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JUDGING CLINICAL COMPETENCE
1026 which look so bad when recorded in a subsequent indictment but which, at the time, can be made to appear as a praiseworthy rallying of the team in adversity. If any further text were needed to support the case for a standard hospital complaints procedure, The Davies South Ockendon has provided it. Committee 12would prefer a system of informal investigating panels, made up of professionally qualified and lay members, under a legally qualified chairman. Such a panel would be available to a complainant dissatisfied by the results of an investigation by management; and, conversely, a health authority would be entitled to call on a panel to examine a complaint. Whatever else is decided (and we hope it is decided soon), the complaints procedure must, above all, be reformed to afford the greatest possible protection for the inarticulate and the vulnerable
long-stay patient. When complaints begin to be voiced, however, things have probably been going wrong for some time. Earlier remedial action could be provided by freeing the native vigilance of laymen concerned in the dayto-day running or long-term management of a hospital from the restraint of over-deference
to
" clinical
judgment " (which seemed to cover a very wide area at South Ockendon). The report’s words are strong: All people charged with the management of a hospital, whether layman or professional, must have faith in their judgment and in the evidence of their own eyes. If they feel that something is wrong they must ask questions until they are satisfied. If they are not satisfied they must take appropriate action." In "
Beech Villa at Ockendon, the pressures of overcrowding and understaffing had been aggravated by a deliberate concentration of difficult patients. After the inquiry in 1971 into events at Farleigh Hospital 13 " preliminary advice " was issued to hospital boards on the care of violent and difficult patients; and later the National Association for Mental Health produced guidelines 14 for those who look after violent patients. The Department of Health is now preparing jointly with the Royal College of Psychiatrists and the Royal College of Nursing formal advice for authorities, doctors, and nurses. Such advice is certainly another line for sustained intervention-at a stage before causes for complaint have developed. To the long-apparent need for yet more support for the subnormality service, the new Secretary of State for Social Services has responded by asking all health authorities to review practices and standards of care, resource allocation, and staff training in all long-stay hospitals. Whatever they say, the kind of legerdemain which Mrs Castle must now practise within her budget (if it is not increased overall and if she is to augment the share for subnormality) provides another of those recurrent ministerial headaches of reallocation. It is true that the hopes of the 1971 white-paper 15 have been partly fulfilled, but the gaps still yawn. Capital expenditure of regional hospital boards on hospitals for the mentally handicapped has increased by more than 60% in real terms since 1968-69; and expendi12. 13. 14. 15.
See Lancet, Jan. 12, 1974, p. 52. ibid. 1971, i, 790. ibid. 1971, ii, 112. ibid. p. 29.
inpatient week has gone up by more than a staffing has increased by about a third. and staff are responding to the spasManagement modic awakenings of Government and public conscience : if Mrs Castle can conjure more out of the kitty, particularly for nurses’ pay and for the community care of some of those patients now in hospital, ture per
third.
Nurse
morale and standards may rise further. And if the role of the psychiatrist in mental handicap can be clarified and fortified, and his misgivings dispersed,16 then the multi-disciplinary teams to which the Ockendon report looks for the determination and control of policy in such hospitals may well come nearer to
cheerful reality.
JUDGING CLINICAL COMPETENCE
A MEDICAL student’s factual knowledge can readily be tested by objective methods, but assessment of clinical competence is more difficult. At the latest meeting of the Association for the Study of Medical Education (A.S.M.E.) one promising approach was suggested by the department of psychiatry, For introductory-course had made a television programme to illustrate facets of history-taking in difficult situations. The film could be stopped at nodal points where students could be presented with certain decision alternatives, and the possible consequences of each course of action were then discussed. Such a technique, it was thought, could be used for evaluation as well as for teaching, and might yield valuable information on a student’s attitudes. Prof. Henry Walton, too, was interested in the objective assessment of professional attitudes. Medical teachers, he said, allow their impressions of attendance, diligence, and manners to influence their judgments, although this aspect of medicine is neither taught to students nor formally expected of them. Some speakers, despite the inability of existing tests accurately to predict later attitudes, pressed for personality testing early in the course. Though students who were unsuitable for clinical work might flourish in specialties such as pathology and microbiology, here too personality was important in interpersonal relations. One great problem in assessing clinical competence lies in the variability of examiners. Dr R. H. Harden (Dundee) and Prof. G. M. Wilson (Glasgow) described a structured clinical examination which allowed for " more objectivity; and the meeting agreed with Stokes that at least two pairs of examiners should be used, each examiner writing down his assessment before conferring with his partner. Much of the subsequent discussion centred on the in-course assessment scheme in use in the Medical School of the University of Birmingham. There were clearly many advantages to such a scheme: students could be assessed by many teachers during a course and the effects of examiner variability could thus be reduced; the clinical competence of students could be assessed under more natural conditions than those prevailing during an examination; and account
Birmingham University. students the department
16. ibid. Feb. 2, 1974, p. 156. 17. Stokes, J. F. The Clinical Education. Association for the Medical Education.
