220 POSTGRADUATE MEDICAL JOURNAL April, 1965

HERXHEIMER: I just wanted to ask how many of thegeneral practitioners in Ipswich used the librarycompared with the number that attend the Fridaymeeting, because I think one experience has beenunfortunate. I have heard of a Library in Texaswhich is very munificently endowed whidh was usedby about 2% of the practitioners, and is empty mostof the time. I was just wondering whether this shouldbe designed primarily for hospital doctors with G.P.sbeing, of course, welcome to use it and invited to useit but not designed primarily for them.

PAULLEY: I am sorry to hog this machine but myanswer is that still not many of the practitioners whocome to the Friday Club are using the Library. Webelieve that in the long run more will do so, par-ticularly if they start to produce papers for theFriday Club or the Clinical Society they will haveto use the Library. When they do, a glance at theLibrary attendance book always reveals it a week orso before the meeting. But I don't really think thepractitioners are going to use or properly appreciatelibraries until the Medical Schools start to teach themhow to do so, as I have said already.

THE GLASGOW POSTGRADUATE MEDICALTELEVISION PROGRAMME

DAVID JOHNSTONEProducer of the Programmes for Scottish Television

THESE programmes originated in a GlasgowUniversity conference on TV in education, atwhich it became clear that the desire of ScottishTelevision (especially of its director, Dr. NoelStevenson) to see an expansion of educationaltelevision chimed with a desire of the GlasgowPostgraduate Medical Board (especially of theDean, Dr. A. C. Fleming) to find a way ofreaching doctors who could not attend ordinarymeetings and courses. Fifteen monthly pro-grammes have now been transmitted: they havebeen much appreciated, and are now beingused by more than half the commercial TV

companies in the country, and may soon beseen abroad. Though aimed uncompromisinglyat doctors, many others listened to them, es-pecially members of the associated professions.They have demonstrated that good specialisttelevision educational programmes can be pro-duced relatively cheaply; the fact that S.T.V.were a commercial company has proved no realobstacle. The necessity of avoiding peak viewinghours was a disadvantage, but there is no ulti-mate solution apart from the opening of a neweducational TV channel.

THE GLASGOW POSTGRADUATE MEDICALTELEVISION SERIES: PRODUCTION PROBLEMS

ON THE MEDICAL SIDEBERNARD LENNOX, M.D., Ph.D., F.R.C.P.(G), F.C.Path., M.R.C.P.

Department of Pathology, Western Infirmary, Glasgow.

KNOWING that conferences on medical educationhave a sad reputation for consisting mainly oflong dull lectures on the necessity of not givinglong dull lectures, I resolved to stick to astrictly practical account of some aspects ofthe work of the medical production committeefor the Glasgow series. Today's conferencehas, of course, not deserved that reputation, but

I propose to hold to concrete description never-theless. Though our own programmes have notreached Kent yet, B.B.C. 2's version will soonbe here. Even for those with no prospect oftaking part, it adds to the interest of watchingsuch a programme if you know something ofthe problems involved.

I want first to expand a point already touchedon by David Johnstone. These programmes

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April, 1965 LENNOX: Glasgow Postgraduate Medical Television Series 221

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FIG. 1.-Reproduced with the permission of Scottish Television, Ltd.

differ more fundamentally than you might atfirst suppose from such familiar series as theB.B.C.'s "Your Life in Their Hands" whichcater for a mass audience, and however muchuseful information they may convey inciden-tally, are fundamentally entertainment. Thismeans, of course, that a great deal more moneycan be spent on them, but quite apart fromthat the role of the professional televisionproducer in them is very different. Since whatgoes out must be comprehensible to the generalpublic, it must be comprehensible to him.Since he understands it he can take full res-ponsibility for it. Once briefed, he can writethe script and decide just how everything isto be done.

In a postgraduate programme, we can saywith certainty that if what we want to get overcan be totally understood by our producer,we're under-shooting our mark; we're wastingour time and our audience's time on explanationof elementary stuff. And this applies not onlyat the obvious level of producing the script anddeciding what is to be said and what can beleft out. It applies at such apparently technicallevels as the work of the director and hiscameraman while actually shooting. So longas we stick exactly to a script, the director canfollow it and knows from experience of therehearsal what is wanted. When, however,anyone deviates from the script, or in any

period of free discussion, the director is aptto lose the thread of the argument simplybecause it isn't his language that's being talked.One effect of this is to enforce the use of acompletely scripted programme. It is possibleto avoid this if those taking part understandthe director's difficulties and do a little self-direction, contriving to give him the necessaryhints as to what is likely to be wanted next:but this needs experience.

