Training for general practice

Training for general practice

Book Reviews its contents. In the first two sections of the conference (and book), participants adressed the specific topic “Ethical Review of Clinica...

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Book Reviews its contents. In the first two sections of the conference (and book), participants adressed the specific topic “Ethical Review of Clinical Research” while in the third section attendees explored “Medical Ethics in Medical Education” and in the fourth they discussed “Medical Education and Government”. By way of general comments, it is apparent that little effort was expended on focusing and coordinating the various contributions. The quality of the papers varies greatly with respect to both content and style. Nevertheless, substantial valuable material is presented. A major theme of the book is stated in the conference’s keynote address by Dr Hector Acuna, Director of WHO‘s Pan American Sanitary Bureau. Dr Acuna draws our attention to potential differences between ethical considerations involving individual doctor-patient relationships and the ethics of public health or the relationship between the scientific and wider communities. He notes a special concern with regulation of research. The reader does not have to struggle to hear in his remarks the concern in the “Third World” that the poor and poorly educated populations are at risk for exploitation, especially by capitalist enterprises. On the one hand are economic. social, political and cultural barriers to collective or individual informed consent to be research subjects. On the other hand, there is a desperate need for scientific work and creative trials to solve the health problems of the underprivileged. This theme is echoed in the papers that follow. The American philosopher. John Ladd. while pointing out common confusions regarding the ethics of human experimentation, reminds us that consent is more of a legal concept than a moral one. This usual notion of informed consent assumes some measure of equality of knowledge and power on the part of experimenter and subject. For those living in poverty and ignorance, such a legal conception “of informed consent does not, in certain cases at least, provide a sufficient basis for the morality of an experimental project”. Ironically, Dunn’s paper is followed by one from Robert Levine, Yale’s ponderer of the ethics ofclinical research, who presented a historical view of Institutional Review Boards (IRBs) that is unfortunately completely bound by the “high-tech” medical research establishment in the affluent United States of America. John Dunne, Senior Medical Officer at WHO, then presented his organization’s guidelines for ethical review of human research. The WHO considerations of regulation of research reveal a more cautious, global perspective. The second set of papers on ethical review of research are narrowly focused: two discuss the situation in single countries (Argentina and Chile). one piece is about a special group of subjects-women. and another gives the perspective of the Latin American Association of National Academies of Medicine. The first two papers provide an interesting contrast. The piece from Argentina notes the cultural impossibility of informed consent in certain circumstances. while the Chilean author insists on the value of subjects receiving “complete information”. Whether these views reflect real national differences or the ideas of their writers. is hard to determine. The paper on women is a review of the hazards and successes of contraception and, while interesting. does not belong in the collection. There is inadequate effort to relate the maternal to themes of the conference. The paper on National Academies is only summarized in English. with a full text in Spanish. The summary suggests a wholly Catholic view of research and its regulation, trusting that faith and avoidance of forbidden pursuits (e.g. population control) are adequate to govern medical science. The section on ethics in medical education continues the debate about the proper scope of bioethics. Mark Siegler from the University of Chicago asserts that clmical ethics must center on real patients in the midst of substantive clinical training. By contrast. Edmund Pellegrino of the Catholic University in Washington. DC. extolls the virtues


encompassing the of medical humanities programs. teaching of law. literature, social and behavioral science, history, etc. August Leon, Professor of Medicine at Central University, Caracus. Venezuela. states that Latin American physicians have little or no knowledge or interest of medical ethics beyond codes of etiquette. He proposes a farreaching efiort in his country to establish a foothold for this “new” discipline. A paper from Vienna on ethics in psychiatry contains virtually no consideration of education. Like the paper on women. it does not belong in the compendium. The conference’s last session on medical education and government has a series of short papers that consider the role of educational institutions and governments in influencing a critical area of concern in bioethicssresource allocation. Here we clearly see different priorities regarding the competition for support for medical service, teaching/learning. and research. The contributions to this volume by authors from the U.S.A., whose work is familiar to me. arenot in and of themselves especially noteworthy. (To be sure, the papers by Ladd and Siegler are lucid and substantive.) The conflicts of value and contrasts of cultures emerge clearly once one has finished the separate papers and stepped back for reflection. The reader looking for pace-setting articles on medical ethics and medical education should search elsewhere. Those interested in the cultural and economic influences on ethics in medicine and medical education may well find the book interesting. Deparrmenr of Pediatrics Children’s Hospital qf Pirtslnqh University qf Pitrshurgh Pittsburgh, PA. U.S.A.


