We are very pleased that Richard Lehman is back with us after a break. As before, his ever popular journal blog will be published weekly.  This week, Richard gets off to a splendid start by covering a range of subjects from Greek nymphs to footstools and defecating…

JAMA  25 Mar 2009  Vol 301
The problem of pain was the subject of CS Lewis’s first attempt at popular theological argument, prompting a fellow don at Magdalen College, Oxford in 1940 to remark that “the problem of pain is quite bad enough without Lewis writing about it.” It is indeed easier to write about pain than to endure it all the time, as I’m told that Lewis acknowledges - I would look it up myself, but I fear for the safety of nearby ornaments. Every pain is different, but there are some generic aspects to chronic pain management which we tend to skimp on in primary care, and that is the issue which this US trial attempted to address. The intervention was administered by a psychologist and an “internist”, and usually involved a face-to-face assessment with specific treatment recommendations plus a 4-session workshop encouraging self-management and activity. The gains, though significant, were sadly modest at the end of 12 months for these patients with chronic musculoskeletal pain.

NEJM  26 Mar 2009  Vol 360
Oddly enough, the human foreskin carries a theological pedigree almost a long as the problem of pain, though I am not sure whether CS Lewis ever wrote on the subject. God is found commanding its removal to Abram and his household as early as Genesis Ch 17, whereupon Abram becomes Abraham; Paul, apostle of Jesus to the Gentiles, later prudently decided that God no longer demanded it, whereas Muhammad, who was made of sterner stuff, got out the knife once more for all his followers. The rather curious result is that the foreskin is regarded a sacrosanct in certain European countries, including Britain, but is routinely done away with as soon as possible in large parts of the Middle East and also - for less obvious reasons - the United States of America. Africa falls between, and of course circumcision has been in the news a lot as a possible means of containing the spread of HIV. This study examines its effect on two other sexually transmitted infections - herpes simplex virus 2 and syphilis. Such is the popularity of the procedure in Uganda that randomisation was between immediate and delayed circumcision, rather than no circumcision at all. The immediately circumcised duly showed fewer of both infections. Expect changes in African health policy that will produce bagsful of foreskins to rival those brought back from Philistia by David, who later became the legendary King of Israel (see 1 Sam 18.25).

More uncomfortable reading for male readers of the New England Journal: 38,343 annual digital rectal examinations and PSA tests in the intervention group, thousands of transrectal prostate biopsies, hundreds of radical prostatectomies and lots of radiation above the genitals. And after 7 years, the result of all this prostate screening? 50 deaths from prostate cancer in the screened group and 44 in the control group. This was - and still is, since it is only half-complete - the US trial called PLCO, where the PSA cut-off for biopsy was 4.0. Treatment data are not given, and the study goes on: it has not been stopped for futility. But it’s not looking good.

The study called ERSPC by contrast is really a series of linked trials in European countries with differing recruitment and randomisation procedures and a PSA cut-off of 3.0 in every country except Finland. At 14 years from randomisation, there was no difference in prostate cancer mortality, but at fifteen years the control group suddenly fares a lot worse (see Fig 2); and if you take the mean of about 9 years, you get a 20% difference in favour of screening. This benefit was limited to those under 70, and to prevent one death from prostate cancer you would have offer screening to 1410 men and submit 48 to surgery and/or radiotherapy. Digital rectal examination and PSA are just not good enough for the detection of the prostate cancers that matter. The trials go on, but I think the strategy is dead.

There aren’t many effective interventions for chronic obstructive pulmonary disease, but one that seems to produce real improvements in quality of life in trial settings is pulmonary rehabilitation. This article is a straightforward description of how it’s done in the USA. “The successful coordinator has excellent interpersonal skills, since (at least initially) a primary task is to motivate people to do what they find unpleasant.”  Most people with COPD show an initial benefit, but this declines after a few months. Keeping people doing things they find unpleasant is never easy.

Lancet  28 Mar 2009  Vol 373
Body mass index is one of many measurements in medicine that enjoys a popularity beyond its modest deserts, but at least we have data from lots of prospective studies which are pooled here to give an estimate of cause-specific mortality in 900,000 adults. At a BMI below 22.5, smokers die much faster and thus give all thin people a spuriously bad prognosis. If you read the Summary you will get the opposite impression due to misuse of the word “inversely”. Cardiovascular mortality tends to rise steadily with all levels of BMI, but a little middle age spread does no harm to overall prognosis provided you stay below 30. Once BMI goes over 40, you are looking at a drop of life expectancy of 8-10 years, similar to life-long smoking.

