Specialist training.

Specialist training must be reshaped to meet the challenges of new systems for the delivery of health care and rapid expansion in biomedical knowledge. An adequate and affordable supply of trained specialists and generalists able to deal with the health problems of populations served, is the responsibility of governments and policy-makers that fund and those who deliver graduate education. Clearly defined objectives for specialist training are needed, linked to planning for the medical workforce size. A balance between numbers of specialists and generalists is essential, although flexibility in programmes should allow individuals to change. Curricula for all specialties should be published. Strategies and methods for delivery of graduate education and training must be coherent with those of medical schools. Training should be planned and sequenced to meet the identified needs of individuals. Those who teach should themselves learn how to train and assess trainees. The location for training should reflect present and future clinical practice if disfunction between medical education and the health of populations served and their need is to be avoided. Specialist training should form the basis for continuing education by encouraging lifelong, evidence-based learning. Any reshaping of specialist training must be consistent with the continuum of medical education. Instruments for assessment of specialists in training have to be refined, based on action research. Ensuring mastery in the competencies of each component of the curriculum is essential. Those competencies will change in consequence of altered societal needs plus advances in technology and biomedical knowledge.

The hospital component of vocational training for general practice.

Trainees and educationalists in general practice have some grounds for suggesting that the hospital component of vocational training should be restructured and teaching improved. However, the implications for other trainees and secondary care have to be considered. Changes that are needed include a curriculum for senior house officers in each specialty; appointment of training consultants with the necessary skills; and a different attitude by everyone towards study leave, including arrangements for funding. The optimum duration of hospital posts for trainees in general practice might be shorter than now, but the effects on others must be considered and competencies guaranteed in a briefer training period. Changes in the regulations for vocational training could help to improve specialist experience if trainees in general practice were allowed to be supernumerary. Alternatively, senior house officer posts for trainees in general practice could be split between secondary and primary care, thus encouraging a broader perspective.

Libraries, postgraduate medical education and the management of change.

The changes surrounding the funding of postgraduate medical and dental education are outlined and the funding implications for libraries considered. The management of this period of change is vital if all players are to appreciate the advantages of implementation, not least cost-effectiveness. In conclusion three problem areas in the post-reform NHS are identified and briefly discussed: the need for access and provision of information to all; development of regional librarian role across all regions to ensure effective co-ordination of resources; a national policy which will integrate national, regional and unit structures for the delivery of health-care information needs to be developed.

Ocular reaction to timolol maleate.

A patient prescribed timolol maleate for the control of hypertension developed dryness of the eyes. The symptoms improved on withdrawal of the drug. Vigilance for such adverse reactions must be observed in the use of any beta-adrenoreceptor blocking agent.

Left ventricular failure with labetalol.

A patient treated for hypertension with labetalol developed left ventricular failure. When the drug was withdrawn and the BP controlled with 2 other agents, the signs of heart failure regressed. The ill effects in this case could have been because the beta-blocking effects of labetalol are 4 to 6 times greater than the alpha-blocking effects. Caution should be exercised when prescribing this drug for patients with heart failure or with previous symptoms.

Long-term ventricular pacing in treatment of sinoatrial block.

Six patients with symptoms due to sinoatrial block are described in whom no relief or improvement in block occurred when they were treated with isoprenaline or ephedrine. All six patients were treated by ventricular cardiac pacing with complete relief of symptoms. Despite the theoretical disadvantages of parasystole and loss of accrochage in treating these patients by ventricular pacing they have survived for periods of 18 months to over five years.