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Future of Postgraduate Education

THE LANCETLONDON SATURDAY, JULY 20, 1946

IN his Frederick Price lecture to the Royal Collegeof Physicians of Edinburgh last week, Sir FRANCISFRASER said that the aim must be to enable everydoctor to be in constant touch with leaders and teachersof medicine. Hitherto, shortage both of replacementsand of suitably qualified teachers has hindered

postgraduate studies ; but these difficulties shouldeventually be overcome. In the proposed -NationalHealth Service each region,

" centred for professionalguidance on a university and its medical school,"will be composed of areas each of which will provideall the ordinary hospital and specialist services. Themain hospital in each area will be staffed by specialistswho could contribute largely to the further develop-ment of postgraduate teaching ; they will be in contactboth with the university and medical school of theregion and with general practitioners and the staffsof the smaller -hospitals. The professors and otherteachers of the university departments should, inSir FRANCIS FRASER’S opinion, be fully occupied inthe basic education of undergraduates and in research,and should only exceptionally be diverted to post-graduate instruction ; so it may well be advisableto adopt the practice, now being rapidly developedin - London, of instituting chairs and departmentsexpressly for advanced education in those branchesof medicine and surgery that belong more especiallyto the postgraduate field. The universities’ acceptanceof responsibility for developing postgraduate educationis welcome, since it makes sure that the instructionwill be of university standard ; in other words, it willbe not simply technical and vocational but also rationaland cultural, thus fostering both knowledge andjudgment. "A national medical service," said SirFRANCIS, " might easily produce a corps of time-servers. The maintenance of its standards is, there-fore, a vital problem now for the medical profession,and the answer to the problem is largely an educationalone and one for the medical schools to- supply." Ina letter to Monday’s Times Lord MORAN likewiseputs great emphasis on the part the universitiesshould play through their influence on postgraduateteaching at hospitals working under the regional boards:

" Each university must demand that every teacherin its region is recognised and approved by its medicalfaculty, just as all those who now teach in the twelvemedical schools of London have to apply to the LondonUniversity for recognition. In that fashion the facultywill ultimately be largely responsible for the qualityof the staffs and in consequence for the efficiency - ofall sizable hospitals outside the special ’ teachinggroup

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Lord MORAN points warningly to the alternative,which he dreads-namely, that the undergraduateteaching hospitals will be a caste apart, while thehospitals under the regional board provide an inferiorservice and their staffs lose heart.Turning to the training of the clinical specialist,

Sir FRANCIS FRASER said it is generally agreed thatat least five years’ postgraduate- instruction is needed

for his education. The holding of a hospital appoint-ment does not, of itself, suffice. The candidate’sduties must be light enough to enable him to studyhis cases thoroughly ; he should share his problems,in group discussions ; he must have ready access tolibraries, and he should be in touch with other clinicaldepartments ; part of his training period should bespent in the preclinical departments of a medicalschool or in a laboratory ; he should be encouragedto undertake research and to show his aptitude forteaching ; and above all he must be supervised. Inshort, the training of specialists can only be carriedout in a well-provided university department ; anda system of transfer from one unit to another andfrom one hospital to another should be devised.

The further education of general practitioners hashitherto been limited to intensive refresher courses,developed particularly in London, and to regularmeetings for discussion, as practised at Newcastle-on-Tyne. Sir FRANCIS thinks that their needs couldbest be met by (1) clinical assistantships at nearbyhospitals, .(2) regular half-day sessions at the chiefarea hospital, (3) short courses, lasting one or two days,on recent progress in specific subjects, at the regional.medical school or teaching hospital, and (4) intensivegeneral refresher courses of a week or more, to beattended once a year at a centre remote from the placeof practice. The intensive general refresher courselasting two or three weeks, and attended at intervalsof several years, is not entirely satisfactory, either forthe practitioner, who is liable to mental indigestion,or to the teacher, who is often conscious that the Jimegiven to preparing lectures is largely wasted. Thereis much truth in the suggestion that general practiceis itself the most difficult of the specialties and thatthese courses rarely include discussion of the problemsthat most concern practitioners. To carry out the

proposed programme, medical schools will have to.enlist the help of many hospitals. It will be, someyears before it can be brought into full operation,but a beginning can be made now, and a postgraduatedean or director and a postgraduate committee shouldbe appointed in each medical school or faculty. Theunique facilities offered by London are to be developedby the British Postgraduate Medical Federation,1which has been established by the, University ofLondon to coordinate the many general and special,hospitals, both voluntary and municipal. The aimis to develop for postgraduate students universitydepartments in each of the major specialties. It was-originally proposed that the component departmentsand institutes should be sited close to each other andto a central hospital or group of hospitals, and though =this plan is at present impracticable an influentialcommittee is now considering what parts of the’centre should be completed first. Meanwhile a centraloffice has - already been opened, to marshal the’scattered facilities. It will, among other functions,organise postgraduate studies for practitioners in theLondon area, and one of its most important dutieswill be to provide for the large numbers of graduatesfrom overseas. It should become a channel for distri-bution to all parts of the United Kingdom.This country, because of its geographical, economic,

social, and political position, is- suitable for the estab-lishment of a great postgraduate medical organisation

1. See Lancet, 1946, i, 507, 693.

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to serve graduates from all parts ; and there is a

special duty to provide such an, organisation to meetthe needs of the Dominions and Colonies. It willtake some years to build up departments staffed andequipped for research and education on universitystandards. In the meantime, all resources should bemade accessible to doctors in this country and fromoverseas ; and, Sir FRANCIS concluded, it is not too

early for the wise and bold planning that is neededto establish Britain as a world centre of medicaleducation through which may be moulded the thoughtsand ideals of individuals, races, and nations.

