Assessment of clinical competence.

Despite endless efforts in the quest for credible methods for evaluating clinical competence, the objective remains elusive. The components of competence include both clinical (interview skills, physical examination, differential diagnosis and therapeutic modalities) and technical skills. Written and oral examinations and, more recently, objective structured clinical examinations have been used as instruments for assessing the progress of trainees as well as for college or board certification and licensure to practice medicine. The American Board of Anesthesiology has adopted a more rigorous process for evaluating residents in training (Certificates of Clinical Competence). Newer methods have attempted to measure the competence of practicing physicians, including the analysis of data from physician-submitted 'report cards', 're-certification' examinations, and patient outcome studies. Whole-body computerized patient simulators have become a major area of research for teaching clinical skills and assessing behavior as well as patient management during critical incidents. This review examines the significant literature in each of the areas cited.

The impact of non-physician health directors on full-time public health coverage in Connecticut.

Seven years after passing a 1971 law enabling individuals without MD degrees but trained in public health to become local directors of health, the proportion of Connecticut towns covered by full-time directors had risen from 14 per cent to 38 per cent and the proportion of the population covered had risen from 46 per cent to 63 per cent. The directors of health without MD degrees were satisfied with their positions and believed they had developed good relationships with physicians, the community, and government.

Anesthetic indices--further data.

Anesthetic indices for methoxyflurane, enflurane, and isoflurane in oxygen and halothane in nitrous oxide and oxygen (50:50), were determined in rats using measurements of heart and brain concentrations of the volatile agents at the endpoints of anesthesia, respiratory arrest and cardiac failure. The indices related respiratory arrest to anesthesia (respiratory index-A1r), cardiac failure to anesthesia (cardiac index-AIc) and respiratory arrest to cardiac failure (cardiorespiratory index-AIcr). Isoflurane had a significantly higher AIr (3.1) and AIc (5.7) than enflurane (AIr 1.8, AIc 3.3), methoxyflurane (AIr 2.2, AIc 3.7) and halothane in nitrous oxide and oxygen (AIr 2.4, AIc 3.7). These indices were also higher than those previously determined for halothane (AIr 2.3, AIc 3.0). Isoflurane had a higher AIcr (1.9) than halothane (1.6). Enflurane had a significantly lower AIr (1.8) than any of the other agents studied. These findings suggested a greater margin of safety for isoflurane, especially with respect to the heart, and a greater potential for respiratory depression for enflurane than for the other agents. Nitrous oxide decreased the amount of halothane necessary to produce anesthesia, but also that needed to produce respiratory arrest or cardiac failure. The addition of nitrous oxide, therefore, did not significantly enhance the overall safety of halothane anesthesia with respect to potential respiratory or cardiac depression.

A measure of competence. The first Mushin lecture.

The process by which an individual is finally recognised as a physician and licensed to practice medicine is long and complicated. The physician who chooses to specialise pursues additional study and after successfully completing both written and oral examinations may be certified by a 'specialty board'. Such certification is looked upon as evidence that the physician is competent to practice at the consultant level. The competent clinician possesses the intellectual capacity to make valid medical judgments and the technical expertise in his own special field to implement or to direct the implementation of such judgments. The written examination measures the pool of information essential for the individual to make valid medical judgments in the area tested. The oral examination examines attributes difficult to evaluate by other techniques since attributes demand both observation of the candidate and interaction with him. The oral exam is probably a better way to evaluate a candidate's ability to make clinical judgments, to synthesize information, to relate specific basis information to clinical problems presented and, to some extent, to test the ability of the candidate to react in stressful situations. Inadequacies of the oral examination continue to include a lack of objectivity and the potential for bias. Some specialty boards require certificates of clinical competence issued by the faculty of the training programme on behalf of applicants who seek certification in their specialty. In addition to such judgments of clinical competence, the concepts of peer review, licensure, recertification and continuing education all play a role in the elusive objective of assessing clinical competence.

Changes in airway resistance following droperidol, hydroxyzine, and diazepam in normal volunteers.

The effects of droperidol, hydroxyzine, and diazepam on airway resistance (AR), functional residual capacity (FRC), and thoracic gas volume (TGV) were compared, using a CPI model-2000 body plethysmograph. Significant decreases in AR were seen following droperidol and hydroxyzine at all time intervals. A significant increase in AR also was noted 90 minutes after diazepam injection. FRC significantly decreased at 60, 90, 120, and 150 minutes following droperidol, and at 90 minutes following hydroxyzine, while no change was seen following diazepam. No significant changes in TGV were seen following administration of any of the drugs.

A technique of ventilation during laryngoscopy and bronchoscopy.

A technique for ventilating patients thorugh a catheter with nitrous oxide and oxygen utilizing the venturi principle is described for patients undergoing laryngoscopy or bronchoscopy. Arterial blood-gas measurements in 34 patients reveal that ventilation was adequate.