Clinical competence and curiosity

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BRITISH MEDICAL JOURNAL

described a reduction in flow rate of blood in conjunctival capillaries after the third week of the normal menstrual cycle.6 Cigarette smoking impairs the flow properties,of the blood, and impaired cerebral blood flow in smokers has been described.' As smoking increases noradrenaline secretion,8 the change in blood rheology may be due to red cell stiffening induced by noradrenaline. We have found that filterability of blood from smokers was improved after three weeks' dietary supplementation with oil of evening primrose (Efamol).9 I have found that in young women with the premenstrual syndrome whole blood filterability was less at the end of the third week than at the end of the first week of the cycle (unpublished observations). Dietary supplementation with oil of evening primrose improved whole blood filterability at the end of the third week and reduced or abolished both the somatic and psychological symptoms of the premenstrual syndrome. A recently reported placebo controlled trial concluded that "Efamol treatment alleviated the premenstrual symptoms in general and depression especially better than did a placebo."'0 The evidence for a rheologically based pathogenesis of the premenstrual syndrome is sufficiently compelling to stimulate investigations into whether a relation between noradrenaline and blood rheology exists. The potentially devastating effects of the premenstrual syndrome on the lives of individuals and families justifies ur-ther study of this new approach to an old problem with the aim of achieving more efficacious treatment of the disorder. L 0 SIMPSON

the six individuals shown from brief excerpts of their interviews or of the.representative nature of those interviews drawn by the producers from the 80 applicants whose interviews they videotaped. For example, of those shown, three women were chosen and three men rejected, but 43% of applicants to St Mary's and 44% of entrants are women. A most likeable boy from the Welsh valleys (not, incidentally, "working class" but one whose school did not send many pupils to university) was rejected, yet St Mary's has a long record of taking good Welsh students from just such schools and the year shown was no exception; it was much harder for a panel to reject than to accept that particular applicant, especially under the glare of the lights and memories of The Corn is Green. Thirdly, an interviewer who expressed reasonable doubt about a particular applicant was not "overruled," but the dean did in fairness ask the panel to consider that many girls initially lack the confidence to apply for medicine because of continuing discouragement at school. Fourthly, although both mature students shown were rejected, St Mary's takes more mature students (about 10-15% of the entry) than most UK medical schools: one mature student, who by his own admission did not interview well, was not recommended by the panel because of their reasonable but in the event unnecessary concern about his academic ability, not his "determination." Matters, of agreement: firstly, selection panels undoubtedly vary-that may be a weakness or a strength. Secondly, no one has to my knowledge proved that they can precisely define the qualities of a good doctor, measure these qualities in graduates undertaking varied careers in medicine, or reliably recognise them by record or by interPathology Department, University of Otago Medical School, view. I am not aware that "expert help" is availDuedin, New Zealand able, but I should be delighted to know more. The 1 Wiener JS, Elmadiian F. Excretion of epinephrine and nor- subject is one for research and we for one are epinephrine in premenstrual tension. Fed Proc 1962;21:184. conducting a long term prospective survey of all 2 Rasmussen H, Lake W, Allen JE. The effects of catechbomine . applicants to St Mary's in 1980-1'4 and again in and p ndins upon human and rat 1985-6 wherever they ended up reading medicine. BiochimBiophysActa 1975;411:63-73. 3 Rebaudi S. La vscosite du sang pendant la grossesse et The Horizon project will have served a useful l'accouchement. Arch de ma! du cwe, 1909;p 256. purpose if it stimulates not only debate but wider 4 Dintenfass L, Julian DG, Miller G. Viscosity of blood in healthy research, by laying open the limitations of an young women. Lancet 196i:234-5. 5 Gundersen HJG, Cbristensen NJ. Intravenous insulin causing imperfect yet, so far as we can make it here, loss of intravascular water and albmin and increased humane process of selection and education of adrenergic activity in diabetics. Diabeis 1977,26:551-7. a community of diverse, talented, and spirited 6 Landesman R, Douglas RG, Dreishpoon G, Holme E. The vascular bed ofthe bulbar conunctiva in the normal menstrual students, who will teach, learn from, and encycle. Amy Obseet Gynecol 1953;66:988-%. courage each other on a long road to becoming 7 Kubota K, Yamaguchi T, Abe Y, Fujiwra T, Hatazawa 1, committed and effective doctors. Matsuzawa T. Effects of smoking on regional cerebral blood flow in neurologically normal subjects. Strke 1983;14:720-4. 8 Cryer PE, Haymond MW, Santiago JV, Shah SD. Norepinephrine and epinephrine relea and adrenergic mediation of smoking associated hemodynamic and metabolic events. N