Study
of
1027
could be taken of the views of junior medical and nursing staff about student attitudes, motivation, and general sense of responsibility. While this system was not free of criticism, it had many advantages and seemed to offer most promise of an efficient and just clinical-competence examination system.
CANCER IN CHINESE MIGRANTS ALTHOUGH in the past many Chinese migrated from their homeland, the migrants have received less attention than their Japanese counterparts from cancer epidemiologists. In the vastnesses of China there were striking variations in the frequencies and types of cancer, and some of these variations persisted in the migrants.2.3 Others disappeared, because they were related to specific local factors (such as Chlonorchis sinensis infestation, which predisposes to intrahepatic bileduct carcinoma 4.5). In the U.S.A. the total cancermortality rate for Chinese males probably now exceeds that in White males and is similar to that in Black males.But the overall cancer-rate for Chinese women in the U.S. is significantly lower than for Black or White women, the chief difference being in much lower rates for breast and cervix uteri. The main cancer problem for Chinese of both sexes is nasopharyngeal carcinoma: over the other main racial groups males have a 26-fold excess and females a 22-fold excess. Chinese women in the U.S. also do worse than White women for carcinoma of pharynx, liver, lung, and uterine body, and they are more For the prone than Black women to leukaemia. Chinese male in the U.S., rates are below those of both other races for prostatic and bladder cancers and below those of Whites for brain tumours and leukaemia.
by Fraumeni and Mason 6 contains some surprising and stimulating observations. In the Chinese American male the risk of nasopharyngeal carcinoma is evidently decreasing; the high risk of hepatocellular carcinoma persists; susceptibility to leukaemia is about the same as in fellow Americans; The report
and the risk of colon cancer is above average. The increased tendency to colon cancer, which has not appeared in Chinese females, seems to have arisen quite quickly. Chinese women have lost their native7 high rate for choriocarcinoma, remain relatively free from breast cancer (except perhaps in Hawaii 8), but retain their excess of lung cancer/.1o which in Hong Kong, at least, is predominantly adenocarcinomatous.11I These observations fit into a whole series of investigations in migrants, founded on increasingly accurate Maxwell, J. L. China med. J. 1929, 43, 462. Ho, J. H. Rec. Adv. Cancer Res. 1972, 15, 57. Shanmugaratuam. K., Tye, C. Y. J. chron. Dis. 1970, 23, 443. Hon, P. C. J. Path. Bact. 1956, 72, 239. Belamavic, J. Cancer, 1973, 31, 468. Fraumeni, J. K., Mason, T. J. J. natn. Cancer Inst. 1974, 52, 659. Shanmugaratuam, K., Muir, C. S., Tow, S. H., et al. Int. J. Cancer, 1971, 8, 165. 8. MacMahon, B., Cole, P., Brown, J. J. natn. Cancer Inst. 1973, 52, 21. 9. Shanmugaratuam, K. Singapore med. J. 1973, 14, 69. 10. Avellano, M. G., Linden, C., Dunn, J. E. Br. J. Cancer, 1972, 26, 473. 11. Lee, S. H., Ts’o, T. O. ibid. 1963, 17, 37. 1. 2. 3. 4. 5. 6. 7.
