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him. He neither sees nor needs them as he faces themirror.What of the man with a longer sentence, the cancer

patient? Is he not frightened? Indeed he is, if he does notknow, has not been told. He falters, for his mind then lagsbehind in the touchstone world while his suspicions andinstinct urge him that he should be moving from the lightwhich reveals the touchstones to the shadow which dis-solves them. He stands insecure at the Styx.Not the moment of death but the occasion of its

knowledge-that is the real Styx. And we, as Charon,should guide his way with understanding. Instead we standbeside him looking backwards into the light at well-lit formand substance, and thus deny him relief from his life’schains. Introspection, our own requirements, our failureto understand, prevents him casting off, for we still enter-tain the fears of death which are the lot of the whole inbody. But the good doctor knows what the journey is: thatit is back to the beginning, is undertaken in reverse; thatsubstance must give way to, abstract; that love was firstand shall be last; that we should reveal what is to comeand thereafter cherish. Until-snap, and the mirror turns.

BRYAN N. BROOKE.

Round the World

United States

NURSES ON STRIKE

In recent years our hospitals have suffered repeatedstrikes by their employees. The strikers have usuallybeen the non-professional staff whose wages and conditionsof service have not risen proportionately to those of otherworkers. But now the San Francisco hospitals, both publicand private, have been largely shut down, save for emergen-cies, because of action by registered nurses. This strikeis not about salaries or terms and conditions of service,but about a whole series of other more difficult issues.The registered nurses are demanding more say in theadministration and running of the hospitals, and moredirect personal responsibility for the treatment of patients.The hospital administrators, who could no doubt haveseen their way to an early settlement of a wages and con-ditions strike, are not prepared to give way, and the medicalstaff in general support this attitude.

Basically, the grievance turns on the question of who isresponsible for the treatment of the patient. Traditionally,this has been the physician, and the nurse has executed theorders of the physician. But the complexities and gadgetryof modern medicine are eroding these old attitudes.Patients are monitored more by machines than by physi-cians, and monitor and nurse may be by the patient whilethe responsible physician is miles away. Under theseconditions the nurse may be far more skilled in using themachines than the physician, and, should a crisis develop,the nurse might need to draw on a degree of diagnosticskill and therapeutic ability which could well exceed thatof the physician.The physicians, of course, will not readily abdicate their

responsibility for the totality of the patient’s care. But thereluctance of the physicians is slight in comparison withthat of the hospital administrators, who see major medico-legal problems ahead if the nurses prevail. It is doubtful,in fact, if the nurses recognise themselves the medicolegaltraps they are approaching. The present demands reflect inpart the shortage of nurses now that so many new possi-bilities of employment have opened to women. There have

long been divisions in the nursing world between theregistered nurses, who take degrees in nursing and go intomanagement and organisation, and the usually degreeless"

practical nurses ", who actually nurse patients. Com-

plaints are heard that many registered nurses have littleability or practice in actually nursing sick patients, but theyare the nurses who manage the monitors.

While nurses have seen more opportunities openingfor them, and their conditions and salaries have benefitedfrom the shortage of nurses in one respect, their positionshave on the other hand been eroded in the wake of thecreation of the physician’s aides-chiefly after-Servicemedical corpsmen. These now go through a training tohelp physicians in history-taking and in recording physicalexaminations and treatment-many of the things thatnurses might do. But the aides are not nurses, and lurkingantagonisms exist. Clearly the situation is a very difficultone, and it seems unlikely that either side will be happywith the results of the strike.

POSTGRADUATE TRAINING

On April 24, 1974, Congressman Roy introduced a Bill(H.R. 14357) in the House of Representatives. The purposesof this Bill are " to revise the programmes of studentassistance, to revise the National Health Service Corpsprogramme, to establish a system for the regulation ofpostgraduate training programmes for physicians ", &c. Alladmirable sentiments and all necessary, but scratch a littlemore deeply and it becomes evident the means of effectingthe provisions of the Bill are frightening in their doctrinaireauthoritarianism. The Bill proposes to set up a series ofnational and regional councils, the members of which areto be appointed by the Secretary of Health, Education, andWelfare. Each council is to consist of 19 members, ofwhich 2 will be associated with medical schools, and anadditional 2 will come from organisations associated withpostgraduate physician training-e.g., the American Collegeof Radiology, the American College of Physicians. As onereads through the Bill, it becomes evident that its mainpurposes are, first, to control graduate and specialtytraining programmes, and, second, to obtain a more evendistribution of physicians throughout the U.S. In short,these councils are to decide that Alabama needs 7 radiologistsand, hence, the Council will allocate a specific number oftraining positions in radiology to Alabama. Certain post-graduate training institutions that have specialised expertisein training certain medical disciplines may well find theirprogrammes emasculated, while other institutions will beencouraged to start training programmes for which theyhave neither the staff nor the facilities. The medicalschools and various organisations responsible at present forpostgraduate and specialty training are’to be given a minu-scule representation on the councils. Granting that thevarious colleges have done nothing, or almost nothing, totailor the size of their residency training programmesaccording to the country’s needs, they have done much toprovide adequate specialty training and have been instru-mental in maintaining professional standards. If this Billbecomes law, the function of the colleges will be taken overby a bunch of politically appointed faceless Kafkaesquebureaucrats.

The Bill goes on to propose financial penalties for thosefacilities which try to provide postgraduate training in theabsence of approval by a regional council. However onelooks at the proposed legislation, it can only be describedas the direction of labour and as such goes beyond anythingknown at the present time in Western Europe. There is

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little doubt that what Congressman Roy is hoping to achieveis necessary; what is disheartening is the means he proposesto achieve his ends.