COMMENTARIES
One promising approach was suggested to me by a Spanish neonatologist, Dr Jose Arizcun. He convinced all the intensive and intermediate care nursery directors in the province of Madrid to agree to a common, SO-item ‘minimum neonatal data-set’. Nurseries are free to collect whatever other data they might desire, but they must be able to provide the SO items, a sort of outcome Esperanto. Coupled with the use of standardized definitions and common denominators (livebirths at each facility and livebirths born to residents of Madrid) such a dataset will permit valid inter-nursery comparisons. Could we not do the same for outcome studies for high risk infants? One can envisage such a minimum data-set: livebirths as the denominator, a common definition for cerebral palsy (Evans et al. 1986), two or three standardized tests, masked evaluators, random sampling. Then, at the very least, we could be certain our studies werc comparable: a very good start toward dispelling some of the darkness.
Gabriel J. Escobar The Permanente Medical Group Division of‘Research 3451 Piedmont Avenue Oakland, Calijornia 9461 I
References Ellenberg J. H. &Nelson K. B. (1979)Birthweight and gestational age in children with cerebral palsy or seizure disorders. Ani.1 Dis Child 133, 1044-1048. Escobar G . J., Littenberg B. & Petitti D. B. (199I ) Outcome among surviving very low birthweight infants: a meta-analysis. Arch Dis Child 66, 204-2 1 1.
3
Evans P., Johnson A., Mutch L. & Alberman E. (1 986) Report of a meeting on the standardization of the recording and reporting of cerebral palsy. Der Med Child Neurn128,543-549. Evans P. M., Evans S. J. W. & Alberman E. (1990)Cerebral palsy: why we must plan for survival. Arch Dis Child 65, 1329-1 333. Hack M., Horbar J. D., Malloy M. H., Tyson J. E., Wright E. & Wright L. (199 I ) Very low birthweight outcomes of the National Institute of Child Health and Human Development neonatal network. Pediatrics 87, 587-597. Hagberg B., Hagberg A. & Olow I. (1984) The changing panorama of cerebral palsy in Sweden. IV. Epidemiological trends 1959-78. Acra Paediarr Scand 73, 433440. Hagberg B., Hagberg A,, Olow I. & Von Wendt L. (1989) The changing panorama of cercbral palsy in Sweden. V. The birth year period 1979-82. Acta Paediatr Scund 78,283-290. Kitchen W. H. & Murton L. J. (1985) Survival rates of infants with birthweight between 501 and 1000 g. Improvement by excluding certain categories of cases. Am .I Dis Child 139, 470-47 I . Liptak G . S. & Revell G . M. (1989) Community physician’s role in case management of children with chronic illnesses. P ediatrics 84, 46547 I . Oftice of Technology Assessment ( 1987)Neonatal 1ntensii.e Care,fiir Low Birthweight InJants: Costs and Ejjectiveiress. Health Technology Case Study 38. Washington D.C.: US GovernmentPrinting Oftice. Pharoah P. 0. D. & Alberman E. (1988) Annual statistical review. Arc,h Dis Child 63, 151 1-1515. Pharoah P. 0. D. & Alberman E. (1990) Annual statistical review. Arch Dis Child 65, 147-1 5 1. Stanley F. J. & Watson L. (1988) The cerebral palsies in Western Australia: Trends. 1968 to 1981.Am/OhsterGynecol158,89-93. Stanley F. J. & Blair E. (1991) Why have we failed to reduce the frequency of cerebral palsy? Med .I Aust 154, 623-626.
