Section of Pathology
717
70-80 %. The remaining samples for culture consist of fluctuating numbers of swabs from the London SWI) throat, ear, nose, vagina and skin lesions. Feces, both for culture and for examination for parasites, form an important group. Sputum is less freMicrobiological Aspects quently (and less usefully) submitted. I have studied the interaction of general pracSerological tests form about one-eighth of our titioner and laboratory in two departments. The general practice work. They include not only first was a Scottish university department whose conventional tests such as Widal and brucella primary duty, apart from teaching, was to meet the agglutinations, antistreptolysin titrations and inmicrobiological needs of local authorities and vestigations for syphilis, but also some procedures general practitioners throughout a region with an which are not strictly microbiological, such as tests for rheumatoid factor and tissue antibodies. Pregarea of about 2500 kM2, and a population of about 700 000. The associated teaching hospital was nancy tests and samples for seminal analyses in served by a separate sub-department. The regional infertility or after vasectomy are also submitted service provided for the mixed urban and rural occasionally. We supply traditional specimen containers, but population was similar to that described recently in another part of Scotland (Taylor et al. 1975). After our standard swabs are albumen-coated and those experience in an Indian city (Selwyn 1968), I for the genital tract are charcoal-coated or, in entered the very different environment of a London special cases, gently abrasive and highly absorptive teaching hospital and medical school. The resident plastic sponge swabs (Oates et al. 1971). The use of population served is a compact one, only one-fifth Stuart's, or similar, transport media is helpful for all swabs taken in general practice, where some as big as that of the Scottish laboratory, and the investigations carried out for general practitioners delay is inevitable, and the new commercially form a small part of the workload, which is mainly produced kits of swabs and transport media (e.g. Transwab, Medical Wire and Equipment) are concerned with the teaching hospital. versatile, robust and convenient. Similarly, 'dip slides' have proved a convenient alternative to Specimens from General Practitioners During my ten years in London the number of traditional methods of submitting urine for culture specimens received from general practitioners has (Grob 1977), although microscopy is still essential. The comprehensive printed pamphlet 'Pathology doubled, in close parallel with specimens from our hospital patients, and the proportion has remained Laboratory Services Guide' that the Westminster remarkably constant over this period of growth Hospital issues has been widely appreciated and (Table 1). This applies both to specimens sub- has helped to avoid confusion and wasted effort. mitted for culture (c. 3 % of those from the Happily, our general practitioners are usually hospital) and those for serological tests (c. 2 %). exemplary in providing full information about their The 104 general practitioners who were regular patients on the request form - unlike some of our users of the Aberdeen laboratory each sent an former students who work in hospitals! average of 91 specimens per year (Taylor et al. Specimens and request forms are brought in 1975). This was remarkably similar to the average mostly by patients, or their relatives and friends, of 95 specimens submitted by the 21 London who rarely object to travelling moderate distances. practitioners who consistently use our service. The In contrast, the far-flung Scottish regional services relative proportion of different specimens for cul- depend largely on postal and van deliveries which ture is also very similar, with urines accounting for work surprisingly well. Dr Sydney Selwyn
(Westminster Medical School,
Table I Microbiological specimens from general practice Specimens for culture Year 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976
No. 791 979 1238 1590 1866 1899
1612 1655 1726 1743
Percentage of total workload 2.7 2.3 2.8 3.5 3.3 3.5 3.0 2.9 3.1 2.7
Specimensfor serology No. 195 83 91 101 118 269 359 220 234 283
Percentage of total workload 2.2 1.2 1.1 1.3 0.8 2.1 2.6 1.5 1.6 1.8
Total No. 986 1062 1329 1691 1984
2168 1971 1875 1960 2026
Percentage of total workload 2.1 2.1 2.6 3.1 2.8 3.2 2.9 2.6 2.6 2.5
718
Proc. roy. Soc. Med. Volume 70 October 1977
