call this competition-competition for the candidate, not ...

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Oct 23, 1971 - 4 Mullard, K., Hunterian Lecture, Royal College of. Surgeons of England .... merit award and considerably less prospect of extramural income ...

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Reflux and Hernia SIR,-Surgeon Captain T. L. Cleave (2 October, p. 50) approaches the problem of reflux and hiatus hernia from the physiological aspect emphasizing the normal variation in gastric motility in response to the volume of gastric contents. I am sure his approach is sound. Recent work by Cohen and Harris' which he quotes and by Castell and Harris2 has shown variation in gastro-oesophageal sphincter tone, probably dependent on the gastrin secretion and Heitmann3 has shown variations in sphincter tone in cases of sliding hiatus hernia. Gastric motility patterns can be observed and oesophageal circular muscle motility patterns can be measured and both show variation, normal and abnormal. Oesophageal longitudinal muscle contractions are seldom observed and cannot yet be measured, and have so far been ignored. However, it seems likely that abnormal contractions of the oesophageal longitudinal muscle distract the oesophago-gastric sphincter to cause incompetence and cause hernia, so that the oesophageal shortening so often observed radiologically and by surgeons operating on these cases is the cause and not the effect of the hernia and the incompetence. I have endeavoured to draw attention to these aspects4 which can be summarized in the statement that sliding hiatus hernia is a motility disorder of the foregut and especially of the oesophageal longitudinal muscle and not a localized anatomical lesion at the hiatus and that treatment, both medical and surgical, in order to be successful must take note of this. This view of the problem arising from much experience in the surgical treatment of hiatus hernia points in very much the same direction as Surgeon Captain Cleave's.-I am, etc., K. S. MULLARD Wessex Cardiac Thoracic Centre, Southampton Western Hospital, Southampton I Cohen, S., and Harris, L. D., New England Yournal of Medicine, 1971, 284, 1053. 2 Castell, D. O., and Harris, L. D., New England journal of Medicine, 1970, 282, 886. 3 Heitmann, P., Deutsche Medizinische Wochenschrift, 1970, 95, 824. 4 Mullard, K., Hunterian Lecture, Royal College of Surgeons of England, 11 February, 1971, in press.

Job Hunting-Why Not Emigrate? SIR,-As somebody who has worked in foreign countries and been treated with the utmost courtesy, I feel for Mr. B. S. Sengupta (2 October, p. 52). Like Othello, he and many others are foreigners who have been employed here in positions of trust, authority, and responsibility; like Othellos they have done the State some service and we know it. All who work in the hospital service in this country recognize this-or ought to. That so many of these trained, skilled individuals are unwilling or unable to return home and use their talents where they are so much needed is one of the great tragedies of the contemporary medical scene. I do not know the answer to their problem, but in the meantime these men and women, if we have nothing else to offer them, at least deserve our thanks and sympathy. It

ill-becomes us to summon them (or anybody else) to interviews when we know they will not be successful; still worse, and the height of incivility, is to ignore completely their application for posts.-I am, etc., W. K. COWAN Newcastle upon Tyne

SIR,-May I be allowed to agree with a foreign colleague? (2 October, p. 52). I too have had this experience of being called to interview and told that I am too senior. Indeed I have also been asked why do I not emigrate. As an additional finesse which may be shared by others could I offer the following: a referee refuses to support one because he declares that one is not applying for jobs senior enough, thereby making it almost impossible to obtain them! There is absolutely no doubt that these committees have their prepared candidates, and invite along others just to be on the safe side, in my opinion. The more insidious and bizarre the questions, especially the well known one which begins, "Doctor, you say here in your application that . . . You do understand, do you not ...." the greater the chance that there is something to hide.I am, etc., W. T. MENKE Kettering and District Hospital, Kettering, Northants

Tetralogy or Tetrad? SIR,-Since you have taken the trouble to print Dr. John Matthews's letter on "Fallot's tetralogy" (4 September, p. 585) as well as my own longer variation on the same theme many years ago (28 March 1953, p. 733), one must presume that you support the plea for the abolition of this term in favour of "Fallot's tetrad." However, the fresh letter is likely to be as ineffective as the former and perhaps others earlier still. The answer, Sir, is for you to agree with the editors of all the heart and chest journals to do your editing properly and, by use of your blue pencil, to see that the term "Fallot's tetralogy" never again appears in print.-I am, etc., R. T. D. FITZGERALD Sheerness, Kent

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ments. They are after the best man, and he is after the best job. The candidate is, from the onset, at a grave disadvantage as his mere appearance at the interview depends upon recommendations from his boss. He cannot even think of changing jobs without his boss knowing. No one in his right mind will admit at an interview to really being interested elsewhere, because the chances are he will not be offered the job. The answer to this problem is two-fold. Firstly, those responsible for arranging and conducting interviews should consult the bigger industries and realize that their problems are in reality minor irritations compared with some. Secondly, the candidates at an interview should be graded, then the job offered progressively downwards. If the descent continues below the fourth or fifth candidate, the hospital should have a long hard look at the job it is offering.-I am, etc., A. S. CHILVERS Mayo Clinic, Rochester, Minnesota, U.S.A.

