- Email: [email protected]
Doctors' pay
1599
Noticeboard London
shake-up
In Greater London levels of medical staffmg must be cut by 30%, about 10 acute hospital units surplus to the capital’s future requirements should be closed, and annual medical student intake should be reduced from 1350 to 960, says the King’s Fund Commission on the future of London’s acute health services.’ This strategy for change is founded on the profound health inequalities in London and the demographic changes expected during the next decade. In Inner London the range of hospital care that is provided is poor because of the concentration of specialist centres, whilst specialist services are limited in the periphery. Furthermore, with three renal units lying within 4 miles of each other (at Guy’s, St Thomas’s, and Dulwich Hospitals), and with inner-city health care costing, on average, 45% more than elsewhere in the UK, service budgets for the elderly, single-parent families, the homeless, the mentally ill, and ethnic minorities are inevitably squeezed. Patients increasingly expect more information about health and most wish to have a more active role in their treatment. An ageing population will lead to a greater pressure on services for the disabled, and degenerative disease will become a large part of routine care. Thus the Commission recommends that, for health services to be planned according to the needs of the population, the main responsibility for health promotion, diagnostic investigation, and treatment should be placed in the primary care sector. Implementation of this plan would require a c250 million investment. Hospital care should be rationalised, with specialist services (eg, for trauma, burns, and transplantation) being centralised. Medical manpower should be redistributed away from Central London, where bed numbers are
declining. Education and research have not been unaffected by poor strategic planning. Most medical schools are unable to provide comprehensive training in all disciplines and the training they delegate to outer London hospitals is often poorly monitored. Research facilities have been fragmented among 8 medical schools and 10 postgraduate institutes, and links with university science faculties are often non-existent. The Commission believes that medical schools and the university departments must join to form larger groupings. Under Imperial College would come St Mary’s, Charing Cross, and Westminster Medical Schools, and the Royal Postgraduate Medical School, the Institute of Cancer Research, and the National Heart and Lung Institute. University College would have under it University College, Middlesex, and Royal Free Medical Schools, and the Institute of Neurology, Institute of Child Health, and the London School of Hygiene and Tropical Medicine. Queen AAary[Westfield College would be grouped with St Bartholomew’s and London Medical Schools, as well as the Institute of Ophthalmology. King’s College would be linked with Guy’s, St Thomas’, and King’s Medical Schools, and the Institute of Psychiatry. The University of Surrey would be associated with St George’s Medical School. With seven million people, London has become Europe’s largest city and has developed into an international business centre. Yet, as the report notes, "in many important respects, London’s health services appear stuck in a time warp, having been shaped a century ago". The King’s Fund proposes a task force to implement this programme over 5 years. Prof Sir Bernard Tomlinson and his committee, who have been appointed to review the future of health services in London, are due to report later this year. Can they meet the challenge set up by the King’s Fund Commission? 1.
King’s Fund Commission on the Future of London’s Acute Health Services. London: health care 2010. London: King’s Fund. Pp 116. £14.00. ISBN 0-951889354.
Europe vs GMC:
round 2
After six months of escalating pressure
on
the UK General
Medical Council (GMC), which stemmed from the high
court
decision against their accreditation policy in December, 1991,1 the
Department of Health has been forced to step in to resolve the issue of the UK definition of specialist status. The "T" list, which came into effect from Jan 1,1991, was intended to denote "completion of
specialist training". Legal advice obtained by the Department of Health indicates that such a list has introduced a two-tier system of specialist qualification, which would infringe EC law if specialist diplomas from other European countries were not accepted in the UK as evidence of completion of full specialist training. UK guidelines restrict the freedom of movement of European
specialists. A meeting was held in London this week between the GMC and representatives of the Royal Colleges, senior consultants, and junior doctors, and chaired by Dr Kenneth Calman, the chief medical officer, to overcome disagreements that have emerged among the profession. Junior doctors are seeking the abolition of accreditation and the consultant grade; they support the formation of a single category of "specialist", as defined under EC law. The GMC already keeps such a specialist register, but has so far refused to publish its contents. The GMC and Royal Colleges would prefer to set the UK definition of specialist at the current level required for accreditation. The British Medical Association, which represents both junior doctors and consultants, is caught between these two opposing positions. The result of last week’s meeting was inconclusive and all participants were requested not to discuss the matter with the media, further meetings with officials from the Department of Health are planned. 1.
