EDITOR,-The Junior Doctors Committee is cur- ... 1 Beecham L.Junior doctors and specialist medicine. .... aneurysms were responsible for an average of 5564.
Specialist training EDITOR,-The Junior Doctors Committee is currently submitting evidence to the chief medical officer's working group on specialist training. It calls for a structured training within each specialty with regular appraisal of practical skills, continuing education, reciprocated assessment of trainer and trainee, and a fixed period of training within each specialty.' I recognise the benefits of these aspects of training. The committee's preferred outcome (option 4) makes further proposals for more radical changes in postgraduate medical education, including some that may lead to a large number of junior specialists who have completed a limited training within their specialty and then remain at this "health service consultant" grade for an unlimited time. They also support the idea of a single training grade. The collegiate trainees committee of the Royal College of Psychiatrists, which consists of elected representatives from all regions in the United Kingdom and Ireland, has represented the views of trainees in this specialty since 1979. Perhaps the college's willingness to have trainee representation on its committees may have contributed to the development of psychiatric training schemes that already have weekly continuing education, approval teams of which a trainee is a part, and reciprocal assessment of trainer and trainee, as well as firm recommendations for the duration and structure of each phase of training. Through such mechanisms individual posts and individual trainers can be "disapproved." The collegiate trainees committee recognises the need for continual efforts to improve training, particularly in matters such as career guidance. The collegiate trainees committee recently discussed both option 4 and its own submission to the chief medical officer's working group. The collegiate committee, which represents 8-1 0% of hospital junior doctors, in no way supports the Junior Doctors Committee's proposals. Their implementation would lead not only to no improvement in psychiatric training but also to a possible decline in standards and potentially to more "stuck" doctors who would not have the benefits of being "trainees." The collegiate trainees committee believes that the current duration of training in the specialty to become a consultant (six and a half to eight years) is about right and that the different grades of trainee are essential to enable subspecialty training. There are clear differences in the structure and goals of general psychiatry training and higher training at the senior registrar grade. In its submission to the chief medical officer's working party the collegiate trainees committee supports many of the proposals outlined in "option 1" detailed by the working party. ROBERT F KEHOE Chairman, collegiate trainees committee, Royal College of Psychiatrists,
All junior doctors in Britain, whether members of the BMA or not, are represented through the Junior Doctors Committee, which consists of elected representatives from the regions and nations of the United Kingdom. The committee debated specialist training in June this year, as did the annual conference of junior doctors the next day. While these resolutions determined the course of events through the summer, a special conference devoted entirely to specialist training was held in September.' All junior doctors had the opportunity through their regional or national Junior Doctors Committee to send motions to that special conference or to be elected as a representative. Dr Edwin Borman, who has been associated prominently with the committee's policies on specialist training, was re-elected chairman of the committee the next day. The reforms that the Junior Doctors Committee is proposing are those that will be best for junior doctors. Existing agreements between training and specialist grades, such as Achieving a Balance, retain their fundamental importance, and the profession will not accept a solution that does not reduce the current time between registration with the General Medical Council and specialist recognition. Reform at any price is not being pursued. But what of the newly recognised specialist? Perhaps inevitably, many juniors on the brink of appointment as a consultant, after far too long slogging through the training grades, feel that there is more to lose than to gain from reform of the system. These concerns are shared by the Junior Doctors Committee, which is committed to maintaining the status of consultants while recognising, as do the Department of Health and most other parties, that the present process of recognising those suitable for appointment as a consultant contravenes certain laws. R R Tumock proposes a referendum.2 The Junior Doctors Committee's policy has been formulated with scrupulous attention to the diversity of views among the nearly 30 000 junior doctors. It is not usually appropriate to hold a referendum during an evolving process; the time and question must be chosen carefully. The Junior Doctors Committee's submission to the chief medical officer's working group is but a step on the path, and when the secretary of state for health releases her views in the new year I will be among those arguing that every junior doctor in the country should be asked whether the proposed course of action is acceptable.
