1419
that he will have a fair hearing. The Cuban Embassy in Ottawa, on June 3, confirmed that Dr Arana was arrested on Oct 26,1990, and stated that he has been charged with "terrorism" but the position in respect of a fair and open trial on this charge remains unclear. Lancet readers who wish to support Dr Arana could write to Dr Thomas L. Perry, Sr, Department of Pharmacology and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia V6T 1Z3, Canada, preferably by FAX to Mrs S. Hansen (010-1-604 822 6012).
J. G. FOULKS J. G. MCLARNON T. L. PERRY, SR
D. V. GODIN C. KRIEGER B. A. MACLEOD C. C. Y. PANG T. L. PERRY, JR D. M. J. QUASTEL M. C. SUTTER B. SASTRY M. J. A. WALKER E. PUIL R. A. WALL J. M. WRIGHT of British Canada Columbia, Vancouver, BC, University
HIV test in pregnancy SiR,—The letter from Professor Chamberlain and colleagues (May 18, p 1219) contains inaccuracies. The study referred to in their first paragraph is the Government sponsored, Medical Research Council funded, unlinked, anonymous survey of HIV seroprevalence in antenatal rubella screening sera, in which 34 centres in six regions now collaborate. It is coordinated by the Public Health Laboratory Service AIDS Centre. A sample of residual serum is stored from every specimen received for routine antenatal rubella serology by collaborating centres. Information available for each sample is: patient age group, quarter year of specimen collection, and centre (district) of specimen origin. Information about "racial origin" is not available or collected. The survey is
one
of several in the unlinked anonymous HIV
prevalence monitoring programme.’ The surveys are not designed to measure directly the incidence of HIV infection, but to measure the rate of change in HIV seroprevalence over time. The programme forms a major part, together with AIDS case-reports and monitoring of reports of named HIV tests, of the comprehensive surveillance of the HIV epidemic in England and WalesPreliminary results from the unlinked anonymous HIV surveys were made public by the Department of Health on May 17, 1991, and will be published in Communicable Disease Report. PHLS AIDS Centre, Communicable Disease Surveillance Centre, London NW9 5EQ, UK
JULIA HEPTONSTALL ANGUS NICOLL
1. Gill ON, Adler NW, Day NE. Monitoring the prevalence of HIV. Br Med J 1989; 299: 1295-98. 2. PHLS AIDS Centre. The surveillance of HIV-1 infection and AIDS in England and Wales. Commun Dis Rep 1991; 1 (review no 5): R51-R56.
NHS waiting list initiatives SiR,—Malcolm Dean in his May 18 London Perspective mentions the waiting list initiative bid being submitted by the Royal Liverpool Childrens Hospital, Alder Hey, for an increase in cardiac surgery. He fails to understand the background. The approach within this hospital was to try and increase the workload in the cardiac department so that we could reduce waiting times. We would emphasise that this is additional workload and does not affect the contracts we have agreed with a large number of health authorities, including North Manchester. Unfortunately, only about half the districts approached could support such an initiative, with those in the North-West Region unable to commit themselves. Nonetheless, what we have achieved means that more operations will be done and that waiting times will be reduced. We were not asking for an additional C7500 premium on each case, as Dean states. We were asking districts to support additional workload out of waiting list initiative funds. The normal workload covered by the contract is protected. Royal Liverpool Childrens Hospital, Alder Hey, Liverpool L122AP, UK
PEARSE BUTLER JOHN MARTIN
Specialist training for medical graduates SIR,-In your April 27 editorial you rightly point out evidence that the advancement of female medical graduates in the USA is the same as that of male graduates, according to a Columbia University study. Roberts/ an American internist and journalist, has described the pitiful progress of female medical graduates in the British system. However, both you and Roberts skate around the most important differences between the American training system and the British apprenticeship system and their eventual outcome. The American system trains most of its specialists in about five years after qualification. The average length of training in the UK is twice this time and in certain specialties it can be very much longer. Most hospital staff appointments in the USA are open, the criteria for appointment being the appropriate board certification in a specialty and current state licensure. "Old boy" networks, which you say are helpful for senior hospital appointments in the British system, in general have no bearing upon appointments in the USA. Having been trained in the UK and having been more than ten years in private practice, I can state that the UK apprenticeship is highly wasteful of both male and female medical talent. Surely the time has come for the UK Government, currently reforming medical care, and the Royal Colleges to agree upon proper training programmes that would last for a predetermined period-no more than seven years. Examinations would be at the end of this training period and lead to specialist certification. Hospital appointments should be open to all those individuals appropriately qualified. The apprenticeship system is convenient for the UK Government, which does not want too many highly paid specialists. The Royal Colleges publicly bemoan the lack of specialists, but are privately happy not to rock the boat. The public is ill-served by this collusion, which leads to long waiting lists in many parts of the country, and inferior medical care because ofa lack of specialists. Male and female UK medical graduates, who have been largely trained at the taxpayer’s expense, should be set free to serve the general public, not a monopoly of British middle-aged men. 408 North
Lilly Road, Suite C, Olympia, Washington 98506, USA 1. Roberts J. Junior doctors’
JOHN C. D. PLANT
years: training not education. Br Med J 1991; 302:
225-28.