British Journal of Obstetrics and Gynaecology January 1992, Vol. 99, pp. 3 4
MD madness The United Kingdom is virtually alone in encouraging a second post-graduate qualification before becoming a consultant, or even a senior registrar, in obstetrics and gynaecology. The irrelevance of the FRCS diploma has been debated in these columns (Studd 1983; Cameron 1984) and this view, together with the introduction of more demanding requirements by the Royal College of Surgeons, have now discouraged trainees from pursuing this path. It is good that subsequently there has been a greater emphasis on the clinical research which is essential for the development of new clinical skills but have we merely exchanged one obstacle for another-the MD‘? An important personal view (Pinion 1991) from a skilled FRCS/MRCOG after years of hard clinical labour revealed a failure even to be shortlisted for many senior registrarjobs; the candidates interviewed all holding the MD in addition to the MRCOG. This, together with numerous examples known to us all, suggests a considerable defect in training, and unfairness in
the process of selection for promotion. It is probable that this Gadarene stampede for a research degree has been counter-productive. An MD is now seen as the fast lane to success. The trainee who emerges from a ‘paper factory’ without comprehensive clinical skills but being supported more by the research reputation of his supervisor than by his own ability is more likely to be appointed to a senior registrar or consultant post than the trainee with more extcnsive clinical experience and vocational motivation to treat hisher patients well. Such is the price of abandoning the FRCS without creating an alternative period of relevant clinical research or sub-specialty training. What does an MD mean‘? Is it merely a piece of shorthand for committee members who have not made themselves aware of the candidate’s original work? Is it necessary for a teaching hospital post, a district general hospital consultancy or an academic position? Three of the four NHS consultants in one
4
COMMENTARIES
London teaching hospital have an MD but only one of the five academics, with their undoubted clinical skills and international research reputations, has felt it necessary to submit such a thesis. This in no way impugns their ability but the only conclusion to be made is that this most academic of degrees does not separate the academics from the rest. It may (but usually does not) select those who subsequently distinguish themselves in hospital research but certainly does not indicate competence for the hard clinical slog of a district hospital. A case can be made for a formal presentation of a thesis for those whose ultimate goal is a senior lectureship or a chair. Perhaps an MD should be evidence of formal training in clinical research and should be considered only for academic appointments. But, at the moment an MD is often merely a device to occupy 2-3 years of a training which is already far too long. The time taken to train a specialist should not cxceed 6-7 years, and trained specialists deserve to be appointed to a permanent post by the age of 30-32 years. Research should be an optional extra for those with a real interest in such clinical or laboratory developments. The paradox of prolonged training, long waiting lists for inpatient care, and an ever decreasing research output is fundamentally a result of the inadequate number of consultants allowed by our monopoly state employer. We have the least number of consultants per unit population compared with almost any other country in the Western world and have only 2.5% of consultants of other EEC countries (Innes Williams 1986). The 900 consultant obstetricians and gynaecologists in England and Wales is close to the number (850) of ACOG Members found in rural North Carolina and compares very unfavourably with the 3000 in New York State (Studd 1989). This demonstrates the shameful deficiencies in senior staffing levels in the NHS. These few are expected to cope with the vast clinical workload in obstetrics and gynaecology, the development and introduction of new techniques, teaching of trainees, audit, administration and the maintenance of a 'profile' at a local and international level as well as supervising the research that is becoming increasingly part of training. Many more consultant posts are necessary in order to remove these anomalies but as little extra money will come from any government the principle way of achieving this will logically and inevitably be through funding from the private sector (Studd 198.5). However, this realization is a long way off as few such posts, even those containing considerable rcsearch potential, are yet recognized for training or accreditation by the colleges.
Part of the solution to the manpower deficiency could be to make accredited (or even second year) senior registrars eight session consultants who would be allowed to make up their missing income from private practice or research sessions (Studd 1986). This would produce more real consultants at little extra cost, reduce the bottle neck, the length of training and the need for the irrelevant obstacles of an MD thesis or FRCS Diploma. It would also allow them time to develop new, yes even marketable, clinical skills. If any consultant doubts whether this scheme would be attractive to the trainees, 1 would challenge them to ask their registrar or senior registrar! Two problems are indivisibly linked: the lack of consultant posts leads to the necessity to obtain the extra degree and academics, including myself, have a vested interest in having a continuous supply of able trainees to carry out research projects. Many trainees benefit from this period of research and it is clearly appropriate for the results to be published but I question whether the writing of an MD thesis is necessary for the vast majority. Trainees are now too obsessed with the importance of obtaining a research job as they are aware that an MD will be seen as separating the successful from the failures at interview. They are also clearly aware that good clinical practice, labour ward and surgical skills and the kind care of patients have relatively little influence in promotion. If they are correct, and I believe they are, we have a great deal to put right. A change in our attitude to the importance of the MD and consideration of those professional qualities which discriminate between the good and the less good doctor, would be a start.
John Studd Consultant Gynaecologist Kitig's College Hospital, London References Cameron M. (1 984) Commentary. Obstetricians, gynaecologists and the FRCS (letter). Br.1 Ohstet Gynuecol 91, 407-408. Innes Williams D. (1986) Conimission on the Provision o f S p ~ i u / i s / Services. Royal College of Surgeons, London. Pinion S. (1 99 I ) Personal view. Rr Med .I 302,599. Studd J. W. W. (1983) Commentary. Obstetricians,gynaecologists and the FRCS. Br J 0hstc.t Gynuecol 90, 785-786. Studd J. W. W. (ed) (1989) Preface, Progress in Ohsretrics & Cymecv/o,yy, Vol. 7. p. v, Churchill Livingstone, London. Studd J. W. W. (1985) Refuge in the private sector. B r J Hosp Med 33,