knowledge of incidence-rates for cancer the world over. 12, 13 Such work depends on cooperation at all levels, personal, institutional, national, and international; and the results, almost without exception, point to one conclusion-that virtually all human cancers are diseases of locality and environment; as Doll put it,1there is "no cancer that is common anywhere that is not rare somewhere else ". Some agencies and institutions are trying earnestly to define the environmental factors; but epidemiological work on cancers is very inadequately financed, and the number of investigators is minuscule compared with the legions engaged in basic research ". Epidemiological work on cancer is showing lead after lead, but laboratory disciplines are seldom brought to bear. A fresh look at priorities is badly needed. "
CONTINUING EDUCATION: CONTINUING PROBLEM THE continuing education of the profession is
one
challenges of our time. Since the problems are inherently similar on both sides of the Atlantic, the subject was an opportune choice for the latest in the series of Anglo-American conferences sponsored jointly by the Royal Society of Medicine and its American counterpart the Royal Society of Medicine Inc. (this time with the University of North Carolina School of Medicine as hosts). In the event there proved to be as many contrasts as similarities. of the greatest
In the United States accreditation of institutions began in 1966. Now over three hundred are regarded as being suitable to provide postgraduate education. The area health education centres (A.H.E.C.) promote local education and research, principally on the basis that the larger units cooperate to help the smaller. The annual programme, including building, is likely The American to approach$15 million by 1980. Medical Association has played a leading part in encouraging postgraduate education (the latest education number of its journal listed 2441 courses offered by 697 institutions and organisations). Self-assessment examinations, particularly for identification and correction of areas of weakness, were introduced by the American College of Physicians in 1968. Fourteen national medical specialist societies now have programmes in operation. One innovation has been the physicians recognition award (P.R.A.) which is based on a specified number of hours’ participation in continuing education over a specified period. More controversial is the introduction of professional standards review organisations (P.S.R.O.).14 These will judge the treatment of Medicare and Medicaid patients according to local standards of care. They may reduce " chronic remunerative surgery " but may equally encourage the practice of " defensive medicine which is also very expensive. There has been an enormous increase in malpraxis suits. Of 12,000 cases in 1970, 1200 came to trial. The standard for " due skill " is infinitely higher than it formerly Doll, R., Muir, C. S., Waterhouse, J. A. H. Cancer in Five Continents; vol. II. Geneva, 1970. 13. See Lancet, March 30, 1974, p. 547. 14. Lancet, Feb. 16, 1974, p. 260. 12.
long-stay patient. When complaints begin to be voiced, however, things have probably been going wrong for some time. Earlier remedial action could be provided by freeing the native vigilance of laymen concerned in the dayto-day running or long-term management of a hospital from the restraint of over-deference
to
" clinical
judgment " (which seemed to cover a very wide area at South Ockendon). The report’s words are strong: All people charged with the management of a hospital, whether layman or professional, must have faith in their judgment and in the evidence of their own eyes. If they feel that something is wrong they must ask questions until they are satisfied. If they are not satisfied they must take appropriate action." In "
Beech Villa at Ockendon, the pressures of overcrowding and understaffing had been aggravated by a deliberate concentration of difficult patients. After the inquiry in 1971 into events at Farleigh Hospital 13 " preliminary advice " was issued to hospital boards on the care of violent and difficult patients; and later the National Association for Mental Health produced guidelines 14 for those who look after violent patients. The Department of Health is now preparing jointly with the Royal College of Psychiatrists and the Royal College of Nursing formal advice for authorities, doctors, and nurses. Such advice is certainly another line for sustained intervention-at a stage before causes for complaint have developed. To the long-apparent need for yet more support for the subnormality service, the new Secretary of State for Social Services has responded by asking all health authorities to review practices and standards of care, resource allocation, and staff training in all long-stay hospitals. Whatever they say, the kind of legerdemain which Mrs Castle must now practise within her budget (if it is not increased overall and if she is to augment the share for subnormality) provides another of those recurrent ministerial headaches of reallocation. It is true that the hopes of the 1971 white-paper 15 have been partly fulfilled, but the gaps still yawn. Capital expenditure of regional hospital boards on hospitals for the mentally handicapped has increased by more than 60% in real terms since 1968-69; and expendi12. 13. 14. 15.
