Br J Vener Dis: first published as 10.1136/sti.25.1.16 on 1 March 1949. Downloaded from

THE TEACHING OF VENEREOLOGY* BY R. LEES Director of the Venereal Disease Department, General Infirmary, Leeds It is very opportune at present to consider the Standards and Scope of Instruction teaching of venereology for this specialist branch On the type and-amount of teaching of venereo- of medicine has received formal recognition from logy to students, to graduates, and to specialist two important bodies, the British Medical Associa- trainees will depend the present and future of our tion (by formation of a venereologist group), and subject. So we must define our standards and the the Ministry of Health and National Health Service. scope of instruction, and try to persuade our A circular from the Ministry of Health states colleagues to permit us to reach our set standards. emphatically that " the diagnosis and treatment of We must recognize the present limitations and venereal diseases constitut% a separate clinical difficulties inherent in the subject, and, so far as specialty, and should not be left to become a minor may be possible, remove the obstructions. Let us interest of specialists in other fields " ; also that recognize too, that teachers are seldom born, and " specialists in this, as in other fields, should have that a long and difficult apprenticeship is required, an adequate experience of general medicine and with skilled guidance in the art, so that the future surgery as well as a sufficient training in their own specialist and teacher of the venereal diseases may particular field." rank equal with the most eminent of his colleagues. copyright. The special difficulties I have noted are (1) the The Present Standing of Venereology short time available to the sttudent, (2) the infinite The specialty of venereology is at a critical phase variety of clinical types of disease, (3) the need for of development. In one respect the venereologist secrecy for the patient, (4) the intricacy of laboratory has come into his own and--has an opportunity to methods, (5) social problems, and (6) the reluctance develop the subject fully, untrammelled by local of some schools to recognize the desirability of committees and health departments. His status instruction in venereology. http://sti.bmj.com/ is recognized, and he may hope for adequate pay. We have suffered recently from a spate of plan- On the other hand the venereologist finds that his ning, -and many committees have issued their learned work is becoming less, for treatment methods are reports on medical training and medical schools and simpler and safer, and complications fewer, so that the services for the treatment and prevention of general practitioners commonly undertake to treat *disease. Venereal diseases have been considered patients with venereal disease who would formerly in all these, in some instances only in a cursory have been passed to the specialist. Also specialists fashion, in others in more detail. I suggest that on September 29, 2021 by guest. Protected in other fields, such as dermatologists, gynxco- our society should consider more fully, as befits a logists, neurologists, surgeons, and many doctors specialist society, the standards ofteaching adequate with doubtful claims to any specialist knowledge, for undergraduate and postgraduate medical in- are lured by the attraction of cash fees to undertake struction, and perhaps also the standard necessary the treatment of venereal disease as a profitable for nurses, midwives, health visitors, almoners and side-line. Thus we are nowadays frequently invited other auxiliaries. to take over hospital patients, but receive infrequent invitations to take over private fee-paying patients. Undergraduates So the venereologist must deserve well of his The object of a medical school is to turn out a colleagues and command respect from both the young doctor. who has been trained reasonably well medical profession and the public by the high in the basic sciences, who is expert in the methods standard of his specialist work and the quality of of examination of a patient, and who is familiar his teaching. with the manifestations of the commoner ailments of man and the methods of treatment coming *An address to the Medical Society for the Study of Venereal Diseases, Nov. 26, 1948. within the scope of a general practitioner. He 16 Br J Vener Dis: first published as 10.1136/sti.25.1.16 on 1 March 1949. Downloaded from TEACHING OF VENEREOLOGY 17 should also be trained to observe accurately, to completely up-to-date. Attendance should not be draw deductions, and to assimilate new claims and compulsory. If the lecturer fails to secure an observations critically; and he should be able to audience his employers should be entitled to inquire advise in methods of maintenance of health. This into the reason, and if necessary replace an in- is a formidable task, and it is commonly held that competent teacher. the curriculum is cluttered with many courses of Visual Aids.