934
Health in tobacco control SIR,-During the past few decades various efforts to control the of tobacco products have been undertaken because of the serious
use
health consequences of tobacco smoking; the objective is to promote health. However, the health aspect seems to have been forgotten in some cases where very strict, restrictive legislation is being advocated. Thus, for example, prohibition may only work for behaviours under rational control. However, maintenance of tobacco use is largely attributable to nicotine dependence,’ an addiction that cannot easily be eliminated by legislation alone. Therefore, although we agree that legislation should be regarded as an indispensible part of tobacco use control, we suggest that maximum restriction may not necessarily provide maximum benefits to health. There is, clearly, a danger that these policy issues may be too simplistic. An example is provided by the proposal of an EC directive that would force its member states to prohibit the sale of moist snuff (fine-grained smokeless tobacco for oral use) (see March 21, p 732). Although the use of this product does, indeed, entail certain health risksthese risks are small compared with those of tobacco smoking.3,4 Yet virtually all snuff users are nicotine dependent and if deprived of their usual source of nicotine they will probably switch to cigarette smoking. These people would consequently be exposed to an increased health risk by such legislation. In some countries the use of snuff is so rare that these concerns seem unnecessary. In others, however, the increased health risks will probably affect a subtantial number of people-for example, close to one million people in Sweden alone. The World Health Organisation study group on smokeless tobaccos made clear distinctions between countries with different tobacco use and traditions and did not recommend a ban of smokeless tobacco in those where the products are already well established. If the use of moist snuff among young people tended to increase the prevalence of adolescent smoking, this would be an argument for a ban, but the longlasting experience from Sweden suggests that this is not SO.6 Tobacco control efforts should be based on a comprehensive combination of various strategies applied with caution to avoid negative side-effects but to obtain the best reduction of tobaccorelated morbidity and mortality and, thus, to promote health. Kabi Pharmacia, S-251 09 Helsingborg, Sweden
K. O. FAGERSTROM
Institute for Tobacco Studies, Stockholm
L. M. RAMSTROM
Department of Pharmacology, Karolinska Institute, Stockholm
T. H. SVENSSON
1. US
Department of Health and Human Services Nicotine addiction: a report of the Surgeon General 1988. DHHS publication no 88-8406, Rockville, Maryland:
Center for Disease Control, 1988. 2. US Department of Health and Human Services The health consequences of using smokeless tobacco: a report of the advisory committee to the Surgeon General. National Institute, of Health publication no 86-2874, Bethesda Maryland’ NIH, 1986. 3. Axell T, et al. Snusning och munhålecancer—en retrospektiv studie (Snuff dipping and oral cancer: a retrospective study). Lakartidningen; 75: 2224-26. 4. Huhtasaari F, et al. Ar snusning mindre farligt for hjartat an rokning? (Is snuff dipping less harmful to the heart than smoking?). In: 1991 National Congress of Medicine, Swedish Medical Society, Stockholm, 1991: 182. 5. World Health Organisation. Smokeless tobacco control. Report of a WHO study group. Tech Rep Ser 773. Geneva: WHO, 1988. 6. Ramstrom L. Smokeless tobacco: a potential gateway to smoking? In: Durston B, Jamrozik K, eds. Tobacco and health 1990 the global war (Proceedings of the Seventh World Conference on Tobacco and Health, 1990.) Perth: Health Department of Western Australia, 1991: 451-52.
