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DOCTORS AND THE DRUG MAKERS

SIR,-As chairman of the Association of the BritishPharmaceutical Industry (ABPI) Code of Practice Committee, I

read with interest Professor Rawlins’ article (Aug 4, p 276) and.welcome the positive comments he makes regarding our work.However, certain of the matters he raises call for a reply.Rawlins asserts that the committee is "over-represented by

industry". Surely this is only proper for a self-policing bodyoperated by a trade association to enforce the standards it requires ofits members. There are three independent members includingmyself, and case-reports are now made public so justice can be seento be done. These reports are sent to the Department of Health andSocial Security, the British Medical Association, and thePharmaceutical Society of Great Britain, and copies are available onrequest from the ABPI. The ABPI believes it to be important thatdoctors and pharmacists should see such reports before they areprinted in national newspapers.Records for the last six months reveal an average time lapse of 3

months from receipt of a complaint until notification of theoutcome. In many instances the advertisement has been withdrawnin the interim. Rawlins’ most recent complaint, which was dealtwith in 4 months, was based entirely upon hearsay evidence whichpresented the committee with some difficulty in determining thefacts. Others have already commented on the mechanism to actwithin a few days where public safety is concerned (Aug 18, p 404). Icannot envisage speedier action through recourse to any otherforum.

"Bringing the industry into disrepute" is sufficient ground forupholding a complaint. Clause 2 of the code provides that "methodsof promotion must never be such as to bring discredit upon, orreduce confidence in, the pharmaceutical industry". Thecommittee can, and does, rule a breach of clause 2 in isolation butusually, if an activity is likely to discredit the industry, otherbreaches will also have occurred.The ABPI has always had the power to expel a member company

if gross abuse of the code has occurred. Most companies readily givethe undertakings required of them following an adverse finding andthey can be asked to withdraw material from those to whom it wassent and to ensure that there is no recurrence.

I always welcome open discussion of these matters, but regret thedegree of sensationalism which sometimes accompanies it. Thatthere are problems of the kind discussed by Rawlins is undoubtedand if they are brought to the attention of the committee it willalways do its best to handle such complaints promptly, fairly, andeffectively.1 King’s Bench Walk,Temple, London EC4Y 7DB PHILIP J. COX

OFFSHORE MEDICAL SCHOOLS

SIR,-Dr Imperato (June 2, p 1238) might be interested to knowthat, at a two-day conference of Caribbean (CARICOM) ministersof health in Dominica last month, the ministers issued a specialdeclaration expressing concern about the operations of offshoremedical schools in the Caribbean region. They emphasised theinadequacies of these schools-the lack of proper training facilities,the use of itinerant lecturers, training programmes not geared toproduce doctors for the Caribbean, and the instability inherent inthe fact that these schools, established by entrepreneurs, will notcontinue if they are not financially viable.

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The conference noted the decision of Barbados to establishmechanisms for determining and enforcing academic standards towhich offshore medical schools must adhere, to limit activities ofoffshore medical schools to preclinical training, and to grant theregional University of the West Indies exclusive right to use thegovernment medical institutions for clinical training.The ministers also recognised the high international standing of

the University of the West Indies’ degrees and urged member statesto desist from any steps which would impair that standing.The conference urged that any further establishment of offshore

medical schools in the Caribbean should be viewed with extremecaution and that member countries in which these schools are notestablished should take specific action to discourage their nationals

from entering any of these schools located in the Caribbean, therebyensuring that these institutions are totally "offshore" in itsclientele.

Finally, the ministers recommended that member states in whichsuch schools are established should seek means of ensuring thattheir nationals pursue medical training at the University of the WestIndies and, in line with this position, negotiate that scholarshipsgranted by offshore medical schools be tenable at the University ofthe West Indies or, where this course is not available to the student,at a university of the governments’ choice.