-Full use must be made of visual instruction which are probably useless as a mental aids, such as pictures, photographs, diagrams, training and discipline and whose facts are obsolete. models, and films, and we should organize the I consider that the undergraduate teacher of supply of such aids and pool and interchange our venereology must eschew narrow specialism, and resources. Good lantern slides of skin lesions may nmust mould his instruction to the pattern of the have almost as much value as demonstrations on a general teaching programme of the medical school, few patients, and can be available constantly and placing emphasis on methods of examination, not only on rare occasions. How frequently we interpretation of observed facts and laboratory are mortified that ideal teaching cases turn up data, logical deductions, and critical evaluation, where there are no students ! We should be that he must some and finally impart elementary prepared to give copies of all our best teaching instruction in methods of treatment. The venereo- photographs and slides to any of our colleagues, logy class, therefore, will supplement and continue and they should reciprocate, this being done on the the planned scientific instruction in clinical medicine, understanding that they would not be published the illustrations being drawn from a wide variety of without the original owner's consent nor used in manifestations of ill-health of a type seldom seen unethical ways. It would be easy to incorporate in the general wards of hospitals or in out-patient in a photograph or lantern slide an indication of departments. The instruction must be on the its origin, if safeguards were felt to be necessary. highest plane, and there is no place for bawdy jokes and risque stories. Demonstrations.-Clinical teaching is limited to We do not seek to produce a lot of ill-informed some extent- by the necessity to preserve secrecy for copyright. semi-specialists who will shortly embark on the the patients. Many female patients refuse to be treatment of their patients fortified by the know- used for demonstration, even to their own sex. It ledge that they have " done V.D.," and armed with is surprising, however, the number of men who will inaccurate notes and schedules of injections. We exhibit genital lesions to a " mixed " class of men seek to round off the general instruction in the and women. I prefer to show selected patients medical arts, using another set of illustrations to who have previously given consent to be demon- teach the same methods and lessons. And we strated, rather than have a group of students http://sti.bmj.com/ have marvellous chances, for in one short term we hanging around the clinic waiting to see what will can illustrate the pattern of a chronic disease due turn up. This, however, does not teach the student to infection by consideration of the earliest mani- the correct way of obtaining a history nor the festations: the primary syphilitic sore, then the attitude to adopt in dealing with venereal disease exanthemata, the phenomena of body resistance patients. Details of sexual behaviour and informa- and immunity, the late lesions, the intricacies of tion regarding " contacts " can be obtained only special systems, and as a golden thread running when the patient believes he is alone with the on September 29, 2021 by guest. Protected through all our work, the sociological considerations doctor and that the latter is completely trustworthy. and preventive medicine. Mental health and The venereal disease cases admitted to a teaching psychiatry are never far from our thoughts, and hospital should be available for teaching purposes we have an almost unrivalled field in which to In general medicine. Even though I have very teach the correct employment of our specialist few beds under my control, I receive every term cofleagues and medical auxiliaries. a request from the medical staff that my cases be How is this to be done ? I suggest there is a used for demonstration, or an invitation is extended limited field for didactic lectures. These are largely for a combined teaching session. The latter obsolete since the recital of facts by a badly trained technique is very useful: it teaches the specialist speaker with a faulty memory is a very poor sub- to integrate his work with general medicine, while stitute for a few hours of study of a good textbook. the student and physician learn that the venereal The lectures should be devoted to exposition of disease specialist knows a lot about pathology, points that are usually obscure and confused or medicine, and therapeutics. I have recently joined are omitted in standard textbooks, to supplementing my medical colleagues in two demonstrations; the books by personal views, experiences, and the first was an ambitious " combined operation" illustrations, and to keeping the subject fresh and on neuro-syphilis, and the second a clinico-patho- Br J Vener Dis: first published as 10.1136/sti.25.1.16 on 1 March 1949. Downloaded from 18 BRITISH 'JOURNAL OF VENEREAL DISEASES ldgical discussion on hepato-splenic' cirrhosis and epidemiological factors. Similar demonstrAtiohs syphilis. with, the gynecologist could be arranged for C1liecting Specimens.