acronym, but deals with only a minor part of the variability in measured performance. The logistics of clinical examinations do not allow each student enough cases for detailed statistical analysis of performance, but two long cases would be reasonable, provided both the lower and the higher marks were considered in deciding the pass or fail grade of the student. A low enough grade in either case should be enough to require further training in specific areas. It is sobering to note that lawyers thrive on doctors’ errors, but our triumphs of skill and ingenuity merely give personal satisfaction and some recognition by our colleagues. On a more personal note, if a doctor failed to diagnose my (hypothetical) prostatic carcinoma, it would be small consolation to know that he had done brilliantly in his clinical long case on multiple sclerosis.
of the drug. The patient started attending an outpatient detoxification programme. Nevertheless, a random blood sample in October yielded a serum fentanyl concentration of 3-48 ng/mL, indicating continuing misuse. Late in November the patient was readmitted, complaining of nausea and muscle stiffness, but without cardiorespiratory compromise. The serum concentration of fentanyl by now had reached 21-2 ng/mL. This underscores the fact that, with regular misuse, physical and mental dependence as well as tolerance are likely to develop. Illicit fentanyl seems to be gaining popularity in Europe. Because fentanyl is chemically unrelated to morphine, it is not reactive in immunoassay screening tests for opioids. We therefore suggest that it should be specifically tested for, particularly in cases with suspected opioid misuse, good response to naloxone, but negative screening for morphine and the like. Unfortunately, it is to be anticipated that these tests will need to be carried out post mortem in many drug misusers *A I L Berens, A J Voets, P Demedts *Department of Psychiatry, Algemeen Ziekenhuis Stuivenberg, 2060 Antwerp, Belgium; Department of Internal Medicine, Slotervaartziekenhuis, Amsterdam, Netherlands; Laboratory of Clinical Chemistry and Toxicology, AZ Stuivenberg, Antwerp l Poklis A. Fentanyl: a review for clinical and analytical toxicologists. Clin Toxicol 1995; 33: 439-7. 2 Henderson GL. Fentanyl-related deaths: demographics, circumstances, and toxicology of 112 cases. J Forensic Sci 1991; 36: 422-33. 3 Smialek JE, Levine B, Chin L, et al. A fentanyl epidemic in Maryland 1992. J Forensic Sci 1994; 39: 159-64. 4 Hibbs J, Perper J, Winek CL. An outbreak of designer-drug related deaths in Pennsylvania. JAMA 1991; 265: 1061-63.
Long-case clinical examinations SIR-van der Vleuten’s March 16 commentary’ on longcase examinations was timely, and he states clearly the statistical problems of reliability. However, I question his views on validity. I start with three assumptions. The first is that the principal role of medical graduates is to prevent, diagnose, and treat illnesses; the second is that the primary aim of medical education is to produce broadly capable and safe practitioners; and the third, that examinations and assessments govern what the medical student will learnthey de facto define the curriculum. If these assumptions are correct then clinical long-case examinations are central to assessment. They must therefore be retained and made relevant to clinical medicine. The publications that van der Vleuten cite indicate that there are wide and real differences in the competency of students in different clinical situations. It seems that we are not testing underlying clinical abilities, but rather several task-dependent skills. Taking the mean mark of several such cases does not answer the problem. Rather, we should use the information contained in the variability of the marks. For the statistically minded, the coefficient of variation is just as important as the mean mark. We should congratulate the student and clinical tutor on good performances and then concentrate on the importance of the lower grades. Soon after graduation, the former student will be consulted by patients who may have any disease, or no disease at all. If the doctor has defective areas of clinical knowledge, then he or she is not "safe", no matter how high the best or average mark in clinical examinations. The objective structured long examination record (OSLER) suggested by van der Vleuten has the advantage of a catchy
Alan
Dugdale
Department
of Child Health,
University of Queensland, Q 4072, Australia
Uninsured in the USA SiR-Your March 16 editorial’ underscores a lamentable decline in objectivity coupled with lurid and inflammatory writing. Decrying "deceit" in industry lobbyists and "Republican saboteurs" for interdicting "a well-intentioned new President," you equate health insurance with "a social prescription for deciding who does or does not get to see the doctor according to need". No evidence is proffered, however, to substantiate a lower level of physician contact or provision of medical services for uninsured Americans than, for example, workers in the UK who are benefactors of a universal coverage system. The flaw in your argument is the presumption that, in the USA, those without insurance are denied medical care. To illustrate your faulty logic, consider the medical events attending the collapse from a myocardial infarction of an illegal alien on a city street. Would coronary angioplasty or bypass surgery be as likely in London or Liverpool as in New York or San Francisco? Further to the point, who would be more prone to get a bone marrow transplant for acute myelogenous leukaemia, an uninsured child in New York City assigned an urgent Medicaid number, or a working class child with standard insurance in London? Similarly, under which system is hip replacement more probable? Finally, you need look no further than the prevalence of treatment for otherwise fatal end-stage renal disease (302 per million in the UK versus 802 per million in the USA2) to appreciate how disingenuous are your crocodile tears for undeserved Americans. Unquestionably, serious flaws exist in the delivery of medical care in the USA. Indeed, the cost of high technology diagnostic and therapeutic regimens stresses hospitals, insurers, and physicians striving for egalitarian provision of services. Many well motivated agencies now struggle to effect a rational resolution to the recognised need for universal health care here. While this evolutionary process continues, The Lancet’s outrage, sarcasm, scathing criticism, and invectives dissipate creative energy that is sorely needed to correct deficiencies within the UK. Eli A Friedman University of New
State
York Health Science Center at
Brooklyn,
Box 52,
Brooklyn,
NY, USA
1 2
Editorial. Uninsured in the USA, and still waiting. Lancet 1996; 347: 703. US Renal Data System, USRDS 1995 Annual Data Report. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, April, 1995: 167.
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