London’s
hospitals: a fossil’s reply
SiR,—Articles by Malcolm Dean should be read with care by the older fossils of London, for he seems to have a direct line to those preparing the fourth (or is it the fifth?) special report on London since 1968. His March 28 article abounds with prejudice, which portrays coded messages for those who await the report of the most recent inquiries into the London medical schools. May I, through your columns, seek to interpret these coded messages to forewarn the blissfully contented, glamorous, status seeking, Nelsonian London consultant? The barbarian hates history ("lots and lots of
history") so beware the Medieval schools; a high land value ([150 million) is too tempting, so poor St Thomas’ and perhaps St Bartholomew’s are just too rich a prize. On the other hand the east end of London, with its inner city deprivation and its old buildings, is just like home, so the Royal London is bound to survive, especially since it foreshadowed the modem pattern of medical education rather than earlier foundations by its marriage to Queen Mary College. St Mary’s can take some solace in their marriage with Imperial College, but their predilection for rugby, rag days, and student balls is frowned upon as decadent. If a school is dominated by clinical staff and more closely associated with its parent hospital than with the University, the outlook is grim, so those distanced on Hampstead Heath or in the marshes of Fulham and Chelsea having rejected solicitations from the University may well find the fairy tale coming to an end. In case the glamorous consultant applies the telescope to the wrong eye Dean adds intent to his message by pointing out the failure of the three (or is it four?) previous reports to effect change. Producing eight medical schools from twelve is merely called restructuring, compared with the radical departures that should make the hospital-bed-based approach as outdated as some of London’s buildings. In fact, Tomlinson believes that older buildings are more adaptable than buildings of the 1960s. The final thrust drives to the very heart of traditional London teaching-the patient. The student does not need them. The solution was drawn up at Maastricht. The answer-the student needs a "skillslab" which allows him (it is always "him") to practise physical examinations, therapeutic skills, interviews, and counselling without a real patient in sight. Enough is enough. If a group is told for long enough that they are underperforming fossils, they will believe it; this situation has arisen in London, for the once proud London surgeon is but a technocrat-a hard working, dour drudge living under the cloud of progress. Yet, it is doctors in the acute sector, particularly surgeons, who have made possible some of the advances that have enabled medically disabled people to return to the community, creating the historic switch of focus from the cure of specific disease to the management of disability and handicap. Community is a word uttered with bated breath; it is the new "God" and encompasses all that is excellent about the new medicine. Its advantages are so great and so obvious that no trial, no study, no statistical meta-analysis is necessary to determine that scarce resources should be mainly directed there. By similar logic students must be taught there. Expensive acute hospitals drain resources from the community, and so should be curtailed, yet who is going to manage the leukaemic child or the cirrhotic mother? As so often in medical matters, there is a lack of appreciation of the difference between the requirements of the acute and community sectors. Both are essential, and both need different solutions. Us older fossils do want London’s teaching-hospital crisis to have a happy ending, but not one in which the hospital is submerged as an annex of the community. We want to be able to hold up our heads in Europe, the USA, and the developed third world, to be equal in our achievements, and to have something to show our visitors about which we can be proud. The present inquiries have an awesome responsibility, for strong, vigorous, and internationally recognised teaching hospitals in London will ensure the good health of British medicine. Middlesex Hospital, London W1 N 8AA, UK
R. C. G. RUSSELL
Impact of staffing structure on hospital laboratory productivity and cost SIR,-Staff costs are generally accepted as being about 70% of a laboratory’s total budget. There has lately been a trend towards employing low-paid unqualified staff with a few highly trained (and highly paid) staff to manage them. Services provided by pathology laboratories were evaluated with a view to rationalising laboratory work within the Guy’s and Lewisham Trust. The effects of the different staffing structures of the clinical biochemistry departments were compared in the two hospitals. The equipment for routine analysis and the total staff number is similar at both sites. In the previous 5 years the total
935
SUMMARY OF DATA FROM SERVICES REVIEW DOCUMENT’ I
I
...I
-I
We believe that research in the care of desperately ill people is important and that society would not wish it to be obstructed. Major advances are being made in intensive care, especially in septic shock, and these have the potential to save many lives. It is better that new interventions should be studied systematically rather than on an ad hoc basis, as will inevitably happen if LRECs place insuperable difficulties in the way of researchers. Child Development Centre, St George’s Hospital, London SW17 0QT, UK
DAVID HALL
1. Petros
A, Bennett D, Vallance P. Effect of nitric oxide synthase inhibitors hypotension in patients with septic shock. Lancet 1991; 338: 1557-58.
*New appointment with shared responsibilities totally funded from Guy’s budget
at
Guy’s
and Lewisham,
AZT: zidovudine
although
SIR,-Medication
errors
or
on
azathioprine?