SIR,-I see two serious dangers in Dr. J. de Swiet's proposal (25 September, p. 770) to deal with the candidate who accepts verbally the appointment committee's offer of a post and subsequently fails to take it up. Many mistakes can be made, and to wrongfully inform a referee that the subject of his reference has broken his word could be very damaging. The safeguard that is proposed, that a copy of the letter be sent to the alleged offender is useless, for many of these doctors are in temporary accommodation or are doing locums, situations where the forwarding of mail is always unreliable. At the risk of upsetting Dr. de Swiet again I would point out that many appointments committees cover themselves when offering a post by saying that they are merely advisory, so allowing themselves second thoughts before the candidate is informed in writing. If the appointments committee is so anxious to secure the candidate it merely needs to get a formal contract signed on the day of the interview. This would be equally binding on either party in respect of a breach.-I am, etc., ROGER HOLE Newcastle upon Tyne

Hospital Staff Appointments The New F.F.R. SIR,-Rather belatedly (the British Medical SIR,-The questions posed in my letter (28 Journal takes over one month to reach the August, p. 533) have been reinforced by the Middle-west of America), I would like to letters from Dr. C. G. Whiteside (11 Septemcomment on Mr. W. E. Jacobs's letter (14 ber, p. 639) and others. So far no response August, p. 435) concerning the "irrespon- has been forthcoming from those directly sibility" of junior doctors applying for jobs. concerned with Faculty policy. Can it be It is time that those responsible for appoint- that the questions are not answered because ing medical staff reconsidered what it is like there are no answers?-I am, etc., to be on the job circus. Good jobs are hard to come by; all jobs are a gamble. Because F. PYGoTT of the chaotic way in which the commence- Isleworth, ment and termination of jobs is arranged, a Middx young man has to apply for several jobs at a time just in case the one he really wants goes to someone else. If he is accepted into a Preclinical Salaries grade C post, he may well turn it down if he is later offered a better grade B job. You SIR,-We have noted with interest the comcall this competition-competition for the ments of a clinical colleague, Professor K. R. candidate, not by him. Hill (10 July, p. 116), and share his concern Today hospitals are little better than regarding the serious decline in recruitment industry when it comes to making appoint- of medical graduates to the permanent staffs

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of the preclinical departments in our expanding medical schools. The situation is, in fact, even more serious than he suggests, since medical graduates are being lost from the career staffs of these departments to appointments overseas and to clinical appointments in this country. Most of the medical graduates at present in preclinical departments entered at a time when the career and ultimate salary prospects compared favourably with those in other academic branches of medicine. The present situation, however, is so radically different that it is almost impossible to attract medical graduates to the permanent staffs of preclinical departments where the maximal salary of a senior lecturer is the same as that in all university departmentsnamely, £4,401, with no possibility of a merit award and considerably less prospect of extramural income than in certain other university departments. By contrast, medical graduates in departments such as experimental pathology, chemical pathology, bacteriology, virology, haematology, and social medicine are accorded "clinical status," even though direct responsibility for the management of patients is usually not entailed. The maximal salary for a clinical senior lecturer is £6,330, and there may be the added bonus of a merit award. His overall career earnings are therefore likely to be at least £50,000 in excess of his preclinical counterpart and his superannuation prospects run parallel. We believe that there is an immediate need for a general survey of the present staff structure in preclinical departments to determine the proportion of medical graduates on the permanent (career) staffs, together with their age distribution and in particular the number below the age of 35. Our own department is probably exceptional in including nine medical graduates among a staff of 22, but only one is below the age of 35; in fact, only three are below the age of 40. Professor G. R. Kelman (28 August, P. 537) reported that in the physiology department in Aberdeen there are only two medical graduates among a staff of 12, and both are professors. Should it be found generally that the majority of medical graduates remaining in preclinical departments belong to an older age group, the day cannot be far distant when many of these departments will be unable to maintain effectively their vital links with clinical medicine. It would then be impossible to ensure orientation of the course towards clinical medicine, to maintain satisfactory working liaison with clinical colleagues, or to preserve research links between the basic sciences and clinical practice. Besides, it is unlikely that the preclinical departments would be able to continue their important contributions to medical postgraduate education or to the training of ancillary medical staff. Though the B.M.A. has laboured for many years to gain for us rewards comparable with those in other sections of the profession its efforts have so far been in vain, and the gap continues to widen. If the profession as a whole shares our concern, and is in agreement with the view expressed in the Todd report' that medical graduates should make a substantial contribution to preclinical teaching, it must, as a matter of urgency, lend its considerable weight to support us, and in so doing maintain its own

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stake in the future of medical education. We are, etc.,

B. F. MARTIN P. ECKSTEIN S. H. GREEN D. DARLINGTON D. B. THOMAS

A. GLASS R. M. FLINN M. BERRY J. D. HATCH

Department of Anatomy, The Medical School, Birmingham 15 Royal Commission on Medical Education. Report, 1965-68, Cmnd. 3569, London, H.M.S.O., 1968.

