Ectopic pregnancy with oral contraceptive use has been overlooked

NHS Direct

Doctors may gain time to use their trueskills if people start using NHS Direct

Editor—O’Cathain et al’s paper confirmingthat advice offered by nurses through NHSDirect was useful to callers1 should make usquestion the generally hostile opinions onthis service propounded in free publicationsthat derive their income from pharmaceuti-cal advertising.2

Telephone advice can form an impor-tant part of an NHS that needs to meetpeople’s concerns, even if some of theseconcerns seem trivial to doctors workingunder pressure. The primary end point ofNHS Direct should be whether it meets theneeds of its callers for information notwhether it reduces work for any sector of themedical profession. If an increasingly infor-mation hungry population cannot get infor-mation from the NHS it will turn to othersources, which may be less reliable orrelevant.

Too often, medical staff see their role astough gatekeepers of the NHS, excluding apublic that would demand too much. Thisdemeans the public and those working inthe front line of the NHS. If the NHS devel-ops several different front doors doctors

may be freed to use their skills without wag-ing a continual battle to persuade membersof the public that they do not need furtherinvestigation, treatment, or referral.Steve Kempley consultant neonatologistRoyal London Hospital, London E1 [email protected]

1 O’Cathain A, Munro JP, Nicholl JP, Knowles E. Howhelpful is NHS Direct? Postal survey of callers. BMJ 2000;320:1035. (15 April.)

2 Hayes D. The case against NHS Direct. Doctor 2000 Apr13:36-9.

Clinicians must be able to providefeedback and evaluate advice given

Editor—O’Cathain et al report that mostrespondents found advice from NHS Directto be helpful and reassuring.1 However,mothers of several young children recentlyadmitted to our paediatric department havereceived advice from NHS Direct that in ret-rospect was concerning and inadequate. Wereport one such case here.

The mother of a 6 month old boytelephoned NHS Direct for advice overthree consecutive days. He had been unwellwith vomiting and increasing lethargy overthis period. She was interviewed, andbecause he was still drinking copious fluidsand frequently wetting nappies she was re-assured on each occasion. He was subse-quently admitted with severe diabeticketoacidosis.

Although diabetes is rare in infants, leth-argy is an important, although non-specific,symptom.2 Reassuring information, such asthe history of adequate fluid intake andurine output, should not be taken inisolation.

Monitoring and audit of NHS Direct areessential, particularly as the evidence for theefficacy of telephone triage in this popula-tion is lacking.3 Some evidence of efficacyhas been the absence of major adverseevents in recent studies, but are these eventsbeing reported?

We attempted to give feedback on thiscase. The NHS Direct website has no facilityfor clinicians to give feedback. Use of theNHS Direct telephone line to give feedbackled to a succession of telephone calls, culmi-nating in the suggestion that we write toNHS Direct care of the NHS Executive inLeeds.

Users are rightly able to providefeedback via the NHS Direct website andtelephone, but attempting to give feedbackas clinicians was time consuming, arduous,

and unsatisfactory. We strongly recommendthat a system for feedback from clinicians beprovided and made readily accessible.Kate Farrer specialist registrarNeonatal Intensive Care Unit Guy’s Hospital,London SE1 9RT

Peter Rye consultant, paediatric intensive careLinda Murdoch director, paediatric intensive careMurray Bain consultant paediatricianDarryl Hampson-Evans consultant anaesthetistSt George’s Hospital, London SW17 0QT

1 O’Cathain A Munro JF, Nicholl JP, Knowles E. Howhelpful is NHS Direct? Postal survey of callers. BMJ 2000;320:1035. (15 April.)

2 Hewson PH, Humphries SM, Roberton DM, McNamar JM,Robison MJ. Markers of serious illness in infants less thansix months old presenting to a children’s hospital. Arch DisChild 1990;65:750-6.

3 McClellan N. NHS Direct: here and now. Arch Dis Child1999;81:376-7.

Cost effectiveness and effectiveness interms of health outcome needs to bedetermined

Editor—It is not surprising to find thatpatients like to be able to pick up thetelephone and obtain advice.1 What we needto know is whether the diversion ofresources into NHS Direct is cost effectiveand effective in terms of health outcome.

If the service is used as an additionalsource of advice by patients who then goalong to their general practitioner or anaccident and emergency departmentanyway—or if, even worse, it encouragespatients who would have got better anywayto present to their doctor—then all NHSDirect is doing is to give a nice warm feelingto those involved.

No matter how many P values and 95%confidence intervals are calculated, patientsatisfaction questionnaires are a soft audittool and do not constitute scientific inquiry.Bob Bury consultant radiologistLeeds General Infirmary, Leeds LS1 [email protected]

1 O’Cathain A, Munro JP, Nicholl JP, Knowles E. Howhelpful is NHS Direct? Postal survey of callers. BMJ 2000;320:1035. (15 April.)

Ramifications of Ledward caseEditor—The case of Rodney Ledwardraises two serious concerns.1

Firstly, on the presumption that slipshodsurgery will result in large numbers of com-pensation claims, his medical protectionsociety would have early warning of allegedincompetence. Since they have alreadyestablished the principle of risk categoriesfor subspecialties, did they, do they, orshould they have a system of loading orexclusion for high-claim individuals?

Advice to authorsWe prefer to receive all responses electronically,sent either directly to our website or to theeditorial office as email or on a disk. Processingyour letter will be delayed unless it arrives in anelectronic form.

We are now posting all direct submissions toour website within 24 hours of receipt and ourintention is to post all other electronicsubmissions there as well. All responses will beeligible for publication in the paper journal.

Responses should be under 400 words andrelate to articles published in the precedingmonth. They should include <5 references, in theVancouver style, including one to the BMJ articleto which they relate. We welcome illustrations.

Please supply each author’s currentappointment and full address, and a phone orfax number or email address for thecorresponding author. We ask authors to declareany competing interest. Please send a stampedaddressed envelope if you would like to knowwhether your letter has been accepted or rejected.

Letters will be edited and may be shortened.

[email protected]

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Secondly, it is notable that this and theBristol cause célèbre have involved very sen-ior staff, who would sail unscathed throughany peer led revalidation procedure. For ouremployer to demand high standards of us isright and proper; but our profession iscurrently tying itself in knots over this issuewhen it is the right and duty of ouremployer—the government—to decide whatit wants and to organise it. We must heed thewarning of the police complaints authority;police investigating police will never con-vince the Guardian of their objectivity, andneither will doctors revalidating doctors.W G Sellwood consultant anaesthetistCannock Chase Hospital, Cannock WS11 2XY

1 O’Neale Roach J. Management blamed over consultant’smalpractice. BMJ 2000;320:1557. (10 June.)

Doctors’ attitudes resemblethose of the old aristocracyEditor—To become a doctor one has tostudy medicine (for eight to 11 years inFrance) and pass exams. These exams arenecessary to show that the basic medicalknowledge has been correctly acquired andthat the doctor practises his or her jobcorrectly. It therefore does not seemscandalous that every 10 years or so doctorsshould have to pass similar exams again.

