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medicine or surgery is a special department in the wholestructure. It benefits from the lack of a limiting labeland from a keener sense of the power of detailed factsto teach principles.

In the growing interest in the state of medical educationtoday, both here and in America, Mr. Patey sees a hintof a deeper conflict. The predominant fact of our timeis that civilisation has been challenged. It is therefore

urgently aware of the need to perfect its own institutions,of which medical education is but one.

PUBLIC-HEALTH NURSING HERE AND INFRANCE

STOCKTAKING is one of the most useful of scientific

techniques. At present a pilot study of social work andpublic health, sponsored by the World Health Organisa-tion and the Rockefeller Foundation, is being made hereand in France, to analyse the health and welfare needsof the family, define the functions of welfare workers,and ascertain the type of worker required. Dr. ReneSand, professor of social medicine at Brussels University,is director of the study in France, and Dr. Leslie Banksprofessor of human ecology at Cambridge, is in chargeof the English study. The French one is more advanced,and Dr. Sand, speaking at the Royal College of Nursingon Nov. 3, was able to give some of the preliminaryfindings.

French social-welfare workers-assistantes sociales-are trained rather differently from our health visitors.They have one year of nursing experience in hospitaland then a further two years’ training in social workbefore they take their diploma. After this basic trainingsome specialise in such things as tuberculosis and mental-health work, and many take a midwifery qualification.The A.s. diploma does not qualify them for home nursing :in order to get a nursing diploma they have to take asecond year in hospital. Our own health visitors havea much greater nursing bias in their training : most ofthem have taken State registration before they enteron their further training as health visitors, and so

have spent at least three and probably four years inhospital. This would seem an extravagant way of

training a social worker if we were not short of nurses ;and if the health visitors themselves did not claim thattheir nursing training was constantly of use in their work.As it is, we get their services as student nurses for severalyears ; and since they are women of a particularly goodtype this is a decided gain to the hospitals. In comparisonwith their nursing training, their training in socialwork is sketchy and ill planned; and Dr. AndrewTopping, who spoke later in the meeting, mentioneda new course for health visitors which is to be held next

year at the London School of Hygiene and TropicalMedicine. This will carry less physiology and bacterio-logy than the current course, but much more aboutinfection and immunity, nutrition, household manage-ment, and, especially, social economy. The physio-logy taught will deal with pregnancy, childbirth, infantlife, and children’s growth.

In the French survey questionaries have been sentout to assistantes sociales in various Départements chosenso as to give representative types of population-rural, industrial, urban, and suburban. Only 60% haveanswered, but most of those who have not replied areeither in religious orders or employed by industrialfirms ; and these, Dr. Sand said, will probably have tobe visited personally. Meanwhile the answers receivedshow that 75% of the assistantes sociales are unmarried,and that their average age is 37. They each have a case-load of 300 families, which he said was much too much-to the amusement of his audience of British healthvisitors. Some 40% of the French worker’s time is

spent in practical health and social work, 25% in

secretarial work, and 10% in travelling and attendanceat conferences. Analysed in another way, the figurbshow that assistantes sociales give education and ad,icein 60% of cases, take administrative measures of onekind or another on behalf of a further 16%, get relieffor 3%, place 14%, and give nursing care (those whohave a nursing diploma) in 2%. There is no workerin France corresponding to our district nurse-a seriousgap in the welfare services.The comments of the assistants sociales on their work

reveal some minor weaknesses of an otherwise goodsystem. They regret the isolation of many of the

villages, and would like fewer cases, less administrativedrudgery, and a car. The paramount need of the popula.tion, they say, is education in health, household economy.and the art of living. Dr. Topping seconded this lastopinion on behalf of the British : the final year at schoolof girls of fifteen, he said, should consist largely in courseson nutrition, cooking, laundry work, and the basiccauses of disease. French children stay at school a

year longer than ours, and the curriculum in theirfinal year, according to Dr. Sand, includes sociology,psychology, and ethics. A final year combining theessence of both courses might perhaps be regarded asinstruction in the art of living.Two points mentioned by Dr. Sand struck the meeting

with special force. The law expressly forbids anyprofessional person to disclose any facts learned in thecourse of professional duties : they cannot, as we canhere, be compelled to disclose such matters in a courtroom. The second point was the revolt of the Parisianassistantes sociales against the practice of sending welfareworkers from a dozen different agencies into the samehouse. The result has been that a single ass-istaritesociate has been made responsible for a certain definedarea, and if she needs specialised help in a given case-for instance, in a case of tuberculosis-she calls in acolleague who has trained in that branch. This arrange.ment has proved so successful that it has now been madecompulsory in every Dipartenieitt, though it is not yetfully in action in all of them.