*** The Committee of Vice-Chancellors and Principals has recently issued a questionnaire to universities about staffing precinical departments (Supplement, 16 October, p. 10) -ED., B.M.Y.

N.H.S. Salary Cheques SIR,-My monthly cheques from the executive council seldom arrive on the last day of the month but a day or two later. Should the end of the month fall on a Friday, then the cheques never arrive until Monday. In contrast, I observe that cheques from the Southeast Metropolitan Board are always handed to me a day or two early, especially if a weekend intervenes. Obviously this is only a small point to the individual doctor, but the saving of interest must be enormous to the N.H.S. if the practice is widespread. In view of the recent spate of publicity (Daily Telegraph, 24 September and 11 October) about doctors being paid for work they don't do-which we know to be mostly unfounded-I think this point merits consideration, since I have never heard of this happening in any other industry.-I am, etc., DAVID CHASTELL Broadstairs, Kent

Practicalities of Nursing SIR,-Your leading article (4 September, p. 545) fails to make its point with regard to the real practicalities of nursing. It is erroneous on two points: firstly, it shows lack of understanding about the essential differences between the medical and the nursing professions; and, secondly, it shows a complete misunderstanding of management and its application as recommended by the Salmon report.' The article criticizes the report's exaggerated devotion to the administration of the nursing services, but if one reads the committee's terms of reference, they were specifically related to senior nursing structure. Surely, a good report sticks to its terms of reference, and Salmon was about management. There is a danger of interpreting this report other than in management terms. This is illustrated by the quote referring to senior nurses interfering in ward matters. The committee was right to place emphasis on this point, because only by effective delegation can such a management system work, and in the past nurses have been particularly guilty of not delegating. This leads to the apparent lack of understanding in the article about the main differences between the two professions, as shown by the statement "The proper care of the patient depends on nursing, not on administration." Everyone would agree that the standards and skill of those giving the

nursing care is essential. However, this standard and skill can function only by the use of effective nursing management. Also, the quality of care can be improved by relieving nurses of non-nursing duties, and it is only nurses who can decide what nursing is and what it is not. From this need to provide a service, the essential variance between medicine and nursing becomes obvious: that although they have much in common, and work in harmony, their social setting in the hospital differs-tradition and professional norms are apart. No one in the nursing profession, at any level, seriously considers that the motives for entering the profession are to become administrators, just as they would not conceive being tutors or midwives either. In nursing, there is room for people at all levels of reasonable educational attainment who can provide, at different levels, a useful service both to the profession and to the patient. However, there is a need to provide a system of education in nursing which will attract well-educated men and women into the profession. At present there is a conflict between service and training, and the reasons that you give for wastage, recruitment, etc., are over-simplified. The idea of the nurse consultant is an excellent concept. However, we must be realistic and accept that many people believed this would be part of the role of the nursing officer, grade VII. Also, social and economic factors and the structuring within the health service would prevent full exploitation of this role, and would the medical staff really accept this person in his own right? This is an area of doubt to many in the nursing profession. Those criticisms which have appeared in your columns do not apply to the Salmon recommendations, but to their over-hasty implementation in certain quarters, without a real understanding and acceptance. Blame may be laid at the Prices and Incomes Board's doors, possibly for its report No. 60,2 which was the catalyst to this rush for implementation.-I am, etc., M. M. COLLEDGE Department of Nursinz and Welfare Studies, Newcastle upon Tyne Polytechnic, Newcastle upon Tyne 1 Revort of the Committee on Senior Nursing Staff

Structure, Ministry of Health and Scottish Home and Health Department, H.M.S.O., 1966. 2 National Board for Prices and Incomes Report No. 60. Pay of Nurses and Midwives in the National Health Service. Cmnd. 3585. London, H.M.S.O., 1968.

Portrait of Dr. Ronald Gibson SIR,-I have heard from the Secretary, Dr. D. Stevenson, that he has received a sum of £368 donated by members of the Representative Body at their meeting in Leicester with the suggestion, I believe, that it be put towards a portrait of myself, as past Chairman of Council. I have no other way of expressing my most sincere thanks to the Representatives than through a letter to you. My wife and I would like all those who subscribed to this fund to know how very much we appreciate their generous gesture. I am only sorry that it is impossible for me to thank each one in person.-I am, etc., RONALD GIBSON Winchester