Problems and Misuse Shanson (1976) has reviewed the misuse of microbiological investigations in hospital, which includes inappropriate and unsuitable specimens, the start of antimicrobial treatment before taking samples, problems in transit, unnecessary repetition of specimens, inadequate information or consultation, and fallacious interpretation or even total disregard of the laboratory report. General practitioners are not very often guilty, since those who are interested enough to collect specimens at all usually do the job well. However, a notable lapse is inadequate follow up of patients treated for urinary tract infections. The selective use of the microbiology laboratory is less of a 2roblem than is the case in other branches of pathology, partly due to the fact that automation and mass screening have not yet arrived, so that both the collector of specimens and those who process them can exercise discrimination and discretion at all stages. Selection is especially necessary with virological studies, which are not only frequently expensive and protracted but, in our case, often involve imposing on the goodwill of other laboratories. Rapid results are possible for hepatitis B antigen, rubella serology, Herpesvirus hominis isolation, fluorescence studies for respiratory viruses (Gardner 1976) and electron microscopy for viruses including those implicated in enteritis (Flewett 1976). Undoubtedly, the use of pathology services gives confidence and satisfaction to patients and doctors alike. Patients who bring in specimens or who come to the laboratory for specimen collection by members of staff, always express their appreciation of the interest taken by their own doctor. Laboratory reporting in microbiology is still entirely in the hands of human beings. Reports can therefore be personalized and interpretive, presenting information believed to be relevant and useful on organisms, antibodies and sensitivity results. Telephone discussions between microbiologist and general practitioner are mutually appreciated. We give further help by issuing a printed 'Formulary' which includes detailed advice on the use of antibiotics, and a large coloured chart has been produced to illustrate the ranges of activity of the available antimicrobial agents; a pharmaceutical company has recently printed copies of this. We also issue another booklet giving guidance on the use of antiseptics and disinfectants.
Research The regional service provided in Scotland gave ample opportunities for epidemiological research based on general practice (Selwyn 1962, Selwyn & Howitt 1962, Selwyn & Bain 1965). The London department, on the other hand, is ideal for research links with individual general practices. For
example, long-term studies are in progress on skin infection and colonization among patients after discharge from hospital. These and other studies, notably of urinary tract and respiratory infections in the south-east of England (Grob 1977, Manners 1977), emphasize the truly symbiotic relationship which is possible between the general practitioner and the medical microbiologist. Future research should not only be concerned with clinical and epidemiological themes, but must also set out to explain the apparently haphazard use of the laboratory by practitioners (Taylor et al. 1975). Investigations are also needed to confirm the impression that general practitioners who regularly use the laboratory are able, as a result, to economize in their use of hospital outpatient and inpatient resources and in their prescribing of antimicrobial agents (Green 1976). The coordination of general practice and laboratory services at district and area levels in the reorganized National Health Service should facilitate these joint studies, which are now urgently needed at a time of increasing economic stringencies. REFERENCES Flewett T H (1976) Proceedings of the Royal Society of Medicine 69, 693 Gardner P (1976) Proceedings of the Royal Society of Medicine 69, 687 Green R H (1976) Journal of the Royal College of General Practitioners 26. 185 Grob P R (1977) Proceedings of the Royal Society of Medicine 70, 715 Manners B T B (1977) Proceedings of the Royal Society of Medicine 70, 721 Oates J K, Selwyn S & Breach M R (1971) British Journal of Venereal Diseases 47, 289 Selwyn S (1962) British Medical Journal ii, 148 (1968) Report to the World Health Organization on Assistance to Medical Education, Gujarat State, WHO, Geneva Selwyn S & Bain A D (1965) British Journal of Preventive and Social Medicine 19, 123 Selwyn S & Howitt L F (1962) Lancet ii, 548 Shanson D C (1976) Hospital Update 2, 589 Taylor R J, Howie J G R, Brodie J & Porter I A (1975) British Medical Journal iii, 635
Dr P E Crome (Westminster Medical School, London SWJ; Queen Mary's Hospital,
Roehampton) Hiematology Services for General Practitioners The concept of providing laboratory services to general practitioners has developed considerably in the last fifteen to twenty years against a background of debate as to the desirability or necessity of providing such services. Macauley (1962) com-
