1294
Communication SHARING THE RESPONSIBILITY FOR TREATMENT How MOST
can
people who
the doctor help the patient? are
ill
want to recover as
quickly
as
pos-
sible, unless there is some secondary gain from the illness, or apathy and depression predominate. Recovery (or, if recovery is not possible, successful adjustment to an illness or disability) is hastened by any effort that the patient can make and any responsibility he can take for his recovery or adjustment. It seems desirable, therefore, to give the patient as much responsibility for the management of his illness as he is capable of accepting. This will be possible only if he understands what he is suffering from, what the doctor is trying to do and why, and how he, the sick person, can monitor progress. The doctor’s responsibility is to explain to the patient (so far as the patient can understand it) the various courses of action between which a choice must be made, their expected outcomes, and any associated problems and inconveniences that the patient may consider important. If the patient himself cannot understand or does not wish to know about these matters, the doctor should try to share the responsibility with the relatives or the patient’s friends. When a person is ill he needs to be able to ask the doctor, nurse, or other health professional relevant questions-that is, those which will give him adequate information about his illness and its management. He will often need help in the formulation of these questions, either from a non-professional or a
professional
source.
Some simple questions about the use of medicines that are often important for patients appear below, with an explanatory note for the patient. The diplomatic phrasing is intentional, for some doctors easily take offence when the patient appears to "question" his treatment, so it is important for the patient not to seem to cast doubt on the treatment, but to make it clear that he would merely like to understand certain aspects of it. The list also differs from the questions for students’ in
QUESTIONS
WHICH PATIENTS MAY WANT TO ASK THE DOCTOR ABOUT THEIR TREATMENT
most benefit from your treatment if you know why you it and how you should use it. So if there are any questions on this sheet that concern you and that you don’t know the answer to, please ask the doctor.
You will get are
having
1. What for and how? What kind of tablets to
are
they and in what
way do you expect them
help?
How should I take them? Will I be able to tell whether
they are working?
2. How important? How important is it for me to take these tablets? What is likely to happen if I do not take them?
3.
Any side-effects? Do the tablets have any other effects that I should look out for? Do they ever cause any trouble? Is it all right to drive while I’m taking them? Are they all right to take with other medicines I may need? Will alcohol interfere with them?
4. How long for ? How long will I need to continue with these tablets? What should I do with any that are left over? When will I need to see you again? What will you want to know at that time? 1
Herxheimer, A. Lancet, 1976,
u,
1186.
that a patient may be concerned with only one or two questions and the list is really intended as an aid to starting an informative conversation with the doctor. Many doctors, of course, try to give this sort of information to all their patients when they prescribe for them, but often time is short and one or other item may be forgotten. Prescribers who want to ensure that their patients have all the information they would like could therefore put copies of the question list in their waiting-room to encourage patients to ask about these matters if they do not clearly understand them. Pharmacists likewise could prove themselves a more valuable source of information and education for patients. Hitherto they seem to have been inhibited by fears of trespassing on the doctor’s territory, but there can surely be no objection to their suggesting some relevant questions for the patient to put to his doctor. I
am
grateful to my colleagues at the London Hospital Medical ColCharing Cross Hospital Medical School for helpful sugges-
and tions.
lege
Departments of Medicine and Pharmacology, Charing Cross Hospital Medical School, London W6 8RF
ANDREW HERXHEIMER
Round the World
United States NEW RULES ON MEDICAL TRAINING
The Health Professions Educational Assistance Bill of 1976 was recently signed by President Ford and became law. This Act is going to have profound effects on the practice of medicine in the U.S.A. As a result of its passage, medical schools are required to ensure that first-year primarycare training programmes (defined as family practice, internal medicine, and paediatrics) are filled at specified percentages of all filled first-year positions. This means that, in order to qualify for capitation support, without which few if any medical schools could survive, at least 50% of the residency training positions in a medical school must be allocated to trainees in primary care. No longer will certain Ivy League institutions be able to boast that they train physicians for academia only. All in all, this seems a not unreasonable provision, since the U.S. has a surfeit of certain specialists. Also affected will be many foreign medical graduates. No longer will hospitals be able to employ exchange visitors for exclusively service functions; training will be a mandatory part of all posts for foreign medical graduates. The length of stay for trainee specialists coming to the U.S. will be limited to two years, and will be extended for a further year only upon presentation of sufficient evidence to justify the additional year, Before coming to the U.S. all trainees will be expected to have passed Parts 1 and2 of the examination of the National Board of Medical Examiners or its equivalent (for example, the E.C.F.M.G.). The effect of this legislation will be to prevent a foreign medical graduate from completing a full training programme in a specialty in the U.S. In addition, immigration will become far more difficult. Most affected, however, will be the many State psychiatric and chronic diseases hospitals that have been, and continue to be, almost entirely staffed by foreign graduates. In many instances such staff have a provisional licence only, and are paid a salary which is substantially below that which any self-respecting U.S. graduate would accept. The standard of care, the available facilitites, and the overcrowding in many State mental hospitals compare most unfavourably with their British equivalents. On the whole, the effects of the new law should be beneficial, but it is to be hoped that it does not hinder exchange programmes for distinguished scholars and scientists.
