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should be checked, as well as the position of chalk if it isnecessary to draw on a blackboard. It is important tohave a light on the reading desk, and the position of theswitch for this must be noted. Instructions, preferablywritten, should be given to the projectionist as to whichslides should be shown with the light half-dimmed (print)and which should be shown with the lecture hall com-

pletely darkened (colour slides, histological material, andradiographs).

PERSONALITY AND MANNER

Personality is important. One has only to think of agreat teacher whose lectures stand out for their brilliance,clarity, and wit, and are delivered with a showmanshipwhich fixes them in the memory. By contrast, there is theother type of renowned figure, who has talked on thesame theme so many times before that the inspiration hasgone; his manner has become tedious, and his slides toowell worn. The audience depart, pleased to have seen thecelebrity, but disappointed with the lecture. He shouldhave delegated it to one of his subordinates. Another

example of a defective manner is the bright young manwho paces up and down (how irritating are the repetitivemovements of a speaker) talking condescendingly-treat-ing a distinguished audience as if it were a final-year classof students. To speak to those who know little, yet to doso with humility, may not be easy.

It has been said that the research-worker-the back-room boy who has no opportunity to teach-will naturallybe unable to express his thoughts in public. Yet seriousthinkers can usually express their thoughts simply andanalytically.Most bad communications are due to defects of tech-

nique which can be readily remedied. Perfection in

speaking is mainly an acquired characteristic.I am grateful to Dr. T. L. Hardy for his valuable criticism of this

article. My thanks are also due to Miss Sylvia Treadgold of thedepartment of medical illustration at Guy’s Hospital, London, and toMr. T. F. Dee, of the photographic department at the QueenElizabeth Hospital, Birmingham, for their helpful advice.

Symposium

EVALUATION OF DRUGS· FROM A CORRESPONDENT

A SYMPOSIUM on this subject was arranged in Londonon Jan. 23 by the Association of Medical Advisers in thePharmaceutical Industry. The difficulty of securingclinical trials of new drugs, and the possibility that thenew Committee of Drug Safety might cause the loss ofvaluable new drugs, were two of the problems discussed.

Testing of New DrugsThere were no particular difficulties over the initial stages of

drug testing, involving in-vitro and then animal experiments.At the next stage, healthy human volunteers were needed. Inthe U.S.A. paid volunteers were often used. In this countryemployees of drug firms, medical students, and nurses were thegroups usually asked. The Committee on Drug Safety statedcategorically that no patient could be a volunteer, though hemight of course take part in a clinical trial, or refuse to, once thestage of trial in healthy humans was passed. It was questionedwhether digitalis would ever have become available for heart-disease under the present regime: it would depend on how thecommittee interpreted their ruling on the danger of its deleteri-ous effects. There was a possibility that other useful drugsmight be lost through strictness of screening. Perhaps standardscould not be too severe for a drug likely to be widely usedfor minor complaints such as headache or insomnia; but

desperate straits had sometimes justified desperate remedies.A sufferer from so-called incurable cancer, for instance, mightwell be the most suitable subject for trial of some of the anti-cancerous drugs, which are of necessity highly toxic to normalpeople.

Clinical Trials for New Products

The medical profession had a moral responsibility to furtherthe discovery of new therapeutic benefits. At present, red tapeand new regulations, legal considerations, and the difficulties ofpublishing results were making this more difficult; but perhapsthe greatest need today was for more clinical trials.

Clinical trials, it was stated, were easy to criticise, difficult todo, and never wholly satisfactory. Nevertheless they must bedone on every new product offered to the profession. Speedwas vital, not only because of the ethics of withholding apossible cure from the public, but also because industry mightfounder if there was too long a delay between spending vastsums on research on a new product and beginning to coverthese losses with sales.

In the past, clinical trials had been nobody’s job, but thehobby of a dedicated few. Less than 5% of doctors, it was

thought, were ready to experiment. Teaching in therapeuticshad been very patchy, and for too long confined to preclinicalstudents who knew nothing of disease. Moreover, the rationaleof therapeutic research had not been sufficiently explained tothe ancillary staff (nurses, almoners, social workers) even whenthey were actually engaged in clinical trials.The British Tuberculosis Association was quoted as an out-

standing body for its activities in drug research. It had asubcommittee on clinical trials, and its constitution included apledge to further the discovery of new therapeutic means. Ithad been very active in the trial and use of new drugs, andclearly the tuberculosis patient has benefited.