Prevention and Palliation of CancerIN searching for the cause of cancer man seeks a

source of power-the power to provoke continuouscell division. Measured against the power generatedby the union of sperm and ovum this is a compara-tively feeble one, but when set beside any other

physiological or pathological impulse it is enormous.A recurring fashion tends to see this source of poweras a negative quantity or quality. The idea findsfavour from time to time that an original or inherentimpulse for continuous division is repressed in normaltissues by their pressure effect, as perpetual motion is

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restrained by friction. Thirty-six years ago PEYTONRous first discovered a positive source of power ina filtrable transmissible agent residing within the

dividing cell in a sarcoma of a Plymouth Rock chick.He advanced the theory that this agent was the causeof unlimited autonomous proliferation. In his lectureas Walker prizeman, reported on another page, Dr.Rous reaffirmed his belief that filtrable agents or

viruses are the only known cause of cancer, but heallowed that progress in knowledge cannot stand onbiological precedent. Other sources of living powerthat now transcend our imagination may have to befound before the riddle is solved. -

During the last few years there has been a vigorousflow- of experiments and ideas across the Atlantic-with other good things-to refresh and inspireresearchers over here. One fruit of all this work is anew view of cancer as a process made up of manylinks. The process may be set in motion at any timein postnatal life. The foetus alone is guarded from it ;the uterus, so far as cancer is concerned, is the onlyivory tower man ever knows. No tumours appear tobe truly inherited ; there is merely a special liabilityin responsiveness-for example, of the skin to sun-light in xeroderma pigmentosum. By virtue ofunnatural conditions, as in industrial life, some

people are exposed to undue hazards. Peculiar,sometimes hereditary, responsiveness and intermittenthazards sum up during life to provide the right con-ditions for that irreversible cell change which mayresult in cancer. On the other hand, this changemay be latent. This we know from the behaviour ofthe- deadly blue-black mole provided it is undisturbed.Dr. Rous quoted striking figures of prostatic cancerafter the age of 40, obtained from autopsy material.These revealed an incidence of latent disease far abovethat seen in the clinic. Even when the irreversiblechange has occurred the young latent malignanttumour may require encouragement before it can

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grow. The complete process consists of two phases ainduced by two stimuli : initiators and promoters of

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autonomous growth. It is to the analysis of thesefactors that Dr. Rous has contributed so greatlysince 1941 by his study of skin tumours in the rabbit.In these, even after the occurrence of irreversible

change has been revealed by the appearance of warts,the whole proliferation will subside so that its formersite is undetectable even on microscopic scrutiny.Yet if the same carcinogenic stimulus is applied, or,more striking still, if a completely unrelated stimulusbe applied, such as the irritation- of turpentine or

chloroform or the impulse of wound healing, wartswill reappear in the places from which they hadvanished. Even growths already invasive mayvanish if not continually encouraged by some

stimulating agent. -

These new observations teach an old lesson-thatwith cancer prevention is easier than cure. Preven-tion can be applied at two stages :- absolute preventionbefore the change to a cancer cell can take place ; andpalliation that will sometimes succeed in denying thatencouragement which the changed cells still need.Enough knowledge now exists to exploit both these ’-

fields. Both ought to be pursued, because theyprovide with early treatment the best hopes of con-trolling this disease. The analyses made by STEVBN-SON 2 and the KENNAWAYS 3 of the incidence ofcancer at the more exposed sites in various income.groups point the way unmistakably towards preven-tion by education and by raising the conditions oflife of the poorer groups. Palliation through hormoneantagonisms is in its infancy. That the oestrogenshold many, though not all, prostatic growths in checkencourages the hope that in time endocrinology willprovide similar controls in other growths.

Nuclear Physics in MedicineTHE urgent needs of war have led to many striking

advances in the treatment of disease for the benefitof all. Nuclear physics, however, became involved ina race for knowledge which helped to determine theresult of the war, and the secrecy imposed to preventescape of information about destructive processes has

prevented proper discussion of its medical applications.Three papers read before the Faculty of Radiologistsat the annual meeting in Glasgow give some idea ofthe research in progress and of the paths which maybe taken. These run in three main directions buthave numerous branches, many of which alreadyconverge and will later meet. First. come the tech-nical achievements-the betatron, the cyclotron, andlinear electron accelerators. (The betatron alreadygives X-ray beams at 20 M ev, with at least oneoperating up to 100 M ev.) Next there is physiologicalresearch using radioactive isotope tracers. In thethird place, because more tentative, we hear of experi-mental and clinical research on cancer. It is hopedthat some of the new developments are sufficientlydifferent from anything hitherto known, to promisean extension of radiotherapy to conditions in whichlittle success has yet been attained. The X-ray beamfrom the betatron, which gives a higher dose in thetissues than on the skin through which it enters, isalready important. It is only a matter of time before1. MacKenzie, I., Rous, P. J. exp. Med. 1941, 73, 391.2. Stevenson, T. H. C. Biometrika, 1923, 15, 382.3. Kennaway, E. L., Kennaway, N. M. Unio Internationalis Contra

Cancrum, 1937, vol. II, no. 2, p. 101.