I. Studd J. W. W. (1986) Can private sector funds help the NHS? Br J Hosp Med 36, 216-211.
One promising approach was suggested to me by a Spanish neonatologist, Dr Jose Arizcun. He convinced all the intensive and intermediate care nursery directors in the province of Madrid to agree to a common, SO-item ‘minimum neonatal data-set’. Nurseries are free to collect whatever other data they might desire, but they must be able to provide the SO items, a sort of outcome Esperanto. Coupled with the use of standardized definitions and common denominators (livebirths at each facility and livebirths born to residents of Madrid) such a dataset will permit valid inter-nursery comparisons. Could we not do the same for outcome studies for high risk infants? One can envisage such a minimum data-set: livebirths as the denominator, a common definition for cerebral palsy (Evans et al. 1986), two or three standardized tests, masked evaluators, random sampling. Then, at the very least, we could be certain our studies werc comparable: a very good start toward dispelling some of the darkness.
Gabriel J. Escobar The Permanente Medical Group Division of‘Research 3451 Piedmont Avenue Oakland, Calijornia 9461 I
References Ellenberg J. H. &Nelson K. B. (1979)Birthweight and gestational age in children with cerebral palsy or seizure disorders. Ani.1 Dis Child 133, 1044-1048. Escobar G . J., Littenberg B. & Petitti D. B. (199I ) Outcome among surviving very low birthweight infants: a meta-analysis. Arch Dis Child 66, 204-2 1 1.
3
Evans P., Johnson A., Mutch L. & Alberman E. (1 986) Report of a meeting on the standardization of the recording and reporting of cerebral palsy. Der Med Child Neurn128,543-549. Evans P. M., Evans S. J. W. & Alberman E. (1990)Cerebral palsy: why we must plan for survival. Arch Dis Child 65, 1329-1 333. Hack M., Horbar J. D., Malloy M. H., Tyson J. E., Wright E. & Wright L. (199 I ) Very low birthweight outcomes of the National Institute of Child Health and Human Development neonatal network. Pediatrics 87, 587-597. Hagberg B., Hagberg A. & Olow I. (1984) The changing panorama of cerebral palsy in Sweden. IV. Epidemiological trends 1959-78. Acra Paediarr Scand 73, 433440. Hagberg B., Hagberg A,, Olow I. & Von Wendt L. (1989) The changing panorama of cercbral palsy in Sweden. V. The birth year period 1979-82. Acta Paediatr Scund 78,283-290. Kitchen W. H. & Murton L. J. (1985) Survival rates of infants with birthweight between 501 and 1000 g. Improvement by excluding certain categories of cases. Am .I Dis Child 139, 470-47 I . Liptak G . S. & Revell G . M. (1989) Community physician’s role in case management of children with chronic illnesses. P ediatrics 84, 46547 I . Oftice of Technology Assessment ( 1987)Neonatal 1ntensii.e Care,fiir Low Birthweight InJants: Costs and Ejjectiveiress. Health Technology Case Study 38. Washington D.C.: US GovernmentPrinting Oftice. Pharoah P. 0. D. & Alberman E. (1988) Annual statistical review. Arc,h Dis Child 63, 151 1-1515. Pharoah P. 0. D. & Alberman E. (1990) Annual statistical review. Arch Dis Child 65, 147-1 5 1. Stanley F. J. & Watson L. (1988) The cerebral palsies in Western Australia: Trends. 1968 to 1981.Am/OhsterGynecol158,89-93. Stanley F. J. & Blair E. (1991) Why have we failed to reduce the frequency of cerebral palsy? Med .I Aust 154, 623-626.
