CARDS FOR PATIENTS TAKING STEROIDS
1
321 based upon well-observed facts. In addition to emotionally induced changes in mucosa and muscle these include the many studies in emotional and personality types found in ulcerative colitis, from the pioneer clinical observations of Hurst 6 through the character studies of the thirties to the, in some cases, more detailed work of the past decade or so. A few other studies not mentioned by Dr. Sim and Mr. Brooke are listed below.’-9 The presence or absence of diarrhoea as an initial symptom does nothing whatever to detract from these many deep and massive studies of the psychogenesis of ulcerative colitis. To all who have studied it carefully from both aspects this disease is so strikingly based upon a complex of body-mind relationship that it is distressing to find two modern writers who are willing to think such a frail criterion as the time of arrival of liquid stools can leave us " little evidence " of the deeply distorted charac- ters and the profound physical and mental susceptibilities and sensitivities that are causally connected with the svmptoms in sufferers from this disease. RANYARD WEST. Dorrington Grove, near Shrewsbury. "EXPERIENCE AND INCENTIVE" AWARDS? E. O. EVANS. SiR,ńThe principle of differential payments to general practitioners for the quality as distinct from the quantity of their work appears at last to be receiving serious atten- tion. The stumbling-block of " merit " awards lies in the difficulty of finding a method to assess merit. I do not believe that any system which depended primarily on the assessment of the merit of one practitioner by another practitioner could possibly succeed. The idea that a board of consultants might do it would surely be as embarrassing to the consultants as it would be to the general practitioner. May I suggest therefore that the word merit " be dropped altogether and that an alternative experience and incentive " award be considered ? The difference in such an award is that it would not be beyond the reach of all G.P.s at some time in their careers. For this reason I believe it would be more generally acceptable. If payment for it was met out of some fund other than the central pool it could play a big part in what should be its main purpose-i.e., the promotion of good general practice. For such an award only criteria that are fairly easily assessed could be used. I would suggest: (1) 10 years’ experience as a principal. (2) A high standard of surgery premises and equipment. (3) A list of patients not below a certain minimum, nor yet above a certain maximum considered locally suitable. To those critics of such yardsticks (e.g., Burdon 10) I would point out that while experience is no guarantee of merit, it is fair to assume that every doctor is a better doctor for 10 years’ experience (indeed general practice is about the only branch of medicine in which experience is not rewarded). Again, whatever his capacity, any doctor can surely give a better service to 2500 patients than he can to 3500. More- over, an incentive to reduce his list would encourage him to take in a partner, or form a group practice. Similarly, good premises and equipment, though no guarantee of good work, are essential tools for the job. A fourth element, to form the incentive side to such an award, is more difficult to define. t suggest that it should amount to an expression of willingness on the part of the individual to maintain his efficiency. This would take different forms. Some like to take refresher rnnrsM. Others nrefer to enaqge in research or to he 6. Hurst, A. F. Guys Hosp. Rep. 1921, 71, 26. 7. Moscheowitz, E. Amer. J. med. Sci. 1943, 206, 576. 8. Murray, C. D. ibid. 1930, 180, 239. 9. West, R. Lancet 1946, ii, 899. 10. Burdon, J. F. Brit. med. J. 1958, ii, Suppl. p. 27. clinical assistants at nearby hospitals-or to engage in some other form of postgraduate training. The essential thing I suggest is that, to qualify for such an award, the doctor would have to bring evidence of his efforts to improve his efficiency in one way or another. I see no harm in the idea that such evidence should be produced again, say, every seven years-so that the grass shall not grow, &c. Stratford-on-Avon. CARDS FOR PATIENTS TAKING STEROIDS J. J. R. DUTHIE Chairman, Education Sub-committee, Empire Rheumatism Council. Faraday House, 8-10 Charing Cross Road, London, W.C.2. SIR,-It is recognised that sudden withdrawal of steroids in patients undergoing long-term treatment may be dangerous, particularly when such patients have been subjected to sudden stress, such as an acute illness, acci- dent, or emergency