even a hospital paediatric senior house officer post will not necessarily prepare trainees for work in the community. The Hall report clearly argues that such work depends on cultivating an advanced awareness of the way children grow and mature and a sensitivity to family interactions and parental concerns.2 There is an urgent need to draw on the experience of doctors who have given decades of committed service to child health work. It is depressing in the extreme to know that those who will inevitably inherit this work as part of primary family health care will be given financial inducements to take responsibility for the work but that time and funds to support specific training are not in evidence. SONYA LEFF be seen at home, at the hospital, or at work, and 68 were given appointments with the project doctor at their local general practice. None of the 106 respondents failed to attend for an appointment. These observations support the conclusions of Dr Frankel and colleagues that failed appointments reflect inadequacies of communication within the service provided. ROGER SHINTON C BEEVERS Department of Medicine, Dudley Road Hospital, Birmningham B 18 7QH 1 Frankel S, Farrow A, West R. Non attendance or non-invitation? A case-control study of failed outpatient appointments. BrMed7 1989;298:1343-5. (20 May.) Lewes, Sussex BN7 l UJ I Polnay L. Pringle M. General practitioner training in paediatrics in the Trent region. BrMed_J 1989;298:1434-6. 127 May.) 2 Hall D, ed. Health for all children. Oxford: Oxford University Press, 1989. Hospital training for general practice SIR,-Having recently left the North Western region, I cannot leave unchallenged the views expressed by Drs Hugh Reeve and Ann Bowman. As senior registrar in accident and emergency medicine I worked in several departments staffed mainly by doctors on vocational or self constructed general practice training schemes. All of these departments organised formal teaching sessions of between two and three hours' duration each week in addition to a comprehensive introductory teaching programme designed to help familiarise the junior staff with work practices and policies within the departments. Despite this effort and despite the departments having been variously staffed by registrars, senior registrars, and clinical assistants during the teaching sessions we seldom attained more than 50% attendance from those eligible to attend-that is, those not on holiday or taking study leave. Similarly, the knowledge of up to date medical reporting was dismal. At one meeting only one doctor out of four admitted to having read the BMJ within the previous three weeks despite all four receiving it regularly. Education is a two way process: junior doctors have to make the effort to learn when opportunities are presented. T F BEATTIE Royal Aberdeen Children's Hospital, Aberdeen AB9 2ZG 1 Reeve H, Bowman A. Hospital training for general practice: views Of trainees in the North Western region. Br Med J 1989;298:1432-4. (27 May.) Non-attendance or non-invitation? SIR,-Dr Stephen Frankel and colleagues concluded that aspects of the outpatient service were more important in explaining non-attendance than were factors associated with the patients.' In the West Birmingham stroke project, a casecontrol study being conducted in 11 general practices in the West Birmingham area, we have found an excellent response rate among control subjects, who have had little to gain themselves from an appointment for assessment by questionnaire and for anthropometric measurement. Randomly selected control subjects were approached by letter and a subsequent telephone call or visit to arrange an appointment. Those who had moved or died were replaced. Of the 109 controls approached to date, 106 (97%) agreed to participate; 38 opted to 1646 2 lsenberg D. How the GP and the houseman can be friends. World Med 1981 March:33-4. 3 George AM, Maddocks GB. Accuracy of diagnostic content of hospital activity analysis in infectious diseases. Br Med J 1979;i: 1332-4. 4 Whates PD, Birzgalis AR, Irving M. Accuracy of hospital activity analysis operation codes. BrMedJ 1982;284:1857-8. 5 Roger FH. 7he minimum basic data set for hospital statistics in the EEC (E UR 7162). Luxemburg: HMSO, 1981. 6 Johnson R. Medical audit. Lancet 1975;i:679. How to dictate a discharge summary SIR,-Dr T M Penney' is not alone in his efforts to improve the standard of discharge summaries.2 The current systems that produce delayed summaries of variable quality fail not only general practitioners but also hospital staff. The discharge letter should provide the basic data required to code accurately and specifically inpatient diagnoses and treatment. The fact that it does not has been sporadically reported,34 yet the problem seems to be widespread. Although a minimum basic data set of 13 items for discharge summaries has been recommended by the European Community, the practicalities of including these items have not been dealt with.' Difficulties arise when clerical staff attempt to assign codes