1545
pro-life initiative on the part of local and national governments. A pro-life initiative goes far beyond the issue of abortion. Unfortunately, making abortion and related matters political issues has fostered an indifference that is certainly preventing government from investing in other attributes of the pro-life movement. The safe course for politicians, at least in the USA, is not to adamantly lecture those opposed to a single attribute in the pro-life initiative so that others can be put into practice. It was, I believe, political indifference that ignited the recent riots in Los Angeles: the conservatives avoided the slum altogether while the liberals played to the wrong values. 13 Mary St, Cincinnati, Ohio 45216, USA
JACK JUSTICE
1. Greeley A. Who are the Catholic conservatives? America 1991, Sept 21. 2. Fagothey A. Right and reason, ethics in theory and practice. St Louis: C. V. Mosby, 1963: 235-41.
European Boards and Colleges SIR,-Professor Gill’s article (May 16, p 1216) contains several incorrect assumptions. The European Union of Medical Specialists (UEMS) has responded to concerns about discrepancies in specialist training in the European Community (EC), where both doctors and patients are moving between countries with increasing frequency, by providing for the establishment of European Boards within its monospecialist subcommittees. The main objective is to guarantee high standards of specialist care throughout the EC by ensuring that training is of the highest quality. This will be achieved by studying the content and quality of training programmes and making recommendations for change. A common approach by all the monospecialist sections (acting through the UEMS) to the EC has obvious advantages. Although each monospecialist section is free to run its own Board within a specified framework, it is wrong to state that the aim of the Boards is to set up European examinations. This issue has already caused concern throughout the medical profession in the EC, and the Permanent Working Group of European Junior Hospital Doctors has voiced understandable disquiet about the notion of European examinations. The draft statutes adopted by the UEMS Management Council refer only to "recognition of qualification"; each Board is free to determine what form of assessment should precede this recognition, and there is no obligation to set formal examinations. Council of the British Medical Association has taken the view that examinations in addition to national qualifications are unnecessary.
The UEMS does not intend to undermine or usurp the role of national anthorities; any certificates issued will be supplementary to national qualifications, and applications for assessment will be voluntary. It is quite incorrect to state that diplomas and fellowships will be compulsory for doctors trained outside the EC. The analogy with American National and State Boards and the Arab Board is not
helpful. I take issue with Gill’s assertion that "People trained in the UK and Irish systems will be wary of excessive European zeal towards uniformity and conformity". In my experience, doctors in many other countries have great reservations about the establishment of European examinations, support for which seems to come largely from representatives of the anglophone countries. British Medical Association, BMA House,
London WC1H 9JP, UK
L. P. HARVEY
Overseas training and doctors from developing countries SiR,—As teachers in a large medical school in India who have witnessed the large-scale migration of trained doctors towards the west, we would comment on Dr Patel and Dr Araya’s viewpoint (Jan 11, p 110). Last year we made an effort to record the migration rate in our students who graduated in 1984. Out of 150 students who had entered medical school about 40 were abroad. At least 15 had
changed their postgraduate specialty because it was easier to gain admission to that specialty to the west. 20 doctors (and many others
whom we know) have as yet made no effort to return to India. We feel that the doctors who want to return home are probably the exception rather than the rule. Most, we believe, succumb to the luxurious life and material wealth of the west and stay on. There is, it is true, a large gap in income between those in academic jobs and those in private practice in underdeveloped countries such as India, and in fact academic jobs are looked down on. But many of those who get foreign training do so to enhance their market value in private practice-either to get attachments to hospitals or at least a label of "foreign returned". Those seeking to return to an academic job, which is usually in a state hospital, are few. The backlisting of doctors who leave medical school during their training should be seen in context: education in many underdeveloped countries is heavily subsidised by the state and this has a role in disincentives for large scale migration. The obstacles to returning home that Patel and Araya mention are indeed very real and their suggestions are helpful. However, what is probably needed most is a fundamental change in attitude such that there is a genuine desire to return home and to try to make the best out of what is undoubtedly an unsatisfactory situation in many respects. And for this individuals should regard the practice of medicine not only as a commercial venture but also as part of an effort to improve the health status as well as scientific outlook of their countrymen in the third world. Departments of Surgery, Cardiology, and Gastroenterology, Seth G.S. Medical College and K.E M. Hospital, Parel, Bombay 400012, India
SANJAY NAGRAL YASH LOKHANDWALA AABHA NAGRAL
NHS trusts and Jehovah’s Witnesses SIR,-We live in a society that denounces discrimination by sex, or creed. Although not a Jehovah’s Witness, I must protest most strongly against the attitude of Mr Collins (May 23, p 1302). His views seem to be based on one patient whose details he omits. He also ignores the hazards of blood transfusion, or its own high race,
cost.
