919
phocytic infiltration are important pathogenetic prognostic features. However, chronic hepatitis
and
has a and wide of encompasses patholovariety many gical lesions, many of them found together in the same liver. This complex situation requires careful analysis in different centres, so that the natural history and response to treatment of the different components can be accurately determined. Requests for reprints should be addressed to Prof. P. J. Scheuer, Department of Histopathology, Royal Free Hospital, London NW3 causes
20G. REFERENCES 1. De. Groote, J., Desmet, V. J., Gedigk, P., et al. Lancet, 1968, ii, 626. 2. Review by an International Group, ibid. 1971, i, 333. 3. Boyer, J. L., Klatskin, G. New Engl. J. Med. 1970, 283, 1063. 4. Peters, R. L. Am. J. med. Sci. 1975, 270, 17. 5. Diseases of the Liver and Biliary Tract; p. 9. Washington, 1976 (D.H.E.W.
publication no. [N.I.H.] 76-725). 6. Popper, H., Schaffner, F. New Engl. J. Med. 1971, 284, 1154 7. Knolle, J., Born, M., Hess, G., Klinge, O., Arnold, W., Bitz, H., Meyer zum Büschenfelde, K. H. Klin. Wschr. 1976, 54, 567. 8. Sampliner, R.J. Am med. Ass. 1977, 237, 50. 9. Simon, J. B., Patel, S. K. Gastroenterology, 1974, 66, 1020. 10. Rojkind, M., Kershenobich, D. in Progress in Liver Diseases (edited by H. Popper and F. Schaffner); vol. 5, p. 294. New York, 1976. 11. Ware, A. J., Eigenbrodt, E. H., Combes, B. Gastroenterology, 1975, 68, 519. 12. Conn, H. O. ibid, 1976,70,1182. 13. Rappaport, A. M. Beitr. Path. 1976, 157, 215. 14. Schmid, M. Die Chronische Hepatitis; p. 59. Berlin, 1966. 15. Karvountzis, G. G., Redeker, A. G., Peters, R. L. Gastroenterology, 1974,
67, 870. 16. Portmann, B., Talbot, I. C., Day, D. W., Davidson, A. R., Murray-Lyon, I. M., Williams, R. J. Path. 1975, 117, 169. 17. Baggentoss, A. H., Soloway, R. D., Summerskill, W. H. J., Elveback, L. R.,
Schoenfield, L. J. Hum. Path. 1972, 3, 183. 18. Boyer,J. L. Gastroenterology, 1976, 70, 1161 19. Poulsen, H., Christoffersen, P. Hum. Path. 1972, 3, 217. 20. Dietrichson, O., Juhl, E., Christoffersen, P., Elling, P., Faber, V., Iversen, K., Nielsen, J. O., Petersen, P., Poulsen, H. Acta path. microbiol. scand.
1975, sect. A, 83, 183. 21. Ishak, K. G. Am. J. clin. Path. 1976, 65, 787. 22. Gudat, F., Bianchi, L., Sonnabend, W., Thiel, G., Aenishaenslin, W., Stalder, G. A. Lab. Invest. 1975, 32, 1. 23. Gudat, F., Bianchi, L., Stalder, G. A., Schmid, M. Schweiz. med. Wschr.
1976, 106, 812. 24. Bechtelsheimer, H., Gedigk, P., Müller, R., Klein, H. Klin. Wschr. 1976, 54, 137. 25. Popper, H., Schaffner, F. in Progress in Liver Diseases (edited by H. Popper
and Schaffner); vol. v,p. 531. New York, 1976.
Round the World United States The growing dissatisfaction of the U.S. public with the medical profession results largely from the profession’s disinclination to provide the type of care which in Britain is mainly the province of the general practitioner. Home visits have become a thing of the past, and while it is fairly easy to obtain an appointment to see a paediatrician or gynaecologist, there is no-one available to look after the patient who happens to have some minor acute injury or illness. This state of affairs is a consequence of the relative dearth of family practitioners, whose numbers have fallen by about three-quarters over the past 25 years. There are several reasons for the decline of general practice, not least among them being the emphasis that was placed on subspecialisation by the Government during the 1960s and early 1970s-a policy which is now greatly regretted. During this period almost every teaching hospital, and many large community hospitals, established residency programmes in general surgery, neurosurgery, urology, and other
surgical specialties; the Government sponsored
numerous
training
and other
cardiology, hoematology,
in the number of young
graduates entering
this field.
