894 were outpatients, and their group have been less severely depressed.
patients
University Department of Psychiatry, Royal Edinburgh Hospital, Edinburgh EH10 5HF
whole may
as a
might
be desirable
to
introduce
a
standardised examination
structure. Welsh National School of Medicine,
C. P. FREEMAN
University Hospital of Wales,
J. H. LAZARUS
Cardiff CF4 4XN
G. S. KILPATRICK
CONCENTRATING ON LECTURES
G.M.C. SURVEY OF BASIC MEDICAL EDUCATION have SIR,-Bobbie Jacobson (Sept. 16, p. 360) read the report of the General Medical Council survey very carefully. Far from being in contact with "no more than two or three staff’ at each medical school, the survey team received written information from thirty or more staff in each school, and also conducted lengthy interviews with a substantial proportion of these people. Jacobson’s criticism, that we reported a course to be integrated "just because those filling in the questionnaire said so", would be fatuous, except that it has been dignified by appearing in The Lancet. When a course was alleged to be integrated or interdisciplinary in nature, a great deal of additional inquiry, both written and verbal, was instiseems not to
tuted ;
moreover,
an
entire chapter of the report
was
devoted
interdisciplinary teaching in its various manifestations. I am sorry that Jacobson found the factual data boring. Quite a lot of students here in Cambridge have found the
to
report useful in connection with the discussion of curricular reform, and have felt that it does represent reasonably fairly the situation in the medical schools which they know. The report’s principal aim was to provide the G.M.C.’s education committee with factual information about schools’ curricula, and so on, and not to criticise and conclude (which was Sir George Pickering’s intention): publication of the report was decided upon later, in response to requests from the medical schools. The survey team believes that systematic documentation of the objectives, aspirations, and problems of medical schools and the teachers within them in relation to the selection of students, curricula, and assessment, is valid and can be a more useful basis to decision-taking than hearsay. This is not to say that there is no place for a personal report such as Sir George Pickering’s: the approaches are complementary. The possibility of including, as part of the G.M.C. survey, an inquiry into medical students’ opinion was discussed but, for cost and other practical reasons, reluctantly rejected for the time being. It could be that the views of students about their courses would, on their own, produce no more complete or accurate a picture than those of the staff. However, it is probable that a systematic study of medical students similar to that conducted under the auspices of the Royal Commission on Medical Education in 1966, may be soon be done by another
body. Office of Regius Professor of Physic, Cambridge University School of Clinical Medicine, Addenbrooke’s Hospital, Cambridge CB2 2QQ
R. E. WAKEFORD
M.B. FAILURES
SIR,-Despite
the
complexity,
such
as
almost
to
defy analy-
sis, alluded to in your editorial of Sept. 20 we did analyse the structure, character, and results of the final M.B. examinations held in U.K. medical schools in 1974.1 19. 1% of London-based students (range 12-S-246%) failed the final examination compared with 5.7% (0-14-6%) of students in medical schools outside London, a significant difference. We did not have a satisfactory explanation for these differences but the wide variations in the length and character of the examinations in the U.K. led us to suggest, as you do, that it 1. Lazarus, J.
H., Baum, M., Kilpatrick, G. S. Med. Educ. 1976, 10, 109.