-Laboratory technique in (a) genital ulcers, (b) warts, (c) acute and chronic relation to venereal disease should not be taught to gonorrhoea and allied conditions in female, and students in the venereal disease class, but they should (d) prevention of congenital syphilis and ophthalmia be taught how to collect specimens for transmission neonatorum. -to the laboratory. This includes the collection of The venereal disease specialist and -the urologist material for microscopic examination and culture can discuss jointly such matters as non-gonococcal for gonococci, the direct inoculation of "plates," infections of the urethra, prostatitis and epididy- and the use of delayed culture media, such as mitis, and stricture of- the urethra. With the Stewart's medium. Instruction should be given in prediatrician the venereologist should discuss the 'the- collection in capillary tubes of material for clinical features, differential diagnosis, and treat- examination for spirochltes, the methods of ment of congenital syphilis in infancy and also exposure of all genital lesions for this purpose, in school children. With the physician we can and the discuss the difficult problems- of syphilis of the limitations of such methods. It is quite cardiovascular and nervous systems, visceral syphilis, unnecessary and undesirable to attempt to teach the toxic effects of drugs, and the diagnosis and the technique of dark-field microscopy, but it is management of gonococcal arthritis. -valuable to demonstrate S. pallida in the living The student might well have some instruction state, and also other spirochxtes from the ano- in the correlation of psychiatry and venereal genital area and mouth. I find that a rapid and diseases, discussing the sexual habits of man and accurate technique for Gram's stain is seldom some of the commoner abnormalities, perversions, remembered by final-year students, even after all and phobias. the hard work done by bacteriologists, and it is The prevention of venereal disease is also a reasonable to demonstrate this technique and allow neglected subject, and the statistics of venereal students to practise it. disease in the army will illustrate the necessity for Other Technical Procedures.-The technical pro- doctors being well informed on this'subject. copyright. cedures of vein puncture, intravenous and intra- muscular injections, lumbar punctures, and even Arranging the Time-Table.-What amount of intradermal injections have to be taught, though time is required for all this ? I think that if the this is not properly our business. I do not allow lecturer will studiously avoid giving a rechauffi of students to practise 'on my patients, for I am textbooks, but will try to supplement and illustrate books by personal views and experience and try to convinced that perfect technique, with no pain and http://sti.bmj.com/ no reactions, is one of the requisites of a low incorporate the latest developments, he can impart defaulter rate. But repeated -demonstrations of what the undergraduate needs to know in ten correct technique will lay a foundation leading to lectures of forty-five to sixty minutes each. The technical success by the student when he can put subject of the lectures might be: the matter to test, as he does in the wards and 1. The diagnosis of early syphilis: clinical features casualty departments. and differential points. Unusual types. 2. The diagnostic tests in syphilis: the interpreta- Correlation with other Specialists.-Correlation tion of reports and correct use of laboratory tests. on September 29, 2021 by guest. Protected with- other 'specialities should be arranged to a 3. The clinical features of late syphilis: regional much greater extent. I find that some of our col- studies in differential diagnosis. -leagues in other fields seize on veneregl 4. Syphilis of the nervous system, latent, early, late. specialist The cerebrospinal fluid in syphilis. Prevention of ^disease cases and demonstrate them with gusto, neurosyphilis. though I doubt their competence to do so. I 5. Syphilis of the cardiovascular system. Early ,suggest that a joint demonstration by a venereologist diaginosis; differential diagnosis. Prognosis. Prin- and, say, a. dermatologist is the answer. For ciples of treatment. example let us take a case of secondary syphilis. 6. Therapeutics of early syphilis. Syphilis in The- dermatologist would demonstrate the ex- pregnancy. Biusively cutaneous features (though I realize that 7. Hereditary syphilis. Diagnosis and therapeutics. his speciality is not merely skin-deep), and discuss 8. Gonorrhoea: diagnostic technique; therapeutics ,the possible diagnosis. The venereologist would of gonorrhoea. 