1127LEADING ARTICLES

Consultant and Specialist

THE LANCETLONDON : SATURDAY, JUNE 1, 1957

IN the nine short years since the start of therational Health Service the work of hospitals haschanged remarkably. Medical progress has led to

contraction of some specialties, such as tuberculosisand hospital paediatrics, and to expansion of others,such as cardiac surgery ; but these changes, strikingin themselves, have been overshadowed by the

generally increased demand traceable to the disclosure,through the health service, of the population’s fullneed for care.In many hospitals the medical staffs do not suffice

to meet the new demands. The teaching hospitals,in their privileged and largely protected position,are in no acute difficulty, but elsewhere the story isdifferent. The public were quick to note the upgradingof peripheral hospitals and have responded by attend-ing these instead of travelling, as once they wouldhave done, to the teaching centre. In trying to fulfiltheir new responsibilities the peripheral hospitals areimpeded by deficiencies not only in staffs but alsoin buildings and equipment. These deficiencies arerelated ; for, as is seen from our survey on p. 1133,the appointment of much-needed surgeons, patho-logists, or physicians may have to await the comple-tion of new operating-theatres, laboratories, or wards.Nevertheless, it would be quite wrong to suppose thatadditions to clinical staff must all be deferred until new

buildings have gone up. With ingenuity most busyoutpatient departments could manage a few moresessions a week ; and so could some operating-theatres. Nor is there any lack of suitable people forthe work : in the main clinical subjects, and in someothers, too many competent doctors are competingfor what few consultant posts there are. The main

difficulty lies elsewhere. Many clinical consultantsfind that their need for help does not extend overthe whole range of their work : thus the physicianmight get along well if relieved of some of his

outpatients, and the general surgeon if some

of the operating were taken off his hands. A

hospital authority, however, can hardly create a

fresh consultant post for such restricted work ; and,even if willing, it may be unable to do so because oflack of the beds and of the junior staff, includingperhaps a registrar, needed to place a new consultanton a par with his colleagues. There is one way, andperhaps only one, in which such work can suitablybe done without creating new units-namely, bythe appointment of assistant physicians and assistantsurgeons. The need for these is emphasised by themarch of events in the many hospitals where it isproving impossible to find new senior registrars.Noting that, when it comes to applying for a consultant

post, senior registrars in peripheral hospitals are at adisadvantage compared with their teaching-hospitalcontemporaries, registrars are shunning the non-teachinghospitals; and the consultants in these hospitals arehaving to undertake work that might be done by ajunior colleague. Such a situation would be partlyavoided if all senior registrars divided their time between

teaching and non-teaching hospitals under a joint-appointments scheme. These schemes provide diversityof experience and ensure that no senior registrar whoparticipates disqualifies himself for advancement simplyby not working in a teaching hospital. But though in afew regions such a scheme is operating satisfactorily,in others, which seem to be more numerous, a schemetentatively started has run into difficulties, and has evenhad to be abandoned, because of incomplete under-standing and possibly suspicion between the two hospitalauthorities or because of the reluctance of seniorregistrars appointed to the teaching hospital to moveto the periphery. We believe that the country should besurveyed region by region to define the causes of successand failure, and to see whether in fact these schemes canpossibly be extended ; for in regions where there isno hope of their being operated successfully the appoint-ment of senior registrars to peripheral hospitals should bediscontinued, and the sooner this is done the better.

The new grade of assistant physician and surgeonmight be expected to attract both senior registrarsand s.H.M.o.s. For most it would be a step on theladder to a consultant post (a step at a point wheresome senior registrars are at present being thrownoff into mid-air), but others would be content toremain at this level. (One of the faults of the existingarrangement is that those who wish to make a careerin one of the main clinical subjects, but may not evenwant to become consultants, are denied the oppor-tunity.) The clinicians in this specialist grade wouldhave a few beds ; but they would be responsibleto a consultant. Their remuneration should, we

suggest, be spread over a wide scale, starting nearthe top of the present s.H.M.o. scale and stretching,with continuing service, well into the consultant’sreaches.To create a specialist grade of this kind would be

