1361
performance is crucial in respect of patient health and safety, will fall into class II and will require outside approval by an independent certification body. Class II will possibly include kits used for HIV testing and other blood donation screening tests (eg, hepatitis B
and C).
proposed Directive will not prevent from restricting the availability of particular IVDs. This is especially relevant because regulations came into force in the UK on April 1, 1992, under the Health and Medicines Act Section 23(1) and (3), (SI 1992 no 460: The HIV Testing Kits and Service Regulations, 1992). These regulations control the use, sale, supply, and advertising of HIV testing kits and testing services, and ban the sale or supply of HIV testing kits to members of the public. The provision of testing services is now an offence unless they are provided by or in accordance with the directions of a registered medical practitioner. It is
expected
that the
individual member
states
European Section, Medical Devices Directorate, Department of Health, London WC1B 5EP, UK
of mind and level of confidence, with a minimum of diffidence and hesitation and absence of any impression of panic. Such qualities may be to some extent gender dependent in favour of the male psychological constitution. There exists a subgroup of women who no doubt have these qualities and who are more likely than others to succeed in surgery. However, it is conceivable that because of innate gender differences there will tend to be fewer female surgeons overall. Indeed Mr Cobb’s point in respect of women having a better appreciation of the hazards of a career in surgery may be but a further manifestation of such psychological gender differences. A more cautious approach to life and perhaps surgery may be an attribute of the female of the species. 26 Millway Close,
Upper Wolvercote,
Clinical RICHARD GUTOWSKI
J. R. BENSON
Oxford OX2 8BL, UK
training and research in the EC
SIR,-Professor Gill (May 16, p 1216) draws attention to the to harmonise clinical training in the European Community (EC). There is a similar need to harmonise research training, not least because of the increasing requirement of a research degree to succeed in hospital medicine.1,2 The great variation in regulations
need
Nursing’s identity crisis SIR,-Malcolm Dean (May 9, p 1160) seems to have become entangled in current nursing issues. As he says, no consensus exists within the nursing profession about the future role somewhat
of the nurse, and some do indeed wish nurses to take on certain tasks previously within the province of doctors. There may be, as Dean suggests, some nurses who fear that in taking on quasi-medical tasks they risk pricing themselves out of a job. For this reason they favour retaining basic nursing tasks along with those delegated by doctors. But there is also a growing contingent of nurses--generally including those who practise primary nursing-who see the knowledge needed for nursing and medicine as being quite distinct. In their view routine tasks associated with patient care represent opportunities for nurses to relate to their patients and to use specific nursing skills and knowledge. Such tasks are therefore not regarded as unskilled but an integral part of the development of a therapeutic relationship between nurse and patient. Nurses who have adopted this view, far from aping medicine, are struggling to gain recognition for the value of nursing, albeit within a culture that awards privilege to medicine.
JAN SAVAGE
Surgical careers and female students SIR,-Iread with interest reports from Oxford University Medical School of sexual discrimination in respect of surgical careers for women (April 18, p 994; May 16, p 1235). As a graduate of that institution I am reluctant to support the suggestion that women are (unjustifiably) discriminated against and discouraged from pursuing a career in general surgery. Should this impression be gleaned by certain persons, then perhaps they should consider why this might be. We live in a world where a policy of sexual equality, especially at work, prevails. However, in reality the sexes differ not only biologically, but also in less tangible, more subtle ways in respect of psychological make-up (personality, attitude, temperament, emotional reaction). Such differences may become apparent and assume importance in certain occupations, of which surgery is
perhaps an example. Apart from the long and unpredictable hours of work that inevitably involve sleep deprivation, surgeons also sometimes have to operate (often on long and difficult cases) when very fatigued. In my experience female house surgeons are not as tolerant of sleep
deprivation
and
prone to succumb to exhaustion and their male counterparts. Indeed, recent reviews of junior doctors working hours may be a reflection of pressure for change imposed by much increased numbers of women in medicine as a whole. Some aspects of surgery-for example, procedures for emergency thoracoabdominal trauma--demand a certain attitude are more
absenteeism than
are
Royal Free Hospital School of Medicine, University of London,
L. H. BREIMER D. P. MIKHAILIDIS
London NW3 2PF, UK 1.
Johnson R. Requirements of British universities for higher medical degrees. Br Med J 1991; 302: 397-99.
