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Educational benefits of audit
bureaucracy ofnumber crunchers. It is to be hoped that the hospital circular on audit in the hospital and community health services will recognise the leading role that tutors and deans have in achieving improvements in quality of care. This "window of opportunity" is available for a brief moment, enabling the profession to make the threat of audit a chance to improve education and training and create the climate for change. Finally, if postgraduate deans and clinical tutors are to become budget holders for postgraduate education-and if audit is primarily of educational benefit-it would surely be appropriate for audit money to be part of this budget.
SIR,-Reflection and learning should be part of audit. Dr Gifford F Batstone emphasises the procedure described by Dr C R Coles: note practice, learn from that, and change if necessary.' 2 Unless the educational benefits of audit highlighted by the Royal Colleges of Physicians and Surgeons-and accepted by the Secretary of State for Health-are exploited, the imposition of standards will be seen by the profession as a bureaucratic view of how to change practice. Dr Batstone was able to report that some district medical education committees have taken on the J B M ROBERTS role of an audit advisory committee; but this is the exception, however desirable. The complex audit Chairman, structures- that are being established duplicate And j ANDERSON, T J BAYLEY, R M BERRINGTON, existing postgraduate education committees, which R V BOYD, S BRANDON, I P CRAWFORD, P CURZEN, are well able to carry out the role envisaged for I B HOUSTON, G HUDSON, R H JOHNSON, ROSEMARY audit committees. Hard pressed clinical tutors are MULLIGAN, M W N NICHOLLS, B L PENTECOST, being expected to take a leading role in two E SHORE, J TINKER, D H WILSON independent "productions" going on at the same Committee of Postgraduate Medical Deans, time; only one committee-that concerned with London WIN 3PB the wider issue of education-is needed. In the family practitioner services, medical audit advisory 1 Batstone GF. Educational aspects of medical audit. BMJ 1990;301:326-8. groups have been, orare being, established separate CR. Self assessment and medical audit: Educational from the postgraduate educational structure, 2 Coles approach. BMJ 1989,29:807. sometimes with little educational advice on composition. Many regions are setting up audit committees-some (but not all) with the lone educational input of the postgraduate dean. Regional committees are more concerned with Detecting diabetic retinopathy resource allocation than observing practice and reflecting on aims, and much of the allocation is to SIR,-Dr Roy Taylor and colleagues conclude that purchase hardware in the apparent-but mistaken the non-mydriatic camera is at least as good -belief that audit is impossible without a as routine ophthalmoscopy in screening selected patients in hospital outpatient clinics for diabetic computer. Hospital circular EL(90)179 and the secretary retinopathy.' We were surprised that no specific of state's speech to the York conference on post- instruction in fundal examination was given to the graduate medical education recognised that the participating clinic doctors. Ophthalmoscopy was performed by registrars or infrastructure for postgraduate and continuing education must be linked to audit arrangements if senior house officers in 37% of their patients. The the lessons learnt from audit are to be used to equivalent grade of doctors in the United States develop educational programmes for groups and have been shown to fail to diagnose more than half individuals. As it is now being developed, audit is the cases of proliferative retinopathy.' We are not likely to create the conditions to help learning. concerned that the lack of formal teaching could The structures that are being put in place seem have biased the results of this study in favour of the more concerned with controlling the actions of camera. We compared their results with those of our study of the non-mydriatic camera in an doctors. Those who can best advise how learning, based unselected community diabetic population.3 In on experience, can be achieved should be permitted our study the camera detected sight threatening to have a greater lead role in audit. At regional retinopathy in 48 out of 358 patients (13%). Dr Taylor and colleagues report that 10% of level this should be the postgraduate dean, at unit level the clinical tutor; but the assistance of films were of poor quality. Although the percenteducationalists and those skilled in the behavioural age of poor quality photographs-in our study was similar in patients aged less than 50, we found that sciences is increasingly important. Audit is too important an opportunity to enhance the percentage increased with age in older patients. postgraduate and continuing education for it to be The elderly patient is more likely to have small allowed to fail. At present there is a serious risk pupils and cataracts, both of which are known to that the structure and resources will be hijacked by reduce the quality of photographs with the nongroups and individuals with little interest mydriatic camera. Overall a quarter of our films in education but every concern to develop a were of inadequate quality to assess for retinopathy.
We suggest that this reflects the higher number of elderly patients in our unselected community population, and we would be interested to know the age distribution of patients in the study by Dr Taylor and colleagues. As much serious diabetic retinopathy occurs in older patients we would be reluctant to recommend the camera as the primary or sole method of screening. We suggest that, although this study has shown that the non-mydriatic camera can improve the detection of diabetic retinopathy, it has also highlighted the need for further ophthalmological training of doctors and junior staff working with diabetic patients. The camera could provide part of this education. E R HIGGS
Royal United Hospital, Bath BA l 3NG B A HARNEY
Bristol Eye Hospital, BS1 2LX 1 Taylor R, Lovelock L, Tunbridge WMG. Comparison of nonmydriatic retinal photography with ophthalmoscopy in 2159 patients: mobile retinal camera study. BMJ 1990;301:1243-7. (1 December.) 2 Sussman EJ, Tsairas WG, Soper MS. Diagnosis of diabetic eye
disease.JAMA 1982;247:32314. 3 Higgs ER, Hamey B, Kelleher A, Simpson HCR, O'Hare JP. Limitations of the non-mydriatic camera in screening for diabetic retinopathy in the community. Diabetic Med 1990;7:9A.
SIR,-Although we agree that the major problem concerning diabetic eye disease remains that of "identifying retinopathy before the onset of visual impairment," we are concerned that the study of Dr Roy Taylor and colleagues does not deal with the important issue-that of the sensitivity of either method in detecting all cases that require referral. Non-mydriatic photography using Polaroid film does indeed generate debate, but although fluorescein angiography is the "gold standard," most decisions to treat diabetic retinopathy are taken on clinical grounds using visual acuity, detailed fundal examination, and serial observation. Several important points raised by the study deserve attention. Firstly, "the visual acuity was checked" but no use was made of the result. As is rightly mentioned, serial visual acuities are imperative and are arguably the most relevant and simple macular function tests. Much store is placed on the camera's ability to detect maculopathy, yet one obvious screening tool remained unused. Secondly, "no specific training in funduscopy was given" and all grades undertook ophthalmoscopy. Yet only three consultants reviewed the photographs. The authors did not compare like with like-they used a dedicated team to perform one task and a group with variable skill for the other.
BMJ VOLUME 302
19 JANUARY 1991