This nationwide study looked at the rate of epilepsy in every little Dane who bashed his or her head in childhood and was taken to hospital. The risk varies with severity of injury, as you’d expect: kids with skull fractures, or with impaired consciousness for less than 30 minutes, have a twofold risk of later epilepsy, while severe brain injury with unconsciousness of over 30 minutes results in a sevenfold risk.

If you have renal cell carcinoma, your only real chance of long-term survival is that somebody will chance to spot it before you have any symptoms. Even this is no guarantee: more small renal masses are being removed each year because of incidental detection on scanning, but still mortality has increased. So this seminar on the subject concentrates on two ends of the scale: the optimal management of small renal masses and the management of metastatic renal cell cancer. Here there is modest progress, much hyped in the press; bevacizumab does prolong life usefully in a significant proportion of patients.

BMJ  28 Mar 2009  Vol 338
When I became a GP, obstetrics was still a routine part of our job, though I quickly abandoned the role of accoucheur without the slightest regret. The last time I tried to stop premature labour was before that at the Middlesex hospital, where on the instruction of my senior registrar I exhausted that hospital’s entire stock of injectable ethyl alcohol. The lady in question enjoyed her intravenous treat and duly stopped contracting. This most ancient of tocolytics does not get a mention in this review of adverse reactions to drugs given to stop labour, but the beta-adrenergic drugs we used more commonly do get a bad mention here, whereas something called atosiban gets the all clear, and nifedipine lies somewhere between.

Depression scoring systems were devised and validated in research settings and then imposed on British GPs via the QOF system for every patient newly presenting with depression. Two studies of their use are presented side-by-side here; the first one finds - surprise, surprise - that doctors try to administer these things but do not base their treatment decisions on them; and the second finds that on the whole, patients don’t mind filling them in. Such is the mighty evidence base for giving doctors financial incentives to use depression questionnaires.

This article on chronic constipation in adults shows what it calls the correct position for defecation, illustrated by a pensive naked man sitting on a white lavatory with his feet supported by a footstool. A courteous American correspondent of mine, Jonathan Isbit, would half approve. Jonathan says he was inspired by my first piece in the BMJ, a Personal View called “In Praise of Hunch Backing” to back his hunch that many bowel diseases and almost all constipation are the result of modern man adopting the sitting position to defecate. Jonathan would have our knees much higher while defecating than a mere footstool can ensure. Squatting over a hole in the ground, we would prevent appendicitis by pushing our right knees into our iliac fossae and prevent colon cancer, diverticulitis and constipation by getting our rectus muscles into bowel-squeezing action. However, careful placement of the feet is necessary, so as not to give the word “footstool” a whole new meaning.

Arch Intern Med   23 Mar 2009  Vol 169
There have been dozens of trials of vitamin D supplementation for the prevention of non-vertebral fractures and if you pool them all you get equivocal results. However, if you carry out a meta-analysis by oral dosage, there’s a clear difference between trials using a low dose of vitamin D and trials using more than 400u daily. People over 65 reduce their fracture risk by at least 20% if they take a decent amount of vitamin D.

Eating large quantities of red meat is a bad thing for global resources and also a bad thing for people, according to this simple but enormous study of self-reported food intake in 500,000 Americans aged between 50 and 71. There was a 30% difference in mortality between the groups reporting the highest and the lowest red meat intake, when adjusted for a wide but possibly insufficient range of confounders. The extra deaths are from cardiovascular disease and cancer. But you can eat white meat - meaning chicken, I think - not just with impunity but with benefit.

If you are interested in hypertriglyceridaemia, then here’s some detailed epidemiology for you to revel in from 5610 people aged over 20 studied in NHaNES 1999-2004. As usual, it’s a confusing picture, especially as there was no standardisation of sampling conditions, and only rather vague associations emerge, chief of which is physical inactivity.

If you have a close relative who has had venous thromboembolism, your own chances of getting one are at least doubled, according to yet another important study of the subject from Leiden. In fact it’s usually more useful clinically to factor in a family history than to take blood for a so-called thrombophilia screen.