717
70-80 %. The remaining samples for culture consist of fluctuating numbers of swabs from the London SWI) throat, ear, nose, vagina and skin lesions. Feces, both for culture and for examination for parasites, form an important group. Sputum is less freMicrobiological Aspects quently (and less usefully) submitted. I have studied the interaction of general pracSerological tests form about one-eighth of our titioner and laboratory in two departments. The general practice work. They include not only first was a Scottish university department whose conventional tests such as Widal and brucella primary duty, apart from teaching, was to meet the agglutinations, antistreptolysin titrations and inmicrobiological needs of local authorities and vestigations for syphilis, but also some procedures general practitioners throughout a region with an which are not strictly microbiological, such as tests for rheumatoid factor and tissue antibodies. Pregarea of about 2500 kM2, and a population of about 700 000. The associated teaching hospital was nancy tests and samples for seminal analyses in served by a separate sub-department. The regional infertility or after vasectomy are also submitted service provided for the mixed urban and rural occasionally. We supply traditional specimen containers, but population was similar to that described recently in another part of Scotland (Taylor et al. 1975). After our standard swabs are albumen-coated and those experience in an Indian city (Selwyn 1968), I for the genital tract are charcoal-coated or, in entered the very different environment of a London special cases, gently abrasive and highly absorptive teaching hospital and medical school. The resident plastic sponge swabs (Oates et al. 1971). The use of population served is a compact one, only one-fifth Stuart's, or similar, transport media is helpful for all swabs taken in general practice, where some as big as that of the Scottish laboratory, and the investigations carried out for general practitioners delay is inevitable, and the new commercially form a small part of the workload, which is mainly produced kits of swabs and transport media (e.g. Transwab, Medical Wire and Equipment) are concerned with the teaching hospital. versatile, robust and convenient. Similarly, 'dip slides' have proved a convenient alternative to Specimens from General Practitioners During my ten years in London the number of traditional methods of submitting urine for culture specimens received from general practitioners has (Grob 1977), although microscopy is still essential. The comprehensive printed pamphlet 'Pathology doubled, in close parallel with specimens from our hospital patients, and the proportion has remained Laboratory Services Guide' that the Westminster remarkably constant over this period of growth Hospital issues has been widely appreciated and (Table 1). This applies both to specimens sub- has helped to avoid confusion and wasted effort. mitted for culture (c. 3 % of those from the Happily, our general practitioners are usually hospital) and those for serological tests (c. 2 %). exemplary in providing full information about their The 104 general practitioners who were regular patients on the request form - unlike some of our users of the Aberdeen laboratory each sent an former students who work in hospitals! average of 91 specimens per year (Taylor et al. Specimens and request forms are brought in 1975). This was remarkably similar to the average mostly by patients, or their relatives and friends, of 95 specimens submitted by the 21 London who rarely object to travelling moderate distances. practitioners who consistently use our service. The In contrast, the far-flung Scottish regional services relative proportion of different specimens for cul- depend largely on postal and van deliveries which ture is also very similar, with urines accounting for work surprisingly well. Dr Sydney Selwyn
(Westminster Medical School,
Table I Microbiological specimens from general practice Specimens for culture Year 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976
No. 791 979 1238 1590 1866 1899
1612 1655 1726 1743
Percentage of total workload 2.7 2.3 2.8 3.5 3.3 3.5 3.0 2.9 3.1 2.7
Specimensfor serology No. 195 83 91 101 118 269 359 220 234 283
Percentage of total workload 2.2 1.2 1.1 1.3 0.8 2.1 2.6 1.5 1.6 1.8
Total No. 986 1062 1329 1691 1984
2168 1971 1875 1960 2026
Percentage of total workload 2.1 2.1 2.6 3.1 2.8 3.2 2.9 2.6 2.6 2.5
718
Proc. roy. Soc. Med. Volume 70 October 1977