Nowhere else than in Britain do trainees face such a wide clinical exposure and so many weekly working hours,5 and the European Commission is aware of this.67 The directives define only the minimal criteria for the purposes of free circulation; member states are free to impose higher training standards.7 The United Kingdom is not out of line by using a consultant led system. However, the new GMC register denoting accredited specialists might discriminate against "consultant grade" specialists wishing to migrate to the United Kingdom. The purpose of the EC directives was to facilitate the free circulation of doctors within member states by defining certificates and minimum periods of specialist training (three, four, or five years). European specialists can apply for senior registrar and consultant posts in Britain. The directives do not oblige the United Kingdom to convert from a consultant led to a specialist system. In question is the access to private practice, only accessible to the consultant grade in the United Kingdom. Specialist manpower and quality of training was not covered by these directives. Unemployment of doctors on the continent is alarming (France 6%, Germany 8%, Italy 17.3%) but rare in the United Kingdom (03%).; In Germany, the Netherlands, and Spain the numbers of medical students are related to the capacities of medical schools rather than to manpower needs.5 Royal colleges responsible for standards and structure of training do not exist. Therefore a wide variation exists in the quality of specialists, although the European Commission has stated that it was not aware of any complaints." I do not believe that the majority of specialist trainees in the United Kingdom wish to change the consultant led system. The solution lies with the expansion of the consultant grade, proposed by Achieving a Balance and by Baigrie and Reed in their letter.2 A properly organised, continually assessed and audited specialist training programme could be considerably shorter, resulting in better trained specialists in the United Kingdom. However, neither the directives nor the treaties of Rome or Maastricht oblige the other member states to follow-as has been recently shown by our dealings with the exchange rate mechanism.
2 Correspondence. Specialist training and the EC. BMJ 1992;305: 887, 1021-2. (10, 24 October.)
Deputy Chairman, Junior Doctors Committee, Melton Mowbray, Leicestershire LEl 3 1 PW 1 Kisely S, Morriss R. Specialist training. BMJ 1992;305:1021.
(24 October.) RR. Specialist training. BMJ 1992;305:1021. (24 October.) 3 Beecham L. Junior doctors and specialist medicine. BMJ 1992;305:836 (3 October.)
EDITOR,-As the debate on specialist training progresses, misunderstandings have grown up that the Junior Doctors Committee might jettison "the long term quality of [doctors'] careers for short term advantages in becoming specialists more quickly."' The mandate of the committee for developing policies on this issue has been questioned.2 Junior doctors have been foremost among the crafts of the BMA in applying the democratic process to this debate. The quality and duration of training have been adopted as leading issues for the 1990s, and thus the committee was well placed when the European Commission's infraction proceedings prompted the formation of the chief medical officer's working group.
EDITOR,-I have followed with interest Stephen Brearley's editorial,' subsequent correspondence in the BMJ,2 and Calman's letter.3 I graduated in France, wrote an MD thesis on the free circulation of doctors within the European Community,4 and successfully pursued postgraduate training in England. On the continent most specialists practice from their own premises, performing mainly outpatient procedures. A minority are hospital based, achieving promotion to the equivalent of an NHS consultant after several years' experience. Most specialists on the continent have not faced the competition for the senior registrar grade or required research publications, a second qualification, etc. Many patients are treated in the private sector and not exposed to specialist trainees in public hospitals.
London SW1X 8PG 1 Beecham L. Junior doctors and specialist medicine.
1992;305:836. (3 October.)
Birmingham Maternity Hospital, Birmingham B 15 2TG 1 Brearley S. Specialist medical training and the European Com-
munity. BMJ 1992;305:661-2. (19 September.) 3 Calman KC. Specialist medical training in the UK. London: Department of Health, 1992. (PLICMO(92)13.) 4 Mascarenhas LJ. Consequences de la libre circulation des medecins dans la CEE [dissectation]. Tours: Medical Faculty, 1986. 5 Brearley S. Medical manpower. BMJ 1991;303:1534-6. 6 Comite Consultatif Pour La Formation Des Medecins. Rapports, avis et recommendations adoptes par le comite du 6 Avril 1979 au 31 Decembre 1984. Commission des Communautes Europeennes 1985. (III/D/1003/85-FR.) 7 Cresson E. Question ecrite No 816/79 a la Commission des Communautes Europeennes. Journal Officiel des Communautes Europeennes 1978; No C 107/9. (8th May.)
