A recent article in the Medical Education journal looked at this interesting issue. The study aimed to measure changes in the training and workload of pre-registration house officers using a postal questionnaire.

Two hundred and six pre-registration house officers in the south-western region of England were surveyed and asked to report on the education, training and workload of their posts. Results were compared with a survey conducted four years earlier. Since the previous survey, the number of hours on duty had reduced from a median of 80 h week in 1992/3 to 72 h week in 1996/7 (P < 0.0001).

There were no statistically significant changes in the number of patients admitted or clerked in an average week, but house officers’ clinical experience had fallen. All but five of 26 marker conditions showed a decline, which was statistically significant in seven cases. These conditions were:

• acute gallstone disease

• myocardial infarction

• acute asthma

• diabetic keto-acidosis

• head injury

• subarachnoid haemorrhage

• status epilepticus

House officers were keener to include four months of general practice in the pre-registration year and were less adverse to extending the pre-registration year to two years. The reduction in hours of work for house officers has been accompanied by a decline in their clinical exposure to common medical and surgical emergencies. The long-term effects of these changes are unknown.

More structured post-graduate training has generally reduced the amount of time trainees who have completed their pre-registration year spend in training. It is obviously important that improvements in conditions and training of doctors continue. Part of the equation needs to relate to Important decisions about the minimum exposure that doctors need to common conditions in order to become expert

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The Drugs and Therapeutics Journal recently had a review article on this topic.

Postnatal depression affects around 70,000 women annually in the UK. While it usually resolves within a few months, it is occasionally followed by chronic mood disorder, and may sometimes affect the emotional and cognitive development of the child. The diagnosis of postnatal depression requires a high level of awareness in the primary care team. The Edinburgh Postnatal Depression Scale is a simple screening tool which, when used in routine care, can help to identify women who may be depressed and in need of fuller assessment and help.

Smoking prevents dementia? Smoking causes dementia? Over the past decade a succession of research findings has produced apparently conflicting evidence on this question. In the early 1990s results from case-control and family studies suggested a protective effect.

Tobacco companies began to sponsor conferences on dementia. If smoking reduced life expectancy and also reduced the likelihood of survivors developing dementia then, from a policy perspective, there might be a role for the habit in later life.

The potential protective effects have some biological plausibility. Alzheimer’s disease affects neurotransmitter systems, particularly the cholinergic system. Nicotine is a cholinergic agonist. A drug that acts on nicotinic receptors in the brain has just received regulatory approval in Sweden, the first such drug to be approved in the European Union. These effects are likely to be short term, with no obvious mechanism for long term effects. Moreover, smoking’s effect on risk for vascular disease, including cerebro-vascular disease, makes it a likely risk factor for vascular dementia over the longer term.

The effects of smoking on dementia clearly need investigating in relatively unbiased populations and in longitudinal studies of reasonable duration in which the risk factors are examined before the onset of any dementia. In reporting one such study of British doctors in a recent BMJ, Doll et al discussed the earlier case-control studies of risk for Alzheimer’s disease, highlighting the deficiencies of this approach for dementia. In order to take part in a case-control study, patients need to have survived. For Alzheimer’s disease the diagnostic criteria demand exclusion of those with vascular disorders, thus excluding those more likely to have smoked in earlier life. These are among the many reasons why the early case-control studies might have found a spurious “protective effect”. Although these limitations were discussed in most of the papers reporting an apparent protective effect and in commentaries, the reservations did not appear in all the media reports.

A number of longitudinal studies have undermined the case-control evidence. The latest, a study of British doctors has shown no evidence of a significant protective effect in men.

This study was not originally aimed at answering questions about the relationship between smoking and dementia therefore it does not provide the detail necessary to answer questions about the short-term therapeutic effects of nicotine, its effects on minimal dementia and cognitive decline, gene-environment interaction, or gender specific effects. However, its findings are an important counterbalance to the potentially biased earlier studies.