Training for General Practice, by D. J. PEREIRAGRAY. MacDonald & Evans, Plymouth. England, 1982. 324 pp. E9.95 The National Health Service in the United Kingdom since its inception in 1946 has had irs ups and downs. Expanding high technology medicine practised in hospitals has been consuming an ever increasing proportion of the NHS budget. In 1977 the government. whether by a sense of good housekeeping or an enlightened awareness of the potential of home management, gave its backing. with its NHS Vocational Trammg Act. to care outside the hospital and to the general practitioner community. This act stipulated that after the 16th August 1982 it was no longer possible for a doctor to become a principal in NHS general practice in the U.K. without having completed a 3 year programme of training for general practice. In, his book, Training for General Practice, Dennis Pereira- Gray. a general practitioner in Exeter. Senior Lecturer, Department of General Practice, University of Exeter, and. for many years, the Editor of the Journal of the Royal College of General Pracririoners, has succintly laid out the operation and effect of this Act. He also provides an authoritative view of the way likeminded GPs. dissatisfied with the morass into which general practice was sinking. decided to lift themselves up with their boot straps to form, in 1952. a college, later the Royal College of General Practitioners. Thejourney across the hilly. politically minetrapped terrain up to the present day is well mapped out and comprehensible even to a non medico-politico type like myself. The machinations and roles of the General Medical Council. General Medical Services Committee. Local Medical Coinmittees. Councils for Postgraduate Medical Education. Royal College of General Practitioners. British Medical Association. and so on are briefly but adequately revealed. particularly the way in which the Joint Committee on Postgraduate Training for General Practice was established in 1975. The JCPTGP.


Book Reviews

apart from its responsibility for issuing certificates for vocational training in the U.K., has a waatchdog role in maintaining adequate standards of vocational training through its panel of visitors who, every other year, monitor one or more training schemes per region. The chapter on “General Practice: An Independent Clinical Discipline” is a clear rebuttal of Ann Bowling’s denigratory assertions in her book Delegation in General Practice, in which she laid claim to GP role insecurity. inadequate job definition and anxieties about professional status. From that chapter on, the whole book is characterised by clear, decisive thinking, as the author tackles the present state of vocational training for general practice. its bedrock on sound educational principles, and its future fired by the enthusiasm of existing trainers, course organisers and advisers, along with the flush of increasing numbers of vocationally trained GPs intent on raising standards of patient care. There is no flinching from the nitty gritty of emotive issues that can bedevil adult relationships when one doctor is cast in the role of learner. the other as teacher. Convincing arguments are put forward to justify the payment of general practitioner trainers for teaching in contrast to the hospital based medical (consultant) teachers. As if to back this up. the increasingly rigorous code and practice for selecting trainers is spelled out. as are the requirements for attendance at trainers’ courses, workshops, half day or whole day weekly seminars and the system of reapproval-all added pressures to everyday clinical supervision. If GPs don’t enjoy teaching and learning they won’t last long as trainers. There aren’t many stones left unturned in the chapter on “Characteristics of Training Practices”. It’s worth reading by any trainer-and the practice partners. It forms a basis for a commg seminar using self and peer assessment techniques, involving all trainers and trainees alike. The excellent chapter, “Teaching Methods”, will also be used in the same way. Although I have been in the teaching business for over 10 years and am already familiar with much of the material of both those chapters, nevertheless they draw ideas together to form a practical guide. In its structureandcontent, the book reflects the use of the consultative-educational model in which the learner takes an increasing part in the design, execution and assessment of his own learning programme. The 4th National Conference of Vocational Trainees devised a useful questionnaire circulated to all U.K. trainees which provided Pereira Gray with invaluable trainee opinion on their experience. This information is used well in appraising training practices, trainers, structure of training schemes and also the sanctified ground of the trainer/trainee relationship. The various models of that relationship depicted by the author contain imaginative analogies. both entertaining and pragmatic. “Animal trainer“, “puppet on a string”, “ producer/actor” are but a few that should whet the appetite-if only for blood! This book is of interest not solely for those established in general practice or in training to enter practice. The section on “Training in Hospital and Community Medicine” should prove of equal benefit to our consultant colleagues. Again, like any self respecting teacher, the author is obliged to ask the uncomfortable question “Does vocational training work?” Stung by Cartwright and Anderson’s (1979)Occasional Paper 8 : Patienrs and their Doctor-1977. in which the author found no evidence for and some evidence against the hypothesis that specific training for family medicme increased general practitioner acceptance of family problems, he responds with an impressive variety of indirect or circumstantial evidence along with some direct/ objective data that vocational training for general practice does work and is worth the effort that is put into it. What struck me most were Freeman and Byrne’s (I 973 and 1976) tindmgs. using pre and post course modified essay question techniques. which revealed “changes in personality, especi-

