337

absent, although cholestasis may occur. The abnormalmononuclear cells are seen in the portal tracts and as adiffuse or focal infiltrate in and around the sinusoids.

Mechanical Biliary ObstructionIn virus-induced or drug-induced hepatitis, usually in

severe cases and late in the course of the disease, portal-tract changes may be found which closely mimic those ofmechanical obstruction to the large bileducts (fig. 7). Thenumber of small bileducts in portal tracts seems to beincreased and neutrophils infiltrate their walls and the

surrounding connective tissue. Ducts may also be dilatedand contain plugs of inspissated bile. The correct diagnosismay be made by the finding of typical changes of hepatitiswithin the lobules.

Primary Biliary CirrhosisDamaged interlobular bileducts surrounded by mono-

nuclear cells are seen in a few cases of acute hepatitis, 14and, rarely, a parabiliary granuloma is also present. Thereis so far no definite evidence that these changes representan early lesion of primary biliary cirrhosis.

CORRELATION BETWEEN HISTOLOGICAL, CLINICAL,AND BIOCHEMICAL FINDINGS

Clinical, biochemical, and histological evidence asto the severity, evolution, and prognosis of viral hepa-titis is usually consistent but may conflict. Thus,severe liver-cell damage may be found on liver biopsyin a patient whose hepatitis is clinically mild andanicteric. Conversely, a severe illness is not necessarilyaccompanied by extensive necrosis on liver biopsy,although cholestasis may be heavy. It has already beennoted that the disease may run a protracted course orthe patient may have recurrent attacks of hepatitis,while the biopsy shows changes indistinguishablefrom those of uncomplicated " acute " viral hepatitis.We cannot yet distinguish histologically between shortand long incubation forms of the disease.There is some correlation between immunological

disturbances, as reflected by a variety of abnormalserum antibodies and raised serum gamma-globulinlevels on the one hand, and the presence of plasmacells, lymphocytes, and lymphoid aggregates in a liverbiopsy specimen on the other. As has been discussedabove, the presence of these cells favours, but does notinvariably indicate progression to, chronic liver disease.

Requests for reprints should be addressed to Dr. P. J. Scheuer,Department of Pathology, Royal Free Hospital, Gray’s InnRoad, London W.C.I.

REFERENCES

1. Blumberg, B. S., Alter, H. J., Visnich, S. J. Am. med. Ass. 1965,191, 541.

2. Sherlock, S. Gut, 1970, 11, 185.3. Wright, R., McCollum, R. W., Klatskin, G. Lancet, 1969, ii, 117.4. Sherlock, S., Fox, R. A., Niazi, S. P., Scheuer, P. J. ibid. 1970, i,

1243.5. Creutzfeldt, W., Schmitt, H., Richert, J., Kaiser, K., Matthes, M.

Dt. med. Wschr. 1962, 36, 1801.6. Thaler, H. Beitr. Path. Anat. 1952, 112, 173.7. Rubin, E., Popper, H. Medicine, Baltimore, 1967, 46, 163.8. Klatskin, G. Am. J. Med. 1958, 25, 333.9. Bianchi, L. in Progress in Liver Diseases (edited by H. Popper and

F. Schaffner); vol. III, p. 236. New York, 1970.10. De Groote, J., Desmet, V. J., Gedigk, P., Korb, G., Popper, H.,

Poulsen, H., Scheuer, P. J., Schmid, M., Thaler, H., Uehlinger, E.,Wepler, W. Lancet, 1968, ii, 626.

11. Boyer, J. L., Klatskin, G. New Engl. J. Med. 1970, 283, 1063.12. Klion, F. M., Schaffner, F., Popper, H. Ann. intern. Med. 1969,

71, 467.13. Peters, R. L., Edmondson, H. A., Reynolds, T. B., Meister, J. C.,

Curphey, T. J. Am. J. Med. 1969, 47, 748.14. Poulsen, H., Christoffersen, P. Acta path. microbiol. scand. 1969,

76, 383.

Medical Education

TRAINING OF JUNIOR HOSPITALMEDICAL STAFF

IN THE SOUTH-WEST METROPOLITAN REGION

MICHAEL ESSEX-LOPRESTI

South-West Metropolitan Regional Hospital Board,London W.2

Summary Arrangements for reviewing centrallythe progress and prospects of junior

hospital medical staff, and for offering career guidance,were introduced four years ago in the South-West

Metropolitan Region of England. An analysis of theambitions and progress of 250 registrars reviewed inthis region shows that 54% of them are overseasgraduates and that 18% of these intended to settle inthe United Kingdom. 11% of U.K. graduates pro-posed to emigrate. A scheme has been developedlinking established posts in the senior-house-officerand registrar grades to provide a sequence of appoint-ments for planned training. Doctors may enter these

appointments when they have completed their pre-registration year, and the training is arranged to givethe necessary experience for a career in the hospitalservice or in general practice.

