conscious smokers. It will follow the activities of vectors those who manufacture, advertise, distribute, and sell tobacco products. The journal will pay attention to the host, publishing epidemiological and behavioural research on tobacco use, and will analyse the environment in which tobacco is used. The impact of tobacco on the environment-for example, on public health, the economy, and political processes-will be considered, as will the impact of the environment on tobacco. Programmes and policies that discourage tobacco consumption are an important part of that environment, and publishing evaluations of these interventions will be a priority for the new journal. Similarly, it will publish survey research on public beliefs, opinions, and attitudes related to tobacco. Most of the journal will comprise rigorous, peer reviewed science, but there will also be news on activities throughout the world. Tobacco Control will be as international as possible because tobacco and its vectors know no boundaries. As their home markets shrink the transnational tobacco companiesbased predominantly in the United States and Britain-are aggressively marketing their products in the developing world.4 9-12 A major goal of the journal will be to report on the developing world. To emphasise the journal's international aims it will carry the subtitle An International journal. Its production will involve people all over the world: regional and associate editors and members of the editorial board will represent more than 20 countries from every part of the globe. The
editor will be in the United States, the deputy editor in Australia, and the technical editor in Britain. We hope to achieve an even greater geographical diversity among readers and contributors. RONALD M DAVIS
Chief Medical Officer and Editor of Tobacco Control: An International Journal, Michigan Department of Public Health, Lansing, Michigan 48909 RICHARD SMITH Editor, BMJ I National Committee for Injury Prevention and Control. Injury prevention: meeting the challenge. AmJf Prev Med 1989;Suppl 5:5. 2 Centers for Disease Control. Protective effect of physical activity on coronary heart disease. MMWR 1987;36:426-30. 3 Stevens DJ. Tobacco in the year 2000. Tobaccoj Int 1990;3 (May/June): 16-22. 4 Chapman S, Leng WW. Tobacco control in the Third World: a resource atlas. Penang, Malaysia: International Organisation of Consumers Unions, 1990. 5 Peto R, Lopez AD, and the WHO Consultative Group on Statistical Aspects of Tobacco-related Mortality. Worldwide mortality from current smoking patterns. In: Durston B, Jamrozik K, eds. Tobacco and Health 1990-the global war. Perth: Health Department of Western Australia, 1990:66-8. (Proceedings of the seventh world conference on tobacco and health. 6 World Health Organisation. Report of a WHO consultation on statistical aspects of tobacco-related mortality, Geneva, 9-13 October 1989. Geneva: WHO, 1990. (Document WHO/TOH/CLH/ 90.2.) 7 United States Department of Health and Human Services. The health benefits of smoking cessation: a report of the surgeon general, 1990. Atlanta, Georgia: Centers for Disease Control, Office on Smoking and Health, 1990. (DHHS Publication No. (CDC) 90-8416.) 8 Slade JD. A disease model of cigarette use. N Y Statej Med 1985;85:294-7. 9 Dean M. King Tobacco under attack. Lancet 1990;336:865-6. 10 Mackay J. Battlefield for the tobacco war. JAMA 1989;261:28-9. 11 Chen TTL, Winder AE. The opium wars revisited as US forces tobacco exports in Asia. AmJ Public Health 1990;80:659-62. 12 Davis RM. Promotion of cigarettes in developing countries. JAMA 1986;255:993.
