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MR. CARIDIS AND OTHERS: REFERENCES

1. Landy, M., Braum, W. (editors). Bacterial Endotoxins. Institute ofMicrobiology, Rutgers University, 1964.

2. Zetterstrom, B. E. M., Palmerio, C., Fine, J. Acta chir. scand.1964, 128, 13.

3. Zetterstrom, B. E. M., Palmerio, C., Fine, J. Proc. Soc. exp. Biol.Med. 1964, 117, 373.

4. Greisman, S. E., Woodward, C. L. J. clin. Invest. 1970, 49, 37a.5. Wolff, S. Clin. Res. 1963, 11, 231.6. Reinhold, R. B., Fine, J. Proc. Soc. exp. Biol. Med. 1971, 137, 334.7. Levin, J., Edwin, P. T., Zanber, N., Oser, R. New Engl. J. Med.

1970, 283, 1313.8. Cuevas, P., Fine, J. Surgery Gynec. Obstet. 1971, 133, 81.9. Fine, J., Frank, H. A., Schweinburg, F. B., Jacob, S., Gordon, T.

Ann. N.Y. Acad. Sci. 1952, 55, 429.10. Ravin, H. A., Rowley, D., Jenkins, C., Fine, J. J. exp. Med. 1960,

112, 783.11. Schweinburg, F. B., Fine, J. ibid. p. 793.12. Cuevas, P., Fine, J. Surgery Gynec. Obstet. (in the press).13. Cuevas, P., de la Maza, L. M., Gilbert, J., Fine, J. Archs Surg.,

Chicago, 1972, 104, 319.14. Fine, J., Caridis, D. T., Cuevas, P., Ishiyama, M., Reinhold, R. B.

in Shock Symposium (edited by B. K. Forscher). Amsterdam (inthe press).

15. Graber, C. D., Reinhold, R. B., Breman, J. G., Harley, R. A.,Hennigar, G. R. J. Am. med. Ass. 1971, 216, 1195.

16. Woodruff, P. W. H., O’Carroll, D. I., Koizumi, S., Fine, J. J.infect. Dis. (in the press).

17. Caridis, D. T., Cuevas, P., Fine, J. Surgery Gynec. Obstet. (in thepress).

18. Nahor, A., Milliken, J., Fine, J. Ann. Surg. 1966, 163, 29.19. Fine, J., Palmerio, C., Rutenburg, S. Archs Surg., Chicago, 1968,

96, 163.20. Schweinburg, F. B., Fine, J. Proc. Soc. exp. Biol. Med. 1955, 88,

589.21. Caridis, D. T., Ishiyama, M., Reinhold, R. B., Fine, J. Unpublished.22. Fine, J., Rutenburg, S., Palmerio, C. Ann. Surg. 1969, 170, 947.

Medical Education

PRIMARY CONCERN

H. A. F. DUDLEY

Department of Surgery, Monash University,Alfred Hospital, Prahran, Victoria, Australia 3181

EIGHT years ago Charnley raised the question, oftendebated before but never conclusively settled, of thepathway of entry to the ranks of specialist trainees. 1The gist of his argument was that both the primaryand final examinations constituted intellectual obstruc-tions to training and research. His strictures were

supported by Irvine who refined the criticism bytouching on relevance: " Surely ", he wrote,

" a

postgraduate aspiring to a higher surgical degreeshould be expected to know the applied physiology andclinical literature of his special field in considerabledepth ". The correspondence spluttered on for a fewweeks and then subsided. Little has since been heardof the problem. True, the London College of

Physicians has given us some insight into its examina-tion structure but there has been little debate uponthe fundamental issue raised by Irvine-that ofrelevance. Briefly, the issue can be stated thus: whatis essential knowledge for a graduate at any stage in histraining programme, given that this programme hasa particular technical direction ? A supplementaryquestion might be: what, in addition to this, might beregarded as desirable both in knowledge and attitude ?The distinction between essential and desirable has

become enshrined as " core " and " peripheral " inmany curricular analyses. 4 In university educationthere is much room for debate on the distinction and

its worth. However, in the more confined area oftechnical performance, there is greater need to preventan individual from doing this or that until he hasshown a grasp of the conceptual and factual tools

necessary for the job. To recall an overworked butuseful analogy, we would not place ourselves in thehands of an airline pilot who had demonstrated hisability to perform a simulated take-off under varyingconditions only 50% of the time. We would expecthim to have the core skills and knowledge to achievethis at least 99% of the time. Likewise with post-graduate education for the technological specialties,of which surgery is one.How is " core " to be defined ? Choice of items and