See Lancet, Jan. 12, 1974, p. 52. ibid. 1971, i, 790. ibid. 1971, ii, 112. ibid. p. 29.
inpatient week has gone up by more than a staffing has increased by about a third. and staff are responding to the spasManagement modic awakenings of Government and public conscience : if Mrs Castle can conjure more out of the kitty, particularly for nurses’ pay and for the community care of some of those patients now in hospital, ture per
third.
Nurse
morale and standards may rise further. And if the role of the psychiatrist in mental handicap can be clarified and fortified, and his misgivings dispersed,16 then the multi-disciplinary teams to which the Ockendon report looks for the determination and control of policy in such hospitals may well come nearer to
cheerful reality.
JUDGING CLINICAL COMPETENCE
A MEDICAL student’s factual knowledge can readily be tested by objective methods, but assessment of clinical competence is more difficult. At the latest meeting of the Association for the Study of Medical Education (A.S.M.E.) one promising approach was suggested by the department of psychiatry, For introductory-course had made a television programme to illustrate facets of history-taking in difficult situations. The film could be stopped at nodal points where students could be presented with certain decision alternatives, and the possible consequences of each course of action were then discussed. Such a technique, it was thought, could be used for evaluation as well as for teaching, and might yield valuable information on a student’s attitudes. Prof. Henry Walton, too, was interested in the objective assessment of professional attitudes. Medical teachers, he said, allow their impressions of attendance, diligence, and manners to influence their judgments, although this aspect of medicine is neither taught to students nor formally expected of them. Some speakers, despite the inability of existing tests accurately to predict later attitudes, pressed for personality testing early in the course. Though students who were unsuitable for clinical work might flourish in specialties such as pathology and microbiology, here too personality was important in interpersonal relations. One great problem in assessing clinical competence lies in the variability of examiners. Dr R. H. Harden (Dundee) and Prof. G. M. Wilson (Glasgow) described a structured clinical examination which allowed for " more objectivity; and the meeting agreed with Stokes that at least two pairs of examiners should be used, each examiner writing down his assessment before conferring with his partner. Much of the subsequent discussion centred on the in-course assessment scheme in use in the Medical School of the University of Birmingham. There were clearly many advantages to such a scheme: students could be assessed by many teachers during a course and the effects of examiner variability could thus be reduced; the clinical competence of students could be assessed under more natural conditions than those prevailing during an examination; and account
Birmingham University. students the department
16. ibid. Feb. 2, 1974, p. 156. 17. Stokes, J. F. The Clinical Education. Association for the Medical Education.
Study
of
1027
could be taken of the views of junior medical and nursing staff about student attitudes, motivation, and general sense of responsibility. While this system was not free of criticism, it had many advantages and seemed to offer most promise of an efficient and just clinical-competence examination system.
CANCER IN CHINESE MIGRANTS ALTHOUGH in the past many Chinese migrated from their homeland, the migrants have received less attention than their Japanese counterparts from cancer epidemiologists. In the vastnesses of China there were striking variations in the frequencies and types of cancer, and some of these variations persisted in the migrants.2.3 Others disappeared, because they were related to specific local factors (such as Chlonorchis sinensis infestation, which predisposes to intrahepatic bileduct carcinoma 4.5). In the U.S.A. the total cancermortality rate for Chinese males probably now exceeds that in White males and is similar to that in Black males.But the overall cancer-rate for Chinese women in the U.S. is significantly lower than for Black or White women, the chief difference being in much lower rates for breast and cervix uteri. The main cancer problem for Chinese of both sexes is nasopharyngeal carcinoma: over the other main racial groups males have a 26-fold excess and females a 22-fold excess. Chinese women in the U.S. also do worse than White women for carcinoma of pharynx, liver, lung, and uterine body, and they are more For the prone than Black women to leukaemia. Chinese male in the U.S., rates are below those of both other races for prostatic and bladder cancers and below those of Whites for brain tumours and leukaemia.