I don't want in the least to diminish thecontribution of the television side. All we knowwe've been taught painfully by David Johnstoneand Ian Dalgliesh, our director. But I want toemphasise that whereas (to use the currentjargon) in most television programmes, evenmedical ones, the television side supplies notonly all the hardware but most of the softwaretoo, if you are involved in a programme thatreally sets out to teach doctors as distinct fromentertaining them, you will find you have tosupply a good half of the software yourself.

This side of the Glasgow programme hasbeen in the hands of a Television ProductionCommittee of five. Four are medical-twophysicians, one surgeon and one pathologist,all young to middling consultants, and all withacademic connections. The fifth is a medicalartist with some experience of filming. Hisrole has been a most important one. Doctorsthemselves, or medical artists without special

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experience, produce diagrams that are badtelevision: the television company's own artistswaste endless time getting the medical detailsright. And good diagrams and display materialmake an enormous difference to the successof a programme.We decide on a subject and on an expert

to present it at least six months ahead. Onemember of the production committee is thenallotted to that programme, and usually actsas Chairman during the actual presentation togive a stiffening of experience. The expertthen decides on the outline of the programmeand on any other additional participants. Ascript is then worked out. It is criticised bythe rest of the committee and about a monthbefore shooting, a meeting of all concerned,including the S.T.V. side, results in an agreedversion. Work then starts on the displaymaterial, including, if necessary, new film. It isimportant that the script be modified in detailto conform with the final layout of the displaymaterial so that the two tell one continuousstory.So ultimately to the recording, which usually

takes about 6 hours of studio time on a Sunday:about two full rehearsals with cameras and thenthe take (Fig. 1). We have always so farmanaged to produce the whole programmein one continuous take-multiple takes followedby editing add considerably to the cost.The rest of what I have to say is by way

of commentary on a film made up of sixexcerpts from our programmes.

The following excerpts were shown:From "Immunization Programmes": a description of

the natural process of acquirement of immunity inpoliomyelitis. This illustrated the straightforwardlecture technique, even to the successful use of anordinary blackboard. About ten minutes is, how-ever, the useful limit for continuous lecturing.

From "Peptic Ulcer": part of an account of operativeprocedures for duodenal ulcer. A more casuallecturing technique, with diagrams handled by thelecturer.

From "Diseases of the Hip in Childhood": a briefaccount of the anatomical effects of walking on thedislocated hip. A demonstration that it is possibleto be convincing when using the autocue. Mostspeakers are happier on autocue if they have apassage of any length to deliver, especially if theyare new to television, and by ensuring that theystick to the prepared script it greatly eases thedirector's problems.

FIG. 2.-Reproduced with the permission of ScottishTelevision Ltd.

Ortolani's sign in congenital dislocation of the hip,using a silent film with a live commentary. Thiswas a good film that fitted well into the programme,but the interpolation of film can bring surprisinglynumerous difficulties.

From "Autoimmune Disease": a semi-animateddiagram illustrating a serological reaction ofrheumatoid factor. True animation of the cartoon-film type is very expensive, but we have made muchuse of a kind of poor man's animation in whichthe removal of cardboard masks running in slotsreveals successive parts of, a diagram, as in theexample shown, or even simulates some simplekinds of movement.

From "Chromosomal Abnormalities": showing non-dysjunction in the origin of mongolism. Anothermethod of presenting a complex process in dia-gram form, using magnetised models of chromo-somes moved about on a vertical metal board.

From "Peptic Ulcer": part of a free and totallyunscripted discussion on the treatment ofhaematemesis. Sir Charles Illingworth had intro-duced all the earlier programmes, and for this one,the last before his retirement, he was asked tospeak briefly on three topics and then to answerquestions posed by the members of the productioncommittee. Apart from some interesting views onpeptic ulcer we obtained a unique record of amajor personality (Fig. 2).These excerpts were of course chosen from

programmes or parts of programmes wherewe thought we had put across what we intendedto fairly successfully. I do not want to makeit appear that we have always been as success-ful. We have a great deal to learn. But wehave found it a fascinating undertaking, andwe seem to have done at least a little good.

