chart. Once treatment for acute asthma has been started how does the doctor or the patient know when the attack is over without some form of objective measurement? In my experience of using home monitoring of peak flow for this purpose it takes from one to 20 days for the diurnal variation to settle below 15%. A 47 year old woman consulted her general practitioner with severe acute asthma. She was distressed and had pulsus paradoxus of 20 mm Hg and a peak flow rate of 1301/min. After 10mg nebulised salbutamol, oxygen, and 40 mg oral prednisolone her reading had increased to only 140 1/min. The hospital medical registrar was asked to admit her. She returned to the surgery later that day, having been discharged by the registrar and told to take another 30mg prednisolone. The peak flow rate had not been measured, and the decision to discharge her had been based on normal findings on examination and a clear chest x ray film. She was treated in the community with high dose inhaled budesonide, terbutaline, and 60 mg prednisolone tablets daily and home monitoring of peak expiratory flow. It took nine days of treatment with high doses of oral prednisolone for her diurnal readings to settle within 15% of her best attainable value. Doctors working in hospitals often state that most deaths due to asthma occur in the community. The risk resulting from the early discharge of patients with uncontrolled acute asthma and the stress that their management puts on general practitioners may not be so well known. The British Thoracic Society's guidelines recommended that patients should be discharged to their general practitioner if their condition has improved one hour after treatment,2 but doctors may be lulled into a false sense of security during the early relief phase after nebulised treatment in patients with acute asthma. The guidelines also suggested that a peak flow meter should be provided in addition to the general practitioner following up the patient the next day, and I believe that this advice has the potential to considerably reduce readmissions to hospital and deaths from asthma. MARK LEVY GPs in Asthma Group, Kenton, Middlesex HA3 5JZ

1 Vathenen AS, Cooke NJ. Home peak flow meters. BMJ 1991; 302:738. (30 March.) 2 British Thoracic Societv. Guidelines for managcment of asthma in adults: II-acute severe asthma. BMJ7 1990;301:797-800.

Triage of x ray films? SIR,-I should like to reply to several points made by H J Nawrocka and J D Nawrocki' about our paper.2 I believe that the extra category of "insignificantly abnormal" is valid. The study was set up to see whether radiographers could take over instant casualty reporting from radiologists. As radiologists, we are continually being asked by clinicians whether an abnormality is significant. Radiographers providing a casualty reporting service should be able to make these distinctions as the decision is not always clinical. We emphasised that we were comparing the radiographers with the current reporting arrangements, which are partly provided by junior radiologists. An instant reporting system provided entirely by experienced consultants would be ideal, but to compare radiographers with such a system would be unrealistic. To claim that radiographers' seniority has been shown to affect their accuracy is overstating the case. Berman et al said that "performance correlated reasonably well with seniority" but did not back this up with any

figures.3 Finally, however, I am pleased that we agree that radiographers are an underused resouce in the casualty department, as shown by Mr I K

1210

Dukes.' I firmly believe that radiographers should be offered the opportunity of extra training in interpreting x ray films obtained in casualty departments. Our department is currently trying to obtain funding for a formal assessment of such training. I G H RENWICK

Department of Radiology, St James's University Hospital, Leeds LS9 7TF 1 Nawrocka HJ, Nawrocki JD. Triage of x ray films? BMl7 1991;302:1024. (27 April.) 2 Renwick IGH, Butt WP, Steele B. How well can radiographcrs triage x ray films in accidenit and emergency departments? BMVJ 1991;302:568-9. (9 March.) Ebar 3 Berman L, de Lacey G, Twomey E, Twomey B, Welch T, R. Reducing errors in the accident and emergency department: a simple method using radiographers. B.IJr 1985;290:421-2. 4 Dukes IK. Triage of x ray films? BlMJ 1991;302:1023-4. (27 April.)

Misuse of temazepam SIR,-As chairman of the Advisory Council on the Misuse of Drugs, I am writing to express the council's serious concern about the illicit misuse of temazepam. It seems that there is a significant diversion of temazepam into the illicit drug market. As a result of commendable cooperation from the pharmaceutical industry the liquid filled capsules of temazepam have now been phased out after a reformulation by the manufacturers. It was hoped that this would prevent drug misusers injecting the contents of such capsules. There is evidence, however, that the new gel filled capsules are now being used by determined misusers, who liquefy the contents by heating before injecting. The council would be pleased if doctors would take this information into account when prescribing temazepam, be aware of how much temazepam is being prescribed to a patient, and assess whether a new patient requesting a prescription for temazepam is acting in good faith. D G GRAHAME-SMITH Chairman