Women in general practice Time to equalise the opportunities Five out of 10 medical graduates and four out of 10 doctors completing vocational training in general practice are women, yet recent studies suggest that they feel discriminated against -both when applying for posts in general practice and when a practice's workload and profits are shared out (p 762).' 2 Women with children, who often work part time, feel this most strongly, and many would prefer full time work. Although many women work nominally part time, their rates of consultation and the time they spend with patients are almost identical with those of their male partners.3 Two in three work out of hours.2 The need to increase the number of women general practitioners was recognised in the government's white paper WorkingforPatients, published two and a halfyears ago.4 Since then things may have got worse. The new contract for general practitioners, apart from relaxing regulations for maternity leave, has done little to encourage women principals in general practice, and practices may have responded to its pressures by appointing assistants or practice nurses instead. Women have many attributes which should make them good general practitioners.5 Women practitioners are more concerned than men about preventive care, encouraging the uptake of cervical screening and immunisation and promoting health opportunistically.6 Patients often prefer a woman doctor, and women perform better than men in the examination for the MRCGP.7 Unfortunately, women's traditional responsibilities for bringing up children account for many of their difficulties. Time out from medicine leads to lack of confidence, both in clinical and in managerial skills.28 On returning to work women partners may defer to their male colleagues, an BMJ VOLUME 303
28 SEPTEMBER 1991
attitude that may persist indefinitely. The retainer scheme may help to provide clinical continuity during these years, but little attention has been given to maintaining and improving managerial skills. The prospect for improvement seems gloomy, with the government seeking more commitment to late surgeries at times when both men and women want and need to be with their own families. Extending basic practice hours from 20 to 26 and increasing the proportion of income derived from capitation have both worked against women entering general practice. The poor representation of women on the General Medical Services Committee and the council of the Royal College of General Practitioners doesn't help. Although both bodies actively encourage participation by women, few women balancing their career and family can make the necessary commitment. With applications for vocational training posts falling, now is the time for a radical rethink if a crisis in general practice is to be avoided. What would make general practice more attractive, particularly to women? Improving access to part time training would help, as would identifying suitable hospital posts for part time trainees. Paying a full trainer's grant might encourage practices to take part time trainees: at present, training practices receive only half the grant for supervising and teaching a part time trainee, although most will give an equal amount of tutorial time. There are still few women trainers and course organisers, and recruitment of course organisers is likely to remain low while the present restrictions on pay and workload persist. Little flexibility exists for regional advisers to dedicate course organisers' time to the particular problems of women trainees. 733
Although family health services authorities encourage and support women entrants to general practice, they may need to play a more active part in monitoring women's workload and share of partnership income. Authorities could determine how many minimum full time practitioners previously working 20 hours a week are now working 26 hours for the same share of the profits, how many now do night work, and whether they treat applications for job sharing in singlehanded practices equally. The Royal College of General Practitioners supports continued education in the early years in general practice.9 Doctors on retainer schemes and those returning after a break from full clinical responsibility may have special educational needs, particularly regarding practice management. This group may have low incomes, and meeting their needs may require additional grants. Women are an asset to general practice. The profession, the government, and the family
health services authorities have a responsibility to ensure that they are treated equally. JACKY HAYDEN Regional Adviser in General Practice, Department of Postgraduate Medical Studies, Gateway House, Piccadilly South, Manchester M60 7LP I Osler K. The employment experiences of a group of socationally trained doctors. BMfJ
1991;303:000-00. 2 Hooper J, Millar J, Schofield P, Ward G. Part-time women general practitioners-workload and remuneration. J R Coll Gen Pract 1989;39:400-3. 3 Wilkin D, Hallam L, Leasey R, Metcalfe D. Anatomy of urban general practice. London: Ta'istock, 1987. 4 Secretaries of State for Health, Wales, Northern Ireland, and Scotland. Working for patients. London: HMSO, 1989. (Cmnd 555.) 5 Gray J. The effect of the doctor's sex on the doctor-patient relationship. J R Coll Gen Pract 1982;32: 167-9. 6 Preston-Whyte ME, Fraser R, Beckett JI.. Effect of a principal's gender on consultation patterns. J R Coll Gen I'ract 1983;33:654-8. 7 Royal College of General Practitioners. 1990 Mfembers reference book. London: Sabrecrown, 1990. 8 Allen 1. Doctors and their careers. London: P'olicy Studies Institute, 1988. 9 Royal College of General laractitioners. Qualitv in general practice. London: RCGP, 1985.
