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We respond to Richard Smith's observations (June 2004 JRSM) in relation to our study1 of surgical training amongst ophthalmic senior house officers (SHOs). At the outset, we too expected SHOs in district general hospitals (DGHs) to gain more surgical experience than those in teaching hospitals but found that the proportion of year 3 and 4 SHOs that met the College requirement to be achieved by the end of year 2 (50 completed phako operations) was 36.8% in DGHs and 46.4% in teaching hospitals. Our cross-sectional survey does not allow us to test his suggestion that SHOs in teaching hospitals perform more phako procedures because they have more surgical experience. However, our data do show that, amongst SHOs in their second year of training, those in a teaching hospital perform more phako procedures per week than those in a DGH. This is most striking when gender is taken into account: the year-2 woman SHO in a DGH fares very badly compared with her male counterpart in a teaching hospital—mean number of phakos performed per week 0.44 and 1.20, respectively. Most year-1 SHOs do work in a DGH (96 of 112 respondents), but we are unable to comment on how they move from the DGH to teaching hospital. Richard Smith's suggestion that teaching hospitals somehow manage to cream off a surgically-elite group of SHOs in the second year is intriguing.
No doubt there are a number of ways of ensuring that a trainee surgeon's surgical experience is protected, and Richard Smith offers one simple method of quantifying this. With the anticipated reduction in time for surgical training this is an important debate,2 and one that is justifiably attracting considerable attention in the medical press.3