Having been unwisely drawn into a public argument about diabetes, I have only one hope of getting everybody to agree with me, and that is to keep saying nice things about metformin. It’s the only treatment which can actually be shown to improve outcomes in type 2 diabetes without any shadow of doubt, and every patient with this condition should be persuaded to take it unless the gastrointestinal side-effects are completely intolerable. The key to its action is probably to reduce insulin resistance, and the trial here attempts to gauge its value in type 2 diabetics who require insulin. This important fact fails to get a mention in the title of this paper, which also claims to report “long-term” effects, though the mean follow-up was 4.3 years. Over this relatively short period, patients randomised to metformin lost weight, had better glycaemic control, needed less insulin, and had fewer macrovascular adverse events. But unfortunately, as in so many diabetic trials, the investigators chose to lump all sorts of dubious “microvascular” outcomes into their primary end-point and thereby failed to reach statistical significance by dilution.

Plant of the Week: Daphne odora

Daphne, you will remember, was the nymph who eluded the amorous attentions of Apollo by turning into a tree. This was a popular subject for artists and sculptors like Bernini (see The Mirror of the Gods  Malcolm Bull, 2005) and even for the first composer of a German opera, though sadly we have lost the music which Heinrich Schütz wrote in 1627 to be sung by his tree.

Many plants were once given the name of Daphne, but for some reason Linnaeus settled the title on a genus of low shrubs, little resembling the nymphs of Thessaly except perhaps in their gorgeous perfume. Of all the daphnes, this small evergreen plant is perhaps the most ravishingly scented, though there are many competitors among her sisters and cousins. In fact it is possible, with reasonable care, to enjoy the scent of different daphnes throughout the year. Let us begin like the Iranians at Now Ruz, the spring equinox:

March-April: Daphne odora, D blagayana
April-May: D tangutica, D collina
May-June: D x burkwoodii, D cneorum
June-July: D x hybrida, D sericea
July-Oct: D x transatlantica, D x napolitana
Oct-Nov: D susannae
Nov-March: D bholua, D jezoensis, D mezereum

The trouble is that one or other of these will invariably die on you just when you most look forward to it. D odora is relatively robust, though tradition has it that the clone with yellow-edged leaves, Aureomarginata, is the only one reliably hardy in English gardens. I have just bought a handsome Japanese clone called Sakiwaka with good plain leaves and I’ll let you know how it gets on next winter.

The shake up in medical training this year means not only are doctors coming out of Foundation Year II looking for posts, but so are all those who were still in Senior House Officer jobs. With the debacle over the computerised system, abandoned mid-way through the process, and the switch to individual deaneries handling appointments directly, there has been some delay. Round II is not due to finish until October.
Sian Thomas, deputy director of NHS Employers assured the public that there would not be a crisis: “Information gathered from employers indicates that trusts have been able to appoint very good doctors to specialty training posts this year and that the relatively small number of vacancies remaining can be covered through use of locums and other temporary staff cover.”
But the BMA sees things differently. It says that in England alone, around 30,000 doctors are due to be starting new posts — around 10,000 in foundation programme posts, and 20,000 in specialty training posts. The numbers starting new jobs on 1 August this year is significantly higher than in previous years, it says.
“The impact of Modernising Medical Careers on patient care is currently unknown,” said the BMA in a statement. It said this was largely because the SHAs have not published their plans, so there was no way of being sure about continuity of service on 1 August. “In some trusts, doctors are reporting that all routine operations are being cancelled,” said a spokesperson.
But it sought to allay fears that the changeover might result in more risk for patients: “The large number of doctors starting new jobs does not in itself mean that there will be an impact on patient safety,” said the BMA. “Research in the past has found no evidence that hospital deaths increase on 1 August. The vast majority of doctors are dedicated professionals who will never neglect their patients - their poor treatment at the hands of this system does not mean they will work to a lower standard.”
NHS Employers admitted that the next few weeks would be challenging. “But they are well prepared to ensure that both trainees and patients are looked after,” said a spokesperson. “The quality of applicants has been very high this year and trusts have recruited the best doctors to the available posts.”
About 1000 posts out of 15,600 in England are yet to be filled and further training posts will be released later in the year, the organisation said. For those junior doctors working in the NHS who have not secured a post, career counselling and guidance was available, including a new medical careers website was due to be launched in the next few weeks.
Trusts report being able to redeploy many of those who have not secured a post until the recruitment process comes to an end this October.
According to the BMA, the government has said that doctors currently working in the NHS will have their employment protected until the end of the recruitment process in October and that will be around 1000 additional short-term training posts for doctors who remain unappointed then, and an unspecified number of non-training posts.
But the BMA says many doctors have already left the UK preferring to take their chances elsewhere, including in Australia and New Zealand.
The latest details about Round 2 training opportunities are available at the Modernising Medical Careers website.