Morrell wonders whether the medicaldinosaurs are heading for extinction.1 I thinkthat the reluctance of many doctors to havetheir basic medical knowledge checked atregular intervals resembles the mentality ofthe old aristocracy. Those people found itnatural to have their privileges maintainedfor their entire lives without feeling any needto justify this.Joseph Watine hospital doctorLaboratoire de Biologie Polyvalente, CentreHospitalier Général, F-12027 Rodez Cédex 09,[email protected]

1 Morrell P. Doctors and complementary medicine. BMJ2000;320:1145. (22 April.)

Antibiotic prescribing ingeneral practice

Practices should use the technology

Editor—All my prescriptions, except thosefor controlled drugs, are computer gener-ated. The general practice administrationsystem for Scotland (the commonest prac-tice computer system in Scotland) has a for-mulary option, which allows me to presetthe dose of drug and length of course. I usethis option extensively because it saves metime. (It can of course be overridden.) Byspending a minute or two converting theformulary entry I have made sure that all myprescriptions for trimethoprim for urinarytract infection are for only 3 days. Presum-ably other systems have a similar facility.Computers don’t get bored or forget thatthey ought to change behaviour.

This simple and basic procedure mighthelp to remove the need for computerised

reminders, loose leaf practice manuals, andeducational activities to implement thisparticular change.1

David Syme general practitionerLoch Tay Cottage, Killin, Perthshire FK21 [email protected]

1 Lipman T, Price D. Decision making, evidence, audit, andeducation: case study of antibiotic prescribing in generalpractice. BMJ 2000;320:1114-8 [with commentary byT Greenhalgh]. (22 April.)

Authors’ solution may not beeconomically sound

Editor—I enjoyed Lipman and Price’sarticle on antibiotic prescribing in a groupgeneral practice and Greenhalgh’s dramaticcommentary on it.1 But I come to a differentconclusion from the authors. The shortercourse of trimethoprim did seem to result inmore patients returning, as the nursesremarked, even if the confidence intervalswere wide. A quick calculation showed thisto add up to 14 consultations over the year.If you cost this out at £20 a visit, the cost of a3 day course is £280 a year. This is at a timewhen the administration seems to bemaking much political capital over appoint-ment times in general practice.

I am going back to 5 day courses of thedrug. The evidence from this paper seemsstronger than that in the Cochrane Library.David Taylor principal in general practice57 Woodland Road, Northfield, BirminghamB21 [email protected]

1 Lipman T, Price D. Decision making, evidence, audit, andeducation: case study of antibiotic prescribing in generalpractice. BMJ 2000;320:1114-8 [with commentary byT Greenhalgh]. (22 April.)

Study raises several questions

Editor—Often in general practice we takethe evidence for the way we practise forgranted, not asking how sound this evidenceis. It is helpful to read narratives written bygeneral practitioners about their own prac-tices, particularly when these doctors areready to admit shortcomings or failures.Increasingly we as doctors are asked tojustify what we do and don’t do.

I wish to raise a few points arising fromLipman and Price’s paper.1 Although theauthors conclude that small group edu-cational processes are better for makingmanagement decisions, I am not sure it is asafe conclusion that they are better forimplementation of these decisions.

I would be concerned if my partners andI had “by consensus” agreed to a protocol(for example, to prescribe trimethoprim for3 days in uncomplicated urinary tract infec-tion) but a year later “some partners claimednot to have heard the new policy.” Lipmanand Price do not mention how manygeneral practitioners are in WesterhopeMedical Group, but given this breakdown incommunication would the use of strongerevidence be better implemented?

I have misgivings that trimethoprim wasprescribed for 7 days in 16 cases when nogrowth was obtained on culture and in 31cases when no culture was performed at all.The group studied comprised women of

childbearing age and older. Trimethoprim isa folate antagonist and contraindicated inpregnancy. There is no mention of whetherpregnancy had been excluded; the groupmay have included women who, in the earlystages, were unaware they were pregnantand not taking folate supplementation.

I would question whether too few urinecultures were done before and after treat-ment. As doctors we strive to optimise our useof antibiotics and often have to treatinfections empirically. This, however, shouldbe backed where possible with laboratory evi-dence. By the authors’ protocol a patientcould have required a third course of anti-biotics before an uncomplicated urinary tractinfection was successfully treated. Why wasanalysis of urine dismissed as not reliable?

Finally, the term “uncomplicated” is notparticularly useful and disliked by many bac-teriologists; all infections have the potentialfor complication, especially if they are beingtreated blind and no cultures are awaited.David Carvel general practitioner13 Edgemont Street, Glasgow G41 3EH

1 Lipman T, Price D. Decision making, evidence, audit, andeducation: case study of antibiotic prescribing in generalpractice. BMJ 2000;320:1114-8 [with commentary byT Greenhalgh]. (22 April.)

Author’s reply

Editor—Syme’s point is well made, and thepractice computer system has now beenchanged with regard to trimethoprim forurinary tract infection. As Taylor points out,the shorter course seemed to lead to morepatients returning, but the 95% confidenceintervals included no difference betweenproportions (although it could be arguedthat, had this been a clinical trial, it wasunderpowered to find a true difference).

Taylor’s assertion that “the evidencefrom this paper seems stronger than that inthe Cochrane Library” is flattering butuntrue, in that evidence of clinical effective-ness from randomised controlled trials mustalways be stronger than that from retrospec-tive audits. Taylor argues that the extra con-sultations resulting from the short coursesincrease costs and therefore 5 day courseswould be preferable. I don’t think the figuressupport that conclusion. But this was a nar-rative case study, and team members’opinions and actions were also of interest.Some second consultations came aboutbecause of clinicians’ lack of confidence inthe 3 day regimen rather than its failure.

Carvel would be concerned if he and hispartners had agreed to a protocol and a yearlater some partners denied knowledge of it.So would we. The lesson we drew was that webecame aware of this only because we startedto have regular education sessions in pro-tected time and were therefore able toaddress the problem. Good communicationcannot be taken for granted; it must beworked at, and an educational process provedmore effective than an administrative one.

The British National Formulary states thattrimethoprim is potentially teratogenic in thefirst trimester. We would regard urinary tractinfection in pregnancy as complicated andthus excluded from the guideline. I have not

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found reports of fetal abnormalities causedby trimethoprim and would regard a 3 (oreven 7) day course as carrying an acceptablylow risk in unsuspected pregnancy.

I disagree that we should have donemore urine cultures. Only seven of 176urine cultures at the first consultations greworganisms insensitive to trimethoprim, andnot performing a urine culture was amoderate predictor of no second consulta-tion (negative likelihood ratio 0.34). Treatingempirically is thus likely to be successful inmost cases and reduce the number ofsecond consultations. We plan to repeat theaudit for the period July 1999 to June 2000.

Analysis of urine in practice conditionshas low predictive values.1 We criticallyappraised the paper by Winkens et al andconcluded that the results of analysis ofurine would not alter our clinical decisions.Toby Lipman general practitionerWesterhope Medical Group, Newcastle upon TyneNE5 [email protected]

1 Winkens RA, Leffers P, Trienekens TA, Stobberingh EE.The validity of urine examination for urinary tractinfections in daily practice. Fam Pract 1995;12:290-3.

Family history is important inestimating coronary riskEditor—The new Sheffield table and itsalternatives make little use of a cardinal riskfactor that is easy to assess.1 A family historyof coronary artery disease, especially whenpremature, is a powerful and independentindicator of a person’s risk. Failure toinclude this element will cause these tablesto underestimate the 10 year risk ofcardiovascular disease and cannot be cor-rected for by simply adding six years to thepatient’s age, as suggested in the Sheffieldtable. The increase in risk depends on theexact details of the family history and thepatient’s age and sex.

