Specialists in the United States: what lessons?

Abstract

Several pressures are forcing a rethink of the way that consultants in Britain work. Perhaps the most acute pressures come from the current moves to reduce junior doctors' working hours and the Calman proposals for more structured and shorter specialty training programmes. Together these will mean fewer juniors available to do service work within the NHS and a greater load on the consultants who have to teach them. But patients and purchasers are also demanding that more clinical work should be done by fully trained doctors, not trainees, and the requirements of the new NHS require consultants to take part in auditing, contracting, and managing the service. Last week (11 March, p 673) the BMA council heard consultants' anxieties that the numbers of consultants were not growing in line with the demands of the Calman implementation plan. There is a feeling that something will have to give, and the BMA fears the proliferation of subconsultant grades (staff who are not trainees but do not have full clinical autonomy) to fill the growing gap between the work to be done and doctors available to do it. Also, on 6 April the Central Consultants and Specialists Committee of the BMA is holding a conference to discuss consultants' career development in the face of these changes. We have commissioned four articles to contribute to this debate about how consultants should organise themselves and their work in future. In the first of these our North American editor, John Roberts, outlines the effect of similar pressures on the way that specialists in the United States organise their work, and how their working practices are changing. The American specialist and the British consultant travel separate but often parallel roads. Both have recently been buffeted by the same storms: privatisation and competition; demands for account-ability; problems of …