Eastern Caribbean Medical Scheme,Department of Medicine,University of the West Indies,Port of Spain,Trinidad, West Indies COURTENAY BARTHOLOMEW

MRS WARNOCK’S BRAVE NEW WORLD

SIR,-I respect the views on the human embryo held by Dr Heleyand her medical colleagues of LIFE (Aug 4, p 290). I admire, indeedmarvel, at their belief they can convert the rest of the world. As far asI can see there will always be an unbridgable gap. But theirarguments against in-vitro fertilisation gain nothing from colourfulvituperation-"a bleak and nightmarish future ... test-tube

adultery". When was the future ever not a nightmare to the

pessimist? Hope, not despair, is the better side of human nature. Weonly strive out of optimism. Is conception from a sudden passingpassion preferable to that in a test-tube? The test-tube baby is

wanted, planned, worked for, born out of enduring love, to be loved.What better?Dr Heley wants the medical profession to campaign against the

Warnock Committee’s recommendations. I hope, on the otherhand, most doctors will campaign to help the childless throughevery means endorsed by Warnock. The fertile are assisted in everyway, as much out of expediency as compassion. The infertiledeserve no less. There are lay organisations working for the child-less. Perhaps it is time for concerted medical action. I would be gladto hear from-or join-interested doctors.

University Department of Obstetricsand Gynaecology,

Bristol Maternity Hospital,Bristol BS2 8EG MICHAEL G. R. HULL

REFEREEING REQUESTS FOR EMERGENCYMICROBIOLOGY

SiR,—Dr Harrison and Professor Speller (Aug 18, p 406) rightlystate that emergency requests should not be singled out for criticismor for cuts when resources for pathology services are beingconserved. We should not, however, underestimate the cumulativevalue of a consistent policy of referral which, besides saving somemoney, conserves medical laboratory scientific officer (MLSO)services and provides opportunities for training less experiencedresidential hospital medical staff.Our microbiology specimen workload increased from 65 000 in

1971 to 130 000 in 1983, more as a result of increased number ofinvestigations per patient than an increase in the number of newpatients tested.’ The number of emergency calls has remainedstable, as expected for a population that has not increased

significantly over this period; we believe that our system of referralof out-of-hours requests has contributed to this. The emergency"on-call" service is manned on a paid but volunteer basis by a smallnumber of MLSOs. Requests for examination of cerebrospinal fluidare accepted without referral as are urine samples where a negativefinding is to be followed by surgery (eg, appendicectomy) that night.Blood for culture can be taken and incubated and swabs held in

transport media without the need to call out technical help. Forother requests the doctor is referred to a consultant microbiologist.About half of these referrals do not reach the consultant,presumably because the house-officer, on reflection, regards the testas not truly essential. Of requests referred useful discussion onimmediate therapy and action takes place in all instances; about 1 in3 of the requests are refused. The MLSO providing the emergency

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EMERGENCY REQUESTS 1971-83

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service must usually also give a full day’s work the following day, asubstantial night-time commitment can reduce that individual’sefficiency and accuracy during daytime duties. In sections of

pathology other than microbiology where emergency calls are morefrequent "recovery time" has had to be provided during normalworking hours to compensate for the night-time fatigue-a seriousloss of workforce.Our stable number of emergency calls in microbiology contrast

with the situation in haematology and biochemistry (table) where ithas been found impracticable to provide so stringent a referralservice, though some of the increase in requests in these disciplineswill doubtless reflect changing patterns of management over theyears.Until departments of pathology are adequately funded and staffed

it seems reasonable to restrict emergency requests to essential work

only (40% of those at Bristol); perhaps requests where the result isdeemed likely to be only "useful" could be postponed until normallaboratory hours. Sometimes the usefulness cannot be predicted.The referral service which we have been able to provide hasdepended on the cooperative support of our clinical colleagues andthe highly motivated and responsible team of MLSOs whoappreciate the purpose of and need for the system.Public Health Laboratoryand Department of Microbiology,

Royal Shrewsbury Hospital,Shrewsbury SY3 8XH C. A. MORRIS

1. Morris CA. Trends in microbiology work-loads in the National Health Service:England and Wales (1968-79). Health Trends 1981, 13: 8-13.

PRACTICAL HELPERS

SIR,-Dr Hopkins’ article (June 23, p 1393) begins with theproblems of community care for the elderly but turns into an attackupon social workers and the remedial professions. He has tried toestablish that all therapy from speech and occupational therapistsand physiotherapists is ineffective and unnecessary and suggeststhat it could be given just as well by housewives. He cites a study on’speech therapists and volunteers which indicated that both partiestreated dysphasic patients equally well when working from adetailed assessment. Hopkins indicates that an assessment of anysort was not a required factor. I invite him to treat my patients for aweek with no access to assessment or specialist training. (I woulddecline swapping roles with him in deference to his greater skills inneurology.)

