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.)
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