to return to realities-to recognise the facts as theyare today and as they were long before the NationalHealth Service was thought of. The Spens Com-mittee, so wise in many ways, ignored one big factwhen it left no place in its scheme for the manydoctors in our hospitals who are neither traineesnor consultants, but are certainly specialists ; and,though the gap has been filled by calling them hos-pital medical officers, their morale has been damagedbecause even the most senior are paid less than ayoung consultant and because even the most juniorfeels himself out of the running for a consultant post.The Spens Committee was wrong, too, when it pre-sumed that in an organised service the senior registrarwould become a consultant about the age of 32,soon after finishing his formal training, or, if not,would (and should) find work elsewhere-in, generalpractice or outside the N.H.S. Whereas in the old

days the future consultant, in his 30s, often hadto be content with small and miscellaneous appoint-ments, through which, gaining experience, he workedhis way up to major responsibilities, the Spens Com-mittee prescribed an immediate long leap for every-body-with removal from the hospital service as

penalty for anybody who could not jump the wideningchasm. Because it has been so obvious that the

hospitals need them, the majority have not in factbeen asked to pay this penalty ; but they have under-gone, and are still undergoing, grave hardship;and because they are denied promotion the hospitalsare often denied the full help they could give. Oversix years ago we remarked that senior registrars

1. Lancet, 1950, ii, 749.

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were doing advanced work satisfactorily, "and itseems a little odd to tell them that they must forth-with stop doing it because, now that their training isover, our principles forbid us to offer them anythingless than the consultant posts they cannot get."Beneath the reluctance to face this situation has

lain an undercurrent of fear that if a grade of specialistswere created the Ministry of Health might ruthlesslyswell its ranks with the aim of securing cut-priceconsultants. Such a fear is surely baseless. It wouldbe for the profession to agree by negotiation on theratio of specialists to consultants 2; and thereafterprofessional bodies would ensure that the agreementwas observed. The picture of a conscienceless groupof Civil Servants riding roughshod over a supinemedical mass is out of keeping with facts. Our repre-sentatives have had no difficulty in securing thestrict observance of the agreement for limitationof s.H.M.o. posts, and there is no reason why theyshould be less successful with those for specialists.The proposal to introduce a specialist grade deservesfresh and unprejudiced attention.

2. Ibid, 1954, i, 1277.3. Wheatley, D. Ibid., Jan. 19, 1957, p. 164.4. Landsman, J. B., Grist, N. R., Black, R., McFarlane, D.,

Blair, W., Anderson, T. Brit. med. J. 1951, i, 326.5. Chapple, P. A. L., Franklin, C. M., Paulett, J. D., Tuckman, E.,

Woodall, J. T., Tomlinson, A. J. H., McDonald, J. C. Ibid,1956, i, 705.

6. Bishop, J. M., Peden, A. S., Prankerd, T. A. J., Cawley, R. H.Lancet, 1952, i, 1183.

7. Brumfitt, W., Slater, J. D. H. Ibid, Jan. 5, 1957, p. 8.8. Fry, J. Ibid, Jan. 26, 1957, p. 211.

Antibiotics and Sore ThroatANTIBIOTICS are expensive and not without risk.

Should they be used routinely in the treatment ofsore throat ? Every doctor with a child of his ownthat has had an acute pharyngitis will know what atemptation it can be to give penicillin or one of thenewer antibiotics, and will feel himself in sympathywith WHEATLEY,3 who favours giving rather thanwithholding these agents. Yet in this country fourstudies on the natural history and therapy of acutefebrile sore throat-two in general practice 4 5 and twoin military personnel 6 7-do not on the whole supportsuch a policy. They show that the majority of suchsore throats settle down, untreated, in a few days ; thatstreptococci can be recovered from only about half totwo-thirds of the patients ; and that sore throatassociated with -haemolytic streptococci cannot bereliably distinguished on clinical grounds alone fromother sore throats. Penicillin can shorten the illness alittle but is really necessary, it seems, only for severecases and those with such immediate complications asotitis media or sinusitis. The compelling argument, intheory at any rate, for the " blanket " policy oftreating all sore throats promptly with penicillin arisesnot from these considerations but from the danger ofdelayed non-septic complications (rheumatic fever,nephritis), which can be prevented by adequate treat-ment of the preceding sore throat but once they havearisen are not susceptible to radical cure and maycause serious invalidism and shorten life. Does thistheory hold good in practice ? In over 400 cases ofsore throat associated with (3-haemolytic streptococcithat were seen in general practice,4 5 8 or undersimilar conditions, 6 7 and that were not treated withpenicillin, rheumatic fever ensued in not a single

