Journal of the Royal Society of Medicine Volume 72 August 1979
the findings suggest that collagenization of Desse's spaces might be an important finding in patients with PHT.
Postsinusoidal PHT In practice as well as in theory any cause of increased venous pressure from the postsinusoidal region via the heart and lungs to the left side of the heart can cause PHT. Thus mitral stenosis, pulmonary hypertension, constrictive pericarditis, congestive cardiac failure and right atrial myxoma, to name a few, have all been described. More recent causes of the so-called Budd-Chiari syndrome include the presence of a diaphragm across the hepatic vein or inferior vena cava, most commonly described in India, and the cases of hepatic vein thrombosis in young women on oral contraceptives. Whether the latter is a true association or not has yet to be clarified. As previously stated, cirrhosis has classically been described as a postsinusoidal PHT with narrowing and distortion of the hepatic venules by regeneration nodules. This explanation for PHT has now to be challenged not only from the point of view of the site of resistance but also from the contribution of increased blood flow secondary to congestive splenomegaly in some patients (Williams et al. 1968). Our understanding of the pathogenesis of PHT, let alone its complications, remains rudimentary. In the last few years the recognition of the part played by increased inflow due to splenomegaly in patients with both noncirrhotic and cirrhotic PHT, together with the presence or absence of what may prove to be important additional light and electron microscopic changes, may help to clarify some of these remaining mysteries. Laurence M Blendis Department of Gastroenterology Toronto General Hospital Toronto, Ontario, Canada References Blendis L M, Banks D C, Ramboer C & Williams R (1970) Clinical Science 38, 73 Blendis L M, Parkinson C M, Shilkin K & Williams R (1974) Quarterly Journal of Medicine 43, 25 Blendis L M, Smith P M, Lawrie B W, Stephens M R & Evans W D (1978) Gastroenterology 75, 206 Coutinho A (1968) American Journal of Medicine 44, 547 Edmondson H A, Peters R L & Frankel H H (1967) Medicine 46, 119 Edmondson H A, Peters R L & Reynolds T B (1963) Annals of Internal Medicine 59, 646 Galambos J T, Warren W D & Rudman D (1976) New England Journal of Medicine 295, 1089 Huet P M, Gwillaume E & Cote J (1975) Gastroenterology 72, 275 Langer B, Rotstein L E, Stone R M, Taylor B R, Patel S C, Blendis L M & Colapinto R F (1979) Surgery, Gynecology and Obstetrics (in press)
0141-0768/79/080551-02/$01.00/0
551
Morris J S, Schmid M & Newman S (1974) Gastroenterology 66, 86 Ofrego H, Medline A, Blendis L M, Rankin J G & Kreaden D A (1979) Gut 20 (in press) Pimentel L C & Menezes A P (1977) Gastroenterology 72, 275 Reynolds T B, Hidemura R, Michel H & Peters R L (1969) Annals of Internal Medicine 70, 497 Rotstein L E, Makowka L, Langer B, Blendis L M, Stone R M & Colapinto R F (1979) Surgery, Gynecology and Obstetrics (in press) Rougier P, Degott C, Rueff B & Benhamou J P (1978) Gastroenterology 75, 169 Van Waes L & Lieber C S (1977) Gastroenterology 73, 646 Wanless I (1979) Medicine (in press) Warren W D, Salam A, Hutson D, & Zeppa A (1974) Archives ofSurgery 108, 306 Watson-Williams E J & Allan N C (1968) British Medical Journal ii, 793 Williams R, Condon R E, Williams H S, Blendis L M & Kreel L (1968) Clinical Science 34, 441 Williams R, Parsonson A, Somers K & Hamilton P J S (1966) Lancet i, 329
Otolaryngology in the curriculum' The trend in medical education is away from the old concept of training the omnicompetent safe practitioner who is skilled in all branches of medicine and surgery and able to work on his own as soon as he is qualified, and towards the production of the basic educable doctor who will go on learning throughout his career. The General Medical Council has recommended that teaching in the undergraduate stage should be confined to general principles and that the student should be given only such facts as would illustrate these principles. The omission of information irrelevant to basic medical education would be of no consequence because 'the course is founded on the assumption that the period of vocational training after registration will repair the inevitable omissions'. Since a high proportion of students will become general practitioners, and since at least 10% of the work load in general practice is concerned with diseases of the upper respiratory tract, the validity of this assumption in relation to otolaryngology must be questioned. Will any such omissions made in the acquisition of diagnostic skills and the basic knowledge of the specialty be repaired before the trainee completes his training and is eligible to start in practice as a Principal? In the preregistration period there are at present few posts in otolaryngology, either alone or in combination with other specialties; there are probably no more than 12 in the whole of the 1 Based on Mr J F Neil's Presidential Address to Section of Laryngology, 3 November 1978 © 1979 The Royal Society of Medicine