Tentative schemes were suggested for furthering clinicaltrials. One recommended a central fund for clinical trials, ormore academic chairs in clinical therapeutics; under eitherarrangement, junior and senior research fellowships would beoffered, reciprocal to medical-registrar appointments. This

particular plan was worked out in some detail and would costE120.000 a year-or 0.16% of the Drug Bill. It was suggestedthat there would be offers of financial help from industry.Another suggestion would cost El million, but this includedthe expense of the hospital beds and ancillary services. Fiveacademic units were called for, plus fifty research fellows tocarry out clinical trials. They would work with patients alreadyin the existing hospital service, probably dividing their timebetween a teaching hospital and adjoining group hospitals.The patients would remain under the care of their own physi-cians, who would at all times have complete powers of veto overanything suggested in the form of clinical trial. In some casesthe trials would be conducted or continued among outpatients,and here the social workers and psychologists would play agreater part.

Five years ago similar recommendations were made in theHinchliffe report, but there seems to have been no move to

implement them.Role of the Clinical Pharmacologist

Prof. A. G. MACGREGOR spoke of clinical pharmacology asan emergent science. It was already an exact science in someareas of medicine, but when the cause of the illness remainedobscure, as in mental disease and atherosclerosis, it was still

very much an empirical one. Benefit to the patient mustremain the keystone of the science.A greater number of appointed clinical pharmacologists was

called for by Dr. K. G. GREEN (I.C.I.). Clinical trials of drugsmust be part of the ordinary discipline of medicine. Anyoneconducting them must have patients, and must therefore be aphysician. Though there might be room for academic appoint-ments, the great need was for consultant pharmacologists in thehospital service, to work beside the physician, who wouldremain in charge of the case. Physicians should call in con-sultant pharmacologists more often over individual cases,rather than leaving it to their registrars to keep them up to date

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with new drugs. Clinical trials should not be thought of onlyas a filter for screening new drugs; there were many other waysin which they could further research in therapeutics.

Medical Ethics in PharmacologyIn the long run we must depend on the quality and integrity

of the people conducting pharmacological research. Forinstance, one industrial research-worker remarked that he was

‘

never able to hand over a drug for clinical trial without firsttrying it on himself; it was a matter of conscience. An overallbelief in progress and an optimism about discovering hithertounknown cures remained the driving force. Sir DERRICKDUNLOP spoke of the deep-rooted built-in ethics of the pro-fession as the greatest safeguard, greater than any rules thatcould be drawn up by committees.

Medical Education

NEW DOCTORS FOR THE CONGO

IN 1960 the Congo had not a single Congolese doctor.Though the Leopoldville and Kisauta schools gave diplomasto students who had undergone a short training and werethen named " medical assistants ", none of these hadgraduated as doctors. Towards the end of 1960 theFrench Government, at the request of the World HealthOrganisation, agreed to admit a number of the medicalassistants to medical schools in France, where an organ-ised programme for further training of African studentsfrom Dakar and Tananarive was already in being. Now,accompanied by their wives and children, 59 out of 61Congolese medical assistants have returned to their

country as fully trained doctors after three years of intensivetraining. Their education was financed through W.H.O.by the United Nations Fund for the Congo.The students were divided among the university medical

schools of Bordeaux, Lyons, Montpellier, Nantes, and Rennes.There, in addition to the regular instructors, a professor wasspecially appointed as adviser to each group, and a full-timeconsultant (appointed by W.H.O.), with the dean and pro-fessors of the faculty, arranged the course and examinations.Supplementary teaching enabled students to catch up with theFrench students, and there were special vacation courses forthe 10-20% of candidates who failed in the June examinations,but who finally passed in October.Thanks to this programme of intensive medical education,

80% of the students passed the first time (8 with highestdistinction). At the end of the three-year programme all hadgraduated. In their last year the students attended specialcourses for a diploma in the tropical diseases institutes ofBordeaux, Lyons, and Montpellier, and a four-month course inemergency tropical surgery at Bordeaux, Lyons, Montpellier,and Nantes.W.H.O. arranged that the wives and children should

accompany the students when they went to France. Accom-modation was found for the families, and the children went toFrench schools, where they adapted themselves withoutdifficulty and became excellent pupils. Many of the motherswere illiterate and without a knowledge of French; but in theend some did well in courses in French and domestic science.To broaden the purely medical education provided for the

students a three-year course in arts was organised by the rectorsof the universities. All the students passed the examinations atthe end of the course.