sometimes involve
drug
names
that
number of tests undertaken by each laboratory increased by an average of 10% per year. Unlike other teaching hospitals, the Guy’s clinical department is not supported by a large academic department, so the financial situation is comparable with Lewisham. Lewisham has adopted the currently popular structure of a small number of biochemists working with a large number of medical laboratory scientific officers (MLSOs), medical laboratory assistants (MLAs), and clerical staff (ratio 1/4-5), whereas Guy’s has maintained a larger proportion of biochemists (1/14). The table shows details of the staff structure, workload, and productivity of the two laboratories in 1990/1991. This clearly shows that the Guy’s site achieves the greater productivity. A wider range of tests including the more complex analyses needing substantially greater staff time are provided at Guy’s, suggesting even greater efficiency at that site. One possible reason for this large difference is the hidden cost of constant training and supervision of MLAs and low-paid trainee staff who have little motivation, often have poor sickness records, and tend to move on to alternative employment. Biochemists are highly trained scientists with a full understanding of the tests they carry out, ability to adapt quickly to new technology, and a far greater commitment to their work than trainees. They also, with medical staff, share the responsibility of providing advice out of hours. It may prove costly to switch from highly trained scientists to staff with limited skills and motivation when robotics technology may soon replace, not the highly educated staff, but the "button
sound alike or are spelled similarly.l,2 Two cases where azathioprine was ordered in place of zidovudine illustrate the serious risk in using abbreviations when communicating prescriptions. The two patients were HIV infected and had CD4 counts below 500/µl. One was a 27-year-old inpatient in the psychiatry service and the other was a 33-year-old woman being cared for on an obstetrics and gynaecology ward. The infectious diseases service had recommended antiretroviral therapy with "AZT" (for azidothymidine) and the prescribing physicians tried to locate AZT in the hospital’s computerised information system. However, in our system this drug can only be ordered by its generic name (zidovudine) or brand name (Retrovir). When looking under "A" section they could not find AZT and chose azathioprine by mistake. The orders for azathioprine were filled by the pharmacy but fortunately the errors were discovered in time-by the attending infectious diseases physician and by a doctor of pharmacy student. A similar incident3 demonstrates how easily error can occur when unofficial names of drugs are used. It has been suggested that the abbreviation AZT be abandoned in favour of ZDV, which more accurately reflects the generic name. However, it would appear wise to avoid abbreviations altogether. Had the prescribing errors reported here not been picked up in time the consequences for the patients (and the health care professionals) might have been disastrous.
pushers".
Philadephia College of Pharmacy and Science and Hahnemann University, Philadephia
S. BIRD M. J. MICHELIN P. A. TOSELAND J. TOWNSEND P. W. TUTT
Clinical Biochemistry Department, 5th Floor Guy’s Tower,
Guy’s Hospital, London SE1 9RT, UK
Philadelphia College
M. THERESA AMBROSINI
of Pharmacy and Science
Department
HILARY D. MANDLER
of Medicine,
Hahnemann
University, Philadelphia, Pennsylvania 19102, USA
CRAIG A. WOOD
J, Azzugnuni M, Di Romana S, Vanhaeverbeek M. Fatal confusion between Losec and Lasix. Lancet 1991; 337: 1286. 2. Kurth MC, Langston JW, Tetrud JW. "Stelazine" versus "Selegiline": a hazard in prescription writing. N Engl J Med 1990; 323: 1776. 3. Cohen MR. AZT: a dangerous abbreviation. Hosp Pharm 1988; 23: 691. 1. Faber
1. Coker N. Clinical services review: Trust. February, 1992.
Ethical
pathology services. London: Guy’s and Lewisham
emergencies
SIR,-Your correspondents (March 14, p 682) indicate some justifiable concern about the ethics of research on patients in intensive care, who are not able to give consent for such studies. As chairman of the Wandsworth Health Authority local research ethics committee (LREC) that approved the study reported by Petros and colleagues,l I would describe the view adopted by our committee members on this difficult issue. We do not believe that relatives should be asked to sign consent, since they have neither the moral nor the legal authority to do so. Instead, they are told about the project and given the opportunity to object on behalf of the sick person. The explanation given to the relatives must be witnessed by a senior nurse or equivalent person who is not directly involved with the research. Moral responsibility for research projects in this situation is shared between the investigators and the LREC, and the members must satisfy themselves that the project is of sufficient importance to justify an additional intervention in the care of a very sick patient.