552
Journal of the Royal Society of Medicine Volume 72 August 1979
United Kingdom (K McLay, 1978, personal communication). However, this situation could improve as the rising output from the medical schools necessitates an increase in the number of preregistration posts. The General Medical Council requires that these posts should offer general experience in medicine and surgery, but has recently stated that service in a medical or surgical specialty could be recognized as fulfilling these requirements, and has altered the minimum period to be spent in medicine and surgery to 4 months each. This opens the way to widening the experience to be gained from this period of further education, and spending some time in a suitable department of otolaryngology could prove of great value to a future general practitioner. In the vocational training scheme for general practice there are no specific requirements for training in or experience of otolaryngology, and there are few posts in which such experience can be acquired. The level of competence of the future general practitioner in the diagnosis and treatment of this group of diseases is therefore based on what they have learnt in the undergraduate clinical course, on the experience gained from the year in training practice, and on taking part in a few seminars conducted by a consultant during the three-year course. They may also attend outpatient clinics if they are interested. This was not the intention of the Royal Commission on Medical Education (1968) which included otolaryngology in the subjects for which training appointments should be arranged where possible. The report suggested that concurrent experience of two or three of these subjects could often be provided in a single training period, and Appendix 5(d) gave three specimen training schemes, two of which gave otolaryngology a reasonable place. The entrant into general practice is expected to have a reasonable competence in the recognition and early treatment of the common diseases of the upper respiratory tract. If the postgraduate experience he receives in this field is insufficient to equip him adequately for his future role, and at present this seems to be the case in many areas, the
undergraduate part of the training assumes a greater importance, and care must be exercised in the selection of information regarding the subject to be retained in or omitted from the curriculum. It should be possible to give the student a sound and adequate knowledge of the symptoms and treatment of the common diseases, particularly those which threaten life, and at the same time use this information to illustrate basic principles. The facts can be given in lectures or tape-slide programmes, and their importance and relevance to medicine can be discussed in seminars. As much practical work as possible should be included in the timetable, with the student clerking patients in the outpatient department and on the wards, and he should acquire some skill in the proper examination of the area so that he may recognize disease, and also be able,to give firm reassurance to those many anxious patients who only fear they have disease. To do this, sufficient time must be allocated to the study of the specialty. According to the General Medical Council Survey (1977) the average time allowed, taking the country as a whole, is 57 hours, but in some schools this may be as short a period as 20 hours, which would make the acquisition of an adequate grounding in the theory and practice difficult to achieve. The increase in student numbers will magnify this. An inadequate allocation of time in the undergraduate period, coupled with a failure to give otolaryngology proper representation in the postgraduate training programme, can only result in overloading outpatient clinics with patients whose treatment should be well within the competence of a properly-trained practitioner. J F Neil Department ofOtolaryngology University Hospital, Nottingham
References General Medical Council Survey (1977) Basic Medical Education in the British Isles, vol 2. Nuffield Provincial Hospitals Trust; p 689 Royal Conmission on Medical Education (1968) Cmnd 3569. HMSO, London
the findings suggest that collagenization of Desse's spaces might be an important finding in patients with PHT.