2. Cobb RA. Surgical careers and female students. Lancet 1992; 339: 1235. 3. Breimer LH, Mikhailidis DP. A thesis for all seasons. Nature 1991; 353: 789-90.
Prenatal
Bloomsbury and Islington College of Nursing and Midwifery, John Astor House, London W1P 8AN, UK
between the current systems makes this impossible. Even within the UK the regulations vary.’1 We have suggested that a unified EC doctorate could be based on work published in internationally refereed journals.3 The thesis itself, which would be comparatively short, can be published in a special European (international) thesis journal. Such an approach would be flexible and allow interaction with countries at present outside the EC, such as Sweden or Japan, where publication-based systems already operate.
diagnosis of haemoglobinopathies in Sicily
SIR,-Dr Giambelluca and colleagues (Jan 18, p 179), discussing the thalassaemia strategy in Sicily, state that although there was a fall in incidence of Cooley’s anaemia births from 1982 to 1989 because of the prenatal diagnosis programme at the V. Cervello Hospital, that improvement has stabilised "due to a gap in health information". We think that to explain these data it would be useful to emphasise other factors too-the true frequency of &bgr;-thalassaemia and sickle-cell carriers and the possibility of a heterogeneous distribution; the efficacy of screening by peripheral centres; and the total number of prenatal diagnoses per year. These haemoglobinopathies are heterogeneously spread in Sicily. Data from the regional health department (personal communication) show a higher prevalence in the east of the island, the two areas having roughly the same populations: Area East West
Cases of Cooley’s anaemia (1980-88) 80 81 82 83 84 85 86 87 88 34 17
46 10
29 15
24 9
27 8
15 9
14 8
14 8
11 1
These data show that after the start of prenatal diagnosis in 1983 the frequency in eastern Sicily remained higher than in the west of the island. In western Sicily and in the interior the frequency is certainly lower than that recorded by Giambelluca et al, and it is difficult to get a reliable estimate of carrier frequency because the screening programme is not centralised and depends on the organisation of local thalassaemia centres. The number of people tested at thalassaemia peripheral centres did increase between 1983 (26 978) and 1990 (43 399) but not all centres screen only young couples, and this may reduce the efficacy of the programme, especially where the carrier prevalence rate is
performance is crucial in respect of patient health and safety, will fall into class II and will require outside approval by an independent certification body. Class II will possibly include kits used for HIV testing and other blood donation screening tests (eg, hepatitis B
and C).
proposed Directive will not prevent from restricting the availability of particular IVDs. This is especially relevant because regulations came into force in the UK on April 1, 1992, under the Health and Medicines Act Section 23(1) and (3), (SI 1992 no 460: The HIV Testing Kits and Service Regulations, 1992). These regulations control the use, sale, supply, and advertising of HIV testing kits and testing services, and ban the sale or supply of HIV testing kits to members of the public. The provision of testing services is now an offence unless they are provided by or in accordance with the directions of a registered medical practitioner. It is
expected
that the
individual member
states
European Section, Medical Devices Directorate, Department of Health, London WC1B 5EP, UK
of mind and level of confidence, with a minimum of diffidence and hesitation and absence of any impression of panic. Such qualities may be to some extent gender dependent in favour of the male psychological constitution. There exists a subgroup of women who no doubt have these qualities and who are more likely than others to succeed in surgery. However, it is conceivable that because of innate gender differences there will tend to be fewer female surgeons overall. Indeed Mr Cobb’s point in respect of women having a better appreciation of the hazards of a career in surgery may be but a further manifestation of such psychological gender differences. A more cautious approach to life and perhaps surgery may be an attribute of the female of the species. 26 Millway Close,
Upper Wolvercote,
Clinical RICHARD GUTOWSKI
J. R. BENSON
Oxford OX2 8BL, UK
training and research in the EC
SIR,-Professor Gill (May 16, p 1216) draws attention to the to harmonise clinical training in the European Community (EC). There is a similar need to harmonise research training, not least because of the increasing requirement of a research degree to succeed in hospital medicine.1,2 The great variation in regulations
need
Nursing’s identity crisis SIR,-Malcolm Dean (May 9, p 1160) seems to have become entangled in current nursing issues. As he says, no consensus exists within the nursing profession about the future role somewhat
of the nurse, and some do indeed wish nurses to take on certain tasks previously within the province of doctors. There may be, as Dean suggests, some nurses who fear that in taking on quasi-medical tasks they risk pricing themselves out of a job. For this reason they favour retaining basic nursing tasks along with those delegated by doctors. But there is also a growing contingent of nurses--generally including those who practise primary nursing-who see the knowledge needed for nursing and medicine as being quite distinct. In their view routine tasks associated with patient care represent opportunities for nurses to relate to their patients and to use specific nursing skills and knowledge. Such tasks are therefore not regarded as unskilled but an integral part of the development of a therapeutic relationship between nurse and patient. Nurses who have adopted this view, far from aping medicine, are struggling to gain recognition for the value of nursing, albeit within a culture that awards privilege to medicine.