Language tests for EC doctors graduates from developing adequately qualified practise medicine in the UK they are required to take the professional and linguistic assessment board (PLAB) test before they are allowed to register with the General Medical Council (GMC). The need for the English language component of the test for overseas graduates is indisputable, even though graduates from most countries-for example, those from the Indian subcontinent--are taught in English. Medical graduates from European Community (EC) countries SiR,—To
countries
are
assess
whether medical
are
exempt from such
to
assessment
and
are
entitled
to
GMC
registration because they qualified in the EC. An increasing number of EC graduates are being appointed to junior hospital posts in the UK. I was recently a locum medical registrar in a Scottish district general hospital. All five junior house officers were EC graduates (4 from Germany and 1 from Spain). Nursing and senior medical staff,
Health in tobacco control SIR,-During the past few decades various efforts to control the of tobacco products have been undertaken because of the serious
use
health consequences of tobacco smoking; the objective is to promote health. However, the health aspect seems to have been forgotten in some cases where very strict, restrictive legislation is being advocated. Thus, for example, prohibition may only work for behaviours under rational control. However, maintenance of tobacco use is largely attributable to nicotine dependence,’ an addiction that cannot easily be eliminated by legislation alone. Therefore, although we agree that legislation should be regarded as an indispensible part of tobacco use control, we suggest that maximum restriction may not necessarily provide maximum benefits to health. There is, clearly, a danger that these policy issues may be too simplistic. An example is provided by the proposal of an EC directive that would force its member states to prohibit the sale of moist snuff (fine-grained smokeless tobacco for oral use) (see March 21, p 732). Although the use of this product does, indeed, entail certain health risksthese risks are small compared with those of tobacco smoking.3,4 Yet virtually all snuff users are nicotine dependent and if deprived of their usual source of nicotine they will probably switch to cigarette smoking. These people would consequently be exposed to an increased health risk by such legislation. In some countries the use of snuff is so rare that these concerns seem unnecessary. In others, however, the increased health risks will probably affect a subtantial number of people-for example, close to one million people in Sweden alone. The World Health Organisation study group on smokeless tobaccos made clear distinctions between countries with different tobacco use and traditions and did not recommend a ban of smokeless tobacco in those where the products are already well established. If the use of moist snuff among young people tended to increase the prevalence of adolescent smoking, this would be an argument for a ban, but the longlasting experience from Sweden suggests that this is not SO.6 Tobacco control efforts should be based on a comprehensive combination of various strategies applied with caution to avoid negative side-effects but to obtain the best reduction of tobaccorelated morbidity and mortality and, thus, to promote health. Kabi Pharmacia, S-251 09 Helsingborg, Sweden
K. O. FAGERSTROM
Institute for Tobacco Studies, Stockholm
L. M. RAMSTROM
Department of Pharmacology, Karolinska Institute, Stockholm
T. H. SVENSSON
1. US
Department of Health and Human Services Nicotine addiction: a report of the Surgeon General 1988. DHHS publication no 88-8406, Rockville, Maryland:
Center for Disease Control, 1988. 2. US Department of Health and Human Services The health consequences of using smokeless tobacco: a report of the advisory committee to the Surgeon General. National Institute, of Health publication no 86-2874, Bethesda Maryland’ NIH, 1986. 3. Axell T, et al. Snusning och munhålecancer—en retrospektiv studie (Snuff dipping and oral cancer: a retrospective study). Lakartidningen; 75: 2224-26. 4. Huhtasaari F, et al. Ar snusning mindre farligt for hjartat an rokning? (Is snuff dipping less harmful to the heart than smoking?). In: 1991 National Congress of Medicine, Swedish Medical Society, Stockholm, 1991: 182. 5. World Health Organisation. Smokeless tobacco control. Report of a WHO study group. Tech Rep Ser 773. Geneva: WHO, 1988. 6. Ramstrom L. Smokeless tobacco: a potential gateway to smoking? In: Durston B, Jamrozik K, eds. Tobacco and health 1990 the global war (Proceedings of the Seventh World Conference on Tobacco and Health, 1990.) Perth: Health Department of Western Australia, 1991: 451-52.