Anonymous. Decision against UK accreditation. Lancet 1991; 338:
1517.
Doctors’ pay Health care is a labour-intensive industry, so control of wages is important in limiting costs and improving resource allocation. "The UK system of doctors’ remuneration is an inefficient product of history ... Tinkering with this payment system, with ad hoc changes introduced in an uncoordinated and untested manner by Government and Pay Review Body ensure that limited resources available in the NHS continue to be used inefficiently." Thus says a discussion paper1 from the Centre of Health Economics in York,
which advocates a system of payment that takes into account workload (intensity of work rather than hours worked), rewards efficiency, and penalises inadequacy. Although the new general practitioner contract tries to link GP incomes to work done by target setting, efficiency may not be achieved because of perverse incentives, says the paper. The strongest criticism is levelled at the system of payment for hospital doctors-both the salary payments and the distinction awards that "appear to be based on prestige rather than amount of work actually done". The authors of the paper believe that the morale of doctors at all levels may be improved by financial rewards for long hours or intense periods of work; the latter, they say, is ignored in overtime pay for junior doctors. The possibility introduced by the NHS reforms of employing doctors on short-term contracts with NHS hospital trusts may be a way of increasing performance incentives but could encourage doctors to concentrate their efforts on
prioritised areas. Ideally, doctors should be paid for improving the health outcome patients, but until assessment of outcome becomes easier the paper recommends adaptation of a system of payment being of
introduced in the USA. The
resource
based relative value scale
(RBRVS) being used there concentrates on relative costs of resource inputs such as work done before, during, and after provision of a service, practice costs necessary to supply the service, and costs of training. The system has limitations inherent in any charge-based system (eg, it does not take into account differential quality of services or patients’ demands for services) and is still being refined. It has had a considerable impact on redistribution of income between specialties, with those such as internal medicine and family practice gaining, and those such as surgery losing. Questions about whether doctors are seriously overpaid were also raised at the Westminster and City Health Care Conference on June 19 by the managing director of Norwich Union Healthcare, who called on private medical insurers to join forces to investigate the earnings of consultants in private practice. His argument was that the C300 000 that could be earned in a year by a consultant in
1600
full-time private practice, compared with the ,E50 000 salary of a full-time NHS consultant, represents overpayment by insurers. 1. Bloor K, Maynard A, Street A. How much is a doctor worth? York: Centre for Health Economics, University of York. 1992. Pp 58. £6.
Better
news on
population
In view of general agreement that overpopulation poses a threat to the future of humanity, it is encouraging news that the average number of children per woman in developing countries has declined from 6in 1965-70 to 39 in 1985-90. This change has occurred in conjunction with the tenfold rise in number of contraceptive users in those countries over the past 25 years, to 380 million. These figures are from a report1 compiled to mark the 20th anniversary of WHO’s special research programme on human reproduction, which is co-sponsored by the UN Development Programme, the UN Population Fund, and the World Bank. Underlining the rapidity of the change in some countries, the report points out that while the number of children per woman in the US took 58 years to drop from 63 to 3-5, the same decrease took only 15 years in Colombia, 8 years in Thailand, and a mere 7 years in China. By the year 2000 the average family size in developing countries is expected to be 3-3. Well behind the trend is sub-Saharan Africa, where only 9% of people have ready access to family planning services. Digging into its databank, WHO says that over 100 million acts of sexual intercourse take place daily, resulting in 910 000 conceptions-"50% unplanned and 25% definitely unwanted’ ’-and in 356 000 sexually transmitted bacterial and viral infections. About 150 000 pregnancies are terminated daily by induced abortion, with 500 deaths due to unsafe conditions. A surprising finding is that liberal abortion laws do not necessarily mean high abortion rates, an example being the Netherlands. Not surprisingly, fear of AIDS, WHO says, is changing sexual behaviour, leading in some countries to a stabilisation, even reduction, in the incidence of sexually transmitted infections. 1.
Khanna J, Van Look PFA, Griffin PD. Reproductive health: a key to a brighter future. Geneva: WHO. 1992. Pp 170. Sw Fr 35 (18 in developing countries). ISBN 924-1561-53X.