(PL 94-484)
Communication SHARING THE RESPONSIBILITY FOR TREATMENT How MOST
can
people who
the doctor help the patient? are
ill
want to recover as
quickly
as
pos-
sible, unless there is some secondary gain from the illness, or apathy and depression predominate. Recovery (or, if recovery is not possible, successful adjustment to an illness or disability) is hastened by any effort that the patient can make and any responsibility he can take for his recovery or adjustment. It seems desirable, therefore, to give the patient as much responsibility for the management of his illness as he is capable of accepting. This will be possible only if he understands what he is suffering from, what the doctor is trying to do and why, and how he, the sick person, can monitor progress. The doctor’s responsibility is to explain to the patient (so far as the patient can understand it) the various courses of action between which a choice must be made, their expected outcomes, and any associated problems and inconveniences that the patient may consider important. If the patient himself cannot understand or does not wish to know about these matters, the doctor should try to share the responsibility with the relatives or the patient’s friends. When a person is ill he needs to be able to ask the doctor, nurse, or other health professional relevant questions-that is, those which will give him adequate information about his illness and its management. He will often need help in the formulation of these questions, either from a non-professional or a
professional
source.
Some simple questions about the use of medicines that are often important for patients appear below, with an explanatory note for the patient. The diplomatic phrasing is intentional, for some doctors easily take offence when the patient appears to "question" his treatment, so it is important for the patient not to seem to cast doubt on the treatment, but to make it clear that he would merely like to understand certain aspects of it. The list also differs from the questions for students’ in
QUESTIONS
WHICH PATIENTS MAY WANT TO ASK THE DOCTOR ABOUT THEIR TREATMENT
most benefit from your treatment if you know why you it and how you should use it. So if there are any questions on this sheet that concern you and that you don’t know the answer to, please ask the doctor.
You will get are
having
1. What for and how? What kind of tablets to
are
they and in what
way do you expect them
help?
How should I take them? Will I be able to tell whether
they are working?
2. How important? How important is it for me to take these tablets? What is likely to happen if I do not take them?
3.
Any side-effects? Do the tablets have any other effects that I should look out for? Do they ever cause any trouble? Is it all right to drive while I’m taking them? Are they all right to take with other medicines I may need? Will alcohol interfere with them?
4. How long for ? How long will I need to continue with these tablets? What should I do with any that are left over? When will I need to see you again? What will you want to know at that time? 1
Herxheimer, A. Lancet, 1976,
u,
1186.
that a patient may be concerned with only one or two questions and the list is really intended as an aid to starting an informative conversation with the doctor. Many doctors, of course, try to give this sort of information to all their patients when they prescribe for them, but often time is short and one or other item may be forgotten. Prescribers who want to ensure that their patients have all the information they would like could therefore put copies of the question list in their waiting-room to encourage patients to ask about these matters if they do not clearly understand them. Pharmacists likewise could prove themselves a more valuable source of information and education for patients. Hitherto they seem to have been inhibited by fears of trespassing on the doctor’s territory, but there can surely be no objection to their suggesting some relevant questions for the patient to put to his doctor. I
am
grateful to my colleagues at the London Hospital Medical ColCharing Cross Hospital Medical School for helpful sugges-
and tions.
lege
Departments of Medicine and Pharmacology, Charing Cross Hospital Medical School, London W6 8RF
ANDREW HERXHEIMER
Round the World
United States NEW RULES ON MEDICAL TRAINING
The Health Professions Educational Assistance Bill of 1976 was recently signed by President Ford and became law. This Act is going to have profound effects on the practice of medicine in the U.S.A. As a result of its passage, medical schools are required to ensure that first-year primarycare training programmes (defined as family practice, internal medicine, and paediatrics) are filled at specified percentages of all filled first-year positions. This means that, in order to qualify for capitation support, without which few if any medical schools could survive, at least 50% of the residency training positions in a medical school must be allocated to trainees in primary care. No longer will certain Ivy League institutions be able to boast that they train physicians for academia only. All in all, this seems a not unreasonable provision, since the U.S. has a surfeit of certain specialists. Also affected will be many foreign medical graduates. No longer will hospitals be able to employ exchange visitors for exclusively service functions; training will be a mandatory part of all posts for foreign medical graduates. The length of stay for trainee specialists coming to the U.S. will be limited to two years, and will be extended for a further year only upon presentation of sufficient evidence to justify the additional year, Before coming to the U.S. all trainees will be expected to have passed Parts 1 and2 of the examination of the National Board of Medical Examiners or its equivalent (for example, the E.C.F.M.G.). The effect of this legislation will be to prevent a foreign medical graduate from completing a full training programme in a specialty in the U.S. In addition, immigration will become far more difficult. Most affected, however, will be the many State psychiatric and chronic diseases hospitals that have been, and continue to be, almost entirely staffed by foreign graduates. In many instances such staff have a provisional licence only, and are paid a salary which is substantially below that which any self-respecting U.S. graduate would accept. The standard of care, the available facilitites, and the overcrowding in many State mental hospitals compare most unfavourably with their British equivalents. On the whole, the effects of the new law should be beneficial, but it is to be hoped that it does not hinder exchange programmes for distinguished scholars and scientists.
(PL 94-484)