London’s
hospitals: a fossil’s reply
SiR,—Articles by Malcolm Dean should be read with care by the older fossils of London, for he seems to have a direct line to those preparing the fourth (or is it the fifth?) special report on London since 1968. His March 28 article abounds with prejudice, which portrays coded messages for those who await the report of the most recent inquiries into the London medical schools. May I, through your columns, seek to interpret these coded messages to forewarn the blissfully contented, glamorous, status seeking, Nelsonian London consultant? The barbarian hates history ("lots and lots of
history") so beware the Medieval schools; a high land value ([150 million) is too tempting, so poor St Thomas’ and perhaps St Bartholomew’s are just too rich a prize. On the other hand the east end of London, with its inner city deprivation and its old buildings, is just like home, so the Royal London is bound to survive, especially since it foreshadowed the modem pattern of medical education rather than earlier foundations by its marriage to Queen Mary College. St Mary’s can take some solace in their marriage with Imperial College, but their predilection for rugby, rag days, and student balls is frowned upon as decadent. If a school is dominated by clinical staff and more closely associated with its parent hospital than with the University, the outlook is grim, so those distanced on Hampstead Heath or in the marshes of Fulham and Chelsea having rejected solicitations from the University may well find the fairy tale coming to an end. In case the glamorous consultant applies the telescope to the wrong eye Dean adds intent to his message by pointing out the failure of the three (or is it four?) previous reports to effect change. Producing eight medical schools from twelve is merely called restructuring, compared with the radical departures that should make the hospital-bed-based approach as outdated as some of London’s buildings. In fact, Tomlinson believes that older buildings are more adaptable than buildings of the 1960s. The final thrust drives to the very heart of traditional London teaching-the patient. The student does not need them. The solution was drawn up at Maastricht. The answer-the student needs a "skillslab" which allows him (it is always "him") to practise physical examinations, therapeutic skills, interviews, and counselling without a real patient in sight. Enough is enough. If a group is told for long enough that they are underperforming fossils, they will believe it; this situation has arisen in London, for the once proud London surgeon is but a technocrat-a hard working, dour drudge living under the cloud of progress. Yet, it is doctors in the acute sector, particularly surgeons, who have made possible some of the advances that have enabled medically disabled people to return to the community, creating the historic switch of focus from the cure of specific disease to the management of disability and handicap. Community is a word uttered with bated breath; it is the new "God" and encompasses all that is excellent about the new medicine. Its advantages are so great and so obvious that no trial, no study, no statistical meta-analysis is necessary to determine that scarce resources should be mainly directed there. By similar logic students must be taught there. Expensive acute hospitals drain resources from the community, and so should be curtailed, yet who is going to manage the leukaemic child or the cirrhotic mother? As so often in medical matters, there is a lack of appreciation of the difference between the requirements of the acute and community sectors. Both are essential, and both need different solutions. Us older fossils do want London’s teaching-hospital crisis to have a happy ending, but not one in which the hospital is submerged as an annex of the community. We want to be able to hold up our heads in Europe, the USA, and the developed third world, to be equal in our achievements, and to have something to show our visitors about which we can be proud. The present inquiries have an awesome responsibility, for strong, vigorous, and internationally recognised teaching hospitals in London will ensure the good health of British medicine. Middlesex Hospital, London W1 N 8AA, UK
R. C. G. RUSSELL
Impact of staffing structure on hospital laboratory productivity and cost SIR,-Staff costs are generally accepted as being about 70% of a laboratory’s total budget. There has lately been a trend towards employing low-paid unqualified staff with a few highly trained (and highly paid) staff to manage them. Services provided by pathology laboratories were evaluated with a view to rationalising laboratory work within the Guy’s and Lewisham Trust. The effects of the different staffing structures of the clinical biochemistry departments were compared in the two hospitals. The equipment for routine analysis and the total staff number is similar at both sites. In the previous 5 years the total
935
SUMMARY OF DATA FROM SERVICES REVIEW DOCUMENT’ I
I
...I
-I
We believe that research in the care of desperately ill people is important and that society would not wish it to be obstructed. Major advances are being made in intensive care, especially in septic shock, and these have the potential to save many lives. It is better that new interventions should be studied systematically rather than on an ad hoc basis, as will inevitably happen if LRECs place insuperable difficulties in the way of researchers. Child Development Centre, St George’s Hospital, London SW17 0QT, UK
DAVID HALL
1. Petros
A, Bennett D, Vallance P. Effect of nitric oxide synthase inhibitors hypotension in patients with septic shock. Lancet 1991; 338: 1557-58.
*New appointment with shared responsibilities totally funded from Guy’s budget
at
Guy’s
and Lewisham,
AZT: zidovudine
although
SIR,-Medication
errors
or
on
azathioprine?