British Journal of Obstetrics and Gynaecology January 1992, Vol. 99, pp. 3 4
MD madness The United Kingdom is virtually alone in encouraging a second post-graduate qualification before becoming a consultant, or even a senior registrar, in obstetrics and gynaecology. The irrelevance of the FRCS diploma has been debated in these columns (Studd 1983; Cameron 1984) and this view, together with the introduction of more demanding requirements by the Royal College of Surgeons, have now discouraged trainees from pursuing this path. It is good that subsequently there has been a greater emphasis on the clinical research which is essential for the development of new clinical skills but have we merely exchanged one obstacle for another-the MD‘? An important personal view (Pinion 1991) from a skilled FRCS/MRCOG after years of hard clinical labour revealed a failure even to be shortlisted for many senior registrarjobs; the candidates interviewed all holding the MD in addition to the MRCOG. This, together with numerous examples known to us all, suggests a considerable defect in training, and unfairness in
the process of selection for promotion. It is probable that this Gadarene stampede for a research degree has been counter-productive. An MD is now seen as the fast lane to success. The trainee who emerges from a ‘paper factory’ without comprehensive clinical skills but being supported more by the research reputation of his supervisor than by his own ability is more likely to be appointed to a senior registrar or consultant post than the trainee with more extcnsive clinical experience and vocational motivation to treat hisher patients well. Such is the price of abandoning the FRCS without creating an alternative period of relevant clinical research or sub-specialty training. What does an MD mean‘? Is it merely a piece of shorthand for committee members who have not made themselves aware of the candidate’s original work? Is it necessary for a teaching hospital post, a district general hospital consultancy or an academic position? Three of the four NHS consultants in one
4
COMMENTARIES
London teaching hospital have an MD but only one of the five academics, with their undoubted clinical skills and international research reputations, has felt it necessary to submit such a thesis. This in no way impugns their ability but the only conclusion to be made is that this most academic of degrees does not separate the academics from the rest. It may (but usually does not) select those who subsequently distinguish themselves in hospital research but certainly does not indicate competence for the hard clinical slog of a district hospital. A case can be made for a formal presentation of a thesis for those whose ultimate goal is a senior lectureship or a chair. Perhaps an MD should be evidence of formal training in clinical research and should be considered only for academic appointments. But, at the moment an MD is often merely a device to occupy 2-3 years of a training which is already far too long. The time taken to train a specialist should not cxceed 6-7 years, and trained specialists deserve to be appointed to a permanent post by the age of 30-32 years. Research should be an optional extra for those with a real interest in such clinical or laboratory developments. The paradox of prolonged training, long waiting lists for inpatient care, and an ever decreasing research output is fundamentally a result of the inadequate number of consultants allowed by our monopoly state employer. We have the least number of consultants per unit population compared with almost any other country in the Western world and have only 2.5% of consultants of other EEC countries (Innes Williams 1986). The 900 consultant obstetricians and gynaecologists in England and Wales is close to the number (850) of ACOG Members found in rural North Carolina and compares very unfavourably with the 3000 in New York State (Studd 1989). This demonstrates the shameful deficiencies in senior staffing levels in the NHS. These few are expected to cope with the vast clinical workload in obstetrics and gynaecology, the development and introduction of new techniques, teaching of trainees, audit, administration and the maintenance of a 'profile' at a local and international level as well as supervising the research that is becoming increasingly part of training. Many more consultant posts are necessary in order to remove these anomalies but as little extra money will come from any government the principle way of achieving this will logically and inevitably be through funding from the private sector (Studd 198.5). However, this realization is a long way off as few such posts, even those containing considerable rcsearch potential, are yet recognized for training or accreditation by the colleges.
Part of the solution to the manpower deficiency could be to make accredited (or even second year) senior registrars eight session consultants who would be allowed to make up their missing income from private practice or research sessions (Studd 1986). This would produce more real consultants at little extra cost, reduce the bottle neck, the length of training and the need for the irrelevant obstacles of an MD thesis or FRCS Diploma. It would also allow them time to develop new, yes even marketable, clinical skills. If any consultant doubts whether this scheme would be attractive to the trainees, 1 would challenge them to ask their registrar or senior registrar! Two problems are indivisibly linked: the lack of consultant posts leads to the necessity to obtain the extra degree and academics, including myself, have a vested interest in having a continuous supply of able trainees to carry out research projects. Many trainees benefit from this period of research and it is clearly appropriate for the results to be published but I question whether the writing of an MD thesis is necessary for the vast majority. Trainees are now too obsessed with the importance of obtaining a research job as they are aware that an MD will be seen as separating the successful from the failures at interview. They are also clearly aware that good clinical practice, labour ward and surgical skills and the kind care of patients have relatively little influence in promotion. If they are correct, and I believe they are, we have a great deal to put right. A change in our attitude to the importance of the MD and consideration of those professional qualities which discriminate between the good and the less good doctor, would be a start.
John Studd Consultant Gynaecologist Kitig's College Hospital, London References Cameron M. (1 984) Commentary. Obstetricians, gynaecologists and the FRCS (letter). Br.1 Ohstet Gynuecol 91, 407-408. Innes Williams D. (1986) Conimission on the Provision o f S p ~ i u / i s / Services. Royal College of Surgeons, London. Pinion S. (1 99 I ) Personal view. Rr Med .I 302,599. Studd J. W. W. (1983) Commentary. Obstetricians,gynaecologists and the FRCS. Br J 0hstc.t Gynuecol 90, 785-786. Studd J. W. W. (ed) (1989) Preface, Progress in Ohsretrics & Cymecv/o,yy, Vol. 7. p. v, Churchill Livingstone, London. Studd J. W. W. (1985) Refuge in the private sector. B r J Hosp Med 33,
I. Studd J. W. W. (1986) Can private sector funds help the NHS? Br J Hosp Med 36, 216-211.