Moreover, the federal Government has also changed its philo-
sophy, and has decided that too many medical graduates have entering specialty training programmes. As a result it has brought pressure to bear on medical schools by insisting that at least 50% of all training programmes should be in primary care-defined as paediatrics, internal medicine, and family practice. If the medical school chooses to disregard the govern-
been
edict, then it loses the capitation fee it receives for every enrolled student. Since this amounts to several thousands of dollars per student, few schools can afford not to comply. In addition, both the American College of Surgeons and the American College of Physicians have accepted the fact that too many specialists have been trained. The College of Surgeons has drastically reduced the number of surgical residencies. The College of Physicians has adopted a different approach, and has been trying to foster the concept of the general internist rather than the subspecialist by persuading teaching hospitals to offer residency training programmes in general internal medicine and to reduce the number of subspecialty fellowships. In this they have been aided and abetted by various charitable orgariisations, in particular the Robert Wood Johnson Foundation, which has awarded grants of several million dollars to certain schools for primary-care training programmes. For a variety of reasons, and perhaps not surprisingly, the response has been disappointing. It is all very well to exhort today’s graduates to become generalists, but it soon becomes evident that the generalist places himself at a financial disadvantage compared with the subspecialist. Unlike the cardiologist with his coronary arteriography, or the gastroenterologist with colonoscopies and gastroscopies, the generalist carries out few invasive procedures. While a routine consultation may be worth$50, a gastroscopy is worth$150. Similarly, although the immediate past-president of the College of Physicians has toured the country giving lectures in support of the general internist, as a department chairman of a well-known medical school he himself maintains an extensive subspecialist fellowship training programme which is mostly supported by the National Institutes of Health, a fact which did not escape his audience. Moreover, the Veterans Administration pays a fully trained subspecialist a far higher salary than it does the general physician, so here again we see official Government policy pulling in two or three different directions. It is difficult not to conclude that the status quo in internal medicine is going to persist until the present fee-for-service system is drastically modified, thereby evening out the financial rewards of the generalist and the subspecialist. ment
CAMPAIGN AGAINST CIRCUMCISION
STILL TOO MANY SPECIALISTS
programmes for
crease
medical subspecialties. There seems little doubt that these policies have contributed to the surfeit of certain specialists, such as neurosurgeons, thoracic surgeons, cardiologists, and those specialising in infectious disease. But things are changing, and the advent of the American Academy of Family Practice has led to a great in-
For all its problems, the United States has done a marvellous job of blending its diverse population. Lacking a common heritage and culture, most Americans somehow or other manage to live in harmony. But, by the same token and perhaps because of its diversity, the country has become a haven for minority sects and religions, for eccentric cults, and for a plethora of far-out societies whose purposes and beliefs often strain the imagination. One of the latest to hit the headlines is Intact, an organisation whose raison d’etre is to preserve the prepuce. Routine circumcision has long been the rule in the U.S.; in fact, as one genitourinary surgeon put it, "it is as American as apple pie"-and far more remunerative. But things are changing, and the American Academy of Pediatrics, along with Dr Spock, have come out against routine circumcision. The operation is slowly becoming less popular, and Intact is doing its best to hasten the process. As far as one can gather, the organisation is composed of both lay and professional people, and one enthusiastic member wrote an article in The Country Lady’s Daybook entitled Circumcision in Social Perspective. Not too long ago in Washington State, a newborn infant was circumcised against the parents express wishes, and the father subsequently sued those responsible. The child was awarded$8000 damages, but, as one wag put it, had the episode taken place in Texas, where things are bigger and better, goodness knows how large the award would have been.