WIST-ful thinking An unsuitable job for a woman Only one per cent of consultant general surgeons are women. I There are two reasons for this according to Isobel Allen's survey of doctors and their careers.2 The first is that surgery is thought to need a full time commitment, which women either cannot or do not want to give. The second is that male surgeons are prejudiced against female doctors. It would be nice to think that the Women in Surgical Training Scheme (WIST), a joint venture from the Department of Health and the Royal College of Surgeons of England, might increase the numbers of women surgeons.3 Its two objectives: to "help women overcome the obstacles... in surgical training" and "to ensure that women are ... fully represented at the highest levels in those specialities which have up to now been extensively male dominated" are clearly desirable for women surgeons. The royal college has already removed one obstacle by stating that there is no bar to part time training. The Department of Health aims to increase the number of part time career registrar posts fourfold over the next five years.4 Twenty two posts will be available in general surgery. Now that women make up half the entrants to medical schools these objectives are not only desirable for women surgeons but also essential for surgery to attract the best trainees. So what does this scheme intend to do for women? The Department of Health has provided only £30 000, and WIST's proposed help is more spiritual than practical.5 The scheme will target women who have passed the first part of their primary fellowship and encourage and monitor their careers through the appointment of regional advisors. It will encourage mutual support groups. "Ultimately ... the outcome should be an increased representation of women in surgery at consultant level." But in the meantime another generation of women surgeons may be lost. It seems short sighted to target women at senior house officer level when they are already underrepresented in surgery. Women make up only 13% of general surgical senior house officers compared with 35% of those in anaesthetics.6 In America-where again only 1% of surgical chiefs are women-women are put off surgery at medical school.7 Surgery is seen to have the most advantages for men -drama and respect-and the most disadvantages for womenirregular hours and prejudice.8 In the United Kingdom Isobel Allen found that students frequently used the word "humi734
liating" to describe their encounters with surgeons. If the Royal College of Surgeons of England seriously wants to help women it should look at the obstacles which exist for men. Surgical training is protracted and haphazard. The hours are incompatible with a normal social life. For a woman to succeed she must give up most of the things which other women have. Success for women in surgery is linked to marrying late-if at all -and childlessness. Men at least have wives. Part time training is not the answer for either sex. The PM(79)3 scheme for part time senior registrar posts has operated in various forms for 20 years, but the first part time senior registrar in general surgery was only recently appointed. There are 10 in ophthalmology. General surgeons still think that part time training means a less than full time commitment. For women with children the pay barely covers the cost of childcare. The hours are still over 40 a week. The way to attract women into surgery is to improve the lot of both sexes. It is to structure training and complete it within a defined time. For the sake of family life it should be more geographically secure. Hospitals should provide creches. Hours must continue to be reduced. But none of this will work unless surgeons change themselves. They must stop perpetuating the myth that you have to be big and strong to do surgery. They must stop asking women discriminatory questions at interviews.9 WIST may alleviate the feeling of isolation that many women training in surgery feel. It may provide women with patronage from the handful of women who have "made it." What it must not do is monitor women for 20 years only to tell us what we know already. LUISA DILLNER
Editorial registrar, BMJ
1 Medical and dental staffing prospects in the NHS in England and Wales 1989. Health Trends 1990;22:96- 103. Allen I. Doctors and their careers. London: Policy Studies Institute Blackmore Press, 1988. Joint Working Party. Women doctors and their careers. London: Department of Health, 1991. Department of Health. Part time opportunities for doctors in training. London: DoH, 1991. Department of Health. Women doctors and thetr careers. London: Department of Health, 1991. (Press release Jan 22.) 6 Medical manpower census of the Department of Health for 30 Sept 1990. London: DoH, 1991. (Prepared for WIST conference Sept 1991.) 7 Delessardri K. The surgical workforce and women surgeons. Journal of the American Medical Women's Association 1988;43:169-77. 8 Ramos S, Feiner C. Women surgeons: A national survey. Journal of the American Medical Women's Association 1989;44:21-5. 9 Allen I, ed. Discussingdoctors' careers. London: Policy Studies Institute, 1988.
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editor will be in the United States, the deputy editor in Australia, and the technical editor in Britain. We hope to achieve an even greater geographical diversity among readers and contributors. RONALD M DAVIS
Chief Medical Officer and Editor of Tobacco Control: An International Journal, Michigan Department of Public Health, Lansing, Michigan 48909 RICHARD SMITH Editor, BMJ I National Committee for Injury Prevention and Control. Injury prevention: meeting the challenge. AmJf Prev Med 1989;Suppl 5:5. 2 Centers for Disease Control. Protective effect of physical activity on coronary heart disease. MMWR 1987;36:426-30. 3 Stevens DJ. Tobacco in the year 2000. Tobaccoj Int 1990;3 (May/June): 16-22. 4 Chapman S, Leng WW. Tobacco control in the Third World: a resource atlas. Penang, Malaysia: International Organisation of Consumers Unions, 1990. 5 Peto R, Lopez AD, and the WHO Consultative Group on Statistical Aspects of Tobacco-related Mortality. Worldwide mortality from current smoking patterns. In: Durston B, Jamrozik K, eds. Tobacco and Health 1990-the global war. Perth: Health Department of Western Australia, 1990:66-8. (Proceedings of the seventh world conference on tobacco and health. 6 World Health Organisation. Report of a WHO consultation on statistical aspects of tobacco-related mortality, Geneva, 9-13 October 1989. Geneva: WHO, 1990. (Document WHO/TOH/CLH/ 90.2.) 7 United States Department of Health and Human Services. The health benefits of smoking cessation: a report of the surgeon general, 1990. Atlanta, Georgia: Centers for Disease Control, Office on Smoking and Health, 1990. (DHHS Publication No. (CDC) 90-8416.) 8 Slade JD. A disease model of cigarette use. N Y Statej Med 1985;85:294-7. 9 Dean M. King Tobacco under attack. Lancet 1990;336:865-6. 10 Mackay J. Battlefield for the tobacco war. JAMA 1989;261:28-9. 11 Chen TTL, Winder AE. The opium wars revisited as US forces tobacco exports in Asia. AmJ Public Health 1990;80:659-62. 12 Davis RM. Promotion of cigarettes in developing countries. JAMA 1986;255:993.
