884 c o R R E s PO N D E N c E

Richard E. Appleton Edmund N. Hey

Alder Hey Children’s Hospital Earon Road

Liverpool L12 2AP

The role of research in the training of an obstetrician and gynaecologist Sir, Professor Thomas’s commentary on the role of research in train- ing correctly addresses the problems faced by many trainees and his solutions are a model for the ideal world. The reality is that trainees feel that a second qualification and a large number of publications are obligatory in order to obtain a Senior Registrar appointment, often to the detriment of their clinical skills and their bedside manner. This is further perpetuated by appoint- ment committees who base their shortlists and appointments on these criteria without giving emphasis to extra clinical skills or to the quality of patient care. In this sense and at a time when the nature of specialist training in the United Kingdom is the focus of much debate we feel that the experience of the Obstetrics and Gynaecology Department of Northampton General Hospital deserves a mention.

In 198Y this department purchased a transvaginal probe for the gynaecological outpatients department ultrasound scanner. After attending a training course, one of the registrars initiated a monitoring service for patients undergoing ovulation induction therapy with gonadotrophins. This was based on a 7 day, 12 h availability of this registrar (on bleep) and resulted in a dramatic increase in the pregnancy rate (33.3% per couple after a maxi- mum of six treatment cycles) associated with a significant reduc- tion (28.5%) in the number of referrals to tertiary centres for assisted conception over the next three years. Transvaginal ultra- sound has already been shown to be safe and accurate (Jansen & Van 0 s 1989) and this method of monitoring has been reported as the main reason for the low incidence of high order multiple pregnancy and the low incidence of and severity of ovarian hyperstimulation syndrome (Shoham etal. 1991) which was con- firmed in our results.

This scanner was further used in the management of pain and bleeding in early pregnancy, resulting in reduced hospital stay and anxiety for many patients as they could either be directly placed on to an emergency operating list or discharged home. It improved clinical management of ectopic pregnancy as these cases were diagnosed earlier and could be managed conser- vatively often using laparoscopic surgery confirming previous findings (Magos et al. 1989) and enabled us to use use the gynae- cological operating theatres more effectively. Finally it benefited the registrars who were able to clock up several thousand scans as well as adequately inform and counsel patients about these procedures.

We feel sure that the quality of patient care and of the training of junior staff is as important as good clinical research and that ways should be found to assess this objectively when appoint- ments are made to higher positions in a properly organised, con- tinually assessed and audited specialist training programme.

Lawrence Mascarenhas Clinical Research Fellow

Birmingham Maternity Hospital (3rd Floor) Birmingham B15 2TG

W. A. R. Davies Clinical Budget HolderKhairman of Divbion

Northampton General Hospital Northampton NNI 5 B D

British Journal of Obstetrics and Gynaecology September 1993, Vol. 100

References Jansen C. A. M. & Van 0 s H. C. (1989) Value and limitations of

vaginal ultrasonography-a review. Hum Reprod 4,858-868. Magos A. L., Baumann R. & Turnbull A. C. (1989) Managing

gynaecological emergencies with laparoscopy. Br Med J 299,

Shoham Z., DiCarlo C., Patel A., Conway G. S. & Jacobs H. S. (1991) Is it possible to run a successful ovulation induction program based solely on ultrasound monitoring? The import- ance of endometrial measurements. Fertil Steril56,836-841.

Thomas E. (1993) The role of research and training of an obste- trician and gynaecologist. Br J Obstet Gynaecol 100,35-36.

371-374.

Sir, Professor Eric Thomas (January 1993) has written a valuable commentary on the role of research in the training of obste- tricians and gynaecologists. He makes a plea for the develop- ment of a research ethos at all levels of our specialty and emphasises that, for many trainees, both professional develop- ment and also the ability to compete for advanced career posts are better served by extra clinical and simple research skills, rather than by the large investment of time and effort in the sort of research post required for a good MD thesis: he does, how- ever, stress the great benefits to all of some exposure to research (usually clinical research) and also the vital importance of input from experienced and committed senior colleagues in planning and subsequently supervising research projects. We are in com- plete agreement with these views.