PETER RICHARDS Dean

VOLUME 293

26 JULY 1986

years.'2 We too appreciate the difficult task of developing and maintaining qualifying examinations: they unfortunately reflect the art of the possible, not the ideal. Since each of us is concerned in either qualifying or certifying examinations, we do, however, appreciate the limitations of current methods.3 Thus, we approached the first Cambridge conference in 1984, not as a platform for a dynamic defence of the status quo for fear "that our brains (might) fall out" but rather with a sense of inquiry and opportunity. For us the conference succeeded. The result has been the careful investigation and testing of new methods for assessing clinical competence, which are now under way at several medical schools and being evaluated by some licensing authorities. Obviously, the Cambridge conference proceedings4 did not stimulate Professor Richards's curiosity or spark his enthusiasm for improving the state of the art. We accept that. We do not accept, however, that in debating the issues respected clinicians and measurement specialists from around the world should have their points of view dismissed out of context as "tilting at windmills" or with blanket statements such as, "cannot expect the confidence of either those who teach or those who learn" or "nor can clinical teachers take seriously those who write." This approach to editorialism is not the rational defence of a differing point of view that one might have hoped for. Your readers are the losers for that. Coincidentally, we have just concluded the second "Cambridge" conference in Vancouver, where we discussed the undergraduate medical curriculum, including a concern about "(loss) of student curiosity and enthusiasm." Ironically, one of the possible explanations for the loss of enthusiasm and curiosity may be inappropriate and unimaginative methods of assessment. Has the debate come full circle? W DALE DAUPHINEE McGif University, Montreal, Canada

GEORGES BORDAGE Universite Laval,

Quebec, Canada

PAULA STILLMAN University of Massachusetts, Worcester, USA

DAvID NEWBLE University of Adelaide, Adelaide, Australia

EDWARD SELLERS University of Toronto, Toronto, Canada

St Mary's Hospital Medical School,

EnglJ Med 1976ffl:573-7. London W2 IPG 9 Simpson LO, Olds RJ, Hunter IA. Changes in rheoogical properties of blood. Procdiigs of the Unveej of Otago 1 McManus IC, Richards P. An audit of admissions to medical MedicalSchool 1984;62:122-3. school: I-Acceptances and rejects. Br Med J7 1984289: 10 Puolakka J, Makarinen L, Viinikka L, Ylikorkala 0. Blo12014.

1 Neufeld VR. An introduction to measurement properties. In: Neufeld VR, Norman GR, eds. Assesing clinical competence. New York: Springer, 1985:39-50. 2 Neufeld VR. Historical perspective on clinical comptence. In:

2 McManus IC, Richards P. An audit of admissions to medical school: 11-Short listing and interviews. Br MedJ7 1984;289: 1288-90. 3 McManus IC, Richards P. An audit of admissions to medical school: III-Applicants' perceptions and proposals for change.

New York: Springer, 1985:3-15. 3 Norman GR, Bordage G, Curry L, et al. A review of recent innovations in assessment. In: Wakeford R, ed. Directions in clinical assessment. Cambridge: Cambridge University School of Clinical Medicine, 1984:9-27. 4 Wakeford R, ed. Directions m clinical assessmet. Cambridge: Cambridge University School of Clinical Medicine, 1984.

chemical and clinical effects of treating the premenstrual syndrome with prostaglandin synthesis prcsuo. J Rerod Med 1985;30:149-53.

O tempora, 0 Mary's

BrMedJ 1984;289:1365-7.

4 McManus IC, Richards P. Prospective survey of performance of medical students during preclinical years. BrMedJ 1986293:

124-7. SIR,-There are some corrections of fact to make to Mr Richard Wakeford's review (12 July, p 127) about Horizon's first programme in a long term examination of the making of doctors, and a few Clinical competence and curiosity

points of agreement. Corrections of fact: firstly, the series arose from the Horizon team's conviction that the subject was of interest and importance and not from an initiative from St Mary's. When approached, however, the school overcame its academic caution in the belief that someone had a public duty to lay medical education in the UK open to examination, warts and all. Secondly, it is impossible to gain a balanced view either of the selection decisions on

Neufeld VR, Norman GR, eds. Asessing clinical competence.

The doctor, the patient, and their contract

SIR,-Professor Alan Maynard and colleagues (31 May, p 1438) condemn out ofhand fee for item SIR,-Several of us who attended the first Cam- of service on the questionable grounds that some bridge conference on clinical assessment read with doctors may do unnecessary work for the sake of anticipation the leading article by Professor Peter increased income.

Richards (7 June, p 1481). As clinical teachers with an interest in the measurement of clinical performance, we were disappointed with Professor Richards's arguments. We agree that Neufeld and colleagues have nicely reviewed the advances in measurement of competence over the past 20

As an expatriate Englishman who has been in family practice in the United States for over 30 years and is paid on a fee for service basis, my observations run counter to those expressed in the paper. I do sigmoidoscopies, fibreoptic laryngoscopies, skin biopsies, and diathermy