From 1957 to 1976 oesophageal resection for carcinoma was performed in 1119 patients reported to the West Midlands Cancer Registry. The operations were performed on 581 patients by 127 surgeons who averaged three or less resections per annum (the 'occasional' group). These were compared with 538 patients (the 'frequent' group) whose resections were performed by four surgeons who averaged six or more resections per annum. Operative mortality was 39.4 per cent in the 'occasional' group and 21.6 per cent in the 'frequent' group (P less than 0.001). The age adjusted 5-year survival was 11.1 and 15.2 per cent respectively (P less than 0.05) but when the operative deaths were excluded there was no significant difference. We suggest that oesophageal resection for carcinoma should be performed only where there is an acceptably low operative mortality rate.
Between 1957 and 1981, 31,716 cases of gastric cancer were registered in the West Midlands, UK. The age-standardized incidence has shown a decrease from 17.42 per 100,000 population during the first quinquennium to 15.30 per 100,000 in the last. There was an apparent increase in the proportion of proximal lesions with a decrease in the proportion of distal, antral cancers. The stage of disease at diagnosis remained constant with 79 per cent of patients having stage IV disease. Less than 1 per cent presented with stage I disease. As a result, the curative resection rate was 21 per cent. The operative mortality rates for curative partial gastrectomy and total gastrectomy were 13 and 29 per cent respectively. Surgeons undertaking more than nine total gastrectomies annually had an overall mean operative mortality rate of 22 per cent. Overall age-adjusted survival at 5 years was 5 per cent. Survival at 5 years for stage I, II and III disease was 72, 32 and 10 per cent respectively. There was a significant increase in survival time for those treated by curative resection between 1972 and 1981 compared with the previous decade. The implications for the management of gastric cancer are discussed.
Summary and conclusionsIn "early" gastric cancer the depth of invasion by the primary tumour is confined to the submucosa of the stomach. Out
To-morrow's Doctors-Ellis ri 1577The present annual /intake of students is short of what we need if medicine is to continue to do all that is now expected of it. But we are in an unfortunate position in which we do not now possess enough doctors to be able to make a lot more very quickly. It is easy to say we must have many more medical schools. But medical education can no longer be completed by medical schools. The limiting factor now is the total training potential there is in the country.We must mobilize our whole potential and provide the money that is needed. It does not necessarily follow, however, that we will then produce the number of doctors that we may guess we need in order to maintain the same pattern of medical care. If we cannot produce enough for that purpose we will have to use doctors only where medicine has something really effective to offer and free them from everything for which a doctor, even if desirable, is not truly necessary.We are losing more doctors from emigration than we can spare. Many different factors will combine, however, to reduce this number. As other countries improve their organization, and as we improve our facilities, the drain should become substantially less.There will always be some emigration. There always has been, and the overseas commitments which caused it have left us with obligations to other countries which the profession is not likely to ignore. Perhaps, however, the greatest contribution we can make to the world can be made here in Britain, by giving an example of how to adapt medical education and medical care to modern medicine. We are far better placed than any other country to do this, despite our shortage of numbers.It will be an expensive task. Already medical education is more expensive than any other-justification enough for making sure we are doing it well. We are prepared to spend money to find out how to make a nuclear warship so that it will be effective in war but safe in peace. We have not so far put public money into research into medical education. For two decades the turbulence of change has clouded the medical scene, but when in the fullness of time the mists clear it will be seen that the doctors of to-day have preserved all that was best in their heritage and have greatly raised the standard of British medicine. If those who follow are to maintain it, and raise it still higher, they must be given a preparation appropriate to their task.
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