EDITOR,-A J K Frew is mistaken in asserting that senior registrars appointed as consultants are automatically accredited on the basis that they satisfied an appointment committee.' Frew may be confused by two factors: firstly, the relevant college may accept up to three months of a consultant appointment as accreditable; and, secondly, it is usual to give three months' notice after accepting an appointment. Thus an unaccredited person might legitimately be appointed up to six months short of his or her accreditation date and, in due course, receive a certificate of accreditation without any "foul play." Frew also alludes to the difficulties of obtaining accreditation for those in academic posts. In
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anaesthesia the accreditation committee of the Royal College of Anaesthetists makes it clear that special consideration will be given to the needs of those in such posts. As one who has recently become accredited from an academic post (lecturer, senior registrar grade), I can attest to the truth of this. Two years in a numbered post in Britain does not seem an unreasonable requirement. Those who accept posts without a number should be aware that they may be heading up a blind alley. The responsibility for advising such doctors lies with the senior clinical and academic staff who permit the proliferation of unregulated posts which are not eligible for accreditation. JROBERT SNEYD Department of Anesthesiology, University of Michigan Medical Center, IG323 University Hospital, Ann Arbor, Michigan 48109-0048, USA 1 Frew AJK. Specialist training and the EC. BMJ 1992;305:887.
Screening for abdominal aortic
aneurysms EDITOR,-It is not at all clear that screening along the lines proposed by P L Harris would have a large impact on reducing mortality from ruptured aortic aneurysms. The best evidence for evaluating screening programmes comes from randomised controlled trials; unfortunately, none have been carried out to evaluate screening for aortic aneurysms. Because ruptured aortic aneurysms are a relatively rare cause of death, such trials are probably impractical because of the large samples required.2 We must therefore use descriptive data to assess the likely benefits of screening. From 1984 to 1988 inclusive, abdominal aortic aneurysms were responsible for an average of 5564 deaths a year,' which is substantially below the 6000-10000 that Harris quotes. Altogether 27-7% of these deaths occurred in women and 8-8% in men aged under 65; none of these deaths could have been prevented by screening men aged 65. Additionally, 30.0% of deaths occurred in men aged 75-84 and 6-3% in men aged over 84, with only 27-3% of deaths occurring in men aged 65-74, the main beneficiaries of the screening programme that Harris proposes. The benefits of screening would be further reduced by non-compliance, especially if the prevalence of aortic aneurysms was higher in those who did not comply. No test has a sensitivity of 1 00%, and failure to detect all the aneurysms in the screened population would reduce the benefits still further. Some of the men diagnosed as having an aortic aneurysm might well be unfit for major surgery, and some other aneurysms would inevitably rupture during follow up. As well as overestimating the benefits of screening, Harris understimates the costs. The figure of C1 million a year that he says is required to run a national screening programme equates to £6000£7000 per health authority. This would have to include the costs of equipment, establishing a case recall register, and employing and training staff. It is difficult to conceive how all this could be done for £7000 per health authority. At least 10% of the screened population would require further follow up for an indeterminate period, and Harris ignores the costs of this. Harris also underestimates the net costs of surgery: 2800 times C4000 equals £1 1 2 million, not C8 million. Up to 5% of the 4300 patients undergoing elective aneurysm replacement would die as a result of their surgery, and an unknown number of others would suffer major complications. If screening for asymptomatic abdominal aortic
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aneurysms is thought to be potentially worthwhile, further research is required into the epidemiology of the condition and into the full costs and benefits of screening, both financial and non-financial, before introduction of a national screening programme is considered.
everyone concerned, both in the community and in hospital units. Reviews such as that reported by Mason and colleagues do not answer this vital question and jeopardise the establishment of such studies. C P SHEARMAN G GRIMSHAW
Department of Public Health Sciences, St George's Hospital Medical School, London SW17 ORE 1 Harris PL. Reducing the mortality from abdominal aortic aneurysms: need for a national screening programme. BMJ 1992;305:697-9. (19 September.) 2 Lederle FA. Screening for snipers: the burden of proof. Clin Epidemiol 1990;43:101-4. 3 Office of Population Censuses and Surveys. Mortality statistics 1984-1988: cause. England and Wales. London: HMSO, 1985-90.