9. Non-specific virus infections of genito-urinary -then approach the case as an example of specific system. infection, establish the diagnosis, indicate the 10. Social factors -and prevention of venereal treatment, and start an investigaticon- of social and disease. - i- Br J Vener Dis: first published as 10.1136/sti.25.1.16 on 1 March 1949. Downloaded from TEACHING OF VENEREOLOGY 199 Throughout all these lectures historical illustra- sessions weekly during a three- to six-month period. tions are invaluable in rousing interest. If our The registrar must not be overburdened -with colleagues will not allocate us ten hours for formal routine- duties ;. five or six sessions per week is didactic teaching, we may suggest that they invite enough. us to give an hour's teaching as part of the system- Foreign Travel atic instruction in say, bacteriology, preventive medicine, pediatrics, etc. There is no doubt that the specialist lacks much Clinical demonstrations should be given for one until he has travelled in other countries and has hour at least twice 'a week throughout a term of seen the best work in America and France. He ten to. twelve weeks. At times the students may may also learn from a sojourn in the tropics. have to be separated according to sex, and shown only patients of their own sex, and small groups Degrees and Diplomas (two or three) may attend routine clinics. I ask The possession of a postgraduate qualification is therefore for ten didactic lectures of forty-five to a convenient label indicating the special ability and sixty minutes each and twenty to twenty-four experience of a doctor. To some extent it demonstrations of one hour. indicates possession of specialist knowledge. I In different medical schools the amount of *consider it very desirable that all venereal disease ieaching in venereology varies very greatly. In specialists should aspire to the M.D. degree and if some, for example Edinburgh, there is a large possible the M.R.C.P. diploma. A special diploma amount of both didactic and clinical teaching, while in venereology may be desirable, but it must have other schools give only about a third of the amount. a very high standard, and I consider that it will be Examinations are unfortunately necessary, and valueless unless it is conferred by an independent I advocate the inclusion in the final written and examining body such as the Royal Colleges or clinical examinations in medicine of questions and University of London. cases relating to venereal disease and the other Teaching for a diploma and examination and special.subjects. award of a diploma might become one of the copyright. functions of an Institute associated with the Uni- Postgraduate Teaching versity of London. Provided the curriculuim were The main purpose of postgraduate teaching in sufficiently wide, and the staff of teachers and venereology is. the- training of specialists, though examiners sufficient and eminent, this diploma we must take our share of "refresher- courses" would rapidly become a coveted' distinction; and for general practitioners and also of public health would be sought by many graduates from abToad courses. as well as all specialists and trainees in Britain. http://sti.bmj.com/ What- is the. ideal course for a future specialist This will be -discussed below in relation to an in venereal diseases.? I suggest the following:. institute for venereology. .. 1 1. Cliniical house appointments year Public Health 2. General practice or military service 1 year 3;iJunior registrars in V.D. depart- Venereal disease was formerly an important part a medical of and ment (teaching hospital) . . 1 year of the work of officer health, on September 29, 2021 by guest. Protected 4.. Demonstrator in university depart- many recruits to the public health field were placed ment, e.g., bacteriology, pharma- in charge of local venereal disease clinics. With the ology, or clinical medicine . 1 year advent of the National Health Service, the medica( 5. Senior Registrar in V.D. depart- officer. of health has no longer any responsibility. ment (not necessarily in teaching venereal diseases and therefore their hospital, but using selected cen- for treatment of tres where adequate instruction diagnosis and treatment need not be taught. to can be given) ...... 2 years plus candidates for the D.P.H. except in so far as they Useful.experience to try to incorporate into the concern prevention of disease and epidemiology. above programme would be instruction in, and I concentrate my teaching in the D.P.H. course experience of, (a) genito-urinary investigation and on the fact of venereal diseases being contagious or treatment, (b) disease of children and principles of hereditary and associated with certain social pediatrics, (c) out-patient psychiatry, (d) dermato- problems, and I then illustrate this conception by- iogy,. and (e) gynecology. demonstrations and discussions of the. problems Such special experience would obviously be on a raised by: minor. scale and such as would be acquired by 1. Isolation and disposal of cases of early syphilis. atttending a special department for one or two 2. Prevention of contagious relapse.. Br J Vener Dis: first published as 10.1136/sti.25.1.16 on 1 March 1949. Downloaded from 20 BRITISH JOURNAL ,OF VENEREAL DISEASES 3. Morbidity and invalidism due to late syphilis. Care associated with such an out-patient department of advanced and chronic syphilitics. elsewhere; otherwise it will not have the material 4. Detection of syphilis and gonorrheea in expectant necessary for teaching and research. mothers, and results of treatment of such cases Venereal disease in children. The laboratories of the parent hospital and the institute must be equipped and staffed so 5. Management of delinquent adolescent girls with that venereal disease. routine work can be done and taught, and research 6 Social and moral re-education of prostitutes anc problems investigated in such difficult fields as habitually promiscuous women. serology, pathology, bacteriology, and pharma- 7. Venereal disease and crime. cology. 