operation. In these circumstances it may be of vital importance for the physician or surgeon responsible for the patient’s immediate care to be made aware that the patient has been on steroid therapy, the form in which it is being administered, and the daily dose. The education subcommittee of the Empire Rheuma- tism Council gave this matter consideration at a recent meeting and reached the conclusion that a useful purpose would be served by the issue of a card to patients receiv- ing steroids, stating the preparation in use and its daily dose. The hospital or clinic supervising the patient’s treatment and the name and telephone number of the family doctor should also be recorded along with simple instructions to the patient. I have been instructed by my committee to bring this matter to your notice, as the Empire Rheumatism Council would be prepared to make a supply of these cards avail- able to any physician who might wish to use them. VENTRICULAR SEPTAL DEFECT SIR,-Your leading article of July 12 favours a classi- fication based primarily on catheter studies and necropsy. Open heart surgery enables one to obtain a more physio- logical appreciation of the anatomical defects; 36 ven- tricular septal defects have been repaired in the past year at this hospital and as a result it is suggested that the presence or absence of an infundibular pulmonary sten- osis plays a major part in the pathological physiology of ventricular septal defects, and that therefore this factor should be included in such a classification. Full cardiac catheterisation figures and operative details are available on 22 of these 36 cases. They suggest that the following classification be used: (1) The pulmonary-artery pressure, right ventricular pres- sure, and systemic pressure are of a similar level. These cases have no obstruction to a shunt of blood from the left ventricle to the right ventricle, and they have no obstruction to the out- flow tract of the right ventricle. The cardiac catheter passes with ease into the pulmonary artery. At surgical repair, though there may be some work hypertrophy of the infundibular muscle, the outflow tract is adequate and no resection of muscle is required. We have had 12 such cases, with 4 deaths. (2) The pulmonary-artery pressure is low; the right ven- tricular pressure high, approximating to the left ventricular pressure. No cyanosis is present. These cases are frequently referred to as an " acyanotic tetralogy of Fallot". The cardiac catheter may pass with some difficulty into the infundibular chamber and at surgery the physiological barrier of muscle which protects the lungs from the raised ventricular pressure may be seen. Resection
Transcript of CARDS FOR PATIENTS TAKING STEROIDS
321
based upon well-observed facts. In addition to emotionallyinduced changes in mucosa and muscle these include the
many studies in emotional and personality types found inulcerative colitis, from the pioneer clinical observations ofHurst 6 through the character studies of the thirties to the, insome cases, more detailed work of the past decade or so. Afew other studies not mentioned by Dr. Sim and Mr. Brookeare listed below.’-9
The presence or absence of diarrhoea as an initial
symptom does nothing whatever to detract from thesemany deep and massive studies of the psychogenesis ofulcerative colitis. To all who have studied it carefullyfrom both aspects this disease is so strikingly based upona complex of body-mind relationship that it is distressingto find two modern writers who are willing to think sucha frail criterion as the time of arrival of liquid stools canleave us " little evidence " of the deeply distorted charac-ters and the profound physical and mental susceptibilitiesand sensitivities that are causally connected with thesvmptoms in sufferers from this disease.
RANYARD WEST.Dorrington Grove,near Shrewsbury.
"EXPERIENCE AND INCENTIVE" AWARDS?
E. O. EVANS.
SiR,ńThe principle of differential payments to generalpractitioners for the quality as distinct from the quantityof their work appears at last to be receiving serious atten-tion. The stumbling-block of " merit " awards lies in thedifficulty of finding a method to assess merit. I do notbelieve that any system which depended primarily on theassessment of the merit of one practitioner by anotherpractitioner could possibly succeed. The idea that a
board of consultants might do it would surely be as
embarrassing to the consultants as it would be to the
general practitioner.May I suggest therefore that the word merit " be
dropped altogether and that an alternative experienceand incentive " award be considered ?
