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Changes In MRCP (UK) ExaminationAuthor(s): Donald MainlandSource: The British Medical Journal, Vol. 281, No. 6249 (Nov. 1, 1980), p. 1219Published by: BMJStable URL: http://www.jstor.org/stable/25441948 .

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BRITISH MEDICAL JOURNAL VOLUME 281 1 NOVEMBER 1980 1219

therefore, if junior doctors would forward their

views on what they would like my committee

to include in its evidence to the Review Body to their regional committee by Monday, 10

November or to me c/o the HJSC, BMA

House, London WC1H 9JP.

Michael R Rees Chairman, Hospital Junior Staff Committee

BMA House, London WC1H 9JP

Prescription for social work

Sir,?Thank you for introducing to your pages a discussion of the current state of social work

(4 October, p 890). Permit me, however, to

correct the slight imbalance which your article

implies.

There have, in fact, been many empirical studies on the effectiveness of social work both in Western

European countries and in the United States, and these studies have influenced the types of problems

which social workers are prepared to attempt to alleviate. The severity of the problem is only one

factor, which may be overridden by others, such as the motivation of the individual to change and the

susceptibility of the problem to adaptation. Social workers make a decision at the outset about the likelihood of effecting change and do not attempt the impossible. None the less, I accept that there are insufficient scientific studies of the usefulness of various forms of social work. This is ascribable

partly to the youth of the profession and partly to the difficulties of measurement which all the social sciences encounter.

Yet there are some areas in which we must intervene irrespective of the likely outcome. If social workers are told, for example by magistrates, to undertake the supervision of an offending 15

year-old they may not be very sanguine about the

response to their contact, but the supervision order or the care order exists. It could be argued that as

many young offenders cease offending without the assistance of a social worker as do those who are

supervised; but the court is required to make a

response within the constraints of legislation, and

they would not be very impressed by being told, "He'll get better anyway"?no one seems to know the answer and society demands a placebo.

In suggesting ways of improving social work doctors fall into the very fault which they are

hoping to alleviate. It has been suggested that social workers would be better employed as

ancillary workers of the health service. On the whole it does not really matter who employs them

provided that communication between other

professions and other agencies is kept as simple as

possible. This requires energy and effort, whatever the employment setting. The institutional response is partly a wish on the part of the doctors to have

things organised decently, and partly the natural wish from which everyone suffers to control things which are not going one's own way. I may not like the way in which a particular shop or a yachting club, say, conducts its affairs, but it is none of my business. Closer to home, I may not like the way in which certain GPs practise, but again I have no

right to reorganise them. Medical social workers

accept that patients are referred to their doctors for medical reasons. Once referred, however, patients present social and emotional problems which inhibit cure or rehabilitation. Hence the

apparent conflict between the pace of the doctor and that of the social worker; for example, the

patient may take longer to adapt emotionally to loss of limb function than he does physiologically

?I am not asking doctors to attend to this?merely to tolerate those whose function it is to attend to social and emotional functioning and to acknowl

edge their expertise.

Social workers on their part will, given time, deliver the goods. Their practice will become

more refined, their evaluative instruments more

precise. The teething troubles of a young, self

conscious profession will disappear, but not, I

hope, its hallmarks of sensitivity and self

criticism.

M J Hughes

Department of Medical Social Work, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP

Changes in MRCP (UK) examination

Sir,?The first of the recommendations in

the letter from the presidents of the royal

colleges (19 July, p 231)?that a greater

proportion of questions be designed to test

knowledge of the scientific basis of clinical

practice?elicited in a retired preclinical teacher an almost reflex favourable response.

Then the cortical centres started to ask

questions: would this plan tend to spread among graduates the information cramming that has been the curse of much under

graduate teaching ? The presidents specified five basic sciences; did they consider that

anatomy was not basic or not a science ? To one who spent rather more than half his

professional life in anatomy the omission is not unfamiliar. In my student days it was

commonly said that physiology was for

physicians, anatomy for surgeons; and the same distinction seems to be reflected in the

relative scarcity of physicians in the recently formed British Association of Clinical Anato

mists (BACA).