phocytic infiltration are important pathogenetic prognostic features. However, chronic hepatitis
and
has a and wide of encompasses patholovariety many gical lesions, many of them found together in the same liver. This complex situation requires careful analysis in different centres, so that the natural history and response to treatment of the different components can be accurately determined. Requests for reprints should be addressed to Prof. P. J. Scheuer, Department of Histopathology, Royal Free Hospital, London NW3 causes
20G. REFERENCES 1. De. Groote, J., Desmet, V. J., Gedigk, P., et al. Lancet, 1968, ii, 626. 2. Review by an International Group, ibid. 1971, i, 333. 3. Boyer, J. L., Klatskin, G. New Engl. J. Med. 1970, 283, 1063. 4. Peters, R. L. Am. J. med. Sci. 1975, 270, 17. 5. Diseases of the Liver and Biliary Tract; p. 9. Washington, 1976 (D.H.E.W.
publication no. [N.I.H.] 76-725). 6. Popper, H., Schaffner, F. New Engl. J. Med. 1971, 284, 1154 7. Knolle, J., Born, M., Hess, G., Klinge, O., Arnold, W., Bitz, H., Meyer zum Büschenfelde, K. H. Klin. Wschr. 1976, 54, 567. 8. Sampliner, R.J. Am med. Ass. 1977, 237, 50. 9. Simon, J. B., Patel, S. K. Gastroenterology, 1974, 66, 1020. 10. Rojkind, M., Kershenobich, D. in Progress in Liver Diseases (edited by H. Popper and F. Schaffner); vol. 5, p. 294. New York, 1976. 11. Ware, A. J., Eigenbrodt, E. H., Combes, B. Gastroenterology, 1975, 68, 519. 12. Conn, H. O. ibid, 1976,70,1182. 13. Rappaport, A. M. Beitr. Path. 1976, 157, 215. 14. Schmid, M. Die Chronische Hepatitis; p. 59. Berlin, 1966. 15. Karvountzis, G. G., Redeker, A. G., Peters, R. L. Gastroenterology, 1974,
67, 870. 16. Portmann, B., Talbot, I. C., Day, D. W., Davidson, A. R., Murray-Lyon, I. M., Williams, R. J. Path. 1975, 117, 169. 17. Baggentoss, A. H., Soloway, R. D., Summerskill, W. H. J., Elveback, L. R.,
Schoenfield, L. J. Hum. Path. 1972, 3, 183. 18. Boyer,J. L. Gastroenterology, 1976, 70, 1161 19. Poulsen, H., Christoffersen, P. Hum. Path. 1972, 3, 217. 20. Dietrichson, O., Juhl, E., Christoffersen, P., Elling, P., Faber, V., Iversen, K., Nielsen, J. O., Petersen, P., Poulsen, H. Acta path. microbiol. scand.
1975, sect. A, 83, 183. 21. Ishak, K. G. Am. J. clin. Path. 1976, 65, 787. 22. Gudat, F., Bianchi, L., Sonnabend, W., Thiel, G., Aenishaenslin, W., Stalder, G. A. Lab. Invest. 1975, 32, 1. 23. Gudat, F., Bianchi, L., Stalder, G. A., Schmid, M. Schweiz. med. Wschr.
1976, 106, 812. 24. Bechtelsheimer, H., Gedigk, P., Müller, R., Klein, H. Klin. Wschr. 1976, 54, 137. 25. Popper, H., Schaffner, F. in Progress in Liver Diseases (edited by H. Popper
and Schaffner); vol. v,p. 531. New York, 1976.
Round the World United States The growing dissatisfaction of the U.S. public with the medical profession results largely from the profession’s disinclination to provide the type of care which in Britain is mainly the province of the general practitioner. Home visits have become a thing of the past, and while it is fairly easy to obtain an appointment to see a paediatrician or gynaecologist, there is no-one available to look after the patient who happens to have some minor acute injury or illness. This state of affairs is a consequence of the relative dearth of family practitioners, whose numbers have fallen by about three-quarters over the past 25 years. There are several reasons for the decline of general practice, not least among them being the emphasis that was placed on subspecialisation by the Government during the 1960s and early 1970s-a policy which is now greatly regretted. During this period almost every teaching hospital, and many large community hospitals, established residency programmes in general surgery, neurosurgery, urology, and other
surgical specialties; the Government sponsored
numerous
training
and other
cardiology, hoematology,
in the number of young
graduates entering
this field.