According to the Department, there were 29,193 applicants for junior doctor training posts in England and of these, 27,849 were eligible to apply for one of the 15,600 vacancies within MTAS. But 25,000 applicants were already working in the NHS.

A total of 15,554 training posts had been made available in round one, 11,816 of them run through training posts and 3,559 fixed term appointments. A further 179 academic posts were also available.

A total of 13,168 training posts had been accepted at the end of round one. Of these, 10,804 are run through (RT) posts and 2,262 of them are one year fixed term specialty training appointment (FTSTA) posts. It leaves 2,320 unfilled posts for applicants in round two. In addition, a further 1000 one-year training posts will be made available to those doctors unable to secure a post at the end of round two, which will end on 31 October.

The figures published so far do not make it clear how many of those who applied were in staff and associate specialist posts, how many were existing SHOs and how many of them juniors. So it is not possible to work out how many doctors currently working in the NHS are facing potential unemployment.

Those in SAS posts will not be unemployed if they fail to secure a post under the current process, but doctors coming out of foundation training or those currently in SHO grades could find themselves jobless. Nor is it clear how many of the eligible applicants were overseas applicants. The figures would indicate that as many as 14,249 eligible applicants had graduated overseas. However, many of these may have been working in the NHS already, often for many years. It is unclear how many medical graduates may have been trying to apply from outside the UK.

Of the 13,600 UK graduates who applied, 9,336 (almost 70 per cent) have accepted a post at the end of Round One.

Health Minister Ann Keen said: “The high fill-rate is good news for patients, the NHS and deaneries across the country and has been achieved despite this year’s problems with implementing the national recruitment programme.
“We are working hard with the NHS on this second round of recruitment, and on the development of a package of support for those appointable applicants who have yet to find a post.”

The Department has announced a package of support for those appointable junior doctors who have not found the right posts following Round Two. It includes:
- some 1,000 extra one-year and GP training posts;
- access to career information about future training options via local Deaneries. (Applicants who are already in NHS Employment will also be able to access career support from their employer.)
- a careers website for junior doctors to support their decision making when looking at future careers
- educational grants allowing appointable but unsuccessful applications who are in service posts to pursue their clinical education and improve their chances of successfully applying for specialty training next year.

The following summary of the statistics has been published by the DH and a full breakdown of the details is due to be posted on the Modernising Medical Careers website:

England Summary of Round 1 Acceptances
Excluding Defence Medical Services

Acceptances data correct as of Round One close on 26 June

All Round 1 Posts:
All 15,554
RT 11,816
FTSTA 3,559
Academic 179

Applicants:
All 29,193
Eligible 27,849

All Acceptances
All 13,168
RT 10,804
FTSTA 2,262
Academic 102

Fill Rate
All 85%
RT 91%
FTSTA 64%
Academic 57%

Round 1 fill-rate by specialty (Royal College groupings)
Royal College Fill rate (percentage of posts filled at close of Round One

Anaesthetists 75%
Anaesthetists/Physicians 76%
Emergency Medicine 82%
General Practitioners 98%
Obstetricians and Gynaecologists 74%
Ophthalmologists 81%
Paediatrics and Child Health 83%
Pathologists 91%
Physicians 85%
Physicians/Pathologists 92%
Psychiatrists 82%
Radiologists 99%
Surgeons 79%

Round fill-rate by Unit of Application (Deanery)
Unit of Application Fill-rate (percentage of posts filled at close of Round One)

Eastern 84%
Leicestershire, Northamptonshire and Rutland 80%
London/KSS 89%
Mersey 91%
North Western 92%
Northern 77%
Oxford 77%
Severn 88%
South Yorkshire & South Humber 74%
Southwest Peninsula 74%
Trent 64%
Wessex 83%
West Midlands 77%
Yorkshire 94%

680 junior doctors responded to the survey, of whom 94% said they felt more stressed than they would normally and put this down to MTAS.
Three in 10 doctors said they had made more mistakes at work in the last six months, and 43 per cent said they cared less about patient care.