PSYCHIATRY AND THE GENERAL PRACTITIONER

OF all the specialties, psychiatry has the greatest needto improve its contact with general practice. Some

practitioners refer their psychiatric problems for specialistopinion in the hope of miracles ; some are frankly"

passing the buck " with a patient who does not respondto sedatives and reassurance. The diffidence with whichmost of them approach a psychiatric problem is seen

in the notes which accompany patients sent to observationwards : " Suffering from mental disorder," with no

history given, is more terse than the briefest of letterssent with a patient to an ordinary hospital. On theother hand, liaison is not helped by a consultant whosends the patient back with a description of his psycho-dynamics but without suggestions on treatment-except.perhaps, a hint that a two-year analysis is the onlypossible approach.

It has long been evident-and this was acknowledgedby the Goodenough Committee-that a much greateremphasis on normal and abnormal psychology is neededin undergraduate training. But much else can be done:and one useful step was taken by the Maudsley Hospitallast week when it held a cocktail party for all generalpractitioners in South London who had referred patientsthere. With true psychological insight, the guests wereencouraged to discuss any aspect of the hospital’s workwith any member of the staff from professor to house-officer ; and this informal method seemed highly success-ful. Over a hundred local practitioners arrived, somewith obvious enthusiasm and others with ill-concealed

suspicion (the popular conception of a psychiatric unitas a lunatic asylum with an able public-relations officer

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has not yet disappeared). Even if the cost had comefrom the public purse (not a penny did) the moneywould have been well spent if the gathering leads toincreased understanding between psychiatrist and generalpractitioner of the other’s problems and potentialities.The harrier between mental-hospital and outpatientpractice often found in the U.S.A. is not so evident here,but completely different approaches to mental and toorganic illness are still too often regarded as inevitable.The general practitioner is the obvious person to contra -dict this ; but before he can do so he must know whatcan-and cannot-be done.

AMERICAN MEDICAL STUDENTS IN HOLLAND

SINCE the American Medical Association early last

year decided to recognise Dutch degrees for doctors whowished to practise in the U.S.A., over 100 Americanshave started to study medicine in Holland. This is nota reciprocal arrangement, for the American M.D. is notrecognised in Holland, where it is felt that there are

already too many doctors.Normally the medical course in Holland takes seven

years : five for the Doctorccccl, and two more for the finalArts examination.* Americans who have graduated B.A.or have passed in the necessary subjects are exemptedfrom the examinations in chemistry, physics, botany, andzoology. They start studying for the second Candidatesexamination in their first year. During the first twoyears they do anatomy, embryology, biochemistry,histology, and general pathology. In their third andfourth years they study clinical subjects for the Doctoraal.They will take the Doctoraal after about four years inHolland, or possibly a little earlier. What they will doafter this is uncertain, for plans about how soon they willgo back to the United States are still vague. Possiblythey may return for their internships. If they remainin Holland, which may not be possible because of over-crowding, they will during the last two years take theSemi-arts examination in internal medicine, paediatrics,psychiatry, neurosurgery, prescribing, and dispensing ;and, after about six years in Holland, the Arts examina-tion in surgery, obstetrics, and gyn2ecology. The Candi-dates and Doctoraal examinations are theoretical; theSemi-arts and Arts practical. The last two years of studyare spent in hospitals and clinics doing practical work as" co-assistants," still with the status of a student.The universities in Holland have been overcrowded

since the war, and their resources were strained beforethe Americans arrived. The proportion of medicals ishigh. In 1949 at Amsterdam Municipal University, 2364students out of B695 were medical, and last year 2412out of 7043 ; so the comparatively small number ofAmerican students cannot have greatly accentuated theovercrowding. To limit numbers the standards of theexaminations have been considerably raised. No lecturesor examinations in Amsterdam are at present given inEnglish, though they may be later. Special classes inthe Dutch language have been organised.There are now in Amsterdam approximately 4