JAN SAVAGE
Surgical careers and female students SIR,-Iread with interest reports from Oxford University Medical School of sexual discrimination in respect of surgical careers for women (April 18, p 994; May 16, p 1235). As a graduate of that institution I am reluctant to support the suggestion that women are (unjustifiably) discriminated against and discouraged from pursuing a career in general surgery. Should this impression be gleaned by certain persons, then perhaps they should consider why this might be. We live in a world where a policy of sexual equality, especially at work, prevails. However, in reality the sexes differ not only biologically, but also in less tangible, more subtle ways in respect of psychological make-up (personality, attitude, temperament, emotional reaction). Such differences may become apparent and assume importance in certain occupations, of which surgery is
perhaps an example. Apart from the long and unpredictable hours of work that inevitably involve sleep deprivation, surgeons also sometimes have to operate (often on long and difficult cases) when very fatigued. In my experience female house surgeons are not as tolerant of sleep
deprivation
and
prone to succumb to exhaustion and their male counterparts. Indeed, recent reviews of junior doctors working hours may be a reflection of pressure for change imposed by much increased numbers of women in medicine as a whole. Some aspects of surgery-for example, procedures for emergency thoracoabdominal trauma--demand a certain attitude are more
absenteeism than
are
Royal Free Hospital School of Medicine, University of London,
L. H. BREIMER D. P. MIKHAILIDIS
London NW3 2PF, UK 1.
Johnson R. Requirements of British universities for higher medical degrees. Br Med J 1991; 302: 397-99.
2. Cobb RA. Surgical careers and female students. Lancet 1992; 339: 1235. 3. Breimer LH, Mikhailidis DP. A thesis for all seasons. Nature 1991; 353: 789-90.
Prenatal
Bloomsbury and Islington College of Nursing and Midwifery, John Astor House, London W1P 8AN, UK
between the current systems makes this impossible. Even within the UK the regulations vary.’1 We have suggested that a unified EC doctorate could be based on work published in internationally refereed journals.3 The thesis itself, which would be comparatively short, can be published in a special European (international) thesis journal. Such an approach would be flexible and allow interaction with countries at present outside the EC, such as Sweden or Japan, where publication-based systems already operate.
diagnosis of haemoglobinopathies in Sicily
SIR,-Dr Giambelluca and colleagues (Jan 18, p 179), discussing the thalassaemia strategy in Sicily, state that although there was a fall in incidence of Cooley’s anaemia births from 1982 to 1989 because of the prenatal diagnosis programme at the V. Cervello Hospital, that improvement has stabilised "due to a gap in health information". We think that to explain these data it would be useful to emphasise other factors too-the true frequency of &bgr;-thalassaemia and sickle-cell carriers and the possibility of a heterogeneous distribution; the efficacy of screening by peripheral centres; and the total number of prenatal diagnoses per year. These haemoglobinopathies are heterogeneously spread in Sicily. Data from the regional health department (personal communication) show a higher prevalence in the east of the island, the two areas having roughly the same populations: Area East West
Cases of Cooley’s anaemia (1980-88) 80 81 82 83 84 85 86 87 88 34 17
46 10
29 15
24 9
27 8
15 9
14 8
14 8
11 1
These data show that after the start of prenatal diagnosis in 1983 the frequency in eastern Sicily remained higher than in the west of the island. In western Sicily and in the interior the frequency is certainly lower than that recorded by Giambelluca et al, and it is difficult to get a reliable estimate of carrier frequency because the screening programme is not centralised and depends on the organisation of local thalassaemia centres. The number of people tested at thalassaemia peripheral centres did increase between 1983 (26 978) and 1990 (43 399) but not all centres screen only young couples, and this may reduce the efficacy of the programme, especially where the carrier prevalence rate is