The survey also found that a third of respondants had increased the amount of alcohol they were drinking. 23 per cent said they had taken more sick leave than normal. Disturbed sleep, loss of appetite and tearfulness were also reported and more than half said they had “a sense of future hopelessness”.
The Telegraph reported Professor Dinesh Bhugra, Dean of the Royal College of Psychiatrists and one of the authors of the study, as saying: “These findings are extremely worrying. We have discovered that a normally robust and highly committed group of professionals is feeling very demoralised.

“The government has a moral obligation to ensure that the next generation of doctors does not feel disenchanted.”

Professors Morris Brown and Steve O’Rahilly held a press conference in London on Tuesday (19 June) to highlight the problem. They released the results of an online survey of 1300 applicants, of whom 49% had not at that stage had job offers.
Professor Brown said the results showed that those who had not had offers were more likely to have a first class degree or a distinction. He said it was effectively a ‘”selective cull of the best”.
Two doctors affected by the situation were at the press conference. One, Sarah (who did not give her surname) had an MS Fellowship and DPhil from Oxford. She has been working on the Maudsley rotation and wants to pursue a career in psychiatry.

She has had one job offer, but for a fixed term staff appointment, not a training post. “It’s just a career grade position,” she said. “I’m not really sure what it is going to lead to. I wanted to try to change the face of psychiatry and the way mental health services are delivered. I’m not sure I can do that from a career grade post.”
Another doctor, Matt, has a first class honours degree, then moved on to degree in medicine at Cambridge. He is currently working on his PhD with a leading cancer specialist.

He’s had one job offer — like Sarah’s it is just for a fixed term staff appointment.
“I know what I want to do and I know where I want to do it,” he said. But the constraints of the MTAS application form made it impossible for his academic credentials to be rated as highly as they should, he claims.
As round 1 comes to an end this week (June 22) it’s hard to know how many posts will be filled. The Department of Health has undertaken to notify all applicants of available posts — including non-training ones — by the end of the following week (June 29). It’s unclear how many of these will be unfilled posts either held back, or not filled, from round 1 and how many will be additional posts created by trusts to ensure there are no gaps in service provision.

NHS Employers has issued guidance to trusts about how they should handle the impending crisis. It includes details on how best to manage any changes in the existing workload of staff to ensure they comply with the working time directive. See
http://www.nhsemployers.org/workforce/workforce-2560.cfm

“I am also concerned about the arrangements for selection of junior doctors into run-through surgical training programmes. Surgery has unique requirements in terms of recruitment – the criteria for selection include diagnostic skills, clinical judgment and manual dexterity. It is neither practical, nor indeed safe, to select junior doctors with a view to a career in surgery without the opportunity for assessing whether they have the full mix of professional skills required.
He said it was “with the greatest reluctance” that he was pulling out of the group.

Yesterday health secretary Patricia Hewitt announced that an extra 200 specialist training posts would be made available for those unable to secure training posts. A further number of non-training posts would be available she said.The BMA said this did not go far enough, with 12,000 applicants under MTAS unlikely to secure training posts.

“Creating more temporary posts on its own is not an adequate solution” said Jo Hilborne, chair of the Junior Doctors Committee. “We need to know that there will be more opportunities to get into long-term training in years to come, and increased flexibility to move between specialties and regions.”

All applicants are due to be told the outcome of their first round interviews by 7 June. They will be offered posts on the basis of their ranking, irrespective of the candidate’s order of preference. They will have until 23.59 on 10 June to accept or decline any initial offers. Candidates have been advised to make their decision straight away to give them ‘the maximum possible time to finalise your personal arrangements’ or ’so that the training opportunity can be passed on to one of your colleagues’.

Any remaining unfilled posts will be offered between 11 and 22 June, with applicants given only 48 hours to respond.