of the International Classification of Diseases (ninth revision) and of the Office of Population Censuses and Surveys to those "free text" summaries that eventually reach them. We have developed a "structured" discharge letter that is undergoing clinical trials here. Its headings provide space for: history, diagnoses, procedures, complications, outcome, drugs on discharge, future care, and comments. The letter is produced with a desk top publishing system; it folds to fit into a window envelope and allows for the use of hospital stickers. Coloured paper is recommended for easy identification in the chart. A photocopy of the letter is sent to the coding unit. This avoids a large accumulation of charts yet provides a clear and comprehensive summary of the essential information for accurate coding. When problems arise the doctor who has dictated the summary can be quickly traced from the signature block. This is an impersonal form of communication, but such letters must serve at least three groupsgeneral practitioners, hospital doctors, and coding staff. When a more personal approach is needed or for complex cases the required details may be included on the obverse of the letter. They are not required in the coding unit and thus do not reach it. Although the approach requires some initial discipline in dictating the rewards of reduced secretarial effort and clear, accurate diagnostic information are considerable. Widespread use of data derived from these commonly flawed systems assumes new importance in the context of hospital information systems and the "opting out" debate. No audit, medical or otherwise, can begin without adequate book keeping and record making.6 ANDREW MACEY J S G MURPHY R A B MOLLAN Department of Orthopaedic Surgery, Musgrove Park Hospital, Belfast BT9 7JB 1 Penney TM. How to do it. Dictate a discharge summary. Br MedJ7 1989;298:1084-5. (22 April.) SIR,-We agree with Mr James F Fair' and Dr Ilora Finlay2 about the importance of informing general practitioners what their recently discharged patients have been told in hospital and with their suggestion that this information should appear in the interim discharge note. We therefore included a section stating this in our recently described information booklet for discharged patients.' By giving patients a copy of the booklet we not only tell general practitioners what their patients have been told but also indicate to the patients what their doctors have been told about why they were in hospital. By appropriate design of the booklet we can also give general practitioners extra information exclusively. Mr Fair also emphasised the importance of providing general practitioners with details of treatment and of the community support services arranged from the hospital, and our booklet also does this. The median time between discharge and delivery of the interim letter by outpatients was three days, considerably less than cited, but if a deputising doctor had been called before the patient had delivered his or her discharge note the patient would have the general practitioner's copy plus his or her own copy of the information about the recent admission, which would be helpful to any doctor called. D A SANDLER J R A MITCHELL Department of Medicine, University Hospital, Queen's Medical Centre, Nottingham NG7 2UH I Fair JF. How to dictate a discharge summary. Br Med J 1989;298:1384. (20 May.) 2 Finlay I. How to dictate a discharge summary. Br Med J 1989;298:1384. (20 May.) 3 Sandler DA, Mitchell JRA, Fellows A, Garner ST. Is an information booklet for patients leaving hospital helpful and useful? BrMedJ 1989;298:870-4. (1 April.) Chemical inactivation of HIV on surfaces SIR,-Dr P J V Hanson and colleagues claim to have produced evidence that 70% industrial methylated spirit and ethanol are unsuitable for surface disinfection of HIV.' This is disturbing news in view of the widespread use of these chemicals for disinfection and because of the suspicion it throws upon their effectiveness in hand disinfection, for which no reasonable alternative is available. We consider that the conclusion of Dr Hanson and colleagues is unjustified. In suspension HIV is very sensitive to 70% ethanol.2 Yet the survival of some of the virus in this study is not unexpected because the procedure left the virus firmly embedded in a layer of desiccated protein of about 20 im in thickness. The poor penetrating ability of ethanol is well known,4 and in all probability it did not penetrate the protein layer sufficiently to reach all the virus particles, which individually measure 0 1 tm. Glutaraldehyde, being less sensitive to the presence of organic material,5 inactivated the virus throughout the protein layer. The lack of penetrating power of ethanol is taken account of by the direction that before disinfection surfaces should be freed from visible contamination.6 There is little doubt that a 0-02 mm thick BMJ VOLUME 298 17 JUNE 1989 layer on a smooth surface is clearly visible. In clinical and medical laboratory settings rough to specialist