INTRODUCTION

WHEN the Joint Working Party on the MedicalStaffing Structure in the Hospital Service was set upin 1958 it faced the urgent problem of a large numberof senior registrars who had completed their trainingbut were unable to obtain consultant appointments.!This problem has been resolved because the totalnumber of senior registrars now is only slightly greaterthan it was twenty years ago, whereas in the same

period the number of consultants has increased bynearly z In the same period, however, the numberof registrars has increased by 125%, and this has ledto the frustration and dissatisfaction among juniordoctors described by Bennett in 1966.3 In Octoberof that year the B.M.A. " Charter " for HospitalDoctors 4 called for limitation on the number of

registrar posts and a well-defined training programmefor future consultants.

Early in 1967 the South-West Metropolitan RegionalHospital Board and its regional postgraduate dean,Mr. Donald Bowie, began discussing with the medicalstaff in its hospitals ways of tackling the problem, andprocedures have been introduced in order to providecareer guidance and a programme of training for thejunior staff, particularly registrars, employed in theregion.

CAREER GUIDANCE

A procedure for reviewing the progress and prospectsof all registrars in the region was introduced in October,1967. The aim is to ensure that a registrar does notspend too long in the grade with diminishing prospectsof achieving a senior-registrar post and the associatedrisk of his becoming so specialised that retraining in adifferent specialty becomes progressively less feasible.

338

When a registrar has been in post for eight months aquestionary is sent from the regional board to thegroup clinical tutor asking him to discuss with theappropriate consultants and the registrar specificquestions relating to his or her career. These includewhether the registrar plans to specialise in the hospitalservice, or to enter general practice or another branchof medicine, and whether or not he intends to remainin the United Kingdom. Higher qualifications ob-tained and being worked for and the number of yearsfor which registrar posts in the present specialty havebeen held are recorded. Finally, the clinical tutor isasked to recommend whether or not the appointmentshould be extended for the second year, and he isinvited to comment on future training and the regis-trar’s prospects of ultimately achieving his or herchosen career. If it is decided that career guidance isrequired, the clinical tutor is invited either to interviewthe registrar concerned or to suggest that he or sheshould make an appointment to see the principalassistant senior medical officer (staffing) or the regionalpostgraduate dean. Should the registrar then beadvised that his or her progress, particularly in anover-subscribed specialty such as general medicine,general surgery, or obstetrics and gynxcology, issuch that the chances of obtaining a senior-registrar postare remote, the possibility of retraining in a differentspecialty is discussed and the registrar then has thewhole of the second year of the present appointment inwhich to decide on what job to apply for next. Thereview takes place after only eight months in the

appointment so as to allow the doctor time to considera change of course without the added anxiety of un-employment.

Sometimes an applicant for a registrar appointmenthas already spent several years in the grade. In this

region, hospital management committees undertakethe arrangements for interviewing candidates for

registrar appointments on behalf of the Board, but theapplications for all posts are examined by the regionaldean and a principal assistant senior medical officerwho are both officially members of every registrarappointments committee. They satisfy themselves onthe value of the post to the candidates rather than ontheir suitability to undertake the duties.When an applicant has already held several registrar

appointments, particularly in a popular specialty, andhas not achieved his higher qualifications, the Boardcould refuse to appoint him in his own interest, butthe doctor may not appreciate the gesture if he is soonto be out of a job. As an alternative, therefore, theappointments committee is asked to ensure that, ifit is recommending this doctor for the post, he isinformed at the time that his appointment will be forone year only and that he should arrange to see theprincipal assistant senior medical officer (staffing) orthe regional dean soon after taking up the appointment.Being offered career guidance at this stage, the doctorhas nearly a year in employment in which to decide onhis or her future and what sort of job to seek next.A third opportunity for reviewing a registrar’s

progress occurs in a few cases when a further extensionof the appointment beyond the second year is reques-ted. This is usually granted if an examination is beingattempted at the time, so as to avoid the insecurity of

TABLE I-AREA WHERE REGISTRARS GRADUATED

TABLE II-INTENTION TO REMAIN PERMANENTLY IN THE UNITED

KINGDOM

job-hunting which would interfere with the doctor’sstudies.The opportunity has been taken of analysing the

250 forms returned between November, 1967, andFebruary, 1970. This figure was chosen because thereare about 250 registrars in our regional hospitals and,as comparatively few of them are extended beyond asecond year in one appointment, the sample should befairly representative. Further information on the

registrars was derived from their forms of applicationfor their present appointment. In this sample 46%of the registrars graduated in Great Britain and Ireland,though these included a few who had come to Britainfor their medical studies (table i).Of those who trained here 11 % will definitely or

almost certainly leave, whereas of the overseas gradu-ates 18% intend to remain in this country (table n).

Emigration does not seem to be directly related toprospects of a career in a chosen specialty in thiscountry (table ill).With two exceptions every registrar intended to

specialise in the hospital service, though the patternis changing slightly as a result of planned trainingschemes developed since the survey was undertaken.