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POSTGRAD. MED. J. (1965), 41, 223

DISCUSSION

Chairman: DR. GEOFFREY TEMPLEMAN; Opener: DR. IRVING MERRILL, Director of Television Research, SanFrancisco Medical Centre, University of California; Participants: A. A. G. LEWIS (London), J. R. ELLIS(London), A. HERXHEIMER (London), B. LENNOX (Glasgow), J. W. PAULLEY (Ipswich), M. SIM (Birmingham),D. BECKER (New York), A. WILLIAMS (Oxford), D. S. CHILVER (Boughton); Concluding Remarks: J. R. ELLIS

(London).

MERRILL: We have been using two methods ofbroadcasting in the States for continuing medicaleducation. I might say that I use the words 'con-tinuing education' to make sure they mean that of apractising physician of some kind either in generalor specialised practice, as distinct from graduate studywhich would be part of what we call a residency.Two methods of broadcasting have been very popularin the United States. One was pioneered by Dr.Frank Woolsey at the Albany Medical College whereviewing was in a hospital, and a group of anywherefrom 10 to 40 physicians and house staff memberswould gather to receive it. Another method, whichwas popular in the West, was that of the Universityof Utah where (at the time our study was designed)television was used for reaching the physician in hishome, and the question arose: which one of thesewould be preferable? The physicians seemed to likeboth kinds and so the result might very well turnon which was more effective from an educationalpoint of view, that is under which situation peoplelearned more. Briefly, in our study, we did use aGreco-Latin-square design which enabled us to usetelevision stations in three different cities, and usethree different types of subject matter, varying theorder of presentation in each of the cities, and wealso used various feed-back and response devices andwe had three of those, and we varied them in thesame way. We did not use physicians in this studybut instead used 120 staff nurses who were currentlyemployed in a general hospital. So, conservatively,I cannot say that I know that the results of thatstudy will be identical for physicians, although Imust add I suspect that they will be. These threeprogrammes lasted over a period of six weeks. Atthe end of that time we called all 120 nurses in foran evaluation session. One of the things we did wasask them whether they attended or not, and the nextthing we did was to give them a little examination, a60-item test which was prepared by the same peoplewho prepared the programme; we had checked outthis test ahead of time so that we were quite surethe results were reliable. We then went into theevaluation session and let them contribute ideas thatthey had to mention. When we had analysed thefindings we found out that those nurses who hadleft the hospital or who, just prior to going to thehospital, had viewed this programme at home, hadlearned far more from the broadcasts than thosenurses who had gathered together as a group at ahospital. Our interpretation of these findings was ahopeful sign for the use of open circuit broadcastingas a means of continuing education in the healthsciences. We are not prepared to say that under allconditions this would be true but at least we didhave some pretty solid evidence that there was noreal reason for not going ahead and using opencircuit broadcasting to reach these people, and I think

that this is a heartening sign for the efforts ofScottish television in the North, and it seems toindicate good possibilities of success for the pro-gramme that the B.B.C. is going to be doing herein the Southern part of England. I think that's asmuch as I'd say at the time.

ReferenceABBEY, S. C., BoYD, V., DECK, E. S., SHROCK, J. G.,and MERRILL, I. R. (1964): Television in HealthSciences Education: Home and Hospital Viewingof Continuing Education Broadcasts Under ThreePresentation-Response Conditions, J. med. Educ.,39, 693.

LEWIS: At the recent A.S.M.E. conference Dr.Charles Fletcher made a most valuable suggestion,which was that if we are going to have televisionprogrammes there might be certain ones of a revisionnature, as it were, which could be linked with localcourses of instruction in certain areas, and that theremight be some advance notice of this given out.I wonder whether anybody would like to commenton that as a possibility?ELLIS: I think I could help a little with the questionDr. Lewis has asked. In regard to the B.B.C. 2programmes which will go out from January onwardsin collaboration with A.S.M.E., we shall see that allwho can receive do get information as to the natureof the programmes, and we will, before they start togo out be in touch with the regional postgraduateadvisers of the relevant areas (the Metropolitan areasand the Birmingham region) so that we can col-laborate not only in sending out information aboutthe programmes and getting back results of ourenquiries as to their effect, but also I hope collalboratetogether so that in the areas of the country andpostgraduate centres we can combine our effortswith television and what goes on in the centres.HERXHEIMER: I should like to ask Dr. Lennox andDr. Ellis what arrangements there are for feed-backfrom listeners and viewers to these programmes sothat there is audience participation. I think thatDr. Graves's talk showed very much how importantaudience participation is and how much more efficientit makes learning; Dr. Paulley has very muchemphasized this and I wonder in what way this canbe used effectively with television programmes.LENNOX: Well, we have, I am afraid, done ver3little on this. We did do one questionnaire fairlyearly and got very encouraging results. The majorityof the G.P.s who replied, and there were I think800 or 900 from the Glasgow area, approved of whatwe had done and thought we were hitting the rightkind of level. Since then simple questions of cost--it is an expensive business-have prevented us doingmore, but with the help of one of the drug firms weare embarking on another questionnaire in the very