Postsinusoidal PHT In practice as well as in theory any cause of increased venous pressure from the postsinusoidal region via the heart and lungs to the left side of the heart can cause PHT. Thus mitral stenosis, pulmonary hypertension, constrictive pericarditis, congestive cardiac failure and right atrial myxoma, to name a few, have all been described. More recent causes of the so-called Budd-Chiari syndrome include the presence of a diaphragm across the hepatic vein or inferior vena cava, most commonly described in India, and the cases of hepatic vein thrombosis in young women on oral contraceptives. Whether the latter is a true association or not has yet to be clarified. As previously stated, cirrhosis has classically been described as a postsinusoidal PHT with narrowing and distortion of the hepatic venules by regeneration nodules. This explanation for PHT has now to be challenged not only from the point of view of the site of resistance but also from the contribution of increased blood flow secondary to congestive splenomegaly in some patients (Williams et al. 1968). Our understanding of the pathogenesis of PHT, let alone its complications, remains rudimentary. In the last few years the recognition of the part played by increased inflow due to splenomegaly in patients with both noncirrhotic and cirrhotic PHT, together with the presence or absence of what may prove to be important additional light and electron microscopic changes, may help to clarify some of these remaining mysteries. Laurence M Blendis Department of Gastroenterology Toronto General Hospital Toronto, Ontario, Canada References Blendis L M, Banks D C, Ramboer C & Williams R (1970) Clinical Science 38, 73 Blendis L M, Parkinson C M, Shilkin K & Williams R (1974) Quarterly Journal of Medicine 43, 25 Blendis L M, Smith P M, Lawrie B W, Stephens M R & Evans W D (1978) Gastroenterology 75, 206 Coutinho A (1968) American Journal of Medicine 44, 547 Edmondson H A, Peters R L & Frankel H H (1967) Medicine 46, 119 Edmondson H A, Peters R L & Reynolds T B (1963) Annals of Internal Medicine 59, 646 Galambos J T, Warren W D & Rudman D (1976) New England Journal of Medicine 295, 1089 Huet P M, Gwillaume E & Cote J (1975) Gastroenterology 72, 275 Langer B, Rotstein L E, Stone R M, Taylor B R, Patel S C, Blendis L M & Colapinto R F (1979) Surgery, Gynecology and Obstetrics (in press)
0141-0768/79/080551-02/$01.00/0
551
Morris J S, Schmid M & Newman S (1974) Gastroenterology 66, 86 Ofrego H, Medline A, Blendis L M, Rankin J G & Kreaden D A (1979) Gut 20 (in press) Pimentel L C & Menezes A P (1977) Gastroenterology 72, 275 Reynolds T B, Hidemura R, Michel H & Peters R L (1969) Annals of Internal Medicine 70, 497 Rotstein L E, Makowka L, Langer B, Blendis L M, Stone R M & Colapinto R F (1979) Surgery, Gynecology and Obstetrics (in press) Rougier P, Degott C, Rueff B & Benhamou J P (1978) Gastroenterology 75, 169 Van Waes L & Lieber C S (1977) Gastroenterology 73, 646 Wanless I (1979) Medicine (in press) Warren W D, Salam A, Hutson D, & Zeppa A (1974) Archives ofSurgery 108, 306 Watson-Williams E J & Allan N C (1968) British Medical Journal ii, 793 Williams R, Condon R E, Williams H S, Blendis L M & Kreel L (1968) Clinical Science 34, 441 Williams R, Parsonson A, Somers K & Hamilton P J S (1966) Lancet i, 329
Otolaryngology in the curriculum' The trend in medical education is away from the old concept of training the omnicompetent safe practitioner who is skilled in all branches of medicine and surgery and able to work on his own as soon as he is qualified, and towards the production of the basic educable doctor who will go on learning throughout his career. The General Medical Council has recommended that teaching in the undergraduate stage should be confined to general principles and that the student should be given only such facts as would illustrate these principles. The omission of information irrelevant to basic medical education would be of no consequence because 'the course is founded on the assumption that the period of vocational training after registration will repair the inevitable omissions'. Since a high proportion of students will become general practitioners, and since at least 10% of the work load in general practice is concerned with diseases of the upper respiratory tract, the validity of this assumption in relation to otolaryngology must be questioned. Will any such omissions made in the acquisition of diagnostic skills and the basic knowledge of the specialty be repaired before the trainee completes his training and is eligible to start in practice as a Principal? In the preregistration period there are at present few posts in otolaryngology, either alone or in combination with other specialties; there are probably no more than 12 in the whole of the 1 Based on Mr J F Neil's Presidential Address to Section of Laryngology, 3 November 1978 © 1979 The Royal Society of Medicine