The GISSI-EFRIM investigators (GruppoItaliano per lo Studio della Sopravvivenzanell’Infarto-Epidemiologia dei Fattori di Ris-chio dell’Infarto Miocardico) showed that afamily history of myocardial infarction is anindependent risk factor for myocardialinfarction, with the number of relatives andthe age at which they were affected influenc-ing the strength of the association.2 Com-pared with subjects without a family history,those with one or two affected first degreerelatives had relative risks of myocardialinfarction of 2.0 and 3.0 respectively.

The danger seems to be greater forwomen than for men and is especially high ifa sister is affected. In one study of patientsaged under 60 with myocardial infarctionthe cumulative risk to women of ischaemicheart disease before age 65 is considerablyhigher if a sister rather than a brother isaffected (26% v 16%).3

Using more precise definitions of a familyhistory allows for a more accurate assessmentof coronary risk. An Australian survey foundthat, compared with an affected parent, anaffected sibling carries a relative risk of 2.5 forcoronary artery disease, regardless of age.4

Hence any female patients defined by theSheffield table as having a 10 year risk of cor-onary heart disease of 15% but who have anaffected sister of similar age may actually havea risk of over 30%. Family history of coronaryartery disease should feature prominently inall guidelines for primary prevention ofcardiovascular disease.John Younger medical registrarJohn Hunter Hospital, Locked Bag 1, HunterRegion Mail Centre, Newcastle, NSW 2310,Australia

1 Wallis EJ, Ramsay LF, Iftikhar UH, Ghahramani P, JacksonPR, Rowland-Yeo K, et al. Coronary and cardiovascularrisk estimation for primary prevention: validation of a newSheffield table in the 1995 Scottish health surveypopulation. BMJ 2000;320:671-6. (11 March.)

2 Roncaglioni MC, Santoro L, D’Avanzo B, Negri E, NobiliA, Ledda A, et al. Role of family history in patients withmyocardial infarction. An Italian case-control study.GISSI-EFRIM Investigators (Gruppo Italiano per loStudio della Sopravvivenza nell’Infarto–Epidemiologia deiFattori di Rischio dell’Infarto Miocardico). Circulation1992;85:2065-72.

3 Pohjola-Sintonen S, Rissanen A, Liskola P, Luomanmaki K.Family history as a risk factor of coronary heart disease inpatients under 60 years of age. Eur Heart J 1998;19:235-9.

4 Silberberg J, Wlodarczyk J, Fryer J, Robertson R, HensleyMJ. Risk associated with various definitions of familyhistory of coronary artery disease. The Newcastle familyhistory study II. Am J Epidemiol 1998;147:1133-9.

Prevalence of obesity inasthmatic adultsEditor—Obesity is an increasing healthproblem, particularly in the affluent coun-tries, and although the reported association(not necessarily causal relationship) withasthma is not new, Stenius-Aarniala et alhave appropriately reported the effects ofweight reduction in morbidly obese adults(body mass index 30-42) with asthma.1 Theyhave also suggested that, because of the highprevalence of obesity,2 a large number ofpatients with asthma will also be obese.

To highlight the findings of the study, inthe context of reporting the prevalence ofobesity specifically among people withasthma, cross sectional data collected duringa previously reported community studybased in some of the socioeconomicallydeprived districts in Birmingham3 have beennewly analysed.

Of the original 689 study subjects withasthma, 535 (77.6%) were adults (293 whiteEuropeans, 242 South Asian) within the agegroup 18-59 years. Only 38.5% of theseadult subjects had a body mass index(kg/m2) within the healthy range (18.5-24.9),whereas most were either overweight(36.4%, body mass index 25-29.9) or obese(19.6%, body mass index 30-39.9).

At the extremes, 1.7% were severely obese(body mass index > 40) and 3.6% under-weight ( < 18.4). The predicted forced expira-tory volume in the first second did not varysignificantly (range 76.6-79.3) between thedifferent categories. Regression analysis inthese subjects showed that there was also anassociation between body mass index andboth age and sex but not with ethnic group.Data overall suggest that almost 58% of adultswith asthma in this community were abovetheir ideal body mass index measurements,but we cannot generalize as to the applica-

bility of the reported study1 and specificallywhether weight reduction would have asimilar impact in all overweight as well asobese individuals.Harmesh Moudgil consultant physicianPrincess Royal Hospital, Telford. TF6 [email protected]

Competing interests: None declared.

1 Stenius-Aarniala B, Poussa T, Kvarnstrom J, Gronlund EL,Ylikahri M, Mustajoki P. Immediate and long term effects ofweight reduction in obese people with asthma: randomisedcontrolled study. BMJ 2000;320:827-32. (25 March.)

2 Seidell JC, Flegal KM. Assessing obesity: classification andepidemiology. Br Med Bull 1997;53:238-52.

3 Moudgil H, Honeybourne D. Differences in asthmamanagement between white European and Indiansubcontinent ethnic groups living in socioeconomicallydeprived areas in the Birmingham (UK) conurbation.Thorax 1998;53:490-4.

Mentally ill people in prisons

Prison service policy on seclusion haschanged

Editor—On 30 March 2000 the prisonservice issued instruction 27/2000, whichannounced the immediate elimination ofthe use of strip cells in the management ofprisoners identified as being at risk ofsuicide or self injury. This long overduedecision on policy may be heavily influ-enced by the Human Rights Act 1998.Interestingly, the prison service crampsgovernors’ budgets by stating that altera-tions to create a safer cell have to be metfrom existing capital resources.

I agree with Reed and Lyne’s proposalthat the care of mentally ill offenders shouldbe provided within the NHS.1 We in theprison service can never provide inpatientcare to NHS standards. We do not have thefunds to do so even though we are measuredby those same standards. Furthermore, wedo not have 24 hour access to our inpatients,even when it is described as a 24 hour serv-ice. Every prison has patrol states—duringparts of the day and all night—when everyprisoner is locked away. Nurses do not haveroutine access to their inpatients.

The present system is dishonest andduplicitous. It is dishonest because weprovide it in name only, and it is duplicitousto attempt to provide a parallel system tothat of the NHS, which is already funded forthe individual as part of capitation funding.The Home Office and the Department ofHealth are tripping over each other inaccessing funds from the Treasury toprovide a service for the same individual—prisoners are resourceful, but they cannot beboth inside and outside at the same time.

Prisons should have several dependencycells on the wings. Those prisoners whorequire regular visits from communitynurses could be located in these cells.Prisons should enter into joint fundedinitiatives with local primary care groups tosecure “visiting rights” from NHS trusts’community based nursing teams. Nurses,acting in these team models, should beemployed under local NHS parenthood, notby the prison service. Nurses within theprison service would experience little

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change to their environmental conditions.They would benefit by rejoining a moremature professional structure. Clinicalsupervision and clinical governance arealready integral components of that struc-ture. The same benefits could be said toapply to our medical colleagues.Steve Gannon health care managerHer Majesty’s Prison Bedford, Bedford MK40 1HG

1 Reed JL, Lyne M, Inpatient care of mentally ill people inprison. BMJ 2000;320:1031-4. (15 April.)

Little has changed

Editor—I welcome Reed and Lyne’s honestand comprehensive assessment of mentallyill people in prisons.1

I think, however, that, save a fewinexpensive tamperings, nothing will benoticeably altered as a consequence of hisfindings. Reed has updated similar findingsmade by John Howard in 1780,2 but little haschanged since then either, from a custodialpoint of view.