. Hopkins feels that all therapists are overqualified and that adegree course in speech therapy is unjustified. I am not about toargue this here, but I will say that as therapists we will never knowenough and it would be a backward step for the professions were weto become complacent enough to think that we do. We treat a widerange of patients-not just those with problems resulting from astroke, and consequently need to know "quite a lot".We are criticised for letting charitable organisations buy some of

our equipment, instead of using our own budget. Our training issaid to be wasted because, since most therapists are female, we tendto leave the profession to have babies. But some of us do return orcarry on and are we to take it that this does not apply to otherprofessional females, such as female neurologists? Hopkinscomplains that we overlap as professionals, despite the fact that thishelps us communicate and work as a team (which Hopkins alsoclaims does not happen). Even psychiatrists, dermatologists, andneurosurgeons have some overlap.He uses the "overlap" criticism to suggest that in future the

professional therapists amalgamate and be called "practicalhelpers" following a year’s training. No entrance qualificationswould be necessary for this training and a syllabus is suggested for

us-200 hours to be spent learning secretarial skills. In support ofthis idea, he states that these trainees "will be better able to copewith their own family problems".

Therapists reading his article will probably feel anger, disbelief,and amusement. Is the author seriously suggesting a return to non-specialist days? Does he feel that the medical specialist is redundanttoo and that we should be treated by a general practitioner for everycomplaint regardless of its nature?

St Leonards Hospital,London N1 LINDA HOLLINGSWORTH

CHILD HEALTH ON THE MOVE

SrR,-In answer to the question posed in your editorial (Aug 4,p 267), health visitors are not only willing but also able to assumeresponsibility for the selection of children to be examined by thedoctor in the child-health clinic. Indeed many health visitors andtheir medical colleagues in primary care would assert that there isnothing new about this. Health visitors, in exercising their functionas highly trained preventive workers, have carried this

responsibility for a good many years, although the Health Visitors’Association would be the first to admit that few data exist regardingthe comparative effectiveness and efficiency of health visitors in theearly detection of deviations from normal child health and

development.The recent move by general practitioners to increase their

involvement in child-health surveillance has provoked healthvisitors and their professional association to review the role of thehealth visitor in this traditional area of her work. The Association isat present consulting its membership on a proposal which suggeststhat health visitors, with access to appropriately trained andexperienced doctors, should undertake the major part of the child-health surveillance programme for preschool children. On

completion of this consultation, the Association hopes to meetorganisations representing doctors working in community health,general practice, and paediatrics, to discuss its views on the

respective role of doctor and health visitor in child healthsurveillance.

Health Visitors’ Association,36 Eccleston Square,London SW1V 1PF SHIRLEY GOODWIN

WHY NOT LET PREPUTIAL ADHESIONS ALONE?

SiR,-Mr Griffiths and Mr Freeman (Aug 11, p 344) describe aneat procedure for separating preputial adhesions, utilising a localanaesthetic cream. Since the conditions of the prepuce in their

patients is not stated it is difficult to determine whether or not thefailures (incomplete separation, recurrent adhesions, and need forcircumcision, 11 - 8% in all) occurred in boys with a tight prepuce.This is of interest since retraction of the tight prepuce easily resultsin overstretching of the prepucial orifice, the end result being ascarred phimosis. I have seen several boys with scarry phimoses whohad a history of forced, painful retractions. Moreover, with a tightprepuce frequent and complete postoperative retractions, necessaryto prevent recurrent adhesions, become difficult.

Griffiths and Freeman seem to regard adhesions per se as anindication for active separation. Preputial adhesions carry a lowmorbidity and probably no mortality, whereas all kinds of surgerycarry a risk of complications and pain for the boy.In 1968 østerl demonstrated that the frequency of preputial

adhesions diminishes with age during childhood. No adhesionswere found in boys of 17. These Danish figures, from a communitywith a low degree of undue interest in healthy boys’ foreskins,probably come near to a description of the natural history ofpreputial adhesions.