Problems and Misuse Shanson (1976) has reviewed the misuse of microbiological investigations in hospital, which includes inappropriate and unsuitable specimens, the start of antimicrobial treatment before taking samples, problems in transit, unnecessary repetition of specimens, inadequate information or consultation, and fallacious interpretation or even total disregard of the laboratory report. General practitioners are not very often guilty, since those who are interested enough to collect specimens at all usually do the job well. However, a notable lapse is inadequate follow up of patients treated for urinary tract infections. The selective use of the microbiology laboratory is less of a 2roblem than is the case in other branches of pathology, partly due to the fact that automation and mass screening have not yet arrived, so that both the collector of specimens and those who process them can exercise discrimination and discretion at all stages. Selection is especially necessary with virological studies, which are not only frequently expensive and protracted but, in our case, often involve imposing on the goodwill of other laboratories. Rapid results are possible for hepatitis B antigen, rubella serology, Herpesvirus hominis isolation, fluorescence studies for respiratory viruses (Gardner 1976) and electron microscopy for viruses including those implicated in enteritis (Flewett 1976). Undoubtedly, the use of pathology services gives confidence and satisfaction to patients and doctors alike. Patients who bring in specimens or who come to the laboratory for specimen collection by members of staff, always express their appreciation of the interest taken by their own doctor. Laboratory reporting in microbiology is still entirely in the hands of human beings. Reports can therefore be personalized and interpretive, presenting information believed to be relevant and useful on organisms, antibodies and sensitivity results. Telephone discussions between microbiologist and general practitioner are mutually appreciated. We give further help by issuing a printed 'Formulary' which includes detailed advice on the use of antibiotics, and a large coloured chart has been produced to illustrate the ranges of activity of the available antimicrobial agents; a pharmaceutical company has recently printed copies of this. We also issue another booklet giving guidance on the use of antiseptics and disinfectants.
Research The regional service provided in Scotland gave ample opportunities for epidemiological research based on general practice (Selwyn 1962, Selwyn & Howitt 1962, Selwyn & Bain 1965). The London department, on the other hand, is ideal for research links with individual general practices. For
example, long-term studies are in progress on skin infection and colonization among patients after discharge from hospital. These and other studies, notably of urinary tract and respiratory infections in the south-east of England (Grob 1977, Manners 1977), emphasize the truly symbiotic relationship which is possible between the general practitioner and the medical microbiologist. Future research should not only be concerned with clinical and epidemiological themes, but must also set out to explain the apparently haphazard use of the laboratory by practitioners (Taylor et al. 1975). Investigations are also needed to confirm the impression that general practitioners who regularly use the laboratory are able, as a result, to economize in their use of hospital outpatient and inpatient resources and in their prescribing of antimicrobial agents (Green 1976). The coordination of general practice and laboratory services at district and area levels in the reorganized National Health Service should facilitate these joint studies, which are now urgently needed at a time of increasing economic stringencies. REFERENCES Flewett T H (1976) Proceedings of the Royal Society of Medicine 69, 693 Gardner P (1976) Proceedings of the Royal Society of Medicine 69, 687 Green R H (1976) Journal of the Royal College of General Practitioners 26. 185 Grob P R (1977) Proceedings of the Royal Society of Medicine 70, 715 Manners B T B (1977) Proceedings of the Royal Society of Medicine 70, 721 Oates J K, Selwyn S & Breach M R (1971) British Journal of Venereal Diseases 47, 289 Selwyn S (1962) British Medical Journal ii, 148 (1968) Report to the World Health Organization on Assistance to Medical Education, Gujarat State, WHO, Geneva Selwyn S & Bain A D (1965) British Journal of Preventive and Social Medicine 19, 123 Selwyn S & Howitt L F (1962) Lancet ii, 548 Shanson D C (1976) Hospital Update 2, 589 Taylor R J, Howie J G R, Brodie J & Porter I A (1975) British Medical Journal iii, 635
Dr P E Crome (Westminster Medical School, London SWJ; Queen Mary's Hospital,
Roehampton) Hiematology Services for General Practitioners The concept of providing laboratory services to general practitioners has developed considerably in the last fifteen to twenty years against a background of debate as to the desirability or necessity of providing such services. Macauley (1962) com-