Round One will close on Friday 22 June, at 23.59.

However, Mr Justice Goldring said medics were justified to feel angry. He described the MTAS system as a “dreadful mess”, adding that its premature introduction had had “disastrous consequences”.
Remedy UK had gone to court over MTAS which has caused so much anger among junior hospital doctors. Remedy had originally argued that the computerised system was so flawed it should have been scrapped completely. But then it argued in court that the interviews carried out so far in round 1 should only be for temporary posts.
Mr Justice Goldring said the premature introduction of the new application system had had disastrous consequences - and although the legal challenge had failed, many junior doctors had “an entirely justifiable sense of grievance”.
He added that individual medics might still have good grounds for appeal under employment law.
A spokesman for Remedy UK said the group would not be appealing the decision. “Obviously we are very disappointed,” he said. “We still feel that careers will be harmed by this situation.”
Health Minister Lord Hunt said the government would now be working to establish the best possible way forward to match doctors to posts.
“We understand the uncertainty that problems with the system has caused junior doctors and their families, and acknowledge the criticisms that the judgement contains,” he said.

“In consultation with representatives of the medical community, including junior doctors, we will continue to work to establish the best possible way forward in order to match trainee doctors to posts.
“We feel strongly that the process of making job offers should go ahead in the interests of both doctors and patients.
“We understand the uncertainty that problems with the Medical Training and Application System have caused junior doctors and their families, and acknowledge the criticisms that the judgement contains.
“We need to ensure that lessons from what has happened are learned and learned thoroughly. That is why the Secretary of State has asked Sir John Tooke to establish an independent review of the process so that the best possible mechanisms are in place for the training of our junior doctors.”
The ruling means that the first job offers, which had been held back until the outcome of the hearing, will now be sent to candidates. However, the BMA has reiterated its concern for the thousands of doctors who will not get posts.
Responding to the judgment, Dr Jo Hilborne, chairman of the BMA Junior Doctors Committee, said:
“We hope the Department of Health will not claim this as a victory when the careers of thousands of doctors remain in doubt because of government failures. The High Court is absolutely right to criticise their handling of this mess, and to point out that our concerns about it were ignored.
“The harsh fact facing us now is that there are not enough jobs. There are 12,000 doctors who will not get training posts through this system, and they must be our priority. We have demanded that the government guarantee that no doctor will be unemployed as a result of this process and called for funding for extra training posts.
“We now hope that doctors will unite to fight for these aims. The past week has been incredibly painful for the medical profession. It’s time for us to start healing the wounds and move on.”
The BMA has requested an urgent meeting with the health secretary to demand further action.
But the Royal College of Surgeons is concerned there has not as yet been confirmation of additional training places for surgeons. It says it cannot support job offers being made until agreement has been reached on the increased numbers for specific surgical specialties and an agreement on the location of those training posts.
“I believe we are close to securing a rescue package from the Department of Health which will bring competition ratios for specialist surgical training in line with previous years,” Bernard Ribeiro, President of the Royal College of Surgeons, said. “This will save good surgical trainees for the NHS who would otherwise be lost. We must not jump the gun on this and put trainees in the position of having to choose a training post not knowing whether other posts would be made available. What we need now is absolute clarity for our trainees.”

His letter, written with Carol Black, chairman of the Academy of Medical Royal Colleges, caused a furore among BMA members over the weekend and led to Mr Johnson’s decision  to stand down on Sunday (20 May).

A number of comments about whether it was right he continue as chairman were posted by BMA council members on the association’s website, he told the BMJ. It’s understood he was placed in a position where he had little choice but to resign.

Many junior doctors had been furious that the BMA representatives on the MTAS review group had gone along with the proposal to continue with the existing interviews, despite the fact they were based on the flawed MTAS computer system. At one point it looked as if Jo Hilborne, chair of the Junior Doctors Committee, would lose a vote of no confidence, but she managed to weather that storm.

Mr Johnson claims his letter was merely reiterating existing BMA policy. What seems to have most annoyed BMA members was the paragraph in which he and Carol Black said they ”restated their support for the Chief Medical Officer and his role in improving junior doctors’ training”.