Howard wrote: “In some few jails areconfined idiots and lunatics . . . many of thebridewells are crowded and offensive,because the rooms which were designed forprisoners are occupied by lunatics. . . . Theinsane, when they are not kept separate, dis-turb and terrify other prisoners. No care istaken of them, although it is probable that bymedicines, and proper regiment, some ofthem might be restored to their senses, andusefulness in life.”John M Hall senior medical officerHer Majesty’s Prison Birmingham, BirminghamB18 [email protected] UK

1 Reed JL, Lyne M. Inpatient care of mentally ill people inprison. BMJ 2000;320:1031-4. (15 April.)

2 Howard J. The state of prisons in England and Wales, 2nd edn.Warrington, 1780:10.

Care is required with costeffectiveness approachEditor—The argument in the letter fromTaylor and Ebrahim starts from the premisethat the cost of providing an anticoagulationservice for patients with atrial fibrillation is15 times higher than that of treating withaspirin.1 The inference that anticoagulationmust be shown to be 15 times as effective asaspirin in the prevention of stroke is notcorrect because it ignores the costs oftreating patients who develop strokes.

The point estimate and confidence inter-vals of the treatment effect shown by Hellem-ons et al2 could be combined with theestimated costs of both preventing and treat-ing strokes. In this way a model of cost effec-tiveness related to different baseline riskscould be constructed. This, however, is ratherdifferent from the way that Taylor andEbrahim suggest using the cost ratio. It isindeed unlikely from the trial data thatanticoagulation is 15 times as effective asaspirin, but this does not mean thatanticoagulation must prevent 15 times asmany strokes to be cost effective.

Since the overall cost of treating patientswith stroke is likely to be higher than the cost

of drugs for preventing stroke, a relativelysmall benefit from anticoagulation might leadto an overall cost benefit in comparison withaspirin. This will be increasingly likely as thebaseline risk of stroke increases.

As authors of other letters in the clusterhave noted, the confidence intervals of therelative risk found by Hellemons et al are nottight enough to rule out a moderatebeneficial effect of anticoagulation in com-parison with aspirin.3 Although cost shouldbe considered in choosing between aspirinand anticoagulation for patients with atrialfibrillation (alongside individual patients’ risksand preferences for treatment), it should notbe used to demand that the statisticaldifference between treatments matches thedifferential costs of one part of the serviceprovision.Chris Cates general practitionerManor View Practice, Bushey, HertfordshireWD2 [email protected]

1 Taylor FC, Ebrahim S. Using anticoagulation or aspirin toprevent stroke. BMJ 2000;320:1010. (8 April.)

2 Hellemons BSP, Langenberg M, Lodder J, Vermeer F,Schouten HJA, Lemmens T, et al. Primary prevention ofarterial thromboembolism in non-rheumatic atrial fibrilla-tion in primary care: randomised controlled trial compar-ing two intensities of coumarin with aspirin. BMJ 1999;319:958-64.

3 Correspondence. Using anticoagulation or aspirin toprevent stroke. BMJ 2000;320:1008-11. (8 April.)

Assessment of competence andperformance at interviewEditor—We read the paper by Wood andO’Donnell on an overhaul of the traditionalinterviewing system with interest.1 They haveidentified an important area in medical edu-cation and assessment that needs to beaddressed. Our current processes of selec-tion pale into insignificance compared withthose for industry, but two issues need to beconsidered.

Firstly, as a profession we seem to havedifficulty in giving constructive and honestfeedback to doctors working with us and inreferences. If we were able to give constructivecriticism more effectively, there would subse-quently be less need to measure competencethrough objective structured clinical examsor other means at an appointment process.

Secondly, at interview we often lack skillsin assessing performance. It is possiblethrough structured questions and experien-tial interviewing to assess how a candidateperformed in a series of situations, ratherthan evaluate how they might perform in afictitious situation. In the North WesternDeanery we have been working with a groupof consultants to identify a range ofquestions that ask candidates—“Tell us abouta time when . . .,” rather than, “What wouldyou do if . . .”. This change in emphasis givesa much greater insight into previousperformance, which is usually the bestindicator of future performance. It has alsoencouraged us to think about the profes-sional values we seek in doctors who applyto join our training schemes, rather thanexperience that they have to date.

We do need to develop better evaluationof performance and competence in theworkplace, and we need to become moreskilled at interviewing, particularly in identi-fying professional values. However, objectivestructured clinical exams are expensive intime and resources and may not beappropriate for selection processes. Moreeffective and honest references and experi-ential interviewing might help us to select atinterview more effectively.Jacky Hayden dean of postgraduate medical studiesJohn Adams associate postgraduate deanDepartment of Postgraduate Medicine andDentistry, Manchester M60 7LP

1 Wood L, O’Donnell E. Assessment of competence andperformance at interview (Career focus). BMJ 2000;320:S2-7321. (5 February.)

Drug use and weapon carryingby young people

Study did not go far enough

Editor—Use of illegal drugs by youngpeople seems to be increasing, and arational and effective response must beguided by sound science. McKeganey andNorrie’s paper on the association betweenuse of illegal drugs and weapon carrying byyoung people in Scotland is based on threesurveys in 20 Scottish schools.1 How theseschools were selected and how representa-tive they and the students surveyed are ofschools and students in Scotland generallyare not reported.

The paper describes an associationbetween use of illegal drugs and weaponcarrying, both measured by self report withan instrument developed by the study team.No details are given to allow assessment ofthe validity or reliability of this instrument.Use of illegal drugs is undefined but seemsto relate to the number of different illegalsubstances ever used. Weapon carrying wasdefined in terms of lifetime, rather thanrecent, carriage. Thus these data couldsuggest that weapon carrying is high amongstudents now, or that many students havecarried a weapon at least once in their life, orthat neither is the case.

The data suggest that students reportinglifetime weapon carriage are more likelyalso to report using more kinds of illegaldrugs. This association could be an artefactgenerated through a common reportingtendency, it could be an example ofconfounding (drug use and weaponcarrying sharing the same antecedents), or itcould be causal (drug use leading to higherprobability of carrying a weapon).

As corroboration of self report was notsought, reporting bias cannot be discounted.Both drug use and weapon carrying arelikely to be associated with social disadvan-tage: in table 3 twice as many students fromLanarkshire schools reported having car-ried a weapon as did those from independ-ent schools. Despite this the proportionspresented in table 2 are not standardised forsocial position. Whether drug use precededweapon carrying or vice versa and the

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temporal relation of both to numerousother potential confounders cannot beassessed since the study was cross sectional.

The authors acknowledge that theirstudy does not clarify the causes of weaponcarrying. We suggest that it provides littleclarification of anything. Such a report,appearing in the General practice section ofthe BMJ and widely publicised in the popu-lar media,2 may subliminally reinforce theimage of young drug users as violent crimi-nals. This is unlikely to encourage generalpractitioners to engage with drug users andis counterproductive in the context of recentadvice both from the Department of Healthand in the BMJ.3 4

John Macleod clinical research fellowRhian Loudon clinical research fellowHealth Inequalities Research Group, Departmentof Primary Care and General Practice, University ofBirmingham, Birmingham B15 [email protected]

Matthew Hickman principal research fellowAli Judd research associateCentre For Research on Drugs and HealthBehaviour, Department of Social Science andMedicine, Imperial College School of Medicine,London SW6 1RQ

Drs Macleod, Hickman, and Judd are funded by theDepartment of Health to review evidence onpsychological and social consequences of drug useby young people.