concepts at any stage will depend upon the concurrentaims of training. It can be assumed that when a

primary examination for the F.R.c.s.(Eng.) was

introduced, this definition was made, if not deliberately,at least by intuitive reference to what the traineeseemed to need. At that time the core skill was adetailed knowledge of regional anatomy so thatwherever the diversified surgeon might put his knifehe would not do harm. Allied to this was an under-standing of gross and microscopic morbid anatomy sothat he might recognise what he saw and discuss its

histology intelligently with a pathologist colleague.Operations directed at physiological processes wereuncommon, surgical care was largely passive, and suchapprenticeship as the embryo surgeon served wasrelated more to menial tasks than to control of thepatient’s course through an assault on homoeostasis.Thus it came about that the primary examination wasfounded firmly on regional and morbid anatomy. In

many medical schools, surgeons had strong associationswith the basic science departments teaching these

subjects and were able to enter with equality andgusto into the examining system. Physiology, bio-chemistry, and new aspects of microbiology, as theybecame increasingly needed for the surgical patient,found no such traditional understanding or alliance.Consequently, they were largely grafted on at theinvitation of the surgeon and at the instruction of hisacademic colleagues in these areas, rather than withan understanding of their relevance.

TODAY’S APPRENTICE

In training for surgery all this has now changed.The surgical apprentice reaches the high road ofskilled performance by treading the pathway of

surgical care: he is expected to look after people ashis primary task and to deploy a wealth of appliedphysiological and other basic scientific knowledge inorder to do so. Much of this he may have acquired" once through " in his undergraduate course, but all

of it needs to be refreshed in the context of his surgicalpatients; extension is also necessary into those areasof learning which have particular application to

surgery. In addition to this concentration on care,surgeons seem tacitly, if reluctantly, to have agreedthat some forms of specialisation are desirable froman early period of training. Thus, choice of a discipline,within surgery as a whole, should dictate the specificdetailed knowledge in any basic science field withwhich the trainee should be equipped in order to

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plan and execute operations. For example, all surgeons

B will know about neural structure and the transmissionof a nerve impulse; neurological and otorhinolaryngo-logical surgeons should know about the detailedconnections of the eighth cranial nerve, whereas

gastroenterologists and cardiac surgeons will con-

centrate on the tenth.The definition of core for the primary examination

of today rests, then, on defining those aspects of thebasic sciences that on the one hand are necessary tocare for surgical patients and on the other hand canform a springboard for detailed regional or intra-

disciplinary knowledge in that specialty the traineewill subsequently undertake. The emphasis on compre-hensive anatomical knowledge at this stage must beunequivocally and explicitly removed; similarly, andof equal importance, invasion by other subjects whichcan carry irrelevant material must be resisted. Both

goals dictate precise factual and conceptual syllabusdefinition-an aim itself justified by the practicalnature of surgery. Within such definitions must be

preserved the possibility of change, for the presenttopsy-turvy position of examining in anatomy beforeit is needed and in other subjects, without detailedconsideration of relevance, has been reached becauseof the lack of machinery to respond to change.

AUSTRALASIAN INNOVATION

The Royal Australasian College of Surgeons hasset out recently to achieve order, relevance, andflexibility: order, by restructuring the examinationinto an integrated one in the basic sciences rather thanin separate disciplines of anatomy, physiology, andpathology; relevance, by syllabus review both initiallyand on a continuing basis; and flexibility, by abandon-ing the textbook as a major learning tool.The choice of an integrated examination was made

on three grounds. First, clinical problems do notpresent in the separate disciplinary areas of conven-tional learning-cross-relationship is always present,and it is at least a tenable hypothesis that knowledgeof relationships between facts contributes to problemsolving. Second, the task of producing agreement ona syllabus (and on an examination) is a much fairer andmore rewarding one for teachers and taught if it isilluminated by the counsel and criticism of those whosee your field from the outside; thus the criteria ofrelevance and of the proper order for the acquisitionof knowledge are more likely to be met. Third, ifthere is, as should be the case, a desire to eliminateredundancy and secure agreement, particularly inrelation to basic concepts, this can only be achievedif all the disciplines are contributing to a detailedanalysis of the syllabus. To take a simple examplethe dynamics of the thoracic structures and respiratorymuscles are important for surgical care: acquisition offacts and concepts in relation to them is therefore partof basic surgical science. However, the method oftreatment of the information is usually different in ananatomical from that in a physiological text, andneither may highlight the points of importance to thesurgeon faced with a patient with a crushed chest.Only by bringing all together is it possible accuratelyto instruct the candidate in what he should know.