by Fraumeni and Mason 6 contains some surprising and stimulating observations. In the Chinese American male the risk of nasopharyngeal carcinoma is evidently decreasing; the high risk of hepatocellular carcinoma persists; susceptibility to leukaemia is about the same as in fellow Americans; The report
and the risk of colon cancer is above average. The increased tendency to colon cancer, which has not appeared in Chinese females, seems to have arisen quite quickly. Chinese women have lost their native7 high rate for choriocarcinoma, remain relatively free from breast cancer (except perhaps in Hawaii 8), but retain their excess of lung cancer/.1o which in Hong Kong, at least, is predominantly adenocarcinomatous.11I These observations fit into a whole series of investigations in migrants, founded on increasingly accurate Maxwell, J. L. China med. J. 1929, 43, 462. Ho, J. H. Rec. Adv. Cancer Res. 1972, 15, 57. Shanmugaratuam. K., Tye, C. Y. J. chron. Dis. 1970, 23, 443. Hon, P. C. J. Path. Bact. 1956, 72, 239. Belamavic, J. Cancer, 1973, 31, 468. Fraumeni, J. K., Mason, T. J. J. natn. Cancer Inst. 1974, 52, 659. Shanmugaratuam, K., Muir, C. S., Tow, S. H., et al. Int. J. Cancer, 1971, 8, 165. 8. MacMahon, B., Cole, P., Brown, J. J. natn. Cancer Inst. 1973, 52, 21. 9. Shanmugaratuam, K. Singapore med. J. 1973, 14, 69. 10. Avellano, M. G., Linden, C., Dunn, J. E. Br. J. Cancer, 1972, 26, 473. 11. Lee, S. H., Ts’o, T. O. ibid. 1963, 17, 37. 1. 2. 3. 4. 5. 6. 7.
knowledge of incidence-rates for cancer the world over. 12, 13 Such work depends on cooperation at all levels, personal, institutional, national, and international; and the results, almost without exception, point to one conclusion-that virtually all human cancers are diseases of locality and environment; as Doll put it,1there is "no cancer that is common anywhere that is not rare somewhere else ". Some agencies and institutions are trying earnestly to define the environmental factors; but epidemiological work on cancers is very inadequately financed, and the number of investigators is minuscule compared with the legions engaged in basic research ". Epidemiological work on cancer is showing lead after lead, but laboratory disciplines are seldom brought to bear. A fresh look at priorities is badly needed. "
CONTINUING EDUCATION: CONTINUING PROBLEM THE continuing education of the profession is
one
challenges of our time. Since the problems are inherently similar on both sides of the Atlantic, the subject was an opportune choice for the latest in the series of Anglo-American conferences sponsored jointly by the Royal Society of Medicine and its American counterpart the Royal Society of Medicine Inc. (this time with the University of North Carolina School of Medicine as hosts). In the event there proved to be as many contrasts as similarities. of the greatest
In the United States accreditation of institutions began in 1966. Now over three hundred are regarded as being suitable to provide postgraduate education. The area health education centres (A.H.E.C.) promote local education and research, principally on the basis that the larger units cooperate to help the smaller. The annual programme, including building, is likely The American to approach$15 million by 1980. Medical Association has played a leading part in encouraging postgraduate education (the latest education number of its journal listed 2441 courses offered by 697 institutions and organisations). Self-assessment examinations, particularly for identification and correction of areas of weakness, were introduced by the American College of Physicians in 1968. Fourteen national medical specialist societies now have programmes in operation. One innovation has been the physicians recognition award (P.R.A.) which is based on a specified number of hours’ participation in continuing education over a specified period. More controversial is the introduction of professional standards review organisations (P.S.R.O.).14 These will judge the treatment of Medicare and Medicaid patients according to local standards of care. They may reduce " chronic remunerative surgery " but may equally encourage the practice of " defensive medicine which is also very expensive. There has been an enormous increase in malpraxis suits. Of 12,000 cases in 1970, 1200 came to trial. The standard for " due skill " is infinitely higher than it formerly Doll, R., Muir, C. S., Waterhouse, J. A. H. Cancer in Five Continents; vol. II. Geneva, 1970. 13. See Lancet, March 30, 1974, p. 547. 14. Lancet, Feb. 16, 1974, p. 260. 12.