Women in general practice Time to equalise the opportunities Five out of 10 medical graduates and four out of 10 doctors completing vocational training in general practice are women, yet recent studies suggest that they feel discriminated against -both when applying for posts in general practice and when a practice's workload and profits are shared out (p 762).' 2 Women with children, who often work part time, feel this most strongly, and many would prefer full time work. Although many women work nominally part time, their rates of consultation and the time they spend with patients are almost identical with those of their male partners.3 Two in three work out of hours.2 The need to increase the number of women general practitioners was recognised in the government's white paper WorkingforPatients, published two and a halfyears ago.4 Since then things may have got worse. The new contract for general practitioners, apart from relaxing regulations for maternity leave, has done little to encourage women principals in general practice, and practices may have responded to its pressures by appointing assistants or practice nurses instead. Women have many attributes which should make them good general practitioners.5 Women practitioners are more concerned than men about preventive care, encouraging the uptake of cervical screening and immunisation and promoting health opportunistically.6 Patients often prefer a woman doctor, and women perform better than men in the examination for the MRCGP.7 Unfortunately, women's traditional responsibilities for bringing up children account for many of their difficulties. Time out from medicine leads to lack of confidence, both in clinical and in managerial skills.28 On returning to work women partners may defer to their male colleagues, an BMJ VOLUME 303
28 SEPTEMBER 1991
attitude that may persist indefinitely. The retainer scheme may help to provide clinical continuity during these years, but little attention has been given to maintaining and improving managerial skills. The prospect for improvement seems gloomy, with the government seeking more commitment to late surgeries at times when both men and women want and need to be with their own families. Extending basic practice hours from 20 to 26 and increasing the proportion of income derived from capitation have both worked against women entering general practice. The poor representation of women on the General Medical Services Committee and the council of the Royal College of General Practitioners doesn't help. Although both bodies actively encourage participation by women, few women balancing their career and family can make the necessary commitment. With applications for vocational training posts falling, now is the time for a radical rethink if a crisis in general practice is to be avoided. What would make general practice more attractive, particularly to women? Improving access to part time training would help, as would identifying suitable hospital posts for part time trainees. Paying a full trainer's grant might encourage practices to take part time trainees: at present, training practices receive only half the grant for supervising and teaching a part time trainee, although most will give an equal amount of tutorial time. There are still few women trainers and course organisers, and recruitment of course organisers is likely to remain low while the present restrictions on pay and workload persist. Little flexibility exists for regional advisers to dedicate course organisers' time to the particular problems of women trainees. 733
Although family health services authorities encourage and support women entrants to general practice, they may need to play a more active part in monitoring women's workload and share of partnership income. Authorities could determine how many minimum full time practitioners previously working 20 hours a week are now working 26 hours for the same share of the profits, how many now do night work, and whether they treat applications for job sharing in singlehanded practices equally. The Royal College of General Practitioners supports continued education in the early years in general practice.9 Doctors on retainer schemes and those returning after a break from full clinical responsibility may have special educational needs, particularly regarding practice management. This group may have low incomes, and meeting their needs may require additional grants. Women are an asset to general practice. The profession, the government, and the family
health services authorities have a responsibility to ensure that they are treated equally. JACKY HAYDEN Regional Adviser in General Practice, Department of Postgraduate Medical Studies, Gateway House, Piccadilly South, Manchester M60 7LP I Osler K. The employment experiences of a group of socationally trained doctors. BMfJ
1991;303:000-00. 2 Hooper J, Millar J, Schofield P, Ward G. Part-time women general practitioners-workload and remuneration. J R Coll Gen Pract 1989;39:400-3. 3 Wilkin D, Hallam L, Leasey R, Metcalfe D. Anatomy of urban general practice. London: Ta'istock, 1987. 4 Secretaries of State for Health, Wales, Northern Ireland, and Scotland. Working for patients. London: HMSO, 1989. (Cmnd 555.) 5 Gray J. The effect of the doctor's sex on the doctor-patient relationship. J R Coll Gen Pract 1982;32: 167-9. 6 Preston-Whyte ME, Fraser R, Beckett JI.. Effect of a principal's gender on consultation patterns. J R Coll Gen I'ract 1983;33:654-8. 7 Royal College of General Practitioners. 1990 Mfembers reference book. London: Sabrecrown, 1990. 8 Allen 1. Doctors and their careers. London: P'olicy Studies Institute, 1988. 9 Royal College of General laractitioners. Qualitv in general practice. London: RCGP, 1985.