Stress and doctors It may be stating the obvious, but doctors and medical students are stressed in their jobs or studies. The British Medical Association’s Stress and the Medical Profession1 examines models about stress, and the physiological and psychological responses. Discussion of the existence of stress and its effects on doctors, their colleagues, their families, and patients is seen as a first step in stress management and reduction. The path for those most unable to cope may lead to burn-out, alcohol and drug abuse, and suicide. The changes to the National Health Service in the UK provide a good example of stresses newly imposed on doctors. A 1991 BMA survey of consultants found fears that job satisfaction would decrease and sick-leave for stress-related diseases would increase. In general practice especially, the new bureaucracy resulting from the new contract and the need to provide services that they do not think are necessary can create anxieties. So what can be done? Some of the answers are obvious but seem difficult to achieve in the present economic circumstances. A decrease in the hours worked by junior hospital doctors in the UK, which must be linked to a reduced overall workload, better facilities for junior staff, and the provision of improved occupational health services would be a start. For medical students, the curriculum should include instruction about recognising and coping with stress, especially in relationships with consultants and peers. This may impinge on an already overcrowded curriculum, but this would be no bad thing, according to a 1991 King’s Fund report which called for less instruction and more learning. 1. British Medical Association. Stress and the medical profession. London: BMA. 1992. Pp107. £7.95. ISBN 0-7279-0758-1.
Tuberculosis in Western Europe
Tuberculosis, the disease that was almost eradicated from Western Europe and the US in the mid 1980s, is making a powerful comeback, according to the WHO. Each year there are over 400 000 new cases of TB and an estimated 40 000 TB-related deaths in industrialised countries. Several West European countries have been having high percentage increases in TB notification rates in the past few years-eg, Switzerland (33%: 1986-1990), Denmark (31%: 1984-90),andltaly(28%: 1988-90). In some countries, such as Denmark and Sweden, the increase in TB cases is mainly among non-indigenous people-but in others, such as Italy, the high increase in incidence is in people with AIDS. Strains of multipledrug-resistant TB have been found in Italy and France, as well as the US. Nevertheless, more than 98% of TB-related deaths worldwide still occur in developing countries. As the DirectorGeneral of the WHO said, "The ever-increasing movement of people from one country to another makes it unrealistic to speak of eliminating the disease in one group of countries without first improving the situation in others". New chemical
safety watchdog
About 1000 000 man-made and naturally occurring chemical substances are used worldwide and up to 2000 new substances come onto the market each year-mostly in commercial products. The possible health and environmental risks posed by the vast majority of these substances have not been evaluated. The potential dangers of these untested chemicals will be most serious in developing countries, few of which have the resources to deal with chemical accidents. As a result of the Earth Summit, an international forum of government-designated experts from more than 70 countries is to be created to improve chemical safety. The concept of the forum was developed by the International Programme on Chemical Safety (IPCS). The forum will work in six priority areas: expansion and acceleration of the international assessment of chemical risks; harmonisation of classification and labelling of chemicals, exchange of information on toxic chemicals and chemical risks; establishment of risk-reduction programmes; strengthening of the national capabilities and capacities for management of chemicals; and prevention of the illegal traffic of toxic and dangerous products.
Wellcome
moves
The Wellcome Foundation this week launched a !1 million investment into an international programme of "positive action" in HIV/AIDS education, care, and community support. The scheme consists of sponsorship of conferences (eg, in conjunction with the UK’s National Children’s Bureau and the Institute of Child Health), workplace initiatives, and funding for non-governmental organisations, which would involve close cooperation with existing public health projects, such as the World Health Organisation’s Global Programme on AIDS. Zidovudine earned Wellcome 170 million in the last fmancial year. The Wellcome Trust opened an international share issue 3 days after the announcement of this international initiative. James Cochrane, director of Wellcome, described the close timing of both events as "unfortunate".
Peers in
Chicago again
"We know that peer review has existed for years without scientific proof of its worth, but will it hold up under the same rigor and scrutiny we demand of science itself?" and "We fear that peer review suppresses innovation, but to what extent?" Good questions, being asked with others in the advance publicity for the Second International Congress on Peer Review in Biomedical Publication. The first congress, in 1989, attracted a mix of original research on peer review and opinion; for 1993 priority will be given to research. The congress will be in Chicago on Sept 9-11, 1993, and further information can be had from Annette Flanagin atJAMA (515 N State St, Chicago, IL 60610, USA) or Jane Smith at the BMJ (Tavistock House, London WC1H 9JR, UK). Abstracts (to Annette Flanagin) have a March 15 deadline.
