in a surgical specialty (or in any specialty, for that matter), it is necessary to sit a stiff entry examination. In general, the ratio of candidates to the places available ranges from 10 to one to 20 to one. Selection is based on the examination results and past academic record. By law, in my specialty, orthopaedics, a training programme entails full time work in wards, outpatient departments, and operating theatres and seminars, tutorials, and formal lectures. Teaching time must amount to at least 400 hours a year, excluding time spent on clinical duties, bedside teaching, and research. A wide variety of basic and clinical sciences is taught, and after two years of more general training most of the teaching time is devoted to the chosen specialty. Each year trainees sit six to eight examinations, and if they fail one of them they must repeat the whole year. rhis can happen only once during the whole programme. At the end a final examination is taken and a thesis defended. Candidates may hold a paid post during the five years of the programme, but they are supposed to pay for the tuition received. A system of studentships is now being set up to cover the expenses of high fliers, but this is not fully satisfactory. The system allows a balanced view of the chosen specialty and has many advantages over the systems implemented in other European countries. For example, practically the whole programme is spent in teaching centres; clinical and basic research is strongly encouraged; tuition is well organised; in training assessment is continuous; and, probably most important, trainees know where they stand. Obviously, the system has its faults, such as the lack of the massive clinical exposure that doctors get in the British system, but it is geared towards training doctors, not merely giving a service. In many aspects it is similar to the training received by would be specialists in the United States or Australia: I am sure that Dr Rao would not dream of denying the title of specialists to doctors completing their postgraduate training there.
periods of high demand) was crucial if serious telephone congestion was to be avoided. At these peak times it should be possible to use other surgery staff to cover telephone duties. When telephone backlogs built up they often took two hours or more to clear. The type of telephone system used at the surgery can have a bearing on the rate that patients can be dealt with. Medium and large practices should have the facility of autoswitching between lines -if one line is busy the call should automatically be transferred to another line, without the patient having to dial a different number. Patient education was found to be of paramount importance in operating an efficient and effective communication system. Patients could be told the appropriate times to call the surgery for specific requests. Repeat prescriptions, non-urgent requests for information, etc, could all be directed to less congested parts of the day, resulting in more efficient use of staff time. The practice leaflet provides an ideal channel through which to educate patients about the practice's policy on telephoning the surgery. Surgery notices and registration interviews with new patients could also help in this respect. Some general practitioners in Solihull have resolved many of their telephone difficulties through having enough telephone lines or receptionists available to handle sudden upturns in demand, and coupling these with a comprehensive educational approach. A copy of the report is available on request from the Solihull Family Health Services Authority (tel 021 704 2555). Solihull Family Health Services Authority, Solihull B91 3QP I Hallam L. Organisation of telephone services and patients' access to doctors hy telephone in general practice. BM7
1991;302:629-32. (16 March.)
Further consultant expansion needed
Newham General Hospital, London E13 8RU I Rao JN. GAIC specialist register. BMJ7 1991;302:851. (6 April.)
Telephone services and general practice SIR,-Ms Lesley Hallam has concluded that further studies of patients' experiences of telephone access to general practitioners' surgeries are required.' Last year, with the cooperation of two local general practices and British Telecom, Solihull Family Health Services Authority conducted a survey to determine how surgery telephone systems coped with the demands placed on them by patients. All the incoming call information on reception telephone lines at two surgery sites was logged. This gave an accurate picture of when the greatest volume of calls was coming through; how many patients' calls were answered; and how many received the engaged tone. We found that for the telephone system to be efficient (that is, congestion does not greatly hamper patients' ability to contact the surgery by phone) one dedicated reception telephone line was needed per 2250 patients registered at the surgery. This compares with the national average of 3659 patients per line in Ms Hallam's paper. We recommended providing one reception line for up to 1000 patients, two lines for up to 4000, three lines for up to 7000, four lines for up to 9000, and five lines for more than 9000 patients. The local medical committee considered and rejected these recommendations. Further research and negotiation is now in progress. Maintaining a high throughput of calls (during
GETHIN R ELLIS LLOYD R JENKINSON Ysbyty Gwynedd, Bangor, Gwynedd LL57 2PW
I Salaman JR. Achieving a balance-a time for action.
2 Ellis H. Achieving a balance-a time for action. BM7 1988;
lDepartment of Orthopaedics,
except that the number of United Kingdom graduates had fallen from 43 in 1987 to 30 in 1990. In view of this difference we analysed the United Kingdom and overseas graduates separately. The United Kingdom graduates were generally younger than their overseas counterparts (mean age 34 (range 30-47) compared with 38 (35-42)). The United Kingdom graduates had completed 12 papers on average (0-23); had been the first author of seven papers (0-1 1); had written 10 abstracts (028); and had conducted 20 presentations (0-58). Overseas graduates had, in comparison, completed four papers on average (0-16); had been the first author of three papers (0-10); had written two abstracts (0-10); and had conducted five presentations (0-16). Although the number of United Kingdom graduates has fallen we have still not yet "achieved a balance." There remains a large pool of highly qualified and experienced registrars in general surgery who have yet to become senior registrars. The results of this survey echo Ellis's conclusions three years ago that continued expansion at consultant level is vital if there are to be any improvements in the career structure for surgeons.'
SIR,-The recent increase in the number of consultants should have alleviated the bottleneck at registrar and senior registrar grades in general surgery that was highlighted by Salaman in 1988.' We analysed data taken from the applications for senior registrar rotation posts in general surgery between South Glamorgan and Clwyd and Gwynedd and compared them directly with Salaman's results based on applications for similar posts in South Glamorgan and Gwent and Clwyd three years ago (table). Initial analysis showed that there were no great differences between the two groups of applicants
Training for minor surgery in general practice during preregistration surgical posts SIR, -The trainee subcommittee of the north west England faculty of the Royal College of General Practitioners shares the concern of Dr Mike Pringle and colleagues that training in minor surgery for general practice may be inadequate.' A similar survey of vocational trainees in April 1990 asked respondents whether they thought that they had received adequate training, had experience, and were confident in 10 of the minor surgical procedures listed in the general practitioners' contract.2 Seventy four of 137 trainees returned their questionnaires. Thirty four of the respondents were on organised vocational training schemes. Nine had been a senior house officer in general surgery, but none possessed a higher surgical qualification. The table gives the responses. The trainees' perceptions of the adequacy of their training varied
Details on registrars applyingfor senior registrar rotation posts between South Glamorgan and ClvydIGwynedd in 1991 and between South Glamorgan and Gwent/Clwyd in 1988' Posts in South Glamorgan and Gwent and Clwyd, 1988' No of applicants No of male applicants Mean age (years) Place of birth: United Kingdom Overseas Mean time FRCS held (years) Mean time at registrar grade (years) Time in research post (years): I 2 3 4 No with thesis undertaken No with thesis accepted No with publication Mean (range) No of publications per applicant Mean (range) No of publications for which applicant was first author Mean (range) No of abstracts published Mean (range) No of presentations given
Posts in South Glamorgan and Gwynedd and Clwyd, 1991
44 43 36
43 8 52 6-0
30 14 53 6-0
11 22 6 0 41 17 47 8 (0-24)
6 24 4 1 31 17 34 6 (0-32)
5 (0-14) 6 (0-35) 12 (0-54)
3 (0-11) 7 (0-28)