1 McKeganey N, Norrie J. Association between illegal drugsand weapon carrying in young people in Scotland:schools’ survey. BMJ 2000;320:982-4. (8 April.)

2 Bosely S, Seenan G. Third of young Scots “carry weapons.”Guardian 2000: Apr 7.

3 Department of Health. Drug misuse and dependence:guidelines on clinical management. London: StationeryOffice, 1999.

4 Keen J. Managing drug misuse in general practice. BMJ1999;318:1503-4.

Authors should have phrased questionsdifferently

Editor—The research by McKeganey andNorrie is plagued by conceptual problems,which compromise its value.1 The authorsasked participants “Have you ever carried aweapon in case you got into a fight?” and “Ifyes, what kind of weapon(s)?” Reporting onthe data generated by their inquiry,McKeganey and Norrie remark that “It is farfrom clear why a substantial number of youngpeople in Scotland feel the need to carry aweapon, and this needs further investigation.”

The reason why a substantial number ofyoung people in Scotland feel the need tocarry a weapon was proposed byMcKeganey and Norrie themselves, in thequestion that they asked in their survey.Many young people in Scotland carry aweapon in case they get into a fight. Surelythe survey would have yielded moreinteresting data about weapon carryingamong young people if McKeganey andNorrie had asked respondents to offer upsome reasons for their carrying weapons.The offending question, however, obviatedthis possibility and perhaps shows a bias onthe part of the researchers concerning theirbeliefs about the cause(s) of weaponcarrying by young people.

The second problem concerns the ambi-guity of the word “fight,” which can refer toverbal confrontations, planned physical con-frontations, anticipated physical confronta-

tions, and fear of unprovoked physical assault.Indeed, even the phrase “fear of unprovokedphysical assault” is rather broad since onemay fear a foreseeable physical assault orhave a general fear of victimisation.

The study prompts three thoughts.Firstly, the questions asked suggest that theonly interesting kind of weapon carryingbehaviour is the one associated with theyoung person’s appreciation or perceptionof the possibility of getting into a fight.Secondly, it would have made more sense toprovide respondents with the opportunityto explain why they carried weapons.Thirdly, the limitations intrinsic to thephrase “in case” precluded any opportunityto learn more from the respondents aboutthe types of feelings and beliefs that maymotivate a young person to carry weapons.

I offer one final observation. If I was a ladseeking to hinder a research project I wouldreport that not only did I routinely takemany different kinds of drugs but I regularlywent about the town armed to the teeth.J Ellis Cameron-Perry legal consultant5 Laird’s Inn Court, Dunkeld, Perthshire PH8 [email protected]

1 McKeganey N, Norrie J. Association between illegal drugsand weapon carrying in young people in Scotland:schools’ survey. BMJ 2000;320:982-4. (8 April.)

Ectopic pregnancy with oralcontraceptive use has beenoverlookedEditor—In their review of ectopic preg-nancy, Tay et al report that previous femalesterilisation and current use of an intrauter-ine contraceptive device are risk factors onlywhen patients with ectopic pregnancy arecompared with pregnant controls and notwith non-pregnant women.1 However, wepublished a review on the effects of oralcontraceptives after fertilisation, in which wereviewed data indicating that the ratio ofextrauterine to intrauterine pregnancies isincreased for women taking combined oralcontraceptives and progestogen only pills,compared with control groups of pregnantwomen not using oral contraceptives.2

The increased odds ratio of ectopicpregnancy in women taking the combinedpill (compared with pregnant controls) wasfound to be 4.5 (95% confidence interval 2.1to 9.6)3 and 13.9 (1.8 to 108.3)4 in studiesincluding a total of 484 women with ectopicpregnancies and 289 pregnant controls. Weused these odds ratios to estimate that in thestudied populations the absolute rate ofectopic pregnancy in women using com-bined pills would range from 0.7 to 19.9ectopic pregnancies per 1000 woman years.We could, however, find only one study, fromZimbabwe, that reported an absolute risk ofectopic pregnancy in women taking thecombined pill—an ectopic rate of 0.5 per1000 women years.

The increased odds ratio of ectopicpregnancy for a woman taking progestogenonly pills (compared with pregnant con-trols) was reported in one study to be 79.1

(8.5 to 735.1),5 which we used to estimate anabsolute risk of 4-79 ectopic pregnanciesper 1000 woman years. This prediction isreasonably concordant with the reportedabsolute rates of ectopic pregnancy inwomen taking progestogen-only pills of3-20 per 1000 woman years.

Like Tay et al, and most researchers inthis field, we restricted our review to studiesusing pregnant controls because when con-sidering the situation where a womanbecame pregnant during the use of a birthcontrol agent one should focus on pregnantcontrols.

We believe that the association of ectopicpregnancies with oral contraceptives hasbeen overlooked in the medical literature onectopic pregnancy and that most whoprescribe or dispense oral contraceptives arenot aware of this association. If a womanwho is taking an oral contraceptive presentswith pelvic pain and unusual vaginalbleeding, we would recommend that thepossibility of ectopic pregnancy be ruled outby using the wise and practical clinicalapproach suggested by Tay et al.Walter L Larimore associate clinical professorDepartment of Family Medicine, University ofSouth Florida, Tampa, FL 34744-5817, [email protected]

Joseph B Stanford assistant professorDepartment of Family and Preventive Medicine,University of Utah, Salt Lake City, UT 84132, [email protected]

Competing interests: None declared.

1 Tay JI, Moore J, Walker JJ. Ectopic pregnancy. BMJ2000;320:916-9. (1 April.)

2 Larimore WL, Stanford JB. Postfertilization effects of oralcontraceptives and their relationship to informed consent.Arch Fam Med 2000;9(2):126-33.

3 Coste J, Job-Spira N, Fernandez H, Papiernik E, Spira A.Risk factors for ectopic pregnancy: a case-control study inFrance, with special focus on infectious factors. Am J Epide-miol 1991;133:839-49.

4 Thorburn J, Berntsson C, Philipson M, Lindbolm B. Back-ground factors of ectopic pregnancy. I. Frequency distribu-tion in a case-control study. Eur J Obstet Gynecol Reprod Biol1986;23:321-31.

5 Liukko P, Erkkola R, Laakso L. Ectopic pregnancies duringuse of low-dose progestogens for oral contraception. Con-traception 1977;16:575-80.

Implementing honesty aboutscreening using communityinformed consentEditor—We support Raffle’s suggestion thathonesty about screening is the best policy.1

But how can that be achieved? Practitionersand planners complain that individualinformed consent to screening is too timeconsuming: the provision of information andthe necessary discussion and reflection on itrequire considerable effort, time, and skill.

We have recently suggested a commu-nity informed consent process: a survey toestablish the distribution of preferencesamong fully informed people potentially tobe screened—for example, from a randomsample of the target population to whomscreening will be offered.2

Firstly, if most of the target populationthink that the harms of screening outweighthe benefits, there is no need to consider fur-ther whether screening should be provided.

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Secondly, if most of the target populationthink that the benefits of screening outweighthe harms, screening can be offered, subjectto an acceptable cost effectiveness ratio.People should be informed that a representa-tive sample of people like them who havebeen given detailed information about thescreening process thought that the benefitsoutweighed the disadvantages. For many, thatmay be sufficient for them to decide aboutscreening. Some may still want more infor-mation, which should then be provided.

Finally, if the target population is dividedabout benefits versus harms, then there is aneed for individualised decisions.