552
Journal of the Royal Society of Medicine Volume 72 August 1979
United Kingdom (K McLay, 1978, personal communication). However, this situation could improve as the rising output from the medical schools necessitates an increase in the number of preregistration posts. The General Medical Council requires that these posts should offer general experience in medicine and surgery, but has recently stated that service in a medical or surgical specialty could be recognized as fulfilling these requirements, and has altered the minimum period to be spent in medicine and surgery to 4 months each. This opens the way to widening the experience to be gained from this period of further education, and spending some time in a suitable department of otolaryngology could prove of great value to a future general practitioner. In the vocational training scheme for general practice there are no specific requirements for training in or experience of otolaryngology, and there are few posts in which such experience can be acquired. The level of competence of the future general practitioner in the diagnosis and treatment of this group of diseases is therefore based on what they have learnt in the undergraduate clinical course, on the experience gained from the year in training practice, and on taking part in a few seminars conducted by a consultant during the three-year course. They may also attend outpatient clinics if they are interested. This was not the intention of the Royal Commission on Medical Education (1968) which included otolaryngology in the subjects for which training appointments should be arranged where possible. The report suggested that concurrent experience of two or three of these subjects could often be provided in a single training period, and Appendix 5(d) gave three specimen training schemes, two of which gave otolaryngology a reasonable place. The entrant into general practice is expected to have a reasonable competence in the recognition and early treatment of the common diseases of the upper respiratory tract. If the postgraduate experience he receives in this field is insufficient to equip him adequately for his future role, and at present this seems to be the case in many areas, the
undergraduate part of the training assumes a greater importance, and care must be exercised in the selection of information regarding the subject to be retained in or omitted from the curriculum. It should be possible to give the student a sound and adequate knowledge of the symptoms and treatment of the common diseases, particularly those which threaten life, and at the same time use this information to illustrate basic principles. The facts can be given in lectures or tape-slide programmes, and their importance and relevance to medicine can be discussed in seminars. As much practical work as possible should be included in the timetable, with the student clerking patients in the outpatient department and on the wards, and he should acquire some skill in the proper examination of the area so that he may recognize disease, and also be able,to give firm reassurance to those many anxious patients who only fear they have disease. To do this, sufficient time must be allocated to the study of the specialty. According to the General Medical Council Survey (1977) the average time allowed, taking the country as a whole, is 57 hours, but in some schools this may be as short a period as 20 hours, which would make the acquisition of an adequate grounding in the theory and practice difficult to achieve. The increase in student numbers will magnify this. An inadequate allocation of time in the undergraduate period, coupled with a failure to give otolaryngology proper representation in the postgraduate training programme, can only result in overloading outpatient clinics with patients whose treatment should be well within the competence of a properly-trained practitioner. J F Neil Department ofOtolaryngology University Hospital, Nottingham
References General Medical Council Survey (1977) Basic Medical Education in the British Isles, vol 2. Nuffield Provincial Hospitals Trust; p 689 Royal Conmission on Medical Education (1968) Cmnd 3569. HMSO, London