sometimes involve
drug
names
that
number of tests undertaken by each laboratory increased by an average of 10% per year. Unlike other teaching hospitals, the Guy’s clinical department is not supported by a large academic department, so the financial situation is comparable with Lewisham. Lewisham has adopted the currently popular structure of a small number of biochemists working with a large number of medical laboratory scientific officers (MLSOs), medical laboratory assistants (MLAs), and clerical staff (ratio 1/4-5), whereas Guy’s has maintained a larger proportion of biochemists (1/14). The table shows details of the staff structure, workload, and productivity of the two laboratories in 1990/1991. This clearly shows that the Guy’s site achieves the greater productivity. A wider range of tests including the more complex analyses needing substantially greater staff time are provided at Guy’s, suggesting even greater efficiency at that site. One possible reason for this large difference is the hidden cost of constant training and supervision of MLAs and low-paid trainee staff who have little motivation, often have poor sickness records, and tend to move on to alternative employment. Biochemists are highly trained scientists with a full understanding of the tests they carry out, ability to adapt quickly to new technology, and a far greater commitment to their work than trainees. They also, with medical staff, share the responsibility of providing advice out of hours. It may prove costly to switch from highly trained scientists to staff with limited skills and motivation when robotics technology may soon replace, not the highly educated staff, but the "button
sound alike or are spelled similarly.l,2 Two cases where azathioprine was ordered in place of zidovudine illustrate the serious risk in using abbreviations when communicating prescriptions. The two patients were HIV infected and had CD4 counts below 500/µl. One was a 27-year-old inpatient in the psychiatry service and the other was a 33-year-old woman being cared for on an obstetrics and gynaecology ward. The infectious diseases service had recommended antiretroviral therapy with "AZT" (for azidothymidine) and the prescribing physicians tried to locate AZT in the hospital’s computerised information system. However, in our system this drug can only be ordered by its generic name (zidovudine) or brand name (Retrovir). When looking under "A" section they could not find AZT and chose azathioprine by mistake. The orders for azathioprine were filled by the pharmacy but fortunately the errors were discovered in time-by the attending infectious diseases physician and by a doctor of pharmacy student. A similar incident3 demonstrates how easily error can occur when unofficial names of drugs are used. It has been suggested that the abbreviation AZT be abandoned in favour of ZDV, which more accurately reflects the generic name. However, it would appear wise to avoid abbreviations altogether. Had the prescribing errors reported here not been picked up in time the consequences for the patients (and the health care professionals) might have been disastrous.
pushers".
Philadephia College of Pharmacy and Science and Hahnemann University, Philadephia
S. BIRD M. J. MICHELIN P. A. TOSELAND J. TOWNSEND P. W. TUTT
Clinical Biochemistry Department, 5th Floor Guy’s Tower,
Guy’s Hospital, London SE1 9RT, UK
Philadelphia College
M. THERESA AMBROSINI
of Pharmacy and Science
Department
HILARY D. MANDLER
of Medicine,
Hahnemann
University, Philadelphia, Pennsylvania 19102, USA
CRAIG A. WOOD
J, Azzugnuni M, Di Romana S, Vanhaeverbeek M. Fatal confusion between Losec and Lasix. Lancet 1991; 337: 1286. 2. Kurth MC, Langston JW, Tetrud JW. "Stelazine" versus "Selegiline": a hazard in prescription writing. N Engl J Med 1990; 323: 1776. 3. Cohen MR. AZT: a dangerous abbreviation. Hosp Pharm 1988; 23: 691. 1. Faber
1. Coker N. Clinical services review: Trust. February, 1992.
Ethical
pathology services. London: Guy’s and Lewisham
emergencies
SIR,-Your correspondents (March 14, p 682) indicate some justifiable concern about the ethics of research on patients in intensive care, who are not able to give consent for such studies. As chairman of the Wandsworth Health Authority local research ethics committee (LREC) that approved the study reported by Petros and colleagues,l I would describe the view adopted by our committee members on this difficult issue. We do not believe that relatives should be asked to sign consent, since they have neither the moral nor the legal authority to do so. Instead, they are told about the project and given the opportunity to object on behalf of the sick person. The explanation given to the relatives must be witnessed by a senior nurse or equivalent person who is not directly involved with the research. Moral responsibility for research projects in this situation is shared between the investigators and the LREC, and the members must satisfy themselves that the project is of sufficient importance to justify an additional intervention in the care of a very sick patient.
Language tests for EC doctors graduates from developing adequately qualified practise medicine in the UK they are required to take the professional and linguistic assessment board (PLAB) test before they are allowed to register with the General Medical Council (GMC). The need for the English language component of the test for overseas graduates is indisputable, even though graduates from most countries-for example, those from the Indian subcontinent--are taught in English. Medical graduates from European Community (EC) countries SiR,—To
countries
are
assess
whether medical
are
exempt from such
to
assessment
and
are
entitled
to
GMC
registration because they qualified in the EC. An increasing number of EC graduates are being appointed to junior hospital posts in the UK. I was recently a locum medical registrar in a Scottish district general hospital. All five junior house officers were EC graduates (4 from Germany and 1 from Spain). Nursing and senior medical staff,