I have operated on many hundreds of Witnesses, the operations ranging from oesophagectomy to prostatectomy, and find that they fare better than those who are transfused. My colleagues report the same for bypass heart surgery. Some years ago, I reviewed all super-major surgery on Witnesses in the Midlands area. It would be unfair to make sweeping statements, but one point was very clear. Not a single case of deep vein thrombosis--an expensive complication--7arose in over four hundred cases. It is my belief that I have benefited from this experience and perhaps even become a slightly better surgeon as a result. Working in primitive communities where hookworm was endemic taught me that people with a haemoglobin half or a quarter of normal survive both surgery and trauma remarkably well, as long as their blood volume is maintained. They have a lower blood viscosity and with it maintain a more rapid circulation that allows them to adequately oxygenate the tissues. We tend to forget that, although haemoglobin is a highly efficient method of carrying oxygen, the final transfer at
tissue level is outside the cells in the serum, as is that of the carbon-dioxide and other metabolites at all times. We should certainly ask for cheaper erythropoietin, which we could use regularly instead of transfusion, but we should not deny others’
rights. Finally, I would note the exemplary mutual help these people give afterwards, saving the National Health Service millions of pounds. 4, Amesbury Road,
Moseley, Birmingham B13 8LD,
G. T. WATTS
UK
Digit sucking SIR,-In your April 18 editorial you point out that the habit of digit sucking is acquired very early in life and that two-thirds of 22-year-old children suck their fingers or thumbs or use artificial comforters. Why so many children do so has puzzled scientists as well
as
mothers for many years, if
not
for centuries. In
our
pro-life initiative on the part of local and national governments. A pro-life initiative goes far beyond the issue of abortion. Unfortunately, making abortion and related matters political issues has fostered an indifference that is certainly preventing government from investing in other attributes of the pro-life movement. The safe course for politicians, at least in the USA, is not to adamantly lecture those opposed to a single attribute in the pro-life initiative so that others can be put into practice. It was, I believe, political indifference that ignited the recent riots in Los Angeles: the conservatives avoided the slum altogether while the liberals played to the wrong values. 13 Mary St, Cincinnati, Ohio 45216, USA
JACK JUSTICE
1. Greeley A. Who are the Catholic conservatives? America 1991, Sept 21. 2. Fagothey A. Right and reason, ethics in theory and practice. St Louis: C. V. Mosby, 1963: 235-41.
European Boards and Colleges SIR,-Professor Gill’s article (May 16, p 1216) contains several incorrect assumptions. The European Union of Medical Specialists (UEMS) has responded to concerns about discrepancies in specialist training in the European Community (EC), where both doctors and patients are moving between countries with increasing frequency, by providing for the establishment of European Boards within its monospecialist subcommittees. The main objective is to guarantee high standards of specialist care throughout the EC by ensuring that training is of the highest quality. This will be achieved by studying the content and quality of training programmes and making recommendations for change. A common approach by all the monospecialist sections (acting through the UEMS) to the EC has obvious advantages. Although each monospecialist section is free to run its own Board within a specified framework, it is wrong to state that the aim of the Boards is to set up European examinations. This issue has already caused concern throughout the medical profession in the EC, and the Permanent Working Group of European Junior Hospital Doctors has voiced understandable disquiet about the notion of European examinations. The draft statutes adopted by the UEMS Management Council refer only to "recognition of qualification"; each Board is free to determine what form of assessment should precede this recognition, and there is no obligation to set formal examinations. Council of the British Medical Association has taken the view that examinations in addition to national qualifications are unnecessary.