American fourth-year students, 15 third-year, 25 second-year, and about 70 first-year. The fourth-year students,who will take their Doctoraal in about a year, came toAmsterdam from Zurich early in 1950, because the Zurichdegree was not then recognised in the U.S.A. Zurichand some other Swiss universities, which are also over-crowded, have, however, since been recognised. Americanstudents are also studying in Great Britain, Sweden, andItaly. More came to Europe this year than ever before.The Americans in Amsterdam are impressed by the

high quality of the lectures, most of which are notcompulsory. " They go out of their way to help," is the* To the English reader this suggests a confusion of faculties, but

in Holland Arts, like the more familiar German Arzt, mean" doctor."

general opinion of those interviewed, " and the higher up

the guy is, the nicer he is." Some, however, are ratherconcerned about the overcrowding in the anatomydepartment, where, with the additional problem of

shortage of cadavers, it is impossible to dissect the wholehuman body with the same thoroughness as at schools inthe United States. This is explained by the strict limita-tion of the number of students admitted to the medicalschools in America, whereas in Holland it has beentraditional to allow all qualified students access to theuniversities. An interesting difference from the Americansystem, where students have to pass tests frequently, isthat in Amsterdam there are few tests during the firsttwo years, and the student is encouraged to work athis own pace.

CONFERENCE OF LOCAL MEDICAL COMMITTEES

AT the Annual Conference of Representatives of LocalMedical Committees in London on Oct. 31, the unsettledbusiness of the practitioner’s remuneration was undoubt-edly in the forefront of most minds. Probably becauserepresentatives were satisfied that the doctors’ case

will be well presented at the promised examination,little time was given to this topic. Dr. S. Wand, chairmanof the General Medical Services Committee, did, however,warn the conference that much remained to be done in

preparing evidence and examining and analysing prac-titioners’ remuneration tables, which had not yet beenreceived from the Ministry of Health. It might well be,he said, that the adjudication could not with advantagetake place until perhaps the end of the winter. He alsorecalled that it would be within the adjudicator’scompetence to backdate any new award.

Turning to entry into practice, representatives criti-cised the criteria adopted by the Medical PracticesCommittee in deciding which areas should be open orclosed to new doctors. A subject which aroused still

stronger feeling was the not uncommon difficulty in

filling a practice vacancy because the appointed successornnus mat some otner uocùor nas uougm me practicehouse. Tripartite discussions between the Ministry ofHealth, the Medical Practices Committee, and theG.M.S.C. have continued for a long time in an endeavourto overcome this obstacle. The solution that is possiblyleast objectionable to the incoming doctor and to theretiring doctor, his widow, or his heirs, was embodiedin resolutions proposed by the Chairman of the G.M.S.C.These call for amendment of the regulations, by whicha new doctor would, for up to one year, be prohibitedfrom practising from the premises of an outgoing doctorexcept with the permission of the local executivecouncil; and the applicant appointed by the executivecouncil, if he wished to buy those premises, wouldundertake to do so, at the price approved by the MedicalPractices Committee, within two months of taking overthe practice (in default of which the vendor would befree to dispose of the premises as he wished). After

long discussion representatives decided that this pro-cedure would create greater injustice than it corrected.The conference found little to criticise in a report

by a subcommittee of the G.M.S.C. on the trainee-assistant scheme. The G.M.S.C. was, however, askedto consider once again whether it could find a betterway of dealing with the claim of a doctor who felt

aggrieved at not being accepted as a trainer, and of

assessing the results of the year’s work by trainer andtrainee.The conference is in future to be held in May or June

of each year.

THE next session of the General Medical Council willopen on Tuesday, Nov. 27, at 2 P.., when Prof. DavidCampbell, the president, will deliver an address. TheMedical Disciplinary Committee is to meet on Wednesday,Nov. 28, at 2 P.M., to hear disciplinary cases.