Noticeboard London
shake-up
In Greater London levels of medical staffmg must be cut by 30%, about 10 acute hospital units surplus to the capital’s future requirements should be closed, and annual medical student intake should be reduced from 1350 to 960, says the King’s Fund Commission on the future of London’s acute health services.’ This strategy for change is founded on the profound health inequalities in London and the demographic changes expected during the next decade. In Inner London the range of hospital care that is provided is poor because of the concentration of specialist centres, whilst specialist services are limited in the periphery. Furthermore, with three renal units lying within 4 miles of each other (at Guy’s, St Thomas’s, and Dulwich Hospitals), and with inner-city health care costing, on average, 45% more than elsewhere in the UK, service budgets for the elderly, single-parent families, the homeless, the mentally ill, and ethnic minorities are inevitably squeezed. Patients increasingly expect more information about health and most wish to have a more active role in their treatment. An ageing population will lead to a greater pressure on services for the disabled, and degenerative disease will become a large part of routine care. Thus the Commission recommends that, for health services to be planned according to the needs of the population, the main responsibility for health promotion, diagnostic investigation, and treatment should be placed in the primary care sector. Implementation of this plan would require a c250 million investment. Hospital care should be rationalised, with specialist services (eg, for trauma, burns, and transplantation) being centralised. Medical manpower should be redistributed away from Central London, where bed numbers are
declining. Education and research have not been unaffected by poor strategic planning. Most medical schools are unable to provide comprehensive training in all disciplines and the training they delegate to outer London hospitals is often poorly monitored. Research facilities have been fragmented among 8 medical schools and 10 postgraduate institutes, and links with university science faculties are often non-existent. The Commission believes that medical schools and the university departments must join to form larger groupings. Under Imperial College would come St Mary’s, Charing Cross, and Westminster Medical Schools, and the Royal Postgraduate Medical School, the Institute of Cancer Research, and the National Heart and Lung Institute. University College would have under it University College, Middlesex, and Royal Free Medical Schools, and the Institute of Neurology, Institute of Child Health, and the London School of Hygiene and Tropical Medicine. Queen AAary[Westfield College would be grouped with St Bartholomew’s and London Medical Schools, as well as the Institute of Ophthalmology. King’s College would be linked with Guy’s, St Thomas’, and King’s Medical Schools, and the Institute of Psychiatry. The University of Surrey would be associated with St George’s Medical School. With seven million people, London has become Europe’s largest city and has developed into an international business centre. Yet, as the report notes, "in many important respects, London’s health services appear stuck in a time warp, having been shaped a century ago". The King’s Fund proposes a task force to implement this programme over 5 years. Prof Sir Bernard Tomlinson and his committee, who have been appointed to review the future of health services in London, are due to report later this year. Can they meet the challenge set up by the King’s Fund Commission? 1.
King’s Fund Commission on the Future of London’s Acute Health Services. London: health care 2010. London: King’s Fund. Pp 116. £14.00. ISBN 0-951889354.
Europe vs GMC:
round 2
After six months of escalating pressure
on
the UK General
Medical Council (GMC), which stemmed from the high
court
decision against their accreditation policy in December, 1991,1 the
Department of Health has been forced to step in to resolve the issue of the UK definition of specialist status. The "T" list, which came into effect from Jan 1,1991, was intended to denote "completion of
specialist training". Legal advice obtained by the Department of Health indicates that such a list has introduced a two-tier system of specialist qualification, which would infringe EC law if specialist diplomas from other European countries were not accepted in the UK as evidence of completion of full specialist training. UK guidelines restrict the freedom of movement of European
specialists. A meeting was held in London this week between the GMC and representatives of the Royal Colleges, senior consultants, and junior doctors, and chaired by Dr Kenneth Calman, the chief medical officer, to overcome disagreements that have emerged among the profession. Junior doctors are seeking the abolition of accreditation and the consultant grade; they support the formation of a single category of "specialist", as defined under EC law. The GMC already keeps such a specialist register, but has so far refused to publish its contents. The GMC and Royal Colleges would prefer to set the UK definition of specialist at the current level required for accreditation. The British Medical Association, which represents both junior doctors and consultants, is caught between these two opposing positions. The result of last week’s meeting was inconclusive and all participants were requested not to discuss the matter with the media, further meetings with officials from the Department of Health are planned. 1.