The UEMS does not intend to undermine or usurp the role of national anthorities; any certificates issued will be supplementary to national qualifications, and applications for assessment will be voluntary. It is quite incorrect to state that diplomas and fellowships will be compulsory for doctors trained outside the EC. The analogy with American National and State Boards and the Arab Board is not
helpful. I take issue with Gill’s assertion that "People trained in the UK and Irish systems will be wary of excessive European zeal towards uniformity and conformity". In my experience, doctors in many other countries have great reservations about the establishment of European examinations, support for which seems to come largely from representatives of the anglophone countries. British Medical Association, BMA House,
London WC1H 9JP, UK
L. P. HARVEY
Overseas training and doctors from developing countries SiR,—As teachers in a large medical school in India who have witnessed the large-scale migration of trained doctors towards the west, we would comment on Dr Patel and Dr Araya’s viewpoint (Jan 11, p 110). Last year we made an effort to record the migration rate in our students who graduated in 1984. Out of 150 students who had entered medical school about 40 were abroad. At least 15 had
changed their postgraduate specialty because it was easier to gain admission to that specialty to the west. 20 doctors (and many others
whom we know) have as yet made no effort to return to India. We feel that the doctors who want to return home are probably the exception rather than the rule. Most, we believe, succumb to the luxurious life and material wealth of the west and stay on. There is, it is true, a large gap in income between those in academic jobs and those in private practice in underdeveloped countries such as India, and in fact academic jobs are looked down on. But many of those who get foreign training do so to enhance their market value in private practice-either to get attachments to hospitals or at least a label of "foreign returned". Those seeking to return to an academic job, which is usually in a state hospital, are few. The backlisting of doctors who leave medical school during their training should be seen in context: education in many underdeveloped countries is heavily subsidised by the state and this has a role in disincentives for large scale migration. The obstacles to returning home that Patel and Araya mention are indeed very real and their suggestions are helpful. However, what is probably needed most is a fundamental change in attitude such that there is a genuine desire to return home and to try to make the best out of what is undoubtedly an unsatisfactory situation in many respects. And for this individuals should regard the practice of medicine not only as a commercial venture but also as part of an effort to improve the health status as well as scientific outlook of their countrymen in the third world. Departments of Surgery, Cardiology, and Gastroenterology, Seth G.S. Medical College and K.E M. Hospital, Parel, Bombay 400012, India
SANJAY NAGRAL YASH LOKHANDWALA AABHA NAGRAL
NHS trusts and Jehovah’s Witnesses SIR,-We live in a society that denounces discrimination by sex, or creed. Although not a Jehovah’s Witness, I must protest most strongly against the attitude of Mr Collins (May 23, p 1302). His views seem to be based on one patient whose details he omits. He also ignores the hazards of blood transfusion, or its own high race,
cost.
I have operated on many hundreds of Witnesses, the operations ranging from oesophagectomy to prostatectomy, and find that they fare better than those who are transfused. My colleagues report the same for bypass heart surgery. Some years ago, I reviewed all super-major surgery on Witnesses in the Midlands area. It would be unfair to make sweeping statements, but one point was very clear. Not a single case of deep vein thrombosis--an expensive complication--7arose in over four hundred cases. It is my belief that I have benefited from this experience and perhaps even become a slightly better surgeon as a result. Working in primitive communities where hookworm was endemic taught me that people with a haemoglobin half or a quarter of normal survive both surgery and trauma remarkably well, as long as their blood volume is maintained. They have a lower blood viscosity and with it maintain a more rapid circulation that allows them to adequately oxygenate the tissues. We tend to forget that, although haemoglobin is a highly efficient method of carrying oxygen, the final transfer at
tissue level is outside the cells in the serum, as is that of the carbon-dioxide and other metabolites at all times. We should certainly ask for cheaper erythropoietin, which we could use regularly instead of transfusion, but we should not deny others’
rights. Finally, I would note the exemplary mutual help these people give afterwards, saving the National Health Service millions of pounds. 4, Amesbury Road,
Moseley, Birmingham B13 8LD,
G. T. WATTS
UK
Digit sucking SIR,-In your April 18 editorial you point out that the habit of digit sucking is acquired very early in life and that two-thirds of 22-year-old children suck their fingers or thumbs or use artificial comforters. Why so many children do so has puzzled scientists as well
as
mothers for many years, if
not
for centuries. In
our