Publication bias SIR,-Dr Easterbrook and her colleagues (April 13, p 867) report that there is a publication bias in favour of trials showing a positive result. The responsibility for this fell more on authors than editors, but do other human failings of editors result in bias? A few years ago I was asked to review for a cardiological journal a paper that described a new technique. The first author worked in the editor’s department and the studies were based on animal work in which the journal’s assistant editor had been involved. I recommended rejection because I had reservations about the theoretical basis for the method, because claims about validation were unjustified, and because the method produced only a qualitative answer to a quantitative question. I was therefore surprised to see the paper published and even more surprised to learn that the second referee wrote "all you can do is reject this paper". With a colleague I set out to test the validity of the method, using a "gold standard" and a sample three times as large. We failed to confirm the findings but the journal that had published the earlier study rejected our paper. We were sent only one referee’s report and were assured that our paper had only been sent to one referee. When I pointed out that at the top of the referee’s report appeared "reviewer no 2" I was informed that another reviewer had seen our paper, and that his conclusions were almost identical to those of reviewer no 2. The journal refused to send me the report of the other referee.In the subsequent correspondence I could not help but notice that the report of reviewer no 2 was typed on the same typewriter as letters from the journal’s assistant editor, and when confronted on this point, he admitted that it was difficult to find a reviewer sufficiently knowledgeable on the subject outside his centre. Is this an isolated case? Department of Cardiology, St Thomas’ Hospital, London SE1 7EH, UK
PETER WILMSHURST
that he will have a fair hearing. The Cuban Embassy in Ottawa, on June 3, confirmed that Dr Arana was arrested on Oct 26,1990, and stated that he has been charged with "terrorism" but the position in respect of a fair and open trial on this charge remains unclear. Lancet readers who wish to support Dr Arana could write to Dr Thomas L. Perry, Sr, Department of Pharmacology and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia V6T 1Z3, Canada, preferably by FAX to Mrs S. Hansen (010-1-604 822 6012).
J. G. FOULKS J. G. MCLARNON T. L. PERRY, SR
D. V. GODIN C. KRIEGER B. A. MACLEOD C. C. Y. PANG T. L. PERRY, JR D. M. J. QUASTEL M. C. SUTTER B. SASTRY M. J. A. WALKER E. PUIL R. A. WALL J. M. WRIGHT of British Canada Columbia, Vancouver, BC, University
HIV test in pregnancy SiR,—The letter from Professor Chamberlain and colleagues (May 18, p 1219) contains inaccuracies. The study referred to in their first paragraph is the Government sponsored, Medical Research Council funded, unlinked, anonymous survey of HIV seroprevalence in antenatal rubella screening sera, in which 34 centres in six regions now collaborate. It is coordinated by the Public Health Laboratory Service AIDS Centre. A sample of residual serum is stored from every specimen received for routine antenatal rubella serology by collaborating centres. Information available for each sample is: patient age group, quarter year of specimen collection, and centre (district) of specimen origin. Information about "racial origin" is not available or collected. The survey is
one
of several in the unlinked anonymous HIV
prevalence monitoring programme.’ The surveys are not designed to measure directly the incidence of HIV infection, but to measure the rate of change in HIV seroprevalence over time. The programme forms a major part, together with AIDS case-reports and monitoring of reports of named HIV tests, of the comprehensive surveillance of the HIV epidemic in England and WalesPreliminary results from the unlinked anonymous HIV surveys were made public by the Department of Health on May 17, 1991, and will be published in Communicable Disease Report. PHLS AIDS Centre, Communicable Disease Surveillance Centre, London NW9 5EQ, UK
JULIA HEPTONSTALL ANGUS NICOLL
1. Gill ON, Adler NW, Day NE. Monitoring the prevalence of HIV. Br Med J 1989; 299: 1295-98. 2. PHLS AIDS Centre. The surveillance of HIV-1 infection and AIDS in England and Wales. Commun Dis Rep 1991; 1 (review no 5): R51-R56.