Anonymous. Decision against UK accreditation. Lancet 1991; 338:
1517.
Doctors’ pay Health care is a labour-intensive industry, so control of wages is important in limiting costs and improving resource allocation. "The UK system of doctors’ remuneration is an inefficient product of history ... Tinkering with this payment system, with ad hoc changes introduced in an uncoordinated and untested manner by Government and Pay Review Body ensure that limited resources available in the NHS continue to be used inefficiently." Thus says a discussion paper1 from the Centre of Health Economics in York,
which advocates a system of payment that takes into account workload (intensity of work rather than hours worked), rewards efficiency, and penalises inadequacy. Although the new general practitioner contract tries to link GP incomes to work done by target setting, efficiency may not be achieved because of perverse incentives, says the paper. The strongest criticism is levelled at the system of payment for hospital doctors-both the salary payments and the distinction awards that "appear to be based on prestige rather than amount of work actually done". The authors of the paper believe that the morale of doctors at all levels may be improved by financial rewards for long hours or intense periods of work; the latter, they say, is ignored in overtime pay for junior doctors. The possibility introduced by the NHS reforms of employing doctors on short-term contracts with NHS hospital trusts may be a way of increasing performance incentives but could encourage doctors to concentrate their efforts on
prioritised areas. Ideally, doctors should be paid for improving the health outcome patients, but until assessment of outcome becomes easier the paper recommends adaptation of a system of payment being of
introduced in the USA. The
resource
based relative value scale
(RBRVS) being used there concentrates on relative costs of resource inputs such as work done before, during, and after provision of a service, practice costs necessary to supply the service, and costs of training. The system has limitations inherent in any charge-based system (eg, it does not take into account differential quality of services or patients’ demands for services) and is still being refined. It has had a considerable impact on redistribution of income between specialties, with those such as internal medicine and family practice gaining, and those such as surgery losing. Questions about whether doctors are seriously overpaid were also raised at the Westminster and City Health Care Conference on June 19 by the managing director of Norwich Union Healthcare, who called on private medical insurers to join forces to investigate the earnings of consultants in private practice. His argument was that the C300 000 that could be earned in a year by a consultant in
1600
full-time private practice, compared with the ,E50 000 salary of a full-time NHS consultant, represents overpayment by insurers. 1. Bloor K, Maynard A, Street A. How much is a doctor worth? York: Centre for Health Economics, University of York. 1992. Pp 58. £6.
Better
news on
population
In view of general agreement that overpopulation poses a threat to the future of humanity, it is encouraging news that the average number of children per woman in developing countries has declined from 6in 1965-70 to 39 in 1985-90. This change has occurred in conjunction with the tenfold rise in number of contraceptive users in those countries over the past 25 years, to 380 million. These figures are from a report1 compiled to mark the 20th anniversary of WHO’s special research programme on human reproduction, which is co-sponsored by the UN Development Programme, the UN Population Fund, and the World Bank. Underlining the rapidity of the change in some countries, the report points out that while the number of children per woman in the US took 58 years to drop from 63 to 3-5, the same decrease took only 15 years in Colombia, 8 years in Thailand, and a mere 7 years in China. By the year 2000 the average family size in developing countries is expected to be 3-3. Well behind the trend is sub-Saharan Africa, where only 9% of people have ready access to family planning services. Digging into its databank, WHO says that over 100 million acts of sexual intercourse take place daily, resulting in 910 000 conceptions-"50% unplanned and 25% definitely unwanted’ ’-and in 356 000 sexually transmitted bacterial and viral infections. About 150 000 pregnancies are terminated daily by induced abortion, with 500 deaths due to unsafe conditions. A surprising finding is that liberal abortion laws do not necessarily mean high abortion rates, an example being the Netherlands. Not surprisingly, fear of AIDS, WHO says, is changing sexual behaviour, leading in some countries to a stabilisation, even reduction, in the incidence of sexually transmitted infections. 1.
Khanna J, Van Look PFA, Griffin PD. Reproductive health: a key to a brighter future. Geneva: WHO. 1992. Pp 170. Sw Fr 35 (18 in developing countries). ISBN 924-1561-53X.