Advisory Council on the Misuse of Drugs, Home Office, London SW I H 9AT

with the need for a continuing high standard of daily care. A "healthy" child with the disease is not necessarily one who does not require an allowance; he or she has probably benefited from comprehensive treatment. Among paediatric patients this treatment is provided primarily by the parents. We have conducted a survey of patients attending the Cardiff cystic fibrosis clinic to see whether they have been granted an attendance allowance. Among the 59 patients who have applied for the allowance 54 have been successful eventually, some after several applications, which for one family included correspondence with their member of parliament. Forty two receive the day allowance and 12 the combined day and night allowance. This success rate of 92% makes a convincing case for the allowance to be available automatically to all who apply. Although the allowance relates to treatment needed (not necessarily to treatment given), we compared the degree of disease among those in our clinic who do and those who do not receive the allowance (using the Schwachman score for general health and the Chrispin-Norman score for features in chest x ray films). The table shows the results. No differences were found in any of the values between any of the groups (Mann-Whitney U test). A report of the Royal College of Physicians on cystic fibrosis in adults stated that, "Certain statutory benefits and allowances are payable in particular situations: these include mobility allowance and attendance allowance, but the success rate of applications is notoriously variable."2 Parents who work hard to preserve and prolong the lives of their children with cystic fibrosis should not be subjected to the harassment of applications, reapplications, and reviews (which for some patients result in the allowance being removedthe disease is, after all, progressive) and the feelings of grievance that these engender. Cystic fibrosis is the most common inherited chronic disease in the United Kingdom; it results in considerable morbidity and limited life expectancy. An attendance allowance (or its equivalent, as it is currently being reviewed) should be available as of right. GWYNETH OWEN SABINE MAGUIRE HENRY RYLEY MARY C GOODCHILD

Attendance allowance for patients with cystic fibrosis

Cystic Fibrosis Unit, Department of Child Health, University Hospital of Wales, Cardiff CF4 4XW

SIR,-We agree wholeheartedly with most of the sentiments expressed by Drs S A Peters and C J Rolles in their letter on the attendance allowance with respect to patients with cystic fibrosis.' We also believe that the allowance should be granted to all paediatric patients with cystic fibrosis, at least at the lower rate (usually synonymous with the day allowance). In our opinion, only some patients would qualify for the higher- rate (day and night allowance), and for these applicants a medical assessment would be appropriate, preferably done by a doctor thoroughly familiar with the disease and the consequences of its treatment. As Drs Peters and Rolles say, "Good health and improving life expectancy in cystic fibrosis are directly linked to diligent daily treatment." There is a natural variation in the manifestations and severity of cystic fibrosis, which is governed to some degree by genetic factors, but such considerations are of secondary importance compared

1 IPeters SA, Rolles CJ. Attendance allowance. BAM 1991;302:966. 20 April.') 2 Royal College of Physicians. C(vstic fibrosis in adults. Recornmendations for care of patients in the UK. Londoni: Royal Collegc of Physicians, 1990:10.

Obtaining a postgraduate qualification in Italy SIR,-Having gained postgraduate specialist qualifications in my country of origin, Italy, and having worked in the United Kingdom for a while, I know that Dr Jammi N Rao's interpretation of the specialist qualifications obtained in countries in the European Community' is incorrect, to say the least. In Italy, to obtain a postgraduate qualification

Degree of disease in all patients with cystic fibrosis at Cardiff clinic and in those receiving attendance allowance. Figures are mean (SD) values (and ranges)

All patients with cystic fibrosis Patients with day allowance (n=42) Patients with day and night allowance (n= 12)

Schwachman score (general health)

Chrispin-Norman score (features in chest x ray films)

Age (years)

84-2 (11-0) (43-98) n=93 84-3 (12-6) (43-98) 79-5 (11 -2) (60-91)

8-6 (5-0) (1-24) n=95 8-4 (5 0) (2-24) 11-3 (6-4) (5-23)

8-9 (5-3) (1-27) n=98 8 8 (4-2) (3-18) 9-5 (2-8) (4-14)

BMJ

VOLUME 302

18 MAY 1991

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

BMJ

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MAY

1991

GETHIN R ELLIS LLOYD R JENKINSON Ysbyty Gwynedd, Bangor, Gwynedd LL57 2PW

BRMJ7

I Salaman JR. Achieving a balance-a time for action.

1988;2%:717-8.

2 Ellis H. Achieving a balance-a time for action. BM7 1988;

296:1006.

S GIDDA

NICOLA MAFFULLI

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

51 49

Posts in South Glamorgan and Gwynedd and Clwyd, 1991

34

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)

15 ((-58)

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Obtaining a postgraduate qualification in Italy.

chart. Once treatment for acute asthma has been started how does the doctor or the patient know when the attack is over without some form of objective...
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