As a two-phase exercise in inter-district audit, with the emphasis on critical evaluation of routine clinical practice, three rheumatologists each examined the same 44 patients with shoulder pain, and recorded their diagnosis and the investigations and treatment they would carry out. In the first phase, 26 patients were seen by each rheumatologist separately; there was complete diagnostic agreement in only 46%, with wide variation in the frequency of requests for standard investigations, but all three rheumatologists recommended steroid injections for most patients. In the second phase, all three rheumatologists examined a further 18 patients together, discussed the symptoms and signs, and recorded their diagnoses separately. There was complete agreement in 78%. The presence of more than one lesion, and differences in the interpretation of certain physical signs, partly explain the lack of agreement in Phase 1. Treatment of specific shoulder lesions is highly concordant, with injection the major treatment modality, followed by physiotherapy. Perhaps the different diagnoses reached, and the fact that treatment might therefore be administered for the wrong diagnosis, may explain some treatment failures. Also, recruitment of patients for studies of the treatment of shoulder lesions requires care to avoid selection of a heterogeneous group.

Innumerable articles and eulogies have been written about Harold Delf Gillies (HDG) detailing his contributions to the field of plastic surgery. There is perhaps more to HDG than this alone. While his singular personality led him to think 'outside the box' in surgical terms, his innovations extended past mere technique and he was perhaps responsible for a more generally applicable philosophy -that of the multidisciplinary team. This article examines some of his achievements and looks behind the surgeon to the visionary.

Twenty-two patients with rheumatoid arthritis and severe chronic bronchial suppuration are described. In 11 patients the respiratory symptoms appeared after the onset of arthritis at an unusually late age. We discuss causes for the disease association, in particular the possibility that disease modifying drugs in rheumatoid arthritis may predispose to the development of chronic bronchial suppuration; such a possibility requires prospective investigation.

Four consultant rheumatologists from different health districts compared their out-patient and in-patient workloads for 3 months. Data collection proved simple and valuable to each local unit. Inflammatory joint disease (particularly severe rheumatoid arthritis) dominated the workload in all centres. Large differences in the number of new referrals with osteoarthritis, soft tissue diseases and polymyalgia rheumatica were observed. Differences were also apparent in the organization of clinics, provision of follow-up appointments for different diagnostic groups, and usage of steroid injections. Although there may be a variety of explanations for these similarities and differences, the data emphasize the need for further audit of rheumatology practice in the UK.

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