“The Chief Medical Officer seems to be a bit of a hate figure within the BMA at the moment,” Mr Johnson said. “I think it is my job to support any member that is being got at and isn’t in a position to support himself,” he added referring to the fact the Chief Medical Officer, a BMA member and architect of the medical education reforms, was under attack from Remedy UK— along with health secretary Patricia Hewitt.

He defended the comments he made on MTAS, arguing that what he wrote was in line with the BMA’s policy:

“MTAS may not be a very good system but we’ve got to be pragmatic,” he said.  The BMA had accepted the current round of interviews should go ahead, albeit on a flawed application system, because:  ”Doctors have to be in training posts by August.”

The suggestion by Remedy UK, up until the eve of their court case, that the interviews carried out so far should be scrapped, was not accepted by the BMA he said. “The rather flawed system has got to go ahead,” he said.

 ”I think modernising medical careers has a lot of faults,” said Mr Johnson. “But in the  past SHOs had no hope of promotion and were just going from job to job.”

But given the sensitivity of the MTAS issue — with many junior doctors threatening to leave the BMA over the line it had taken — Mr Johnson’s letter was bound to offend many association members.

He told the BMJ that he did not consult the BMA before writing to The Times. “The BMA policy is that we support MMC,” he said. “We can’t have a policy we are ashamed of. I don’t have to consult every time I write a letter.”

Mr Johnson said it was “completely untrue” that he wasn’t angry about what had happened over MTAS. “But I don’t regret coming to the aid of a colleague.”

Mr Johnson was probably going to stand down from the BMA next month in any case, after being at the helm for four years. “I was feeling for a long time that four years was enough,” he said. “But I wouldn’t have chosen to end it in this way.

“It’s got to the stage where it is actually damaging the association. There have been a few resignations and if your own council members are being critical of you, that is a situation where I am no longer helping.”

He defended his decision to support the CMO, although many members feel this put the BMA too close to government. “The BMA is always seen as a bit of the establishment. There will always be members who say the BMA isn’t doing enough.

“I’ve no doubt at all that my letter was the correct thing to do.” 

Round 1 interview set up through MTAS and which have already taken place, or which are due to take place, will still be valid.

Ms Hewitt has announced that local deaneries will notify junior doctors of the outcome of the round 1 interviews, rather than trying to continue any further with MTAS, and that selection for round 2 will be done by local deaneries, not via MTAS.

In her written statement to the Commons today Ms Hewitt outlined her concerns at the security breaches that had occurred with the MTAS site and said these would be reported to the police.

“Given the continuing concerns of junior doctors about MTAS, the system will not be used for matching candidates to training posts, but will continue to be used for national monitoring,” she said.

She went on to explain that, subject to the outcome of the current Judicial Review, the first offers for hospital specialities in England would be made on or after 21 May 2007, with all initial offers made by early June.

Her announcement came the day before Remedy UK was due to launch a legal case against the Department of Health against the flawed application process.

Dr Andrew Rowland, vice chairman of the BMA Junior Doctors Committee, welcomed the Department’s decision:

“The Department of Health has at last seen sense and effectively abandoned the unfair, discredited, and shambolic MTAS system,” he said. “We are extremely concerned that the Health Secretary believes criminal offences may have been committed as a result of security breaches.”

The BMA opposes any suggestion that interviews that have already taken place should be written off.

“Some people have called for the system to be scrapped altogether and for the tens of thousands of interviews that have taken place to be written off,” said Dr Roland. “This would be disastrous for doctors, for patients, and for the NHS.”

But Remedy UK — which accepts it is too late to re-run the interviews — believes any appointments made as a result of these should only be on a temporary basis.

Ms Hewitt’s announcement today was old news, said Matt Jameson Evans of Remedy UK, which is bringing the legal action against the Department. “We knew round 2 was going to be done by local deaneries.”

The vast majority of posts would be filled on round 1, he said, which is where Remedy UK claims the Department has abused its power. He says the announcement will not affect Remedy UK’s case, which was due to be heard on Wednesday (16 May).

Ms Hewitt’s written statement follows:

In my oral statement on 1 May 2007 I notified the House that there had been two security breaches of the medical training application service (MTAS) that arose on 25th and 26th April.

