom eventually become primary-care practitioners. It would, however, exacerbate the shortage within primary care. To overcome this shortage, the primary-care physician would become much more a referral point in the group or health-centre practice, with more of his present functions More job being assumed by nurse-practitioners, &c. satisfaction would result all round. Such a redefining of the role of the primary-care physician would do more to integrate care and to promote community care than any structural reorganisation. Reorganisation must be made at the periphery, within the community. The rest of the reorganisation services would flow from this first step. It is quite apparent that the attempt to supply a physicianmanned service-both primary and referral-is beyond the economic and social capacity of any nation, developed or not. This is at last achieving recognition, and many stratagems are being adopted throughout the world-the medical assistant in Africa and elsewhere, the feldsher in the U.S.S.R., the Medex and physician’s assistant in the U.S.A., the expanded role of nurses in Canada and the U.S.A., the rural health technician in Guatemala, and so on. With expanding need deriving from population growth, new programmes such as family planning, the vast accumulation of medical knowledge of this century, and the critical necessity to apply such knowledge effectively and rapidly, The joint U.N.C.F./ new stratagems must be applied. W.H.O. proposals now being adopted by the executive board of U.N.C.F. recognises this need as urgent. For the United Kingdom I believe that a devolution of functions is probably the best to nurses, pharmacists, midwives, &c., route. It is not, however, likely to be an easy route, and your leader should have remarked Department of Tropical Community Health, School of Tropical Medicine, Liverpool L3 5QA.
on
the difficulties.
REX FENDALL.
THE CONSULTANTS’ INCREASE
SIR,-The B.M.A. has now advised consultants to stop working to contract, and extra pay has been awarded to them. All doctors, of course, know that the dispute has been on much more than pay and that many other matters are still at stake. But many lay people do not realise this and think (helped by misrepresentation of our case) that yet another body of people, who are already well-off, have used their power to make others suffer, and have thus demanded more money for this than the country can afford. Can nothing be done to show (as I believe is true) that many doctors are more concerned with the state of the N.H. S. than with our own earnings ? May I return to a proposal which had little support in the bitterness of January, but which might get more sympathy now ? This is that any senior consultant willing to do so should relinquish part of his increase, not to the Government but to his own hospital, where it could form a fund for maintenance and development to be used at the discretion of the Medical Committee. It would, of course, be easier to decide to give this back before we have actually got it. I would not press younger consultants, for they have had to suffer a good deal of hardship, but perhaps anyone drawing over E8000 a year from the N.H.S. might
consider contributing 1 % of it, with higher rates for higher salaries. The total would not be impressive; the gesture might be. If the idealistic reason does not appeal, some might prefer a more material one. As far as I can see the only hope to help the country’s financial position is that some groups should give up something. Could the doctors give a lead here ? Who knows but that it might be followed by senior Civil Servants and even Cabinet Ministers ? If so, it might in the long run make the money we actually do get worth more.
Department of Psychological Medicine, University College Hospital, Gower Street, London WC1E 6AU.
R. F. TREDGOLD.
DOES T4-TOXICOSIS EXIST ?
SIR,-We
were
very interested in the
and his
reply by Dr
colleagues (April 12, p. 868). The
Kirkegaard thyrotoxic patient they described was a 70-year-old woman with " serum T3 within 95% normal range and serum T4 exceeding 95% normal range ". It has been shown that serum-T3 levels fall with age, and we assume that the rather low normal range (35-153 ng. per 100 ml.) Dr Kirkegaard quoted is adjusted for the geriatric population. If this is the case their patient truly has T4-toxicosis. In the Canterbury area of New Zealand, thyrotoxicosis is most prevalent in the 50 + age-group, and a previous report by Dr Kirkegaard2 indicates a similar situation in Denmark. It is therefore essential, before the estimation of total serum-triiodothyronine becomes a routine thyroid-function test, that each laboratory establishes a normal range for different age-groups. Dr Hadden and his colleagues (March 29, p. 754) show a good correlation between serum-T3 and the free-thyroxine index in both euthyroid and thyrotoxic patients. These results are similar to our initial experience3 in a group of 137 patients representing a wide range of thyroid disease, where we correlated total serum-T3 and total serum-T4 levels (r=0-866). However, widely discordant serum-T3 and serum-T4 results do occur in patients with nonthyroidal illness, in patients with thyroidal enzyme defects,5 and in other clinical situations where there is an increased thyroid-stimulating-hormone effect upon the thyroid gland-e.g., after iodine-131 therapy.In relapse of thyrotoxicosis, too, serum-T3 and serum-T4 may be discordant. In this situation the serum-T3 may rise before the serum-T4, but occasionally the reverse may occur. We have one such example, a 22-year-old woman who showed clinical evidence of relapse after a course of antithyroid drugs (serum-T4=12-3 µg. per 100 ml. (normal 3-5-10-0 fg. per 100 ml.), serum-T3=118 ng. per 100 ml. (75-175 ng. per 100 ml.). Although triiodothyronine is thought to be the physiologically more important thyroid hormone, the estimation of the free-thyroxine index at present seems to be the best screening test for thyroid dysfunction. The discordant T3 and T4 results found in many conditions indicates that serum-T3 levels should not be interpreted in isolation. This is particularly important in patients with non-thyroidal illness. We believe that both T3 and T4 toxicosis exist and 1. 2. 3. 4.
5. 6. 7.
Rubenstein, H. A., Butler, V. P., Werner, S. C. J. clin. Endocr. 1973, 37, 247. Ronnov-Jessen, V., Kirkegaard, C. Br. med. J. 1973, i, 41. Sadler, W. A., Brownlie, B. E. W. N.Z. med. J. 1975, 81, 328. Carter, J. N., Eastman, C. J., Corcoran, J. M., Lazarus, L. Lancet, 1974, ii, 971. Gomez-Pan, A., Evered, D. C., Hall, R. Br. med. J. 1974, ii, 152. Sterling, K., Brenner, M. A., Newman, E. S., Odell, W. D., Bellabarba, D. J. clin. Endocr. 1971, 33, 729. Marsden, P., Howorth, P. J. M., Chalkley, S., Acosta, M., Leatherdale, B., McKerron, C. G. Lancet, 1975, i, 944.