Many topographical details that are necessary for good operative surgery are certainly not needed by physicians, but even when these are subtracted there remains much topographical information, even outside the central and peripheral

nervous systems, that is essential for sound

diagnosis. Moreover, even naked-eye anatomy comprises not only relationships displayed by dissection. It is concerned with the principles of

body architecture, intersubject variability, changes in relationships resulting from changes in position; and with body mechanics, including muscle

functions?which, as Wright1 discovered long ago, are not necessarily synonymous with anatomy textbook muscle "actions" inferred from attach

ments. In diagnosis anatomy is the basis for what Mottershead2 aptly called "anatomical reasoning," which is not tested by examination questions on anatomical "facts."

To provide the basis for this reasoning, precisely what kind of information should be offered to MRCP candidates or to any others who wish to become all-round non-surgical practitioners ? I faced such a question 50 years ago, when, after

teaching anatomy as it had been taught to me, I obtained complete freedom to teach what I wanted to undergraduates. The search for information, concepts, and attitudes led into a wide variety of clinical literature in general medicine and the

specialties. It was an exciting adventure because it entailed the selection of material that seemed

most appropriate, the evaluation of evidence, the

rejection of unfounded textbook tradition, and the exercise of caution with the hobbies or id?es fixes of some writers. Because knowledge grows and

medical practice changes, such a search should be

continuous; and, having had little contact with

anatomy during the last 30 years, I have wondered what might be currently apposite examples of

anatomy for physicians. I expected that Motters head's2 informative and very stimulating article "The teaching of anatomy and its influence on the art and practice of surgery" would mostly contain

specifically surgical examples; but when I marked each of the 16 examples either "S" (mostly for

surgeons) or "P" (desirable for physicians) I found only five Ss but 11 Ps, seven of which were items that I do not recall having met in the search that I made 40-odd years ago.

If the presidents' recommendations are acted on and if questions on applied anatomy were to be included, candidates would doubtless wonder what they should study and conscientious examin

ers might also want some guidelines. This demand could offer a challenge to some members of BACA?to produce "Notes on applied anatomy for physicians," giving reasons for the choice of

topics and examples of their application. During the preparation of the notes disputes would arise

regarding the validity of evidence and relevance to clinical problems?a welcome bonus because

controversy could lead to research in a field where some think that little further research is possible.

Perhaps the addition of questions on basic

sciences in postgraduate examinations is not

the best way to promote the application of

these sciences in medical practice. I feel more

encouraged by the spontaneous perception of

the value of renewed study, as exemplified by

Jessop's3 excitement on returning to anatomy

nearly a decade after graduation; but whether

physicians' return to anatomy is compulsory or voluntary a guidebook designed for their

needs would be very valuable.

Donald Mainland

Kent, Connecticut, USA

1 Wright WG. Muscle function. New York: Hoeber,

1928. 2 Mottershead S. Br MedJ 1980;i: 1306-9. 3 Jessop JH. Br MedJ 1979;ii:439.

The consequences of nuclear war

Sir,?Minerva ended her note about Dr Helen

Caldicott's visit (18 October, p 1078) by asking "Is she right ?" about the British Government's

plans for surviving a nuclear war being

laughable. I wish that it were possible to laugh. So long as deterrence implied the threat to

use strategic nuclear weapons against cities, the possibility of their actual use was so

unthinkable as to be dismissed by most of us.

But now that the deployment and use of

"tactical" nuclear weapons is proclaimed NATO policy, the British Government's

seriousness (the British people were never

asked) has to be demonstrated by making open

preparations for the eventuality of being at the

receiving as well as the sending end in a

nuclear war. Civil defence organisers around

the country are arranging discussions, among other things, about how such doctors as

survived could most effectively help civilian

survivors through the immediate aftermath.

The scenario envisaged in the recent civil

defence exercise, which formed part of the

NATO exercise in Europe, was not unlike that

envisaged by Dr Caldicott. Even though the

proportion of the population estimated as

killed outright did not reach her worst case

prediction, it was sufficient to make any

proposed civil defence measures little more

than a sham.

Rather than accept that their duty would

be to do their best in the chaos following a

nuclear weapon attack, doctors should surely be thinking about how to prevent such attacks

from occurring. The only sure way is to get rid of nuclear weapons. Whether the British

Government should set an example by

renouncing those under its control is an

important question which deserves wide

discussion but on which doctors have no

special voice. Their voice would be heard,

however, if they were to decide?after proper consideration of what is known and predictable

?to warn the public, rather than keep quiet, about what the medical consequences of

nuclear war would be.

J H Humphrey

Royal Postgraduate Medical School, London W12 OHS

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