HÆMATOLOGY: ORIGINS OF AN IMPASSE
1
740 SUPRAREGIONAL ASSAY SERVICE Sir noted with particular interest the concluding para- graph in Professor Swales’ article (March 13, p. 577) in which he emphasises the diagnostic value of plasma-renin assay. He rightly draws attention to the logistic problems involved in set- ting up the measurement and in the standardisation of results between assay centres. Some of your readers may still be unaware of the facilities offered by the Supraregional Assay Service (which includes the provision of plasma-renin assays), a scheme which was specifi- cally designed to meet the needs and solve the problems exem- plified by Professor Swales’ comments. The second edition of the Supraregional Assay Service booklet, which describes the services offered and the mechanisms whereby they may be used, is now being distributed by the D.H.S.S. to departments of chemical pathology through regional scientific officers; a further small supply is also being made available to the Associ- ation of Clinical Biochemists for individual distribution. As Professor Swales rightly states, a major obstacle to the widespread exploitation of plasma-renin assays in clinical medicine, as indeed is the case with many other radioim- munoassay procedures, is the lack of standardisation between centres. The Supraregional Assay Service laboratories are cur- rently addressing themselves to this problem, the solution of which probably resides, in many cases, in the selection of stan- dardised matched reagents, the adoption of common assay pro- tocols, and the setting up of rigorous quality-control schemes. In short, getting the best clinical use from many of the newly available immunoassay techniques and avoiding the confusion resulting from a proliferation of independent and uncoor- dinated assay methodologies, essentially depends upon the exis- tence of a channel of inter-laboratory discussion and agree- ment, a function which the Supraregional Assay Service is particularly well suited to carry out and which may ultimately prove one of its most important tasks. Department of Nuclear Medicine, Middlesex Hospital Medical School, London W1N 8AA R. P. EKINS Chairman, Supraregional Assay Service Directors’ Working Party HOSPITAL MEDICAL STAFF SiR,—I read with interest the suggestion by Mr R. C. Helsby and Sir Robert Wright (March 20, p. 631) that medical staffing in hospitals and indeed throughout the National Health Service should be reviewed. This is clearly an urgent matter and long overdue. However, it would be a complete waste of time if there were not a simultaneous review of the work undertaken by medical staff. It is clear that doctors in many specialties are doing work which might be better done by others or not at all. It might be found that the endless hours spent by patients and doctors in outpatient clinics are often wasted, that many of the consultations are totally unnecessary or could be done more economically by a member of the primary health-care team. If the numbers of patients attending outpatient depart- ments were reduced or the number of staff rationalised, it might be found that some of the patients now admitted to hos- pital for investigation and treatment could be managed en- tirely as outpatients. The rationale for many standard proced- ures is ill founded. The drugs that are prescribed both in hospital and general practice are often not taken or are given for conditions which would do equally well or better without. Much of the work done by general practitioners would be done better by ancillary workers. Many of the screening pro- grammes set up for well babies, schoolchildren, and healthy adults have been inadequately researched. This is medical audit in its widest sense. We owe it to our- selves as well as to the patients and the community as a whole to see that it is done thoroughly and soon. The Surgery, 50 the Glade, Furnace Green, Crawley, Sussex GILLIAN STRUBE HÆMATOLOGY: ORIGINS OF AN IMPASSE S!R,—I hope your readers will not think that all haematob. gists agree with the view of Dr Roberts (March 20, p. 641) that "Htematologists are qualified to treat patients when they become doctors". This haematologist, for one, believes that haematologists, like all others, are licensed to treat patients when they become doctors but at that stage possess the neces- sary background knowledge to go on to acquire the skills of pa. tient management. These skills are fully tested in the care of the patients with haematological disorders where both acute and chronic episodes demand a high degree of knowledge and experience. Whether the acquisition of these can be tested by a clinical examination is questionable, but until a suitable alternative is found it should, in my view, be retained. Department of Hæmatology, Addenbrooke’s Hospital, Cambridge CB2 2QQ D. G. CHALMERS SIR,-Some aspects of Dr Rose’s sympathetic irony (March 6, p. 532) may not have escaped Dr Roberts (March 20, p. 641) but Dr Roberts’ short letter does not, I am sure, fully reveal his own attitude to the fundamental question in the Medical Art of who calls in whom to help. How happy our pa- tients would