To The Editor:
We read with interest the Topics in Training article "Trauma and Orthopaedic Training in the United Kingdom" (2002;84:501-3), by Toms et al., and we would like to comment on some of the points that the authors made.
First, the National Health Service in the United Kingdom is not "free" but is funded entirely through taxation. Government spending on the National Health Service is due to rise from £65.4 billion this year to £72.1 billion next year and to £105.6 billion by 2007-8. Health care is free at the point of delivery.
Second, although the bottleneck that existed within the specialist training grade during the early 1990s has largely been resolved, a new bottleneck now exists at the level of senior house officer. Each year, there are 180 to 300 senior house officers who apply for the five available specialist registrar posts on the South Thames (West) rotation. Many senior house officers are now choosing to complete a period of research or a relevant higher degree prior to applying for a specialist registrar post.
Third, as of April 2002, specialist registrars in trauma and orthopaedics are limited to three attempts at the Intercollegiate Board Examination (FRCS [Tr and Orth]).
Finally, we believe that the article did not reflect the true role of research within the specialist registrar training program. Productivity in research is an important part of a satisfactory Record of In-Training Assessment (RITA). Inadequate research output is the most common reason that the lower RITA ratings, "D" (targeted training required) and "E" (repeat training required), are given in our region. To complete the training program and receive a certificate of completion of specialist training, all specialist registrars must produce a training portfolio and publish at least one peer-reviewed paper. Thus, trainees cannot "ignore" research during their training and would do so at their peril!
A.D. Toms, D. McClelland, and N. Maffulli reply:
We are pleased that our article has raised the interest of our colleagues. We shall answer their comments in the order that they were made.
First, Mr. Redfern, Mr. Ricketts, and Mr. Bendall were correct in stating that treatment in the National Health Service is not "free." We meant that it was free at the point of delivery. Although the service is financed through taxation, patients are not requested, or required, to make any payment when treatment is delivered.
Second, the article specifically addressed training in trauma and orthopaedics. The status and current situation of basic surgical trainees (senior house officers) is a separate subject. The program for basic surgical training is itself about to undergo major restructuring.
Third, the limitation of only three attempts at the FRCS (Tr and Orth) examination was first publicized in April 2002 (and our article was published in March 2002), but the ruling will not be introduced until January 2003. This new ruling does not alter the structure or nature of the assessment and training of orthopaedists in the United Kingdom and, since the majority of trainees pass the exam on their first attempt, only a few trainees will be affected by the ruling.
Fourth, our article clearly discussed the role of research within the current training programs. We are very surprised to hear of the experience of Mr. Redfern and his colleagues in the South Thames region. The West Midlands region (where we are based) is the largest region within the United Kingdom, and we know of no situation in which a trainee has been censured for lack of research. We are not aware of any policy statement stipulating that publication is an essential requirement for completion of specialist training.