The first step is providing good evidenceabout all the effects of screening on the basisof randomised trials. We do not see it as adilemma if people are deterred fromeffective screening when they know itsconsequences. If they are truly wellinformed, that represents their preferencesand reflects how they trade the benefitsagainst the harms. Rather, the dilemma ishow to ensure that people indeed have suffi-cient information to make the choice. Thecommunity informed consent process rep-resents a practical solution. Only whenadequate community surveys of preferencesshow that most of those who might bescreened would choose to be screened doesit seem ethical to actively promote screeningwithout detailed individual consent.Les Irwig professor of epidemiologyDepartment of Public Health and CommunityMedicine, University of Sydney, NSW 2006,[email protected]

Paul Glasziou professor of evidence-based medicineDepartment of Social and Preventive Medicine,University of Queensland, Australia

Competing interests: None declared.

1 Raffle A. Honesty about screening is best policy. BMJ2000;320:872. (25 March.)

2 Irwig L, Glasziou P. Informed consent for screening bycommunity sampling. Effect Clin Pract 2000;3:47-50.(http://www.acponline.org/journals/ecp/janfeb00/irwig.htm (accessed 30 March 2000))

Drugs do not only relieve malemenopauseEditor—Gould, Petty, and Jacobs debatedabout facts for and against the existence of amale menopause.1 Both positions focusedon sexual dysfunction. Jacobs referred to anew class of drugs that offer significanttherapeutic potential for male erectile disor-der. But no one mentioned the impact ofdrug abuse or drug treatment on the declinein sexual interest and potency.

For example, it has been described thatmore than 41% of hospital inpatients aged 65years and over were found to use benzodi-azepines and alcohol in excess2 and that drugtreatment account for erectile dysfunction inapproximately 25% of cases.3 In developedcountries, ageing (in men and women) isassociated with an increase in the consump-tion of medical drugs. This contributes toimprove the health of ageing people,although it also increases the risk of adverseevents related to drug treatment. Drug related

sexual dysfunction is distributed dependenton age and sex (unpublished data). Sexualdysfunction should therefore be more preva-lent in young women (because they may betaking psychotherapeutic drugs), whereas inthe male population, old men should bemore affected (principally because they maybe taking antihypertensive drugs and psycho-therapeutic drugs).

The lifestyle in developed countriescould play a more important part in sexualdysfunction than physiological changesrelated to ageing. Drug treatment is animportant matter in this lifestyle and couldexplain more cases of sexual dysfunctioninitially attributed to the supposed male “cli-macteric.” Nowadays, the media are focusedon new treatments for sexual dysfunction,and they forget that drugs also produce it.Cándido Hernández-López clinical pharmacologyresidentIMIM-Hospital del Mar, Barcelona, [email protected]

1 Gould DC, Petty R, Jacobs HS. For and against: the malemenopause—does it exist? BMJ 2000;320:858-61. (25March.)

2 McInnes E, Powell J. Drug and alcohol referrals: are elderlysubstance abuse diagnoses and referrals being missed?BMJ 1994;308:444-6.

3 Keene LC, Davies PH. Drug-related erectile dysfunction.Adverse Drug React Toxicol Rev 1999;18:5-24.

Tinea capitis should be on thepublic health agendaEditor—We welcome the article by Gibbonet al drawing attention to an increasing prob-lem of tinea capitis caused by Trichopyton ton-surans.1 In seeking to document the increasethe authors cite that the Communicable Dis-ease Surveillance Centre has recorded a25-fold rise in cases of infection with Ttonsurans infection since 1995, and a furtherdoubling of incidence was seen within thefirst half of 1999. We believe that themagnitude of the rise given by these figures ismisleading.

The current laboratory reporting regula-tions request that, of fungal laboratoryisolates, only deepseated fungal infections arereported to Communicable Disease Surveil-lance Centre.2 Although substantial numbersof superficial mycoses are reported to thecentre each year, the fact that reports are notrequested, and therefore not received frommost laboratories, hinders any meaningfulinterpretation of changes in numbers of thesereports. Any apparent trends in reports ofsuperficial mycoses are as likely to reflectchanges in local laboratory staff, and theirunderstanding of reporting requirements, asthey are to reflect changes in incidence.

The rise in T tonsurans cases cited by theauthors represents three cases reported in1996, 1 in 1997, and 26 in 1998 (a total of 79were received in 1999) from all NHS andPublic Health Laboratory Service laborato-ries in England and Wales. Of the 105reports received in 1998-9, most were froma single laboratory.

At present there is no national surveil-lance of infection with T tonsurans. Labora-tory reporting guidelines for mycoses are

currently under review. Making T tonsurans areportable fungal infection may provide ameans of monitoring trends in tinea capitis,although a substantial proportion of diag-noses will be made on clinical presentationonly and therefore will not be included inlaboratory reports.

The Public Health Laboratory ServiceMycology Reference Laboratory has since1980 undertaken a five yearly survey tomonitor changes in incidence of differentdermatophyte species. The number ofisolates of T tonsurans and the proportion ofall dermatophytes reported to the MycologyReference Laboratory increased from 0.3%(17/5101) in 1980 to 2.5% (363/14811) in1995.

Clearly there are concerns that the inci-dence of tinea capitis is increasing inEngland and Wales. Tinea capitis should beon the public health agenda, given itsubiquity and potential for permanent hairloss and scarring. Further epidemiologicalresearch is needed to establish risk factorsfor development of tinea capitis and toinform local interventions.Theresa Lamagni senior [email protected]

Barry Evans consultant epidemiologistPublic Health Laboratory Service CommunicableDisease Surveillance Centre, London NW9 5EQ

Colin Campbell top grade scientistPublic Health Laboratory Service MycologyReference Laboratory, Bristol BS2 8EL

1 Gibbon KL, Goldsmith P, Salisbury JA, Bewley AP. Unnec-essary surgical treatment of fungal kerions in children.BMJ 2000;320:696-7. (11 March.)

2 PHLS Mycology Committee. Fungal infections: guidelinesfor reporting. Comm Dis Rep CDR Review 1996;6(5):R75.

Perhaps it is not time to switchfrom whole cell to acellularpertussis vaccineEditor—Although we agree with Finn andBell that it is an opportune moment toreview the British policy on the use ofpertussis vaccines, we cannot agree withtheir conclusion.1 There is ample evidencethat in older children adverse events are lesscommon after the acellular than after thewhole cell vaccine, but this differencebecomes less significant when the vaccine isgiven at two, three, and four months as in theUnited Kingdom.

Miller et al showed that using the currentBritish schedule, of the relatively minor reac-tions only fever was significantly commonerin those receiving the whole cell vaccine,whereas in older children other mild or mod-erate reactions were also significantly morecommon.2 The study performed by Bell et allooked only at relatively minor adverse eventssuch as local reactions and fever. The studycited by Finn and Bell as showing a differencein incidence of febrile seizures andhypotonic-hyporesponsive episodes was, weassume, conducted at two, four, and sixmonths, as is the norm for Canada. Theseresults cannot therefore be extrapolated tothe United Kingdom schedule where one

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would expect a lesser difference, if any,between the two sorts of pertussis vaccines.