The difference in such an award is that it would not be
beyond the reach of all G.P.s at some time in their careers.For this reason I believe it would be more generally acceptable.If payment for it was met out of some fund other than thecentral pool it could play a big part in what should be its mainpurpose-i.e., the promotion of good general practice.For such an award only criteria that are fairly easily assessed
could be used. I would suggest:(1) 10 years’ experience as a principal.(2) A high standard of surgery premises and equipment.(3) A list of patients not below a certain minimum, nor yet above
a certain maximum considered locally suitable.To those critics of such yardsticks (e.g., Burdon 10) I would
point out that while experience is no guarantee of merit, it isfair to assume that every doctor is a better doctor for 10 years’experience (indeed general practice is about the only branchof medicine in which experience is not rewarded).Again, whatever his capacity, any doctor can surely give
a better service to 2500 patients than he can to 3500. More-over, an incentive to reduce his list would encourage him totake in a partner, or form a group practice. Similarly, goodpremises and equipment, though no guarantee of good work,are essential tools for the job.A fourth element, to form the incentive side to such
an award, is more difficult to define. t suggest that itshould amount to an expression of willingness on thepart of the individual to maintain his efficiency. Thiswould take different forms. Some like to take refresherrnnrsM. Others nrefer to enaqge in research or to he
6. Hurst, A. F. Guys Hosp. Rep. 1921, 71, 26.7. Moscheowitz, E. Amer. J. med. Sci. 1943, 206, 576.8. Murray, C. D. ibid. 1930, 180, 239.9. West, R. Lancet 1946, ii, 899.10. Burdon, J. F. Brit. med. J. 1958, ii, Suppl. p. 27.
clinical assistants at nearby hospitals-or to engage insome other form of postgraduate training. The essentialthing I suggest is that, to qualify for such an award, thedoctor would have to bring evidence of his efforts to
improve his efficiency in one way or another. I see noharm in the idea that such evidence should be producedagain, say, every seven years-so that the grass shall notgrow, &c.
Stratford-on-Avon.
CARDS FOR PATIENTS TAKING STEROIDS
J. J. R. DUTHIEChairman,
Education Sub-committee,Empire Rheumatism Council.
Faraday House,8-10 Charing Cross Road,
London, W.C.2.
SIR,-It is recognised that sudden withdrawal ofsteroids in patients undergoing long-term treatment maybe dangerous, particularly when such patients have beensubjected to sudden stress, such as an acute illness, acci-dent, or emergency operation. In these circumstances itmay be of vital importance for the physician or surgeonresponsible for the patient’s immediate care to be madeaware that the patient has been on steroid therapy, theform in which it is being administered, and the daily dose.The education subcommittee of the Empire Rheuma-
tism Council gave this matter consideration at a recent
meeting and reached the conclusion that a useful purposewould be served by the issue of a card to patients receiv-ing steroids, stating the preparation in use and its dailydose. The hospital or clinic supervising the patient’streatment and the name and telephone number of thefamily doctor should also be recorded along with simpleinstructions to the patient.
I have been instructed by my committee to bring thismatter to your notice, as the Empire Rheumatism Councilwould be prepared to make a supply of these cards avail-able to any physician who might wish to use them.
VENTRICULAR SEPTAL DEFECT
SIR,-Your leading article of July 12 favours a classi-fication based primarily on catheter studies and necropsy.Open heart surgery enables one to obtain a more physio-logical appreciation of the anatomical defects; 36 ven-tricular septal defects have been repaired in the past yearat this hospital and as a result it is suggested that thepresence or absence of an infundibular pulmonary sten-osis plays a major part in the pathological physiology ofventricular septal defects, and that therefore this factorshould be included in such a classification.
Full cardiac catheterisation figures and operative detailsare available on 22 of these 36 cases. They suggest thatthe following classification be used:
(1) The pulmonary-artery pressure, right ventricular pres-sure, and systemic pressure are of a similar level. These caseshave no obstruction to a shunt of blood from the left ventricleto the right ventricle, and they have no obstruction to the out-flow tract of the right ventricle.The cardiac catheter passes with ease into the pulmonary
artery. At surgical repair, though there may be some workhypertrophy of the infundibular muscle, the outflow tract isadequate and no resection of muscle is required.We have had 12 such cases, with 4 deaths.
(2) The pulmonary-artery pressure is low; the right ven-tricular pressure high, approximating to the left ventricularpressure. No cyanosis is present.These cases are frequently referred to as an " acyanotic
tetralogy of Fallot". The cardiac catheter may pass withsome difficulty into the infundibular chamber and at surgerythe physiological barrier of muscle which protects the lungsfrom the raised ventricular pressure may be seen. Resection