be if none of us ever had to consider his own pride and reputation when seeking our local answer to this question! At one level of thought one supposes one could learn where one’s help was needed. At another level (better for our patients?) we would submit our half-considered views to at least one other before a diagnostic decision is taken or treat- ment is ordered, even in an obvious "blood case". It is our help in a non-blood case that eludes everybody unless personal pride is regularly submitted to the cuts and thrusts of conference. Haematology is only one such specialty in which medical pride and responsibility engage in battle (if often enough on the same side against a craven indecision); but it is one which has had ploughed into it the seeds of so much phoney sophisti- cation, along with those of real valuable scientific advances, that our confidence and judgment can easily be undermined. Dr Rose’s article will have struck chords of sympathy (or other emotion) in many practising haematologists, but their harmonics will vibrate according to the decade of each man’s training and experience. His article should be required reading for all in contact with this wide-ranging subdivision of the Medical Art-and this means practically everybody. Hæmatology Department, County Hospital, York YO3 7PG G. A. C. SUMMERS MORTALITY FROM LUNG CANCER SiR,—Dr Wald (Jan. 17, p. 136) suggests that the increased mortality among women of all ages from lung cancer in England and Wales since 1955 is due to their more recent adoption of the habit of smoking, whereas men under 60 have a slightly lowered death-rate due to the reduced tar yield of the cigarettes. This age and sexual discrimination on the part of the carcinogens in cigarette smoke, remarkable though it would be if true, still cannot explain the female lung-cancer rise when the percentage of lung-cancer cases statistically associated with smoking in women is calculated. In Hav mond’s prospective survey of 562 671 women’ there were 210 deaths from lung cancer, 128 in non-smokers. Of the 82 deaths among smokers some 35-5 would have been expect even if they had never smoked, leaving 46.5 deaths from lung cancer associated with smoking. So 163.5 of the deaths recorded (78%) were independent of cigarettes. Similar cal- culation from the retrospective studies listed in the 1971 L’.S 1. Hammond, E. C. Natn Cancer Inst. Monogr. 1966, no. 19, pp. 153, 176
Transcript of HÆMATOLOGY: ORIGINS OF AN IMPASSE
740
SUPRAREGIONAL ASSAY SERVICE
Sir noted with particular interest the concluding para-graph in Professor Swales’ article (March 13, p. 577) in whichhe emphasises the diagnostic value of plasma-renin assay. Herightly draws attention to the logistic problems involved in set-ting up the measurement and in the standardisation of resultsbetween assay centres.Some of your readers may still be unaware of the facilities
offered by the Supraregional Assay Service (which includes theprovision of plasma-renin assays), a scheme which was specifi-cally designed to meet the needs and solve the problems exem-plified by Professor Swales’ comments. The second edition ofthe Supraregional Assay Service booklet, which describes theservices offered and the mechanisms whereby they may beused, is now being distributed by the D.H.S.S. to departmentsof chemical pathology through regional scientific officers; afurther small supply is also being made available to the Associ-ation of Clinical Biochemists for individual distribution.
As Professor Swales rightly states, a major obstacle to thewidespread exploitation of plasma-renin assays in clinicalmedicine, as indeed is the case with many other radioim-
munoassay procedures, is the lack of standardisation betweencentres. The Supraregional Assay Service laboratories are cur-rently addressing themselves to this problem, the solution ofwhich probably resides, in many cases, in the selection of stan-dardised matched reagents, the adoption of common assay pro-tocols, and the setting up of rigorous quality-control schemes.In short, getting the best clinical use from many of the newlyavailable immunoassay techniques and avoiding the confusionresulting from a proliferation of independent and uncoor-dinated assay methodologies, essentially depends upon the exis-tence of a channel of inter-laboratory discussion and agree-ment, a function which the Supraregional Assay Service is
particularly well suited to carry out and which may ultimatelyprove one of its most important tasks.
Department of Nuclear Medicine,Middlesex Hospital Medical School,London W1N 8AA R. P. EKINS
Chairman, Supraregional AssayService Directors’ Working Party
HOSPITAL MEDICAL STAFF
SiR,—I read with interest the suggestion by Mr R. C.
Helsby and Sir Robert Wright (March 20, p. 631) that medicalstaffing in hospitals and indeed throughout the NationalHealth Service should be reviewed. This is clearly an urgentmatter and long overdue. However, it would be a completewaste of time if there were not a simultaneous review of thework undertaken by medical staff. It is clear that doctors in
many specialties are doing work which might be better doneby others or not at all.