In considering the use of any vaccine, itgoes without saying that the efficacy of thevaccine should also be taken into account,but this seems to have been overlooked inthe present discussion. The whole cellvaccines used in the United Kingdom havebeen shown to be more efficacious than allbut the acellular vaccines with five compo-nents, which is not available in the UnitedKingdom.3 While pertussis still kills childrenin the United Kingdom, this is an importantconsideration.4 5 Uptake of whole cell vac-cine is currently 94% overall, and there is noevidence to suggest that by adopting anacellular vaccine, the number of childrenbeing immunised would increase. If thisturns out to be true in practice theprotection afforded to the communitywould in effect be reduced. Before this canbe accepted it would have to be shown thatthere was a substantial gain in terms of fewerside effects. We are not convinced that thishas been done.

The voice in the wilderness is not alwayswrong, and we should resist the temptationto change our policy just to conform.David Elliman consultant in community child healthSt George’s Hospital, London SW17 0QT

Helen Bedford senior research fellowDepartment of Epidemiology and Public Health,Institute of Child Health, London WC1N 1EH

1 Finn A, Bell F. Time to switch from whole cell to acellularpertussis vaccines? BMJ 2000;320:975. (25 March.)

2 Miller E, Ashworth L, Redhead K, Thornton C, Wraight P,Coleman T. Effect of schedule on acellular and whole-cellpertussis vaccines: value of laboratory tests as predictors ofperformance. Vaccine 1997;15:51-60.

3 Elliman D. Whooping cough vaccines: where next? Child:Care, Health and Development 1998;24:259-265.

4 Ranganatham S, Tasker R, Booy R, Habibi P, Nadel S,Britto J. Pertussis is increasing in unimmunised infants; is achange in policy needed? Arch Dis Child 1999;80:297-9.

5 Van Buynder PG, Owen D, Vurdien JE, Matthews RC,Miller E. Bordetella pertussis surveillance in England andWales: 1995-7. Epidemiol Infect 1999;123:403-11.

Combination treatment seemsrarely to be used in psoriasisEditor—Ashcroft et al report a systematicreview of the comparative efficacy and toler-ability of calcipotriol, a synthetic vitamin D3

analogue, in chronic plaque psoriasis.1 Wehave recently completed a general practicebased audit of the treatments offered topatients with mild to moderate chronicplaque psoriasis.

We found that only three of 14 patientswho had been prescribed a corticosteroidwere using a vitamin D3 analogue as part ofcombination treatment. The remainder hadnot received a vitamin D3 analogue at anytime. Despite the risks of using topicalsteroids, corticosteroids still remain the pre-ferred treatment for psoriasis, and onaverage 55% of patients receive potent topi-cal steroids.2 Combination treatment withvitamin D3 analogues and corticosteroidshas been recommended for mild to moder-ate plaque psoriasis in numerous trials.3–5

Although our study is limited by its smallsample size, and we cannot conclude thatthese results reflect general trends, we

suggest that the reasons why this combina-tion treatment has not been implementedshould be investigated: is it a cost issue?Patients should be reviewed so that adecision can be made on which ones shouldbe offered combination treatment. Perhapstopical corticosteroids should be consideredonly in those with a poor therapeuticresponse to calcipotriol.4

If a corticosteroid is used for chronicplaque psoriasis, consideration should begiven to prescribing it together with avitamin D3 analogue, since combinationtreatment is more efficacious than cortico-steroids alone.3 We postulate from our smallaudit that although this treatment protocolis recommended, doctors are unaware of it;this needs to be addressed to provideoptimal care.Damien Cullington third year medical [email protected]

Anita Jhamatt third year medical studentLiverpool Medical School, Liverpool L69 3BX

1 Ashcroft MA, Li Wan Po A, Williams HC, Griffiths CEM.Systematic review of the comparative efficacy andtolerability of calcipotriol in treating chronic plaquepsoriasis. BMJ 2000;320:963-7. (8 April.)

2 Kownaki S. Team care in psoriasis. Update 1999;Jan(suppl1):3-5.

3 Kragballe K, Barnes L, Hamberg KJ, Hutchinson P,Murphy F, Moller S, et al. Calcipotriol cream with or with-out concurrent topical corticosteroid in psoriasis: tolerabil-ity and efficacy. Br J Dermatol 1998;139:649-54.

4 Ruzicka T, Lorenz B. Comparison of calcipotriolmonotherapy and a combination of calcipotriol and beta-methasone valerate after 2 weeks treatment with calcipot-riol in the topical therapy of psoriasis vulgaris: amulticentre, double-blind, randomised study. Br J Dermatol1998;138:254-8.

5 Lebwohl M, Siskin SB, Epinette W. A multi-centre trial ofcalcipotriol ointment and halobetasol ointment with eitheragent alone for the treatment of psoriasis. J Am AcadDermatol 1996;35:268-9.

Psychoactive drugs may haverole in pressure sore originEditor—Several letters in the BMJ addressthe need for more research into the originsof pressure sores.1 One aspect that meritsconsideration is the use of psychotropicdrugs in frail elderly people in long termcare who have moderate to advanceddegrees of dementia.

In a one year study in long term care fallsrelated to psychotropic treatment wereassociated with the development of pressureulcers. Eighty five per cent of falls were associ-ated with a psychotropic or psychoactivedrug. Some 13 (65%) of the 20 pressureulcers that occurred during the studydeveloped within two weeks of a fall andimmobility related to a fall. Psychoactive andpsychotropic polypharmacy, antipsychoticdrugs, benzodiazepines, metoclopramidepropoxyphene, antihistamines, and antihy-pertensive drugs were most commonly impli-cated. The average cost per fall was $754,which included the costs of all documenta-tion, treatment of injuries in the 48% of thosewho fell (haematomas, lacerations, fractures,pressure ulcers), and related visits to emer-gency departments and admissions to hospi-tal.2 3 Interventions by consultant pharmaciststo reduce falls and associated injuries byreducing the psychotropic and psychoactive

“load” resulted in a decrease in falls from 0.40to 0.06 per patient per month when acceptedand sustained a rate of 0.28 falls per patientper month when rejected.4

The current mandate in the United Statesunder the Omnibus Budget ReconciliationAct to taper psychotropic drugs in all nursingfacility residents at least two to three timesduring the first year of residence is based onthe apparent harm when these drugs aresimply used as chemical “restraints” that pro-duce unacceptable morbidity. Further studiesare needed to determine the role of drugs inthe development of pressure sores.James W Cooper professor of clinical andadministrative sciencesCollege of Pharmacy, Gerontology, Graduate andHonors Faculties, University of Georgia, Athens,GA 30602-2354, [email protected]

1 Correspondence. Preventing pressure sores. BMJ 2000;320:801. (18 March.)

2 Cooper JW. Consultant pharmacist assessment and reduc-tion of fall risk in nursing facilities. Consult Pharm 1997;12:1294-304.

3 Cooper JW. Consultant pharmacist assessment of psycho-active fall injury incidence and costs within the nursingfacility. Consult Pharm 1997;12:1305-9.

4 Cooper JW. Reducing falls among patients in nursinghomes. JAMA 1997;278:1742.

Underlying psychologicaldistress must be addressed inchest painEditor—The editorial by Capewell andMcMurray states that a rapid cardiologicalassessment service may reduce admissionsof patients with chest pain.1 Such clinicsapparently offer risk stratification, an exer-cise electrocardiogram, and review by askilled hospital cardiologist. This approachalso reduces worry about missed cases ofcoronary heart disease.