WIST-ful thinking An unsuitable job for a woman Only one per cent of consultant general surgeons are women. I There are two reasons for this according to Isobel Allen's survey of doctors and their careers.2 The first is that surgery is thought to need a full time commitment, which women either cannot or do not want to give. The second is that male surgeons are prejudiced against female doctors. It would be nice to think that the Women in Surgical Training Scheme (WIST), a joint venture from the Department of Health and the Royal College of Surgeons of England, might increase the numbers of women surgeons.3 Its two objectives: to "help women overcome the obstacles... in surgical training" and "to ensure that women are ... fully represented at the highest levels in those specialities which have up to now been extensively male dominated" are clearly desirable for women surgeons. The royal college has already removed one obstacle by stating that there is no bar to part time training. The Department of Health aims to increase the number of part time career registrar posts fourfold over the next five years.4 Twenty two posts will be available in general surgery. Now that women make up half the entrants to medical schools these objectives are not only desirable for women surgeons but also essential for surgery to attract the best trainees. So what does this scheme intend to do for women? The Department of Health has provided only £30 000, and WIST's proposed help is more spiritual than practical.5 The scheme will target women who have passed the first part of their primary fellowship and encourage and monitor their careers through the appointment of regional advisors. It will encourage mutual support groups. "Ultimately ... the outcome should be an increased representation of women in surgery at consultant level." But in the meantime another generation of women surgeons may be lost. It seems short sighted to target women at senior house officer level when they are already underrepresented in surgery. Women make up only 13% of general surgical senior house officers compared with 35% of those in anaesthetics.6 In America-where again only 1% of surgical chiefs are women-women are put off surgery at medical school.7 Surgery is seen to have the most advantages for men -drama and respect-and the most disadvantages for womenirregular hours and prejudice.8 In the United Kingdom Isobel Allen found that students frequently used the word "humi734
liating" to describe their encounters with surgeons. If the Royal College of Surgeons of England seriously wants to help women it should look at the obstacles which exist for men. Surgical training is protracted and haphazard. The hours are incompatible with a normal social life. For a woman to succeed she must give up most of the things which other women have. Success for women in surgery is linked to marrying late-if at all -and childlessness. Men at least have wives. Part time training is not the answer for either sex. The PM(79)3 scheme for part time senior registrar posts has operated in various forms for 20 years, but the first part time senior registrar in general surgery was only recently appointed. There are 10 in ophthalmology. General surgeons still think that part time training means a less than full time commitment. For women with children the pay barely covers the cost of childcare. The hours are still over 40 a week. The way to attract women into surgery is to improve the lot of both sexes. It is to structure training and complete it within a defined time. For the sake of family life it should be more geographically secure. Hospitals should provide creches. Hours must continue to be reduced. But none of this will work unless surgeons change themselves. They must stop perpetuating the myth that you have to be big and strong to do surgery. They must stop asking women discriminatory questions at interviews.9 WIST may alleviate the feeling of isolation that many women training in surgery feel. It may provide women with patronage from the handful of women who have "made it." What it must not do is monitor women for 20 years only to tell us what we know already. LUISA DILLNER
Editorial registrar, BMJ
1 Medical and dental staffing prospects in the NHS in England and Wales 1989. Health Trends 1990;22:96- 103. Allen I. Doctors and their careers. London: Policy Studies Institute Blackmore Press, 1988. Joint Working Party. Women doctors and their careers. London: Department of Health, 1991. Department of Health. Part time opportunities for doctors in training. London: DoH, 1991. Department of Health. Women doctors and thetr careers. London: Department of Health, 1991. (Press release Jan 22.) 6 Medical manpower census of the Department of Health for 30 Sept 1990. London: DoH, 1991. (Prepared for WIST conference Sept 1991.) 7 Delessardri K. The surgical workforce and women surgeons. Journal of the American Medical Women's Association 1988;43:169-77. 8 Ramos S, Feiner C. Women surgeons: A national survey. Journal of the American Medical Women's Association 1989;44:21-5. 9 Allen I, ed. Discussingdoctors' careers. London: Policy Studies Institute, 1988.
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