SIR,-Congratulations to Dr Stuart and Dr Rutherford (Sept. 2, p. 514) on their simple but elegant experiment in medical education. However, before one-hour lectures are abandoned in favour of shorter sessions, several points should be considered. Might the general shape of the attention curve be fairly constant, irrespective of the length of the lecture-in other words, might the level of concentration depend to some extent on anticipated duration, so that if the lecture is scheduled to last only 30 min concentration might peak at 5 min, and so on? All but one of the concentration profiles were close to or above average until the last 10 min. Assuming that "average" is a satisfactory rating, this suggests that an hour is not an unreasonable duration for a lecture. It seems odd that the differences in class concentration associated with individual lecturers were present even at zero time. Had the lecturers’ reputation preceded them, or were other variables involved such as time of day, day of week, or nearness to examinations? Finally, if the academic hour is in fact 50 min, can we anticipate that the academic half-hour will be 25min? Department of Preventive Medicine and Biostatistics,
Faculty of Medicine, University of Toronto, Toronto, Canada M5S 1A8
MARY JANE ASHLEY TERENCE W. ANDERSON
PERITONEAL DIALYSIS
SIR,-Your editorial of Aug. 5 concludes, with Popovich et al.,l that continuous peritoneal dialysis (C.A.P.D.) cannot be recommended for general use because of the high incidence of peritonitis, presumably attributable to the high frequency of the drainage/inflow procedures they used. A series of papers on peritoneal dialysis for acute renal failure, both experimental and clinical, published some thirty years ago,2-7 demonstrated that dialysis, if continued long enough, results in peritonitis, and that this is nearly always the result of persisting chemical irritation of the gut by the irrigating fluid, which induces transmural migration of bacteria and endotoxin from the gut lumen to the peritoneal cavity. This view was based on data from radioisotope labels on bacteria and on endotoxins, and on cultural data showing that Escherichia coli was nearly always the infecting organism. Thus the peritonitis was not the result of errors in sterility technique. Alternatives to avoid this complication were intermittent irrigation or antibiotics in the irrigating fluid, or both. Both have proved useful. We have, on several occasions since, suggested a third therapy which can be used if there is a compelling need for continuous dialysis-i.e., a non-absorbable antibiotic present in the colon during dialysis to inhibit transmural migration of bacteria. I suspect that this principle, like the papers referred to2-’ will continue to be ignored or overlooked. Division of Health Services Administration, School of Public Health, Harvard University, Cambridge, Massachusetts 02139, U.S.A.
1. 2.
Popovich,
R. P., and others Ann. intern. Med.
JACOB FINE 1978, 88, 449.
Seligman, A. M., Frank, H. A., Fine, J. J. clin. Invest. 1946, 25, 211. 3. Frank, H. A., Seligman, A. M., Fine, J. J. Am med. Ass. 1946, 130, 4 Fine, J., Frank, H. A., Seligman, A. M. Ann. Surg. 1946,124, 15. 5. Frank, H. A., Seligman, A. M., Fine, J. Ann. Surg. 1948, 128, 3. 6 Schweinburg, F. B., Heimberg, F. Proc. Soc. Biol Med. 1949, 71, 146. 7. Scheinburg, F. B., Frank, H. A., Frank, E. D., Heimberg, F., Fine, J. 1949, 71, 150.
703.
ibid.
patients
University Department of Psychiatry, Royal Edinburgh Hospital, Edinburgh EH10 5HF
whole may
as a
might
be desirable
to
introduce
a
standardised examination
structure. Welsh National School of Medicine,
C. P. FREEMAN
University Hospital of Wales,
J. H. LAZARUS
Cardiff CF4 4XN
G. S. KILPATRICK
CONCENTRATING ON LECTURES
G.M.C. SURVEY OF BASIC MEDICAL EDUCATION have SIR,-Bobbie Jacobson (Sept. 16, p. 360) read the report of the General Medical Council survey very carefully. Far from being in contact with "no more than two or three staff’ at each medical school, the survey team received written information from thirty or more staff in each school, and also conducted lengthy interviews with a substantial proportion of these people. Jacobson’s criticism, that we reported a course to be integrated "just because those filling in the questionnaire said so", would be fatuous, except that it has been dignified by appearing in The Lancet. When a course was alleged to be integrated or interdisciplinary in nature, a great deal of additional inquiry, both written and verbal, was instiseems not to
tuted ;
moreover,
an
entire chapter of the report
was
devoted
interdisciplinary teaching in its various manifestations. I am sorry that Jacobson found the factual data boring. Quite a lot of students here in Cambridge have found the
to
report useful in connection with the discussion of curricular reform, and have felt that it does represent reasonably fairly the situation in the medical schools which they know. The report’s principal aim was to provide the G.M.C.’s education committee with factual information about schools’ curricula, and so on, and not to criticise and conclude (which was Sir George Pickering’s intention): publication of the report was decided upon later, in response to requests from the medical schools. The survey team believes that systematic documentation of the objectives, aspirations, and problems of medical schools and the teachers within them in relation to the selection of students, curricula, and assessment, is valid and can be a more useful basis to decision-taking than hearsay. This is not to say that there is no place for a personal report such as Sir George Pickering’s: the approaches are complementary. The possibility of including, as part of the G.M.C. survey, an inquiry into medical students’ opinion was discussed but, for cost and other practical reasons, reluctantly rejected for the time being. It could be that the views of students about their courses would, on their own, produce no more complete or accurate a picture than those of the staff. However, it is probable that a systematic study of medical students similar to that conducted under the auspices of the Royal Commission on Medical Education in 1966, may be soon be done by another
body. Office of Regius Professor of Physic, Cambridge University School of Clinical Medicine, Addenbrooke’s Hospital, Cambridge CB2 2QQ
R. E. WAKEFORD
M.B. FAILURES
SIR,-Despite
the
complexity,
such
as
almost
to
defy analy-
sis, alluded to in your editorial of Sept. 20 we did analyse the structure, character, and results of the final M.B. examinations held in U.K. medical schools in 1974.1 19. 1% of London-based students (range 12-S-246%) failed the final examination compared with 5.7% (0-14-6%) of students in medical schools outside London, a significant difference. We did not have a satisfactory explanation for these differences but the wide variations in the length and character of the examinations in the U.K. led us to suggest, as you do, that it 1. Lazarus, J.