Capewell and Murray quote Davie et alwho described the 49% of their series of 317patients with non-cardiac chest pain as beingimmediately reassured by a rapid assessmentchest pain clinic and to have a high degree ofsatisfaction at six month follow up. Theseresults, described as crucial by the authors,surprise me. With a consultant cardiologistand psychiatrist, I reviewed a series of 195 firsttime attenders at a secondary referral centrein a hospital in inner London.2 Psychologicalquestionnaires were returned by 113 (58%)patients. Measures used included the hospitalanxiety and depression questionnaire, thesymptom checklist 90 revised (SCL-90), andthe illness behaviour questionnaire. Fifty-two(46%) of the responders presented with chestpain, and of these 23 (20%) had typical angi-nal pain whereas 29 (26%) had atypical chestpain. After review by the consultant cardiolo-gist and investigation as clinically indicated,56 (50%) of the patients had a cardiacdiagnosis and 57 (50%) had non-cardiacsymptoms. Forty (35.4%) of the populationhad serious psychological distress. Logisticregression exploring the absence of a cardiacdiagnosis yielded only two weak predictors,young age and a clinically significant score onthe somatisation subscale of the SCL-90.

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The degree of psychological distressamong those presenting with cardiac symp-toms is high, and I am surprised that users ofchest pain assessment services are reassuredand hold on to such reassurance over timewithout the underlying psychological dis-tress being addressed. Somatisers attendingcardiology centres may continue to presentat some level of care provision, particularlyprimary care. An outcome measure thatincluded repeat presentations with non-coronary chest pain would answer thisimportant resource question. Somatisationcan be explained as a response to transientstress, but it can also herald persistentdistress, care seeking, and disability. Whenunnecessary admissions are avoided illnessbehaviour may well be reduced, as there isno reinforcement of hypochondriasisthrough hospital admission. Non-coronarychest pain is a challenge as there is so muchpotential to reduce costs, minimise distress,and identify somatisation.Catherine Kinane senior registrar in psychiatryShaftesbury Clinic, Springfield University Hospital,London SW17 7DJ

1 Capewell S, McMurray J, Chest pain—please admit: is therean alternative? BMJ 2000; 320;951-2. (8 April.)

2 Kinane C, Puffett A, Watson JPW, Chambers J. How usefulare psychometric rating scales in the cardiology clinic? JAssoc European Psychiatr 1996;11:319.

Is distribution of vacancies forhospital jobs a reflection ofnew NHS?Editor—The NHS is undergoing unprec-edented changes. Hospital trusts are beingasked to supply continued quality care whilerestructuring and modernisation continueapace. In addition, doctors’ hours have beencut and the number of specialist registrartraining posts recommended by the SurgicalWorkforce Advisory Group is falling in sev-eral acute specialties. To maintain servicecommitments to the community how aretrusts coping?

We audited the employment practice ofNHS trusts by counting the number andtype of jobs available in six front line special-ties. We recorded all job vacancies, fromconsultant to any level above senior houseofficer, advertised in the eight BMJ Classifiedsections of August and September 1999.Many middle grade posts were advertisedunder various titles not in common use,such as medical officer, trust specialist, clini-cal specialist, and trust doctor. We classifiedthese posts, which did not include a training

component, as a miscellaneous group. Toexclude locum posts covering short termleave we did not count posts of less than onemonth’s duration.

The table summarises the number ofposts advertised in this two month period. Inobstetrics and gynaecology, orthopaedics,and general surgery over three quarters ofadvertised middle grade posts had noprovision for training. There was a paucity ofadvertised consultant posts in both accidentand emergency and obstetrics and gynaecol-ogy, the former having a high proportion ofstaff grade posts and the latter a highproportion of locum appointment for serviceposts. The figure shows the numbers of train-ing posts and non-training posts by specialty.

Many of the advertisements did notspecify the number of posts available, andthis could influence the study’s accuracy.Short of contacting every hospital in thecountry, however, this is the simplestmethod of ascertaining the pattern ofemployment practice currently being pur-sued by trusts. The results highlight the largenumber of non-training posts being adver-tised in comparison with those that includea training component.

Specialist registrars and locum appoint-ments for training have recognised super-vised education as part of their job. Consult-ants and staff grade doctors are obligated tocontinued postgraduate development. Incontrast, non-training grade juniors receiveno structured training, and no educationalsupport exists for them. This raises concernsthat employing trusts may not always realise

the importance of ensuring appropriateaccess to education and training for thisgroup of doctors. Many of these doctors per-form considerable amounts of out of hoursservice; the developing situation raises ques-tions about risk management when a sizeableproportion of the service is being deliveredby doctors who have no contractual expecta-tion of education and yet are not fully trained.A D Jenkinson specialist registrar235 Baker Street, London NW1 [email protected]

C Ingham Clark consultant surgeonDepartment of Surgery, Whittington Hospital,London N19 5NF

Competing interests: None declared.

Use of polymorphism analysisrequires ethical guidelinesEditor—In their review on pharmacogenet-ics Wolf et al state that one day it may beconsidered unethical not to carry outpharmacogenetic testing routinely.1 I agree,but the ethical use of such testing must beclearly defined.

Because of advances in microarray tech-nology (DNA chips) a DNA profile couldsoon be obtained either in the localpathology laboratory or with a point of caredevice. The DNA chips can performthousands of polymorphisms at a time.Should the doctor treat requests forpharmacogenetic testing in a similar way torequests for measurement of urea and elec-trolyte concentrations and request themwithout specific consent? Or does genetictesting have such implications that requestsfor it should always require specific consent?

The relation between genotype andphenotype is not always clear, and unex-pected findings can occur. The association ofthe ApoE E4 genotype with Alzheimer’s dis-ease should serve as a cautionary tale.2

Investigations into the apolipoprotein Epolymorphisms in familial hyperlipoprotei-naemia later showed an association of oneof these polymorphisms with Alzheimer’sdisease. This resulted in a considerable ethi-cal dilemma for doctors and potentiallytheir patients.

I share the belief that polymorphismanalysis will have a major impact on healthcare, but ethical guidelines must be deter-mined before its widespread use.Martin A Myers consultant clinical biochemistClinical Biochemistry Department, Royal PrestonHospital, Preston PR2 [email protected]

1 Wolf CR, Smith G, Smith RL. Science, medicine, and thefuture: Pharmacogenetics. BMJ 2000;320:987-90. (8 April.)

2 www.hgmp.mrc.ac.uk/omim/searchomim.html (OMIMentry 107741).

Summary of number and type of posts advertised in August and September issues of BMJ Classified

ConsultantStaffgrade

Specialistregistrar

Locum appointment

Miscellaneous TotalFor training For service

A&E 13 20 4 3 4 9 53

Anaesthesia 42 30 11 14 18 18 133

General medicine 41 13 18 16 32 30 150

Obstetrics andgynaecology

17 5 4 8 33 14 81

Orthopaedics 18 4 6 5 5 28 66

Surgery 39 8 7 4 15 36 109

A&E=Accident and emergency medicine.

No o

f job

s

0

20

30

40

50

60

70Training

65%

59%

65%

80%

75%

82%

10

Accide

nt an

d

emerg

ency

med

icine

Anaes

thesia

Genera

l med

icine

Obstet

rics a

nd gy

naec

ology

Orthop

aedic

s

Genera

l surg

ery

Non-training

Number of jobs with training components (specialistregistrar and locum appointments for training) ornon-training components (locum appointments forservice and miscellaneous) by specialty. Proportionof non-training jobs for each specialty is indicated

Correspondence submitted electronicallyis available on our website

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