MWR Infosecurity has now completed a full security review of the MTAS system. Action has been taken by the contractor (Methods) to address the weaknesses identified. Both MWR and CESG (Communications Electronic Security Group), the national technical authority for information assurance, have confirmed that appropriate and sufficiently comprehensive action has been taken. The site was therefore re-opened last week, restricted to postgraduate deaneries only, to support the next steps in the recruitment process.

Because the investigation has made it clear that criminal offences may have been committed, the MWR analysis and report have been given to the police.

Ongoing Recruitment process

Following the recommendations of the review group chaired by Professor Neil Douglas, every eligible applicant for postgraduate medical training has now been guaranteed at least one interview for their first preference post. An additional 15,500 interviews have therefore been arranged as part of Round 1 and are now taking place. I am extremely grateful to the consultants who have made themselves available for these additional interviews.

The review group met again on 9 May to consider the process of offering posts to candidates who are successful in their Round 1 applications. The group agreed that offers for the current round will be managed locally by individual deaneries, on the basis of published MMC guidance.

Offers will be made to successful candidates on a phased basis as
interviews for each specialty are completed. Subject to the outcome of the current Judicial Review, the first offers for hospital specialities in England will be made on or after 21 May 2007, with all initial offers made by early June. This process of making offers will continue until late June 2007, at which time Round 1 will close, ensuring that candidates and employers have time to prepare for appointments commencing on 1 August 2007.
Given the continuing concerns of junior doctors about MTAS, the system will not be used for matching candidates to training posts, but will continue to be used for national monitoring.

As we have stressed before, not all training posts will be filled in the
current round and there will therefore be further substantial opportunities
for those who are not successful initially. The review group has agreed
that this further recruitment will be locally planned and managed by the
deaneries. An announcement of the process will be made shortly.

Deaneries are continuing to work with the NHS and the Postgraduate Medical Education and Training Board to establish what additional training posts will be made available beyond the 23,000 training posts already available across the UK.

The BMJ understands that the big teaching hospitals are being asked to identify temporary positions that can be made available from August for doctors unsuccessful in obtaining ST3 and ST4 posts.

As many as 10,000 such posts may be needed it the figures from the BMA are anything to go by. These posts would be ‘staff’ positions – in other words, they would not be on the career structure towards a consultant post.

The news comes as junior doctors begin to hear the outcome of their first round interviews. It is still unclear how many posts will be held back for the second round. Unless deaneries have deliberately decided not to fill a certain proportion of posts, this could leave some unsuccessful applicants doctors with very limited options at round 2.

Trust personnel officers are seizing the opportunity to create additional posts — which are to be centrally funded to avoid the political embarrassment of having doctors unemployed.

One internal memo seen by the BMJ says that these staff posts will chiefly be equivalent to ST3 and ST4 level and will be for one or two years initially. They would, it says, offer the potential to transfer into a career grade post at a later stage.

Staff are being asked to identify posts which either they had educational approval for but could not fund, or where they could take on an additional trainee without it affecting the training of existing career grade staff.

Funding these additional posts at £30,000 per year each could cost the government as much as £300m in the first year alone.

However a spokesperson for Modernising Medical Careers questioned the 10,000 figure, stating that many of those who failed to get specialist training posts were already working in staff grade jobs in the NHS, so would not be unemployed.

But the true figure has still to be confirmed. NHS Employers refused to comment, passing the matter onto the Department of Health. It is understood a statement is due to be made early next week about the outcome of the first round of interviews.

Meanwhile a group of consultants, led by Professor Morris Brown of Cambridge University, has written to his colleagues nationwide, alerting them to the growing concern among both consultants and junior doctors at the MTAS interviews.

Professor Brown has carried out an on-line poll of 3500 doctors, which showed that 81% of 813 Consultants and 85% of 2422 Juniors who replied wanted a consultant boycott. He also suggests delaying the 1 August start date for the new specialist training posts.

“In our poll,” he writes, “80% of both seniorities would like doctors to stay in their current post. The main downside is a delayed start for the new FY1s, who should be compensated; but at least they have a future ahead of them, whilst 10,000 FY2s and SHOs unsuccessful in their single MTAS interview face a permanent end to their career in hospital medicine.”

TO go to the poll questionnaire, visit www.cai.cam.ac.uk/people/mjb14/

See also a rapid response from Professor Brown at: www.bmj.com/cgi/eletters/334/7601/0?ck=nck#165660