It might be found that the endless hours spent by patientsand doctors in outpatient clinics are often wasted, that manyof the consultations are totally unnecessary or could be donemore economically by a member of the primary health-careteam. If the numbers of patients attending outpatient depart-ments were reduced or the number of staff rationalised, it
might be found that some of the patients now admitted to hos-pital for investigation and treatment could be managed en-tirely as outpatients. The rationale for many standard proced-ures is ill founded. The drugs that are prescribed both inhospital and general practice are often not taken or are givenfor conditions which would do equally well or better without.Much of the work done by general practitioners would be donebetter by ancillary workers. Many of the screening pro-grammes set up for well babies, schoolchildren, and healthyadults have been inadequately researched.
This is medical audit in its widest sense. We owe it to our-selves as well as to the patients and the community as a wholeto see that it is done thoroughly and soon.The Surgery, 50 the Glade,Furnace Green, Crawley,Sussex GILLIAN STRUBE
HÆMATOLOGY: ORIGINS OF AN IMPASSE
S!R,—I hope your readers will not think that all haematob.gists agree with the view of Dr Roberts (March 20, p. 641) that"Htematologists are qualified to treat patients when theybecome doctors". This haematologist, for one, believes thathaematologists, like all others, are licensed to treat patientswhen they become doctors but at that stage possess the neces-sary background knowledge to go on to acquire the skills of pa.tient management. These skills are fully tested in the care ofthe patients with haematological disorders where both acuteand chronic episodes demand a high degree of knowledge andexperience. Whether the acquisition of these can be tested bya clinical examination is questionable, but until a suitablealternative is found it should, in my view, be retained.
Department of Hæmatology,Addenbrooke’s Hospital,Cambridge CB2 2QQ D. G. CHALMERS
SIR,-Some aspects of Dr Rose’s sympathetic irony (March6, p. 532) may not have escaped Dr Roberts (March 20, p.641) but Dr Roberts’ short letter does not, I am sure, fullyreveal his own attitude to the fundamental question in theMedical Art of who calls in whom to help. How happy our pa-tients would be if none of us ever had to consider his own prideand reputation when seeking our local answer to this question!At one level of thought one supposes one could learn whereone’s help was needed. At another level (better for our
patients?) we would submit our half-considered views to at
least one other before a diagnostic decision is taken or treat-ment is ordered, even in an obvious "blood case". It is our helpin a non-blood case that eludes everybody unless personal prideis regularly submitted to the cuts and thrusts of conference.
Haematology is only one such specialty in which medicalpride and responsibility engage in battle (if often enough onthe same side against a craven indecision); but it is one whichhas had ploughed into it the seeds of so much phoney sophisti-cation, along with those of real valuable scientific advances,that our confidence and judgment can easily be undermined.Dr Rose’s article will have struck chords of sympathy (or
other emotion) in many practising haematologists, but theirharmonics will vibrate according to the decade of each man’straining and experience. His article should be required readingfor all in contact with this wide-ranging subdivision of theMedical Art-and this means practically everybody.Hæmatology Department,County Hospital,York YO3 7PG G. A. C. SUMMERS
MORTALITY FROM LUNG CANCER
SiR,—Dr Wald (Jan. 17, p. 136) suggests that the increasedmortality among women of all ages from lung cancer in
England and Wales since 1955 is due to their more recentadoption of the habit of smoking, whereas men under 60 havea slightly lowered death-rate due to the reduced tar yield ofthe cigarettes. This age and sexual discrimination on the partof the carcinogens in cigarette smoke, remarkable though itwould be if true, still cannot explain the female lung-cancerrise when the percentage of lung-cancer cases statisticallyassociated with smoking in women is calculated. In Havmond’s prospective survey of 562 671 women’ there were210 deaths from lung cancer, 128 in non-smokers. Of the 82deaths among smokers some 35-5 would have been expecteven if they had never smoked, leaving 46.5 deaths from lungcancer associated with smoking. So 163.5 of the deathsrecorded (78%) were independent of cigarettes. Similar cal-culation from the retrospective studies listed in the 1971 L’.S
1. Hammond, E. C. Natn Cancer Inst. Monogr. 1966, no. 19, pp. 153, 176