NHS waiting list initiatives SiR,—Malcolm Dean in his May 18 London Perspective mentions the waiting list initiative bid being submitted by the Royal Liverpool Childrens Hospital, Alder Hey, for an increase in cardiac surgery. He fails to understand the background. The approach within this hospital was to try and increase the workload in the cardiac department so that we could reduce waiting times. We would emphasise that this is additional workload and does not affect the contracts we have agreed with a large number of health authorities, including North Manchester. Unfortunately, only about half the districts approached could support such an initiative, with those in the North-West Region unable to commit themselves. Nonetheless, what we have achieved means that more operations will be done and that waiting times will be reduced. We were not asking for an additional C7500 premium on each case, as Dean states. We were asking districts to support additional workload out of waiting list initiative funds. The normal workload covered by the contract is protected. Royal Liverpool Childrens Hospital, Alder Hey, Liverpool L122AP, UK
PEARSE BUTLER JOHN MARTIN
Specialist training for medical graduates SIR,-In your April 27 editorial you rightly point out evidence that the advancement of female medical graduates in the USA is the same as that of male graduates, according to a Columbia University study. Roberts/ an American internist and journalist, has described the pitiful progress of female medical graduates in the British system. However, both you and Roberts skate around the most important differences between the American training system and the British apprenticeship system and their eventual outcome. The American system trains most of its specialists in about five years after qualification. The average length of training in the UK is twice this time and in certain specialties it can be very much longer. Most hospital staff appointments in the USA are open, the criteria for appointment being the appropriate board certification in a specialty and current state licensure. "Old boy" networks, which you say are helpful for senior hospital appointments in the British system, in general have no bearing upon appointments in the USA. Having been trained in the UK and having been more than ten years in private practice, I can state that the UK apprenticeship is highly wasteful of both male and female medical talent. Surely the time has come for the UK Government, currently reforming medical care, and the Royal Colleges to agree upon proper training programmes that would last for a predetermined period-no more than seven years. Examinations would be at the end of this training period and lead to specialist certification. Hospital appointments should be open to all those individuals appropriately qualified. The apprenticeship system is convenient for the UK Government, which does not want too many highly paid specialists. The Royal Colleges publicly bemoan the lack of specialists, but are privately happy not to rock the boat. The public is ill-served by this collusion, which leads to long waiting lists in many parts of the country, and inferior medical care because ofa lack of specialists. Male and female UK medical graduates, who have been largely trained at the taxpayer’s expense, should be set free to serve the general public, not a monopoly of British middle-aged men. 408 North
Lilly Road, Suite C, Olympia, Washington 98506, USA 1. Roberts J. Junior doctors’
JOHN C. D. PLANT
years: training not education. Br Med J 1991; 302:
225-28.
Publication bias SIR,-Dr Easterbrook and her colleagues (April 13, p 867) report that there is a publication bias in favour of trials showing a positive result. The responsibility for this fell more on authors than editors, but do other human failings of editors result in bias? A few years ago I was asked to review for a cardiological journal a paper that described a new technique. The first author worked in the editor’s department and the studies were based on animal work in which the journal’s assistant editor had been involved. I recommended rejection because I had reservations about the theoretical basis for the method, because claims about validation were unjustified, and because the method produced only a qualitative answer to a quantitative question. I was therefore surprised to see the paper published and even more surprised to learn that the second referee wrote "all you can do is reject this paper". With a colleague I set out to test the validity of the method, using a "gold standard" and a sample three times as large. We failed to confirm the findings but the journal that had published the earlier study rejected our paper. We were sent only one referee’s report and were assured that our paper had only been sent to one referee. When I pointed out that at the top of the referee’s report appeared "reviewer no 2" I was informed that another reviewer had seen our paper, and that his conclusions were almost identical to those of reviewer no 2. The journal refused to send me the report of the other referee.In the subsequent correspondence I could not help but notice that the report of reviewer no 2 was typed on the same typewriter as letters from the journal’s assistant editor, and when confronted on this point, he admitted that it was difficult to find a reviewer sufficiently knowledgeable on the subject outside his centre. Is this an isolated case? Department of Cardiology, St Thomas’ Hospital, London SE1 7EH, UK
PETER WILMSHURST