H., Baum, M., Kilpatrick, G. S. Med. Educ. 1976, 10, 109.
SIR,-Congratulations to Dr Stuart and Dr Rutherford (Sept. 2, p. 514) on their simple but elegant experiment in medical education. However, before one-hour lectures are abandoned in favour of shorter sessions, several points should be considered. Might the general shape of the attention curve be fairly constant, irrespective of the length of the lecture-in other words, might the level of concentration depend to some extent on anticipated duration, so that if the lecture is scheduled to last only 30 min concentration might peak at 5 min, and so on? All but one of the concentration profiles were close to or above average until the last 10 min. Assuming that "average" is a satisfactory rating, this suggests that an hour is not an unreasonable duration for a lecture. It seems odd that the differences in class concentration associated with individual lecturers were present even at zero time. Had the lecturers’ reputation preceded them, or were other variables involved such as time of day, day of week, or nearness to examinations? Finally, if the academic hour is in fact 50 min, can we anticipate that the academic half-hour will be 25min? Department of Preventive Medicine and Biostatistics,
Faculty of Medicine, University of Toronto, Toronto, Canada M5S 1A8
MARY JANE ASHLEY TERENCE W. ANDERSON
PERITONEAL DIALYSIS
SIR,-Your editorial of Aug. 5 concludes, with Popovich et al.,l that continuous peritoneal dialysis (C.A.P.D.) cannot be recommended for general use because of the high incidence of peritonitis, presumably attributable to the high frequency of the drainage/inflow procedures they used. A series of papers on peritoneal dialysis for acute renal failure, both experimental and clinical, published some thirty years ago,2-7 demonstrated that dialysis, if continued long enough, results in peritonitis, and that this is nearly always the result of persisting chemical irritation of the gut by the irrigating fluid, which induces transmural migration of bacteria and endotoxin from the gut lumen to the peritoneal cavity. This view was based on data from radioisotope labels on bacteria and on endotoxins, and on cultural data showing that Escherichia coli was nearly always the infecting organism. Thus the peritonitis was not the result of errors in sterility technique. Alternatives to avoid this complication were intermittent irrigation or antibiotics in the irrigating fluid, or both. Both have proved useful. We have, on several occasions since, suggested a third therapy which can be used if there is a compelling need for continuous dialysis-i.e., a non-absorbable antibiotic present in the colon during dialysis to inhibit transmural migration of bacteria. I suspect that this principle, like the papers referred to2-’ will continue to be ignored or overlooked. Division of Health Services Administration, School of Public Health, Harvard University, Cambridge, Massachusetts 02139, U.S.A.
1. 2.
Popovich,
R. P., and others Ann. intern. Med.
JACOB FINE 1978, 88, 449.
Seligman, A. M., Frank, H. A., Fine, J. J. clin. Invest. 1946, 25, 211. 3. Frank, H. A., Seligman, A. M., Fine, J. J. Am med. Ass. 1946, 130, 4 Fine, J., Frank, H. A., Seligman, A. M. Ann. Surg. 1946,124, 15. 5. Frank, H. A., Seligman, A. M., Fine, J. Ann. Surg. 1948, 128, 3. 6 Schweinburg, F. B., Heimberg, F. Proc. Soc. Biol Med. 1949, 71, 146. 7. Scheinburg, F. B., Frank, H. A., Frank, E. D., Heimberg, F., Fine, J. 1949, 71, 150.
703.
ibid.
