The leader by McDonagh regarding outpatient training for rheumatology specialist registrars is a timely and important commentary.1 Having done most of my training in the United Kingdom, for the past two years I have spent time at the University of Toronto, Division of Rheumatology. This experience provides some observations that are relevant to the current debate.

It is impossible to avoid the differences in the organisation of health services and postgraduate medical education in the UK and Canada. These have a significant impact on training. The NHS is consultant-led with a high dependency on doctors at the senior house officer and registrar grades to provide the service. Many outpatients are therefore seen by doctors who may have little or no previous experience in rheumatology. Because of the pressure of numbers and resultant time constraints mistakes in management as well as potentially unnecessary follow ups can go unchecked. The Canadian health care system is consultant-based. Specialists work on a fee for service basis and are required to see each patient. Clinics are organised in …