W.H.O., the French Government, and the medicalschools concerned are to be congratulated on the success’of this well-planned and imaginative undertaking. 59 newdoctors may mean little in countries with establishedmedical schools and thousands of graduates. In the

Congo they are a massive contribution to the welfare of thecountry.

Parliament

The Needs of General Practice

OPENING a debate on Jan. 22 on this branch of the NationalHealth Service, Lord TAYLOR said that the general practitionersof Britain were more disappointed today than at any time in thepast 15 years. Despite continual assurances they felt that theGovernment did not really care enough about them to ensurethe future of their work. They felt frustrated because, unlikethe hospital and local-authority services, they had no ten-yearplan; because they saw no prospect of reducing the number ofpatients on their lists while entrants to general practice con-tinued to dwindle; and because they felt that they had beenfinancially tricked. Taking the financial problem first, LordTaylor said that, though the pool system had been set up at therequest of the doctors, it would take an administrative genius todevise a more unfair system.For a ten-year plan for general practice, Lord Taylor pro-

posed some clearcut targets. We should aim at having enoughgeneral practitioners by 1974, so that the maximum permittedlist could be reduced to 2000. To do this, we should need 5new medical schools straight away. 2 or 3 should be in thegreat conurbations of Northern England, where the shortageof doctors was greatest. By 1974 we should also aim to havemost doctors working in groups. Loans for premises, especiallyin big towns, should be increased. All medical students shouldlearn about general practice, and all general practitionersshould be encouraged to do some work in factories and torelieve the hospitals of some minor surgery. Most important ofall, the pool system of payment should be abolished. Thecapitation fee system, Lord Taylor believed, had proved itsworth, but it should be weighted according to the age of thedoctor. Extra payments should really be extra, and practiceexpenses should be adequate and separated from remuneration.

Negotiations on remuneration were going on with the

present Government. If there was a change of Government inthe next nine months Lord Taylor could give the doctors anassurance that the goals they had in mind were also those of hisside of the House.Lord BRAIN pointed out that the difficulties of the National

Health Service were largely due to concurrent changes inmedicine itself. More was needed than a financial settlement.It must be recognised that general practice was a specialty in itsown right, that entrants needed at least two years’ postgraduatetraining. Some responsible critics said that there was no futurefor the general practitioner and that hospitals and polyclinicswould in time provide all medical services. The real challengefor general practice was to prove, what Lord Brain believed tobe true, that everyone should have a personal doctor; he wouldgo so far as to say, even in hospitals. In one way or another hebelieved that the general practitioner would have to have acloser relationship with the hospital.Lord AMULREE was doubtful whether hard-pressed general

practitioners could find much time for hospital work, but hethought that they could profitably work in closer associationwith the local authorities.Lord COHEN OF BIRKENHEAD agreed that the capitation fee

should remain, but that remuneration must reflect both qualityand quantity of service and offer sufficient incentive to ensurethat general practice was not the refuge of failed specialists.

General practitioners were more than 50% of our medicalforce and dealt with 90% of illness. By 1981, to cover ourpopulation, we should need another 14% of doctors. Accordingto the Robbins calculations, we should have enough to offer thepresent service. But if we wanted to reduce doctors’ lists weshould need more. Clearly we must have new medical schools,but it would be 10 years before they could produce graduates.Meanwhile, could not one of the newer universities give abachelor of science degree in human biology ? He also urgedthe importance of postgraduate education to preserve technicalcompetence, safeguard against isolation, and provide thestimulus without which any professional work sank to empiricaland uninspired routine.