Often this process emphasises uncertainty in the mindsof all and leads to a reappraisal of the whole area.

TEXTBOOKS

If a debate is initiated and continued, as it must bewith the system described, on the structure and orderof a syllabus, it soon becomes apparent that thetextbook is an inappropriate single way of impartinginformation. It has too many diversified reasons forits creation to provide a suitable guide.5 5 Its delaysin production are such that it cannot rapidly incorporateadvances that have become part of care or eliminate

ways of thinking or facts that have lost relevance.

Consequently those engaged in the debate over thesyllabus must do more than specify, they must alsoexpound. Instructions to the trainee in the Austral-asian scheme are in two forms: the general headingsfor the subject matter on the basic sciences he mustencompass; and the specific, detailed content underthese headings of which he must have knowledge.The latter may be indicated by reference to parts orpages of given texts, by original articles, particularlyin review form, and by the production of writtenmaterial where neither of the first two suffices. The

publication of such detailed information conveys withit the clear statement that when a change or additionis made the new material does not become examinablefor six months. The candidate is thus fully conversantwith what he must know for any given date of examina-tion. Moreover, the scene is set for a rolling system ofsyllabus change to which all can be party-examiner,teacher, and trainee. The syllabus emerges as a

loose-leaf manual, updated twice a year-a product ofa committee maybe with all the disadvantages in sucha system, but at least a manifestation of responsibilityby the examining body for what should be taught andlearnt.

It can be objected that this method is spoon-feeding : this is true if by that term is meant detailedspecification alone. However, if room is left forintellectual effort and interpretation, the system is noworse and certainly better in some respects that thepassive aspiration of facts from that text which,rumour has it, gave rise to the most effective pass-ratesin the last examination. It may be remarked in passingthat all this is but the formalising of a technique longused by effective teachers for goal-oriented pro-grammes : notes are made, expanded, and revised inrelation to known or inferred syllabus items, derivedoften from feedback from examiners and their

expressed wishes (or whims), and circulated to

candidates. In the 1930s in Edinburgh, Ian Aird’snotes for the second part, ultimately and perhapsregrettably to see the light of day as a textbook,circulated among the cogniscenti as a certain way ofpassing the examination for fellowship. Their

immediacy and relevancy was better established thanthat of any text.

OBJECTIVE TESTINGDefinition of syllabus in this manner carries the

implicit contract with the candidate that he will beexamined on the material of the syllabus and nothingelse. Objective testing is a necessary corollary ofsyllabus definition, and the best instrument shouldgrow by a similar consensus to that which has been

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used to produce the syllabus. For a variety of otherreasons there is already a swing towards objectiveexamining in all primaries, and by 1973 the AustralasianCollege will be offering an examination, linked tosyllabus definition, which is entirely on this basis.Few would deny that objective testing has manypitfalls and some inadequacies, but a properly con-structed examination on a defined syllabus should beable to assess whether candidates are fit or not to passto the next stage of training.The introduction of objective testing as the sole

instrument of the primary raises the question whetherthere is any longer any need for separate examinationsconducted by individual colleges. The principles ofsurgical care, and the basic science knowledge necessaryfor it, are the same in Kuala Lumpur and Kensington,or in Melbourne and Manchester. Details of subse-quent technical knowledge for practice in a specificfield may vary, although this is arguable. If only anagreed syllabus could be formulated, then it would bebut a small step-and one based on educationaltechnology-to a primary examination which could besat anywhere in the world. This would largely stopthe present shopping around in search for the " easiest"examination. It would remove the venal temptationto make the examination easy in the interests of theCollege coffers. And it would do more to cementCommonwealth relations than any number of jointmeetings at which resolutions are passed, but littleaction taken. Candidates would have the opportunityto travel with more worthy aims than finding a warmcollege library and a theoretical course of instructionleading to success in an examination. It would remaina necessary stepping-stone in their advancement, butone which could be largely surmounted while inservice because of the relevancy of its subject matter.The inconoclastic reader might say-why all this

fuss ? Why have a primary examination at all ? In-service training and continuous assessment may ofthemselves be enough to ensure that candidates forplaces in jobs where surgical skills are deployed aresufficiently well qualified. This may be so, but itremains a fact of life that if, in our complex society,we entrust ourselves to the skill of others, we like tomake sure that they have been tested in some way,whoever they may be-captains of ships, pilots of

airliners, designers of bridges. (Indeed, in medicine,where technical performance now looms so large, wehave been slow to develop and refine our procedures,by comparison with other fields, perhaps mainlybecause the job specification has been so diffuse andill-formulated.) In these technical fields, the criteriaof the test are that it should be relevant and compre-hensive. So also should it be with surgery.