help. Our "hotline" number is 01 580 3160. surfaces should be avoided. The merit of Dr Hanson and colleagues' article is perhaps in drawing attention to these basic rules of chemical disinfection. J C DE JONG B VAN KLINGEREN Laboratories of Virology and Chemotherapy, National Institute of Public Health and Environmental Protection, 3720 BA Bilthoven, The Netherlands Disimpaction of swallowed bolus SIR,-The problem of an impacted food bolus resulting in dysphagia described by Mr P I Ignotus and Dr A Grundy' commonly presents in otorhinolaryngology departments. It is common practice in these cases to treat patients by giving a muscle relaxant such as intravenous diazepam or, more recently, sublingual nifedipine, which allows the lower oesophageal sphincter to relax sufficiently for the bolus to pass.2 Such treatment is quick and simple with minimal discomfort, and we suggest that it should be the first line treatment for an impacted food bolus. If it should fail other methods of disimpaction, such as that reported by Mr Ignotus and Dr Grundy, might be tried before resorting to endoscopic removal. We agree that the possibility of an oesophageal lesion, particularly a tumour, causing the food impaction must not be forgotten, and further investigations may be appropriate in certain cases. A J DRYSDALE J ROWE-JONES Department of Otolaryngology, St George's Hospital, London SW 17 OQT 1 Ignotus PI, Grundy A. Disimpaction of swallowed bolus. BrMedj 1989;298:1359. (20 May.) 2 Bell AF. Nifedipine in the treatment of distal oesophageal food impaction. Arch Otolarvngol Head Neck Surg 1988;114:682-3. Sick doctors SIR,-In Dr Richard Smith's article Dr Clive Richards concludes that there is a need for a special service for family doctors. ' Lest it should be thought that nothing much is available at present I would remind him that the National Counselling Service for Sick Doctors was established in 1985. This offers an independent, confidential, and non-coercive source of help and advice to all doctors in the United Kingdom. We have dealt with over 400 cases to date, and referrals are accepted from sick doctors themselves or from worried colleagues. For general practitioners there are 60 national advisers, all of whom are experienced general practitioners, throughout the country, and they in turn have easy access through the service VOLUME 298 1 Smith R. Sick doctors. BrMedJ 1989;298:1339-40. (20 May.) Compulsory treatment in the community I Hanson PJV, Gor D, Jeffries DJ, Collins JV. Chemical inactivation of HIV on surfaces. BrMedJ 1989;298:862-4. (I April.) 2 Martin LS, McDougal JS, Loskoski SL. Disinfection and inactivation of the human T lymphotropic virus type III/lymphadenopathy-associated virus. J Infect Dis 1985;152: 400-3. 3 Resnick L, Veren K, Salahuddin SZ, Tondreau S, Markham PD. Stability and inactivation of HTLV-III/LAV under clinical and laboratory environments. JAMA 1986;255: 1887-9 1. 4 Sykes G. Disinfection and sterilization. London: E and F N Spon, 1958:271. 5 Hugo WB, Russell AD. Types of antimicrobial agents. In: Russell AD, Hugo WB, Ayliffe GAJ, eds. Principles and practice of disinfection, preservation and sterilization. Oxford: Blackwell, 1982:8-106. 6 Weller IVD, Williams CB, Jeffries DJ, et al. Cleaning and disinfection of equipment for gastrointestinal flexible endoscopy: interim recommendations of a Working Party of the British Society of Gastroenterology. Gut 1988;29: 1134-5 1. BMJ KEN RAWNSLEY National Counselling Service for Sick Doctors, London NW I 5HH 17 JUNE 1989 SIR,-The BMA's mental health committee has prepared proposals for a community treatment order,' which warrant further examination. The proposals suggest (section 3.4i) that the patient should have had at least two admissions to hospital and been consistently unwilling to cooperate with the treatment. If a patient's first admission to hospital follows the first episode of illness then he or she need fail to comply with medication only once more, leading to a relapse and readmission, to become eligible for a community treatment order. Such a patient could be seen as being "consistently unwilling to co-operate with treatment," even though the recurrent nature of the illness had not been apparent to either the patient or the treating physician. At the other extreme patients who have had frequent relapses due to non-compliance and who are then placed under an order may find that if they cooperate with treatment there is no reason for the order ever to end.2 Another condition for a community treatment order (3.4ii) is that the patient lacks insight. What is to be done with the patient who on recovering from an episode of mental illness accepts that he has been ill but does not accept the need for continuing medication? Does he lack insight? "It is necessary for the health and safety of the patient or for the protection of other persons" (3.4vi, my italics). Here the usual phraseology of the Mental Health Act 1983 has been changed from "health or safety" to "health and safety." The difference is