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near future. Some of our own people who attendedthe Tunbridge Wells conference came away with theview that it was possible to pay too much attentionto feed-back and research, and that there was adanger of paying more attention to the research andthe feed-back than to getting a decent programmeto start with. When you are dealing with a newmedium and you haven't very much experience of it,you may be better advised to behave as an artistrather than a scientist and try, first of all, to put outwhat seems subjectively to yourself to be a goodprogramme. Once you have reached the stage whereyou think you can play about with the techniqueyou may then experiment and undertake researchinto the results of your experiments, but I think itcan be a mistake to apply too much research to yourfirst childish efforts in the medium. That, at least,was our feeling.LEWIS: May I speak about audience participation?The best example of this which I found in Americawas in fact at Dr. Merrill's own school, The Universityof California, where telephone lines are linked to themedical centre after an F.M. broadcast and a two-wayconference can then be held with participating hos-pitals. Now in Maine, after the Bingham AssociatesFund television they are gong to hire 14 telephonelines from the Bell Telephone Co., which will belinked up to the panel in the studio and a two-waydiscussion for half an hour can then be held betweenthe studio panel and the audience. Now this is notyet, so far as I know, possible with our wonderfultelephone system but private companies in Americaare only too glad to arrange a hook-up for a con-ference. Business firms think nothing of hooking-upfor half an hour at 12 o'clock on a Wednesday rightacross the States for a conference on privately hiredlines.PAULLEY: Dr. Lewis really said what I wanted tosay and I did ask this question in Manchester: wouldit be possible to use, as it were, existing methods,particularly by encouraging say a free period ofquestions at the end of the programme, and encourag-ing doctors to 'phone in questions; in other words,have somebody sitting there taking in questions andtrying to make, as it were, a small discussion at theend which is alive, even with our existing resources?LENNOX: The first programme that you saw, the oneon the immunization programmes, had a studioaudience of just two general practitioners who askedlive questions. That's one possible way of doing it. Itworked fairly well. It didn't liven up the programmeas much as you'd think but it did help to some extent.We have certainly never tried using telephonequestions. We are starting a magazine for fiveminutes on programmes, and part of that is goingto be devoted to postal queries, if we get them.SIM: There is just one point I'd like to make whichhasn't been stressed, and it's really to reinforce whatDr. Merrill said, and that is that we cannot divorceeducation from the culture into which it is received;it is very difficult to try and draw conclusions fromeducational methods, e.g. in America, and try andtranslate them here. Education or learning is very

largely a matter of reinforcement. As we know,anxiety is probably the most potent factor in thatreinforcement, especially the anxiety that derives fromfull responsibility. I am thinking of the responsibilitythe American doctor has in his office surgery, wherehe can really work up the patient to a degree whichthe British general practitioner, especially now underthe Health Service, is almost incapable of doing.As well as improving our methods of education wehave got to make sure that our students have gotthe cultutral conserve which will reinforce thateducation, and produce the anxiety which will allowthem to effectively improve their knowledge. Asthings are at the moment there is a danger that wewill keep running refresher courses without providingthe motive power, but if we can alter the structureof the service to allow the doctor the facilities for thefull work up of his patients, then we are reallymaking a positive contribution to learning.BECKER: I think it pertinent to point out thatmuch of the success of the newer methods thatwere presented today depend upon a re-examinationof the content of the material that is presented, andan examination of the objectives that one is attempt-ing, or re-thinking of the behavioural characteristicsthat one hopes to achieve in teaching, so that theprocess of preparing material itself appears to beone of the most important elements to the successof teaching. I think perhaps the emphasis on thenew methods will also help the old method ofteaching, where it will emphasize a little more whatgoes into it and encourage us to think about thataspect.WILLIAMS: There is a small group of doctors meetingin Northampton once a week who are taking partvia telephone in a seminar in London-a jointexercise-and they have had to design some specialinstrument which I don't understand, but it soundsas though it oughtn't to be too complicated toproduce it, and use it more widely.CHILVER: I would be interested to hear from Dr.Lennox or Dr. Merrill, or both, whether the laypublic in this country or in America listen to theseopen programmes, and if so whether they use themas rods for the backs of their doctors who areunwise enough not to have seen them themselves.LENNOX: Can I just say that we worried about thisterribly when we started. We know a lot of laypeople do listen-I know my own barber (not abarber surgeon either) greeted me with joy after thefirst time I appeared on television-but we have hadno specific complaints at all about any unpleasantreactions. One thing in which we find ourselvesinhibited is cancer; we haven't talked much aboutthat yet. Also we didn't, though we were verytempted to do so, go ahead with a demonstration ofhow to take a mid-stream specimen of urine. Thatkind of thing is difficult, but on the whole it hascaused a great deal less trouble than we expected.1 think Dr. Merrill has had exactly the same thingto report, based on a good deal more experiencethan ours.MERRILL: That is correct.