ally in their characteristics of rigidity. authoritariamsm and cynicism”. I have no hesitation in recommending this book to trainers and trainees alike. course orgamsers and advisers. and consultants and others mvolved in vocational training. It could also give useful insights to members of other caring professions such as nurses and social workers who are also engaged in the sensitive area of teaching interpersonal communication skills. It is appropriate to conclude with the book’s quotation from Plato: “In medical education as in other kinds of education, what matters most is not the knowledge imparted to a man but what the man himself becomes in the course of acquiring the knowledge.” Boston Vocarional Training Scheme Lincolnshie. England


Das Wort in der Gruppe, by RUTH WODAK. Verlag der Oesterreichischen Akademie der Wissenschaften. Wein. 1981. 316 pp. 62 DM In her book “Das Wart in der Gruppe” (“The Word In rhe Group”) Ruth Wodak describes her adventure in working with a group of people at the “Kriseninterventionszentrum der Stadt Wien”, a crisis intervention clinic in Vienna where she is undertaking psycholinguistic studies. There are 6 chapters. In the first, Wodak gives an overview of the field of psycholinguistics, the linguistic aspects in psychotherapy. Freud stressed the importance of the languagein psychoanalysis. Theconceptions of Wittgenstem, Habermas. Abraham. Lorenzer. Lacan and Watzlawick are briefly described. The importance of communication in schizophrenia for psycholinguistic research is mentioned. In the second, Wodak presents the hypothesis of her study. Therapeutic communication differs significantly from usual everday communication in content and structure. As a background. the author gives an analysis of communication in the group setting. Topics include: different levels of communication, the differences between group and one-to-one therapy, the role of metacommunication (communication at the relationship level). various aspects of meaning in the language, common meaning (“Umgangssprache”, group meaning) and individual meaning (private language). sociological questions such as sex and social class with differences in the response to group therapy, and the attempts to measure the therapeutic effect by the change m verbal communication. In Chapter 3 Wodak gives a detailed description of her project, which is an empirical. longitudinal study. In a crisis intervention clinic from 1976 to 1978, she observed an “open” group of about 12 patients, 30-39 years old. Twothirds of the patients were women. Two therapists work with this group in a symptom-oriented way 4 times a week. In a pilot study, Wodak tapes 4 sessions and evaluates them in order to adjust the hypothetical assumptions. In the main study, 16 sessions are taped during a period of 2 months. At the same time the author registers non-verbal reactions during the group work. In addition. she interviews 10 patients in their homes and asks them about their impressions concerning the therapy. Doing so she gets to know the patients’ language outside the therapeutic situation and their living conditions. She also interviews the therapists and asks them their opinion concerning the therapeutic method. the chances of success and the efficiency of the clinic. The quantitative and qualitative evaluation is the last part of the study. In a very personal and sympathetic way. Wodak writes about theethical aspects and about her feelings m connection with this evaluation. the dilemma between the I-Thou and I-It relationship (M. Buber). She examines the relation between verbal contributions and age social status,sex on