TABLE III-SPECIALTIES SELECTED BY INTENDING IMMIGRANTS AND

EMIGRANTS

* Published by the Department of Health.6

339

PLANNED TRAINING SCHEMES

There is a serious imbalance in this country betweenthe number of junior medical staff in training posts andthe number of career posts in hospital available tothem. 6 This applies particularly to certain specialtiessuch as surgery,’ medicine, and obstetrics and gynx-cology, where the number of juniors required for theservice greatly exceeds the number of trainees neededto fill vacancies in the consultant grade. Attempts arebeing made in the South-West Metropolitan Region toadjust the ratio between juniors and consultants bycreating more posts for consultants, rather than redu-cing the number of juniors. However, if these serviceposts are to be continued, they should be used fortraining doctors for a specialty with reasonable

prospects. This can be achieved by linking suitableposts in a sequence of appointments each aimed at aparticular specialty or at general practice.Planned training schemes in which existing senior-

house-officer and registrar posts in one hospital or inadjacent hospitals were combined as one appointmentfor three or four years were introduced in 1967 andare available to applicants when they have completedtheir preregistration year. A medical registrar postwas thus included in the programme of training for acareer in paediatrics, geriatrics, psychiatry, generalpractice, and other medical subspecialties. General

surgical registrar posts are suitable for the training fora career in orthopxdics, otolaryngology, plastic sur-gery, and even radiology, which is becoming moreoperative than in the past. By this means generalmedical and surgical posts could be filled, but thedoctors appointed to them had no illusions that theywere training for a career in general medicine or generalsurgery.

Several advantages of developing a planned trainingscheme emerged. A doctor completing his preregistra-tion year could apply for an appointment of three ormore years in one area (particularly useful to a marriedman), and the training programme is tailored to providethe experience necessary for a chosen career. Suitable

day-release courses are arranged as part of the scheme;and in several cases a fourth year-that is, a thirdregistrar year-at a teaching hospital is included in theappointment, teaching-hospital representatives attend-ing the appointments committee at the outset. Thefield of applicants for such appointments is better thanwhen the senior-house-officer or the registrar posts areadvertised separately. One hospital offered a three-yearappointment aimed at general practice and includedsix months each in paediatrics and in obstetrics andgynxcology followed by a year as medical registrar andthe third year as a trainee assistant in a neighbouringgeneral practice. Although the hospital usuallyattracted good medical registrars previously, thoseapplying for this scheme were outstanding, with theresult that more of the hospital’s posts were associatedwith general-practitioner training, and senior-house-officer jobs in a neighbouring hospital had to be in-cluded in order to feed the medical registrar posts. Insome hospitals two medical registrar posts are includedin planned training schemes-one aimed at generalpractice and the other, linked with a teaching hospital,aimed at a consultant career in medicine. In the latterscheme, since the registrar spends two years at the hos-

pital (one year on each medical firm), the effect is thateach firm alternates between training for the hospitalservice and for general practice, and this ensures thatthe standard of training for each is seen to be the same.In launching these schemes it is important that postsincluded are those best suited to the training programmeand not those which are inadequate and difficult to fill.As more planned training schemes are developed,

junior doctors will have a better chance of obtainingthe required experience in one area in an organisedfashion. In our discussions with junior doctors weare surprised at the number who have decided upontheir career by the end of the preregistration year,though all the appointments in a scheme are subjectto review at intervals and a doctor is free to opt outat any stage. In many respects the scheme fore-shadowed the period of general professional trainingrecommended in the Todd report.8 Such schemes arevaluable for training not only U.K. graduates but alsooverseas graduates who come to this country for

postgraduate education before returning to their owncountries.9 9

I thank Dr. G. C. Taylor and the South-West MetropolitanBoard for their encouragement and support, and Mr. D. C.Bowie, whose influence continues long after his retirement asregional postgraduate dean.

REFERENCES

1. Report of the Joint Working Party on the Medical Staffing Structurein the Hospital Service. H.M. Stationery Office, 1961.

2. Figures published by Department of Health.3. Bennett, J. R. Lancet, 1966, ii, 539.4. See Br. med. J. 1966, ii, suppl. p. 171.5. Medical Staffing in the National Health Service in England and

Wales. Lancet, 1970, i, 944.6. ibid., 1966, ii, 1399.7. Jones, P. F. Br. med. J. 1969, iii, 464.8. Report of the Royal Commission on Medical Education. Cmnd.

3569. H.M. Stationery Office, 1968.9. Lancet, 1970, ii, 1071.

Reconstruction

METRICATION AND MEDICINE

M. D. RAWLINS

Department of Medicine,St. Thomas’s Hospital Medical School,

London S.E.1

THE introduction of decimal coinage brings us

nearer, at least psychologically, to the general adoptionof the metric system in the United Kingdom. Whilstelaborate timetables have been drawn up for metrica-tion in education, industry, and commerce, littlehas so far been said about the introduction of themetric system into clinical medicine.

The metric system was founded during the FrenchRevolution and was subsequently adopted by manycountries for the official units of weights and measures.Its use in science became widespread, and complexquantities were measured on the basis of three units-the centimetre, the gramme, and the second. The systembuilt up on this basis (e.g., velocity as centimetres persecond) is called the c.g.s. system. This is the systemfamiliar to those who have knowledge of the metric systemin science.

In 1901 it was appreciated that the incorporation ofelectrical units into the metric system would be facilitated

by using the kilogramme and the metre as base units