SIR,-May I comment on two statements in your leader of Jan. 4 ? They read, " The standard [of general practice] on the whole is none too high," and " To be a first-class G.P. is harder than to be a competent
It seems to me that the root of these truisms lies in the prevailing ’system of our medical education; although most students are destined for general practice, this aspect of learning is unrepresented either on the teaching staffs or as a subject for examination. The situation is analogous to that of a would-be architect spending a succession of training periods under the tutorship of plumbers, slaters, joiners, bricklayers, and electricians before being let loose in the field of architecture, there to find a living as best he may. Is it surprising that many aspiring disciples of Hippocrates are discouraged by their inability to understand or mediate so much of illness as met in their world and fail to rise above the mediocrity of bottle-pedlary ? The masters have taught them to believe that the patient is ill because he has a disease, and that the means to cure lies in the application of the materia medica. Now they find that many of their patients have no textbook pathology and the materia medica is rather a farce, with as little power to retard the onset of lesions as to remove most of them when they appear. With the passage of time most general practitioners gain wisdom from association with their patients and colleagues, and largely revert to the laws laid down by the Greeks 2500 years ago : " Man was not an isolated body ; and his disease was no mysterious possession of the body by an evil spirit, but an event in the order of nature, to be followed patiently and to be rectified, not by a single remedy, but by every means that is The practitioner available for producing health." gradually comes to look on ill health as an expression of a noxious environment, and- may even discern the nature of the stress factor in the mode of physical breakdown. Unfortunately his wisdom, laboriously acquired, usually dies with him. The evolution of general practice should not lead towards one of the existing specialties but to a fuller appreciation of man in relation to his environment, particularly as this affects the development of chronic diseases. Why does one person -suffer from asthmabronchitis, another from one or other of the dyspeptic syndromes, another from rheumatism, and yet another from one of the hypertensive diseases ? A comparison of the life situation and emotions of one group with that of another may do much to make these disorders comprehensible. For example, does anyone ever get rheumatism if what he is doing is accompanied by joy, excitement, or interest ? How often is the " doing part " of our bodies driven to perform monotonous tasks to attain a goal, to fulfil an ambition, or merely to earn a livelihood ? The tally of this stress may well turn out to be the measure of our rheumatism. There must be a radical change in the teaching curriculum to enable the fruits of these observations to be garnered, sorted out, and
passed on. Today the
medical ships lack captains. There is no shortage of experts in technical departments-first-class engineers, painters, caulkers, carpenters, and the likebut it is difficult to conceive the emergence of a captain from their ranks. Experience in divers offices is a prerequisite of the premiership. Finally, we practitioners are frequently exorted to take refresher and postgraduate courses. Who is there
to teach us what we need to learn ? We want to know how to modify the earliest iridications of the common forms of ill health : why are we at times prone to colds in the nose, to boils, or to digestive disorders ? How often is the senior practitioner asked to lecture to the junior ? Let there be abundant interchange of viewpoints among all sections of our ancient profession, but let us be consistent. Perhaps the brain surgeons would appreciate an intensivee refresher course from the
dermatologists ! v
G. GLADSTONE ROBERTSON.
THE B.M.A.’s DECISION the present Government came into power many of its members, not excluding the Minister of Health, expressed themselves in a manner calculated to give offence to medical men as well’as to others. The Minister of Health had also a past to live down, or live up to, which was not such as to assure former political opponents that they could expect a fair deal. In these circumstances negotiations commenced. Negotiations involve the meeting together of individuals who are interested in the same subject although from different points of view. These individuals have often mutual suspicions and conflicting political ideals, and there is always a danger that negotiations may break down because the public interest has been subordinated to the clash of personalities. This particular danger threatened negotiations with Mr. Bevan from the very first ; and now, for that or some other reason, they are at a standstill and are menaced with complete failure at a very critical moment for the profession. When we have finished blaming Mr. Bevan for all the difficulties which beset us, is there not still room to inquire whether we ourselves have not sometimes been at fault ? According to the Minister of Health, who has expressed his views publicly and courageously, our representatives were so obstinate and so devoted to argument by slogans that real negotiation became impossible. Mr. Souttar, president of the British Medical Association, took the same view and ceased to be a member of the- Negotiating Committee. We have therefore grounds for thinking that the personal relationships between some at least of the B.M.A. leaders and the Minister of Health have become such that useful discussions would be difficult. These same members have proclaimed that it is the Minister who is altogether at fault and that a breakdown in negotiations is actually desirable. I am no more than an onlooker where the B.M.A. is concerned ; but it is said that onlookers see most of the game. I should like to suggest that a change in leadership before it is too late might well save a professional debacle. GORDON WARD Sevenoaks, Kent. Vice-president,
Medical Practitioners Union.
SIR,-In his letter of Jan. 11 Mr. T. B. Layton accuses the B.M.A. of herding the profession. I am not a member of the B.M.A. (though I now intend to joinof my own free will) and except for an occasional circular asking my support they have made no attempt to herd me.
Can the same be said of the Labour Party and the trade unions ? Is the Labour M.P. allowed the very slightest freedom of vote without incurring the displeasure of his party chiefs and possible disciplinary action ?P Will the workman soon be allowed even the elementary right to work without bending the knee to his trade-union bosses ? I think not. Mr. Layton’s cap will, I think, be found a better fit on other heads than that of the
A. J. FRASER-SIMSON. Chigwell, Essex. THE PLEBISCITE AND AFTER SIR,-Whatever the plebiscite may or may not have done, it has shown that most of us are in medicine to get the best living we can out of it. The majority of the consultants vote Yes because they see private practice remaining in statu quo, and a chance of getting paid in the future for doing what they now do for nothing. Those employed in public-health work and municipal hospitals vote Yes because they don’t see how they can be any worse off, and they might possibly gain something. The G... seeing before him the swings of decreased income, and control increased to potential tyranny-but no compensatory roundabouts-votes No. Then he shrugs his shoulders, grabs his bag, and trots off to his branch surgery. Let the Minister realise that we are a body of professional craftsmen ready and anxious to do a decent job for decent pay and decent conditions of service : let him now put forth some definite and positive offer in respect of (a) remuneration, (b) compensation, and (e) working hours, instead of this hideous blackmail of "If you don’t sign on the dotted line on the proper day you get nothing" ! Failing this, let him huff and puff and threaten to blow our house down as much as he likes,