important.' This wording means that the order can be applied only to mentally disordered people who are a danger to themselves or others and not to those who are mentally disordered but not a danger to anyone. This latter group of patients would most benefit from the community order, rather than dangerous or suicidal patients, who might be better served by admission to hospital. The BMA suggests that "Treatment would include medical treatment, nursing care, medication, habilitation and rehabilitation under supervision" (3.5). It is not really possible for nursing or rehabilitation to be provided in the community against a patient's wishes.2 Similarly many psychotropic drugs cannot easily be given against a patient's will. Compulsory treatment therefore really means compulsory administration of depot neuroleptics. These and other points lead to doubts about the appropriateness and workability of the proposals. Scott-Moncrieff concluded from the Royal College of Psychiatrists' proposal for a community treatment order that "it attempts to equate the position of a mentally ill person in the controlled environment of a hospital with the position of the same person in the uncontrolled environment of the outside world. What are appropriate powers in one situation are either dangerously inadequate (in terms of suitable treatment) or too restrictive (in terms of civil liberties) in the other situation. "2 JOHN DUNN Department of Psychological Medicine, Hammersmith Hospital, London W12 OHS 1 British Medical Association. Annual report of council 1988-1989. London: BMA, 1989:46-8. (Enclosed with BMJ of 1 April.) 2 Scott-Moncrieff L. Comments on the discussion document of the Royal College of Psychiatrists regarding community treatment orders. Bulletin of the Royal College of Psychiatn'sts 1988;12: 220-3. 3 Weleminsky J. Mental Health Act 1983. Bulletin of the Royal College ofPsychiatrists 1987;11: 163. Medical defence peace SIR, -Dr Tony Smith's editorial states that "from the patient's point of view little is gained by health authorities offering doctors indemnity."' The view of victims, those directly concerned, is exactly the opposite. Action for Victims of Medical Accidents, the main, if not the only, organisation for victims, considers that the victims have everything to gain. It has always maintained that HM(54)32, which regulates the way health authorities and medical defence organisations jointly deal with victims' claims, has resulted in the needs of victims being ignored. There is direct conflict ofinterest between health authorities and medical defence organisations because health authorities are concerned (or should be concerned) only for their patients whereas the defence organisations are concerned for their members-namely, doctors. How can they possibly collaborate to the advantage of victims? Action for Victims of Medical Accidents is of course aware that the health authorities will still have to "tackle a legal system that is slow, inefficient, adversarial, expensive, intimidating, and unfair." In addition, health authorities have a built in bureaucracy, which might be used to slow justice for victims even further. Furthermore, if health authorities have to bear the full brunt of the damages payable to victims self interest might make them more obstructive. These are matters which are, however, amenable to public control unlike the behaviour of medical defence organisations. I therefore have high hopes for the change and am disappointed at Dr Smith's dismissal of the proposal. A SIMANOWITZ Action for Victims of Medical Accidents, London SE23 3TP 1 Smith T. Medical defence peace. Br Med (29 April.) J 1989;298:1130. Quackery in Hungary SIR,-In Hungary the media often report questionable treatments of serious ailments and unfounded claims of "cures." It would advance the standard of reporting of such topics in our media if we could invite Mr Duncan Campbell' to study untested "cures" for cancer in our country. In Hungary the problem is not only that of professionals turning a blind eye but also the rather strange attitude of the media. Because doctors and other professionals who work in the state organised health service are seen as being part of the "establishment" they are subject to unfair attack. Claims that the jealousy of the medical profession hinders the introduction of miraculous cures for cancer by non-medical healers are an easy and popular way to attack not only scientific medicine but also the establishment. Moreover, the quackery does not seem to need a sound basis, while those who deny its claims are asked to produce scientific evidence. Unfortunately the media are more interested in circulation and popularity than in serving the public's real interest by helping them to distinguish doctors from witchdoctors. TAMAS FENYVESI 3rd Department of Medicine, Semmelweis University, 1121 Budapest, Hungary 1 Campbell D. An investigative journalist looks at medical ethics. BrMedJ 1989;298:1171-2. (29 April.) 1647
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