no provision for the rapid, simple handling of patients that is required to manage lists for dental exodontia. It has been obvious for many years that the time when each dental surgery could provide general anaesthetic services has been coming to an end. The provision of general anaesthesia is at last being recognised by all but those ignorant of danger as "not something for amateurs" (to quote Minerva2). The general medical practitioners and general dental practitioners who, after a brief undergraduate spell with a rag and bottle or Makesson 100% nitrous oxide machine, provided anaesthesia from the first day of qualification are now all approaching, or past, retirement. When consultants can collect, without quibble, more for a private anaesthetic for a dilatation and curettage than an evening spent stressing the coronaries in a poorly equipped dental surgery,3 why should they give dental anaesthetics? Recent pronouncements by the sheriff in Scottish inquests regarding the need for electrocardiographic monitoring during dental anaesthesia and the condemnation by the coroner of a dentist who failed to resuscitate the first patient who died in his 25 years of giving "anaesthetics" (because he had not had the continuing training that anaesthetists are expected to undergo) also sped up the change. The Poswillo report firmly classifies the polypharmacy employed by some in the name of sedation as general anaesthesia. There will be many patients for whom conservation work in the dental surgery will be impossible without the full set up for general anaesthesia being provided. We provide this service in our community clinic among the original mentally handicapped patients and note greatly increasing demands. We are therefore rather concerned that the provisions for dental anaesthesia in the community service seem to be shrinking in many parts of the country. This is no doubt because short sighted financial restraints have been placed on these services and accordingly consultants are reluctant to venture out from the main hospital to work. We believe that the clinics should be on the site of or in the community hospital so that expensive equipment can serve both. We also believe that if the standard of staffing and equipment of the clinics matches that of the main hospital the safety of the patients will be the same. T B WEBB

J SSANDHAM Dental Clinic, Royal Alexandra Hospital, Rhyl, Clwyd I Padfield A. Proposals on dental anaesthesia. BMJ 1991;302:182.

(19 January.) 2 Anonymous. Views. BMJ 1991;302:188.

3 Allen NA, Dinsdale RCW, Reilly CS. A survey of general anaesthesia and sedation in dental practice in two cities. BrDent_J 1990;169:168.

Academic medicine in South Africa SIR,-In Matthew Curtin's description of the dire straits of South African academics' misleading statements were made about academic medicine in Zimbabwe. It is true that there is a shortage of academic staff in Zimbabwe, and it is true that the degree of the University of Zimbabwe is not recognised in some countries. As a lecturer and consultant in the university teaching hospital in Harare I found that the medical students compared favourably with students I had taught in London medical schools. Visiting professors from British and American medical schools commented favourably, and elective students uniformly said that they wished that the teaching in their British medical schools had been as good as that in Harare. Indeed, one of Zimbabwe's main problems is that

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its graduates have no problem passing other countries' exams (such as the MRCP and that of the Professional and Language Assessment Board) and that many leave to practise in Britain, Canada, and South Africa. The academic staff who remain in Zimbabwe teach in a multiracial society, extending the benefits of medicine to all Zimbabweans (unlike the practice of medicine in South Africa); they have maintained standards and provide an excellent undergraduate medical course. South African academics have been part of their country's privileged minority. They do not gain any credit by inaccurately attacking academics in a country that has rejected that model of privilege, nor does the BMJ by uncritically publishing such opinions. JULIUS WEINBERG London SWII 2RD 1 Curtin M. Academic medicine in trouble in South Africa. BMJ7 1991;302:131. (19 January.)