In fact, the thrust of Professor Thomas’ recommendations are already met by the degree of Master of Obstetrics and Gynae- cology of the University of Liverpool. This qualification has been in existence for 10 years and has aimed at providing a formal pro- cess of postgraduate training in Obstetrics and Gynaecology for Registrars (both career and visiting) who have already become Members of the Royal College of Obstetricians and Gynaecol- ogists. The course lasts for 18 months and a lecture programme covers all of the major subspecialty areas of obstetrics and gynae- cology. Candidates are obliged to perform a research project in one of the subspecialty areas and thcy are supervised in this by a consultant with relevant expertise. As far as training is con- cerned, the Mastership course fulfils all of the aims recom- mended by Professor Thomas. Trainees are also, naturally, concerned about the usefulness of the degree in enhancing their career ambitions; the programme has been much less successful in this respect because of a very widespread uncertainty outside the Mersey Region about thc structure and purpose of the degree.

There is undoubtedly a much greater need for structured post- graduate training in our specialty, and we are pleased to have the opportunity to publicise the merits of this programme.

James P. Neilson John Williams

The University of Liverpool Department of Obstetrics and Gynaecology

Liverpool L69 3BX

Reference Thomas E. (1993) The role of research and training of an obste-

trician and gynaecologist. Br J Obstet Gynaecol 100,35-36.

Sir, Professor Thomas has highlighted the difficulties in the inte- gration of research into a career in obstetrics and gynaecology

British Journal of Obstetrics and Gynaecology Scptember 1993. Vol. 100

(Thomas 1993). Financial considerations are not the only reason for an academic career being unpopular. There is no proper mechanism for the integration of research training into the career structure or the accreditation requirements.

In his comments on Richard Smith’s recent editorial on aca- demic medicine in the British Medical Journal (Smith 1993), Brian Pentecost (1993) states that all specialties accept one year of research towards higher training. My experience shows that this is not true. Our College allows in its accreditation regulations for up to one year of research with a limited clinical obstetrical and gynaecological commitment (RCOG 1991). I have spent thrce and a half years in laboratory based research, directly rele- vant to academic obstetrics, leading to a PhD. I held honorary NHS senior registrar status and undertook a weekly 24 hour obstetrics and gynaecology resident on-call and a full day’s oper- ating list once every two weeks. Although this would appear to fulfil thc regulations my application for just six months recogni- tion for higher training was rejected without explanation. Per- haps, had I spent that time performing second trimester Doppler examinations or videocystometrograms my application might have been successful.

In constrast, subspecialty trainees are allowed a Cull year of credit but are not expected to undertake any general obstetrics and gynaecology whatsoever during their subspecialty years. This indicates that the College believes that a subspecialist trainee has the capacity to acquire general skills in a shorter time than an academic trainee.

Six of those with whom I graduated chose academic career paths including research training for a PhD. Four of these have been in consultant posts in centres of scientific and clinical excel- lence for the past year.

The two of us who remain in training both chose obstetrics and gynaecology. My physician contemporaries are able to devote time and energy to research whilst providing a high quality clini- cal service. My subspecialist trainee colleagucs spend all of their working time in their chosen subspecialty and receive accred- itation for it. Meanwhile I have the prospect of long months of rcsearch work in my lunch breaks whilst I undertake the weekly round of antenatal and incontinence clinics which the authorities consider to be essential to my career development.

Until our specialty recognises the value of an academic career, considers academics as equals and provides a career pathway

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similar to that for subspecialists, it will be an unpopular choice and obstetrics and gynaecology will remain in the scientific shadows.

Phillip Bennett Lecturer in Obstetrics and Gynaecology Queen Charlotte k and Chelsea Hospital

Goldhawk Road London W6 OXG

References Thomas E. (1993) The role of research in the training of an obste-

trician and gynaecologist. Br J Obstet Gynaecol 100,35-36. Smith R. (1993) Academic medicine: plenty of room at the top.

Br M J 306,6. Pentcost B. L. (1993) Academic medicine (letter). Br M J 306,

583. RCOG (1991) Regulations for Accreditation of Completion of

Higher Training of Members of the College. Royal College of Obstetricians and Gynaecologists. London, 3 (para. 2).

Sir. I endorse the views expressed in this Commentary (Thomas 1993) and would advocatc the use of postgraduate training post money for the introduction of a research component to the struc- tured training programmes presently being discussed within the College. This would provide important integration of research into the standard training of gynaecologists. The intellectual benefit of a year divorced from the service commitments and didactic teaching would benefit the candidates for the whole of their lives.

S. K. Smith Department of Obstetrics and G-vnaecology

The Rosie Maternity Hospital University of Cambridge

School of Clinical Medicine Cambridge CB2 2SW

References Thomas E. (1 993) The role of research in the training of an obste-

trician and gynaecologist. Br J Obstet Gynaecol 100,35-36.