instance. The mildness of such sore throats isconfirmed by BRUMFITT and SLATER’S observationthat only 17% of untreated cases of proved group-A6-hsemolytic streptococcal infection showed a signifi.cant (two-tube) rise in antistreptolysin titre. It isdifficult not to conclude that penicillin is needed onlyfor severe cases and those with septic complications.But this conclusion seems to conflict with that of theAmerican Heart Association, which has issued a reporton this subject, from the point of view of preventingrheumatic fever and bacterial endocarditis,9 compiledby a committee composed of experienced andauthoritative workers.

The report summarises the symptoms and signs of thetypical case of streptococcal sore throat, which should betreated with penicillin " on sight " ; but many cases arenot typical, and accordingly the committee suggests thatthroat-swabs should be cultured more extensively. Theprevention of rheumatic fever demands the eradication ofstreptococci from the throat-not just their suppression.The bactericidal penicillin (rather than the bacteriostaticsulphonaiiiides) is the drug of choice, with the lesseffective broad-spectrum antibiotics reserved for patientswho are hypersensitive to penicillin. Of the possiblepenicillin preparations, the committee favours adminis-tration of the injectable long-acting benzathine penicillinG, or procaine penicillin with aluminium monostearate moil, for at least ten days. Penicillin by mouth is alsoeffective, but only if the patient cooperates ; and thusthe committee does not recommend this route. Thecommittee proposes that, where a previous history ofrheumatic fever is clearly established, chemoprophylaxisshould be given in all seasons throughout the rest of thepatient’s life, to prevent streptococcal reinfection. Forchoice the committee would inject each month 1,200,000units of benzathine penicillin G ; or, failing this, it wouldgive by mouth each day 1 g. of sulphadiazine or 500,OWunits of penicillin G.

Outstanding work on the relation of group-AP-haemolytic streptococci to rheumatic fever has beendone by the members of this committee, and particularly by RAMMELKAMP and his associates 9 at FortWarren. Consequently the American Heart Associa.tion has been campaigning widely for chemoprophvlaxis to prevent rheumatic fever ; and in the U.S.Asome would now regard it as negligent not to give apatient known to have had rheumatic fever antibioticscontinuously. But many doctors would feel uneasyabout the committee’s recommendation-it mightalmost be termed a life sentence-that antibioticsshould be administered throughout the lives of

patients who have had rheumatic fever. Furthermore

many would demur at the committee’s implied recom-mendation that all sore throats known or suspected tobe due to group-A (3-haemolytic streptococci should betreated with antibiotics, at least until a throat-swabhas been cultured. These policies are based on thefollowing premises 10: firstly, that approximately 3% Iof haemolytic-streptococcal throat infections are fol. I

lowed by rheumatic fever, irrespective of the age ofthe patient ; secondly, that rheumatic heart-diseasecan be prevented by preventing first attacks andrecurrences of rheumatic fever ; and thirdly, that thebenefits of life-long chemoprophylaxis warrant itsrisks. That rheumatic fever follows infection of thethroat by a group-A P-haemolytic streptococcus in asusceptible subject must now be taken as proved.9. Rammelkamp, C. H., Breeze, B. B., Griffeath, H. I., Houser,

II. B., Kaplan, M. H., Kuttner, A. G., McCarty, M., Stollerman.G. H., Wannamaker, L. W. Mod. Cone. cardiov. Dis. 1956.25, 365.

10. Mortimer, E. A., Rammelkamp, C. H. Circulation, 1956, 14, 1144.