EDITOR,-As organisers of one of the largest programmes of community based screening for aortic aneurysm (the Birmingham community aneurysm screening programme), we take issue with some of the correspondence arising from P L Harris's comprehensive review of the subject.' In Birmingham and Solihull we have now screened 8000 men aged between 65 and 74, achieving a compliance rate of 87% with a single invitation. The aortic diameter was > 30 mm in 545 men and >45 mm in 165. To date, 135 men have had their aneurysms repaired, with a 30 day mortality of 1-5%. Since the introduction of screening, despite an overall increase in the number of aortic procedures there has been a pronounced reduction in elective mortality and morbidity and length of stay in hospital. J M Mason and colleagues claim to have evaluated proposals for aortic screening in south Birmingham but chose to ignore local data from the Birmingham community aneurysm screening programme.2 They used information selected from a narrow range of the world literature, and, as they have acknowledged, "some very strong assumptions" were needed to reach their conclusions (J M Mason et al, Health Economics Study Group, St Andrews, Scotland, June 1992). Local trends are important, and Birmingham seems to be experiencing excess mortality from aneurysms (the standardised mortality ratio for Birmingham was 160 in 1990 (Office of Population Censuses and Surveys)). This is perhaps reflected by the high prevalence of aortic aneurysms (8.4%) found by the Birmingham community aneurysm screening programme in the screened population of Birmingham compared with other published series and those areas outside Greater Birmingham that we have screened. Deaths from aortic aneurysm are increasing in Britain, and it is depressing to see patients continuing to die in the community and depressing for surgical teams to spend long hours treating patients with a poor chance of survival. Unless we conclude that treating patients after rupture of aortic aneurysm is not worthwhile this will probably become increasingly common. At present, little other than screening shows promise of changing the situation. The aetiology of aneurysms is probably far more complex than Mason and colleagues suggest,4 and the introduction of public health measures, even if effective, would take many years to produce benefit and would not address the immediate problem. Preliminary results of screening for aortic aneurysm have been encouraging, with good compliance rates, acceptable accuracy, and low costs compared with those of screening programmes for other diseases. The second phase of evaluation of aortic screening, to determine the effect on community mortality, must now be embarked on rapidly. The only way this can be done, as F G R Fowkes and colleagues suggest,4 is with well conducted randomised studies; to do this needs the full cooperation and understanding of
J D HAMER A CROW
Community Aneurysm Screening Programme, Department of Vascular Surgery, Queen Elizabeth Hospital, Birmingham B 15 2TH 1 Harris PL. Reducing the mortality from abdominal aortic aneurysms: need for a national screening programme. BMJ 1992;305:697-9. (19 September.) 2 Mason JM, Wakeman A, Griffiths RK. Screening for abdominal aortic aneurysms. BMJ 1992;305:1013. (24 October.) 3 Cheatle TR, Scurr JH. Abdominal aortic aneurysms: a review of current problems. Bry Surg 1989;76:826-9. 4 Fowkes FGR, Ruckley CV, Powell JT, Greenhalgh RM. Screening for abdominal aortic aneurysms. BMJ 1992;305: 1013. (24 October.)
EDITOR,-The arguments advanced by Azeem Majeed against a national screening programme for abdominal aortic aneurysms are specious, as is apparent from more careful consideration of the facts. Ruptured abdominal aortic aneurysm is underdiagnosed as the cause of death in middle aged and elderly men.' As necropsy is not universal the mortality statistics from the Office of Population Censuses and Surveys2 are believed to underestimate the number of deaths from this cause by a considerable margin. Although new aneurysms may arise after the age of 65, these are unlikely to progress to rupture for at least another decade. This is why a single examination for men at 65 has been proposed. In the first year or two only a proportion of those at risk in this group will be identified, but this proportion will increase over time. More aneurysms could be detected by extending the scheme to include those with lower risk (women and younger men), but the law of diminishing returns would apply. . It is true that some men diagnosed as having abdominal aortic aneurysm may be unfit for surgery, but screening of asymptomatic individuals might identify a high percentage with low surgical risk. On the question of costs the figure of £1 m a year has been derived by extrapolating costs actually incurred in pilot studies' and is therefore accurate. It will obviously be important not to undermine economies of scale by subdividing the total sum excessively. Majeed offers a simplistic mathematical correction to refute our estimate of the costs for additional operations expected to arise from nationwide screening. He fails to take account ofthe fact that the costs of emergency surgery are two to three times higher than those of an elective operation. After allowance for this difference a figure of fC8m is realistic. The need for continued research as advocated by previous correspondents45 is not disputed. It is appropriate for the Vascular Surgical Society to take the lead in this matter, and a specialist working group has been established to consider the issues in detail, identify deficiencies in current knowledge, and make specific recommendations regarding future progress. The merits of large scale randomised studies as suggested by Fowkes and colleagues and Mason and colleagues will be considered within this exercise. Progressive extension of screening programmes to encompass an increasing area of the country with detailed appraisal at each stage would seem to be a sensible way forward. P L HARRIS
Broadgreen Hospital, Liverpool L14 3LB 1 Armour RH. Survivors of ruptured abdominal aortic aneurysms: the icebergs tips. BMJ 1977jii: 1055-7.