Educational benefits of audit SIR,-The forcefully expressed views of the Committee of Postgraduate Medical Deans' may go some way towards minimising the proliferation of "a bureaucracy of number crunchers," but they fail to address some more insidious threats to the educational value of audit. These arise from the confusion among clinicians themselves about the overlapping but clearly distinct issues of auditing service provision and auditing standards of medical care, particularly among doctors in the training grades. These two varieties of audit serve different purposes, have different procedures and outcome measures, and to a large extent inform separate decision making processes. In some situations these issues are relatively simple. Audit of service provision is performed within units but across disciplines, and provides numerical data (rates of admission, costs, etc) to answer managerial questions relating to resource allocation. Audit of care, on the other hand, occurs within disciplines but across the units within which individuals are employed or trained and provides categorical data relating to attainment of professional standards. None the less, problems may arise because of the conflicting needs of those involved. In the short term, the most damaging of these for the junior doctor is uncontrolled peer review without the provision of any means of rectifying perceived professional deficits. In the longer term, there may be a tendency to usurp the already limited educational time available to juniors in order to hold "audit meetings" at which service provision is discussed under the guise of its educational value. Clearly, the clinical tutor must have a prominent role in planning and monitoring these processes so that their educational content is maintained. It has been argued, rightly, that the situation is more complicated in specialties such as psychiatry that operate within a multidisciplinary clinical framework. If this is so it may be appropriate to adopt procedures to audit clinical performance in relation to the complex interpersonal variables of functioning as a member of a multidisciplinary team-that is, audit within disciplines and within units. If this difficult but laudable aim is to be achieved then the temptation to perform "audit by ward round" must be avoided. Here the combination of limited time and the need for multidisciplinary audit is allowed to override the educational needs of the individual. If professional audit within a multidisciplinary unit is seen to be necessary then adequate time must be set aside, and a proper procedure must be set up locally in consultation with the clinical tutor. Whatever the clinical framework within which audit is to proceed, these pitfalls can be avoided

only if the enthusiasm of audit committees to audit is tempered and guided by real educational aims. It is to be hoped that the central role in audit proposed for clinical tutors by the Committee of Postgraduate Medical Deans will be adopted widely. TEIFION DAVIES

Bexley Hospital, Bexley DA5 2BW I Roberts JBM, Anderson J, Bayley TJ, et al. Educational benefits of audit. BMJ 1991;302:174. (19 January.)

Smart cards SIR,-The news item' reviewing the Exmouth care card evaluation report2 does scant justice to the report, the project, and the Department of Health. The recommendations and the detailed figures and tables contained in the report reveal that this project has not "failed to deliver" as the article suggests. The trial has shown that patient held medical records integrated with existing clinical computer systems can improve information flow between health care professionals. The vast majority of patients greeted the trial with enthusiasm. Average rates of card carrying were over 80% for patients of the practice that had issued cards to all patients. Despite the users' view that card access was slow there was no change in the mean number and duration of consultations after the care card system was introduced. This was probably due to the recorded reduction in the time that it took doctors to gather information from other sources. There were also reductions in routine investigation rates and in prescribing costs. The success of the project is reflected in the positive recommendations for further work contained in the report. The care card system remains in active use in Exmouth and has recently become available as a commercial product for use in other areas. During the trial and since its completion action has been taken on many of the recommendations in the technical report of which I was an author.2 The evaluation report recognises the constraints imposed on the project and recommends future trials of a larger scale. It has been suggested that such a trial might involve all patients and health providers in an area served by a district general hospital. Given the scale of this enterprise it seems that the Department of Health is pausing to consider its priorities and to determine which of the potential benefits should form the focus of future work with such cards. A small, 25 line telephone exchange would, in the early days of telecommunication, have been unable conclusively to demonstrate the range of benefits offered by a national telephone network. Similarly, the task of extrapolating the results of the Exmouth trial requires vision as well as scientific analysis. DAVID C MARKWELL Clinical Information Consultancy, Reading RG3 2SN 1 Smith J. Smart cards: wayward patients. BMJ 1991;302:200.

(26 January.) 2 NHS Management Executive. The care card: evaluation of the Exmouth project. London: HMSO, 1990.

Dutch investigate mentally ill SIR,-The news item headlined "Dutch investigate mentally ill" is misleading and perpetuates out of date thinking and labelling. The news item itself seems to be about services in The Netherlands for people with mental handicaps or learning difficulties but describes these 473

Educational benefits of audit.

no provision for the rapid, simple handling of patients that is required to manage lists for dental exodontia. It has been obvious for many years that...
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