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CONCLUDING REMARKS: J. R.ELLIS: Mr. Chairman, ladies and gentlemen, I won'tkeep you a minute, partly because I think there is noneed for me to comment on the success of themeeting-the fact that we are running over time doesthat anyway-nor is there really any need for me tocomment on its content because I think Dr. Merrillhas done that brilliantly. I would only echo his verywise warning, that all considerations of methodsshould be preceded by the most careful considerationof objectives, particularly in this very difficult fieldin which postgraduate preparation is combined withcontinuing education, and both for more than onetype of doctor. The only other thing I wouldcomment on is the significance of this n- eting. Ithink it has been a wonderful example of the tremen-dous enthusiasm that is arising in the postgraduatecentres, enthusiasm which is both long expected andextremely welcome, very exciting and most important.Long expected because after all there has been agood deal of effort going on up and down thecountry to create it, and also because it was aninevitable consequence of the realisation that we nowdeal with an entirely new medicine. Exciting for thesame reason, that it arises spontaneously out of thenew medicine and its needs, and its new practitioners.Exciting too because it exemplifies all the fun oflocal enterprise with a certain degree of local rivalrycompletely uninhibited by those rather dead-weightproblems that arise when a country has long estab-lished institutions governing both training andeducation and hospital services. Important becauseafter all we have become for the first time, all of us,as opposed to surgeons in the past, important peoplein that we are dangerous. The increased potency ofthe doctor is pretty remarkable but it is mostlyremarkable in the amount of damage that he cannow do. I would claim that surgeons who do thingsat pre-arranged times in front of expert witnesses areabout the safest of us now. The rest, who with aword or a stroke of the fountain pen, add some

ELLIS, M.B.E., M.D., F.R.C.P.really potent force to the life of an individual, arepotentially very dangerous people and the more thatwe can do in the way of continuing education andproper preparation for our task the happier everyonewill be. It is a strange coincidence that all this shouldbe going on with very little money (and that raisedhere and there on an ad hoc sort of basis) at thesame time that the country quite happily put fivemillion into finding out how safely to build a nuclearwarship, which, if you come to think of it, couldn'tconceivably at its worst do anything like as muchdamage as the 50,000-odd practising doctors that wehave in the country. We haven't yet put five millioninto medical education, undergraduate or post-graduate, but we have put some, and we are puttinigmore, and the thin edge of the wedge is in now.The Ministry accepts that postgraduate training is apart of its responsibilities. It even has a staff forMedical Education and Manpower, of which I amvery glad to be one.

I think the forest fire of postgraduate activity isvery well shown by this afternoon's meeting. It isnot the first Sunday I have spent in a girl's schoolbut it is certainly one of the most enjoyable. I viouldsay, too, I think it shows at the very best the newability of medicine to meet with and co-operate withpeople from other disciplines. So, Mr. Vice-Chancellor, thank you very much indeed; and Ithink all of you will agree with me that we shouldthank not only our Chairman and the speakers butparticularly the Kent Postgraduate Medical Centrefor giving us a magnificent time. Thank you verymuch.

TEMPLEMAN: And I'd just like, if I may, to thankDr. Ellis and to re-echo what he said, and say howglad those of us are here-and I can even in a sortof marginal way count myself as one of them-thatyou have come and that the thing has gone so well.

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