Moreover, the federal Government has also changed its philo-
sophy, and has decided that too many medical graduates have entering specialty training programmes. As a result it has brought pressure to bear on medical schools by insisting that at least 50% of all training programmes should be in primary care-defined as paediatrics, internal medicine, and family practice. If the medical school chooses to disregard the govern-
been
edict, then it loses the capitation fee it receives for every enrolled student. Since this amounts to several thousands of dollars per student, few schools can afford not to comply. In addition, both the American College of Surgeons and the American College of Physicians have accepted the fact that too many specialists have been trained. The College of Surgeons has drastically reduced the number of surgical residencies. The College of Physicians has adopted a different approach, and has been trying to foster the concept of the general internist rather than the subspecialist by persuading teaching hospitals to offer residency training programmes in general internal medicine and to reduce the number of subspecialty fellowships. In this they have been aided and abetted by various charitable orgariisations, in particular the Robert Wood Johnson Foundation, which has awarded grants of several million dollars to certain schools for primary-care training programmes. For a variety of reasons, and perhaps not surprisingly, the response has been disappointing. It is all very well to exhort today’s graduates to become generalists, but it soon becomes evident that the generalist places himself at a financial disadvantage compared with the subspecialist. Unlike the cardiologist with his coronary arteriography, or the gastroenterologist with colonoscopies and gastroscopies, the generalist carries out few invasive procedures. While a routine consultation may be worth$50, a gastroscopy is worth$150. Similarly, although the immediate past-president of the College of Physicians has toured the country giving lectures in support of the general internist, as a department chairman of a well-known medical school he himself maintains an extensive subspecialist fellowship training programme which is mostly supported by the National Institutes of Health, a fact which did not escape his audience. Moreover, the Veterans Administration pays a fully trained subspecialist a far higher salary than it does the general physician, so here again we see official Government policy pulling in two or three different directions. It is difficult not to conclude that the status quo in internal medicine is going to persist until the present fee-for-service system is drastically modified, thereby evening out the financial rewards of the generalist and the subspecialist. ment
CAMPAIGN AGAINST CIRCUMCISION
STILL TOO MANY SPECIALISTS
programmes for
crease
medical subspecialties. There seems little doubt that these policies have contributed to the surfeit of certain specialists, such as neurosurgeons, thoracic surgeons, cardiologists, and those specialising in infectious disease. But things are changing, and the advent of the American Academy of Family Practice has led to a great in-
For all its problems, the United States has done a marvellous job of blending its diverse population. Lacking a common heritage and culture, most Americans somehow or other manage to live in harmony. But, by the same token and perhaps because of its diversity, the country has become a haven for minority sects and religions, for eccentric cults, and for a plethora of far-out societies whose purposes and beliefs often strain the imagination. One of the latest to hit the headlines is Intact, an organisation whose raison d’etre is to preserve the prepuce. Routine circumcision has long been the rule in the U.S.; in fact, as one genitourinary surgeon put it, "it is as American as apple pie"-and far more remunerative. But things are changing, and the American Academy of Pediatrics, along with Dr Spock, have come out against routine circumcision. The operation is slowly becoming less popular, and Intact is doing its best to hasten the process. As far as one can gather, the organisation is composed of both lay and professional people, and one enthusiastic member wrote an article in The Country Lady’s Daybook entitled Circumcision in Social Perspective. Not too long ago in Washington State, a newborn infant was circumcised against the parents express wishes, and the father subsequently sued those responsible. The child was awarded$8000 damages, but, as one wag put it, had the episode taken place in Texas, where things are bigger and better, goodness knows how large the award would have been.