Stress and doctors It may be stating the obvious, but doctors and medical students are stressed in their jobs or studies. The British Medical Association’s Stress and the Medical Profession1 examines models about stress, and the physiological and psychological responses. Discussion of the existence of stress and its effects on doctors, their colleagues, their families, and patients is seen as a first step in stress management and reduction. The path for those most unable to cope may lead to burn-out, alcohol and drug abuse, and suicide. The changes to the National Health Service in the UK provide a good example of stresses newly imposed on doctors. A 1991 BMA survey of consultants found fears that job satisfaction would decrease and sick-leave for stress-related diseases would increase. In general practice especially, the new bureaucracy resulting from the new contract and the need to provide services that they do not think are necessary can create anxieties. So what can be done? Some of the answers are obvious but seem difficult to achieve in the present economic circumstances. A decrease in the hours worked by junior hospital doctors in the UK, which must be linked to a reduced overall workload, better facilities for junior staff, and the provision of improved occupational health services would be a start. For medical students, the curriculum should include instruction about recognising and coping with stress, especially in relationships with consultants and peers. This may impinge on an already overcrowded curriculum, but this would be no bad thing, according to a 1991 King’s Fund report which called for less instruction and more learning. 1. British Medical Association. Stress and the medical profession. London: BMA. 1992. Pp107. £7.95. ISBN 0-7279-0758-1.
Tuberculosis in Western Europe
Tuberculosis, the disease that was almost eradicated from Western Europe and the US in the mid 1980s, is making a powerful comeback, according to the WHO. Each year there are over 400 000 new cases of TB and an estimated 40 000 TB-related deaths in industrialised countries. Several West European countries have been having high percentage increases in TB notification rates in the past few years-eg, Switzerland (33%: 1986-1990), Denmark (31%: 1984-90),andltaly(28%: 1988-90). In some countries, such as Denmark and Sweden, the increase in TB cases is mainly among non-indigenous people-but in others, such as Italy, the high increase in incidence is in people with AIDS. Strains of multipledrug-resistant TB have been found in Italy and France, as well as the US. Nevertheless, more than 98% of TB-related deaths worldwide still occur in developing countries. As the DirectorGeneral of the WHO said, "The ever-increasing movement of people from one country to another makes it unrealistic to speak of eliminating the disease in one group of countries without first improving the situation in others". New chemical
safety watchdog
About 1000 000 man-made and naturally occurring chemical substances are used worldwide and up to 2000 new substances come onto the market each year-mostly in commercial products. The possible health and environmental risks posed by the vast majority of these substances have not been evaluated. The potential dangers of these untested chemicals will be most serious in developing countries, few of which have the resources to deal with chemical accidents. As a result of the Earth Summit, an international forum of government-designated experts from more than 70 countries is to be created to improve chemical safety. The concept of the forum was developed by the International Programme on Chemical Safety (IPCS). The forum will work in six priority areas: expansion and acceleration of the international assessment of chemical risks; harmonisation of classification and labelling of chemicals, exchange of information on toxic chemicals and chemical risks; establishment of risk-reduction programmes; strengthening of the national capabilities and capacities for management of chemicals; and prevention of the illegal traffic of toxic and dangerous products.
Wellcome
moves
The Wellcome Foundation this week launched a !1 million investment into an international programme of "positive action" in HIV/AIDS education, care, and community support. The scheme consists of sponsorship of conferences (eg, in conjunction with the UK’s National Children’s Bureau and the Institute of Child Health), workplace initiatives, and funding for non-governmental organisations, which would involve close cooperation with existing public health projects, such as the World Health Organisation’s Global Programme on AIDS. Zidovudine earned Wellcome 170 million in the last fmancial year. The Wellcome Trust opened an international share issue 3 days after the announcement of this international initiative. James Cochrane, director of Wellcome, described the close timing of both events as "unfortunate".
Peers in
Chicago again
"We know that peer review has existed for years without scientific proof of its worth, but will it hold up under the same rigor and scrutiny we demand of science itself?" and "We fear that peer review suppresses innovation, but to what extent?" Good questions, being asked with others in the advance publicity for the Second International Congress on Peer Review in Biomedical Publication. The first congress, in 1989, attracted a mix of original research on peer review and opinion; for 1993 priority will be given to research. The congress will be in Chicago on Sept 9-11, 1993, and further information can be had from Annette Flanagin atJAMA (515 N State St, Chicago, IL 60610, USA) or Jane Smith at the BMJ (Tavistock House, London WC1H 9JR, UK). Abstracts (to Annette Flanagin) have a March 15 deadline.