I am grateful to many colleagues in the Australasian Collegeand on its Part I Examining Board for discussions. Particularlyto Professors H. Eddey and D. Tracy, who have given me a freehand to express my own heterodox views. However, I write asan individual and the above paper does not set out to reflect theAustralasian College’s policy.

REFERENCES

1. Charnley, J. Br. med. J. 1964, i, 1249.2. Irvine, W. T. ibid. p. 1437.3. Owen, S. G., Robson, M., Sanderson, P. H., Smart, G. A., Stokes,

J. F. Lancet, 1967, ii, 1034.4. Dudley, H. A. F. Br. J. med. Educ. 1969, 3, 155.5. Dudley, H. A. F. Lancet, 1966, i, 589.

Letters to the Editor

HISTORY OF RANDOMISED

CONTROLLED TRIALS

SIR,-Dr. D’Arcy Hart (April 29, p. 965) does well toremind us of some of the early examples of carefullycontrolled clinical trials. However, his account of the trialof which Amberson et aU published a description in 1931is incorrect in one important respect. The authors divided24 patients " into two approximately comparable groupsof 12 each. The cases were individually matched, onewith another.... Then, by a flip of the coin, one groupbecame identified as group I (sanocrysin-treated) and theother as group II (control) ". This may be the first instanceof coin-tossing in medical trials, but it cannot be regardedas a satisfactory example of randomisation. There is noguarantee, even in probabilistic terms, that the groupswere comparable in all relevant respects. The authorseffectively used two large experimental " units " (the twogroups), which they had reason to regard as rather similar,and performed a single act of randomisation. There was,therefore, no replication of the sort that would have beenprovided if there had been a spin of the coin for each pair(as in Dr. D’Arcy Hart’s description), and therefore novalid basis for statistical interpretation of the results.Some of the earlier trials in which patients were allocated

by strict alternation are perhaps closer to the spirit ofmodern randomisation. Bull 2 describes a trial by Fibiger 3in which a therapeutic serum was used for alternate casesof diphtheria. Karl Pearson,4 faced in 1904 with the diffi-culties of assessing the effectiveness of anti-typhoidimmunisation from uncontrolled studies, advocated its usefor alternate subjects. This is a particularly interestingreference, since Pearson is not normally associated withtechniques of experimental design which were later de-veloped so brilliantly by R. A. Fisher.London School of Hygiene and

Tropical Medicine,Keppel Street (Gower Street),

London WC1E 7HT. P. ARMITAGE.

ASSESSMENT AND MANAGEMENTOF SEVERE ASTHMA

SiR.—The emphasis of your leading article (May 13,p. 1055) would be misleading if intended to be appropriateto severe asthma at all ages. The leader opened with thedisturbing reminder that when the circumstances of deathin 52 young asthmatics were investigated, no less than 42had died suddenly of asthma in their homes in Englandin 1968-69. Ii

The leader continued with a review of the assessment andcare of adult patients admitted to hospital with severeasthma. Recent experience with severe asthmatic childrensupports the view that such patients are best managed inintensive-care units. Over a period of 33 months (1968-70)there were 74 children admitted with severe asthma to the

’ intensive-care unit of the pasdiatric department in theColorado General Hospital, Denver. 49 were hypercapnicon admission, and all but one survived. 28 with moderatehypercapnia (P aC02 40-65 mm. Hg) recovered on intensivemedical therapy. 21 had severe hypercapnia (pc02 over65 mm. Hg); of these, 7 recovered on medical care, and

1. Am. Rev. Tuberc. 1931, 24, 401.2. J. chron. Dis. 1959, 10, 218.3. Hospitalstidende 1898, 4, 6, 309, 337.4. Br. med. J. 1904, ii, 1243.5. Fraser, P. M., Speizer, F. E., Waters, S. D. M., Doll, R., Mann,

N. M. Br. J. Dis. Chest, 1971, 65, 71.