8. Prevention and management of " default" fron The appointment of a staff for such an institute treatment. presents obvious difficulties. The director must 9. Case finding and contact tracing. have wide scientific and clinical training and 10. The Law relating to venereal disease. experience. It seems preferable that the director and the principal assistants should be appointed on 11. Compulsory notification and treatment. a whole-time basis, so that they can be free from Nurses and Midwives the time-consuming claims and the preoccupations of practice. Also they must be adequately, paid; Nurses and midwives are required to have ar otherwise they will be tempted to forsake the elementary knowledge of venereal diseases. This academic field for the market place. I suggest also should be as simple and general as possible, ancI that there should be a considerable staff of associate should be focused mainly on the nursing problems teachers, these being doctors with conspicuous But trained nurses are also useful vehicles foir ability or knowledge in some part of the subject. spread of medical opinion to the lay public, anci Whether a diploma in venereology be recognized they should have a reasonably well-informec or not, I consider that attendance at an organized opinion on the method of spread and curability o comprehensive course of instruction at such an venereal disease. A good set of photographs anc institute would probably be regarded as evidence copyright. lantern slides is essential for the teaching of nurse Ofo specialist training. And it would soon be as many complete their training without spendinj9 realized that appointment to the junior posts of an hour in a venereal disease department or eve'r the institute was the best approach to specialist seeing a case ofearly syphilis or gonorrhaca. Muclh recognition and to the highest responsibilities of can be done to dispel their ignorant fear an(d our subject. prejudice against nursing such cases.

Refresher Course for (Aenera1 Practitioners http://sti.bmj.com/ Institute for Venereology It is usual,to include at least one lecture-demon- I have only touched on the idea of an institute stration on venereal disease in such courses, and it for venereology in the discussion of postgraduate is easy to make it interesting and profitable. The teaching and the award of a special diploma. most useful subjects for such courses are: It is suggested in the Goodenough report that institutes for special subjects should be formed, an(d 1. Early diagnosis of venereal disease, especially in women.

affiliated to the British Postgraduate Medica on September 29, 2021 by guest. Protected School. I am convinced that there is need for ar 2. Results oftreatment, including failures and relapses, institute of venereology which will be n but not the technique of treatment. mainlF 3. Mistakes of diagnosis and treatment of venereal concerned with postgraduate teaching and research disease. and also with the investigation and treatment b3 I[t 4. Congenital syphilis, clinical types. special meth'ods of difficult and obscure cases. 5. Medico-social work in relation to venereal disease. will be impossible to rival the institutes for neurolog3V at the National Hospital, Queen Square, London1, At present many general practitioners treat all or the Hospital for Sick Children at Great Ormon(d cases of. venereal disease arising in their practice, Street, London, but a very high standard must be and many have no knowledge of the limitations of set. This institute can only succeed in rising abov(e the methods they use or of the value of accurate the second-rate if it is associated with a large general and prolonged observation, so I think the time is hospital, with all diagnostic facilities, pathological opportune to emphasize, for example, the limitations laboratories, and associated staff of specialists. I[t of penicillin treatment. Many doctors, also, do should, however, stand on its own feet and no*t not realize how much benefit can follow skilled shelter behind dermatology or urology. It mus;t treatment of manifestations of late syphilis, and the bave a large out-patient department or be closeliy general practitioner is usually uninterested in theend- Br J Vener Dis: first published as 10.1136/sti.25.1.16 on 1 March 1949. Downloaded from

TEACHING OF VENEREOLOGY 21 results of treatment of such problems as tabes The Venereologist of the Future dorsalis or aneurysm of the aorta. The conception of the venereal disease specialist Where a rural practitioner has to undertake the of the future is that he will be a physician of broad routine treatment of a case, under the observation experience, with a scientific training, and with at and advice of a specialist, the former can have least three years' exclusive training and experience special training in the special technique and a very in venereology. He must be a general physician satisfactory partnership can be evolved. But apart with a special interest, in this case venereal disease, from a scheme designed for remote rural areas, I just as other physicians have a special interest in think that it is generally a mistake to encourage endocrinology, hematology, renal disease, or chest general practitioners to diagnose and treat venereal diseases. diseases, as this very often leads to a lower standard He must be eligible to join the staff of hospitals of work. as an associate physician, and might even aspire to Future of Venereology the highest appointments in medicine. I can forsee, if we now seize our opportunity, a If we look further ahead, I think the diagnosis and new era in which venereal diseases will be treated treatment of venereal disease could be merged into exclusively by specialists. The latter will be men the general fields ofdiagnostic and curative medicine, and women who have been selected rigorously for and could take their place with special sessions for ability, scientific training, and personal attributes, such maladies as the rheumatic disorders, diabetes, and then trained comprehensively to have a broad respiratory infections, etc. ,This would prevent too foundation of medical and scientific knowledge narrow specialism and avoid most of the social with at least three years' special instruction in stigmata associated at present with venereal disease. venereology. This ideal can be realized within I hope that the Medical,Society for the Study of quite a short time, perhaps within ten years, if Venereal Disease will formulate a standard of permanent contracts are not made with those who undergraduate training and will represent its views have no real claim to specialist recognition. The to the British Medical Association or other bodies. standards of all specialists must be raised to the The standard of training and qualification of a copyright. highest level by research, foreign travel, and periodic specialist should also be defined. In addition the study leave. The benefits to this country and to society might help by recommendations on the sufferers throughout the world will be incalculable. status and emoluments ofthe teacher ofvenereology. http://sti.bmj.com/

DISCUSSION ON THE TEACHING OF VENEREAL DISEASE MANAGEMENT

DR. HAMILTON WInL (the President) said that the DR. R. R. WILLcOx said he had much enjoyed the on September 29, 2021 by guest. Protected value of lantern slides could not be over-estimated. lecture, especially the undergraduate part, but he was Patients brought before students, especially patients- in uncertain about the postgraduate part because if he-- a venereal disease department, were easily embarrassed, understood Dr. Lees aright the budding specialist had and slides arranged in a proper series avoided such to lead a subsidized existence for five years, and at the embarrassment and served their purpose well. end of that time he was no longer wanted. Dr. Lees had also mentioned that it was possible in refresher courses given to general practitioners for COLONEL HARRISON wished to join issue with Dr. Lees lecturers to go too deeply into the subject. Dr. in his denunciation of the teaching of the dark-ground Hamilton Wilkie felt that his own experience in Leicester method to students. He thought it brought the method might be of interest inthis connexion. In 1931 he gave home to a student much more thoroughly when he had a lecture on congenital syphilis to an audience of general to set the microscope up, take the specimen, and demon- practitioners. He was new to Leicester then, and was strate it for himself. Also the student should learn to rather annoyed at the beginning of the lecture at seeing stain films properly and to realize that there is a great an unknown elderly practitioner yawning in the first row. difference between a bad Gram and a good Gram. He had been told afterwards that the lecture was far too This brought him to a more fundamental point, which advanced. A few years ago he had given Leicesfer was that he would always teach venereal disease from the medical men a lecture with lantern slides showing acute bottom upwards, in other words from the point of view conditions and many blunders that might be made in of the pathologist. If a student really understood what venereal disease clinics, and they still talked about that was going on underneath, he was much more likely to lecture: it was a treat to see the results. draw correct inferences than if he were taught from the