more thoughts

practising family medicine. We did not intend to imply that excluded physicians were "lesser." We agree that remuneration plays an important part in determining patterns of clinical practice and health promotion. However, our study aimed to describe the patterns of preventive practice and the level of compliance with the recommendations of the task force rather than the barriers to compliance. The principal purpose of the task force has been to provide a scientific basis for screening programs and to ensure that screening activity is based on objective evidence rather than on physician's whims or anecdotal experience. No screening program will ever be able to detect all people with cancer or avoid subjecting well people to occasional indignity. The task force offers a beacon of scientific evidence in a sea of uncertainty. Having identified significant areas of noncompliance we hope that others will take up the quest of how to deliver the bestquality health promotion and screening service to all Canadians. Helen E. Smith, BM, BS, MSc, MFPHM Director Wessex Research Network Southampton, UK

The Part II examination: more thoughts fter reading the responses by A\ Drs. Richard K. Reznick and Dennis A. Kendel (Can Med Assoc J 1994; 150: 13-14), to this letter (Can Med Assoc J 1994: 150: 12-13), by Dr. Anthony Kenyon, I add my comments to Kenyon's. I feel that I bring a unique view to this debate because I was one of the first Canadian graduates to have been forced to write the Medical Council of Canada Qualifying Examination (MCCQE) Part II. I agree with Kenyon that the examination is not cost-effective; it was a waste of time, a rehash of cases and skills on 1540

CAN MED ASSOC J 1994;

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which I had been examined at least twice during my training. As the examination day grew longer I grew angrier! The direct and indirect cost of the examination to me was approximately $2100, a ridiculous expense for any recent or soon-to-be graduate, especially because the examination repeated past ones. Kenyon implies that the skills tested in the MCCQE Part II should be learned and tested during medical school. Reznick states that this is impossible because there is no uniform approach to such testing. A simpler and much cheaper solution would be to test this knowledge in a standard format as part of a medical school's accreditation. One doesn't need to "train" patients: our hospitals are full of them. The "realpatient" examination appears to be good enough for the Royal College of Physicians and Surgeons of Canada (RCPSC) in their testing of internal medicine residents, why not for the MCC? I agree that clinical skills are important and that every graduate must possess them, but the MCCQE Part II is the proverbial sledgehammer going after the nut. The new postgraduate training requirements of at least a 2-year residency period and successful completion of a clinical-skills examination means that the MCCQE has probably outlived its place in the hurdles a Canadian graduate must overcome for licensure. A student must now satisfy the medical school, the residency program, the provincial colleges and the MCC. Either these bodies are unable to satisfactorily test graduates, or there is tremendous duplication. I tend to think the latter. Perhaps the MCC should accept the examinations of the RCPSC and the College of Family Physicians of Canada in lieu of the MCCQE. Reznick's claim that the MCCQE Part II will aid portability and mobility within Canada is laughable. Each provincial licensing college requires a different number of weeks in each discipline for licensure. In addition, the provincial med-

ical associations and governments are stopping the free movement of physicians within Canada. Even if I pass the Part II, I will be unable to work in Alberta, Saskatchewan, Ontario, Quebec and, as far as I know, the Atlantic provinces. Surely a national qualifying examination that does not let physicians practise nationally is absurd. I would like to attend the Sixth Ottawa Conference on Medical Education, to be held June 26 to 29, 1994, in Toronto, as Kendel suggests, but it seems my budget is a little stretched this year. Drew Digney, MD Prince George, BC

The MCCQE Part II became part of the requirements for licensure in Canada in January 1992. All medical graduates intent on practising medicine in Canada must pass this examination (at a cost of $1200). The examination's stated objective is to assess clinical skills. Having recently taken it I believe that it fails hopelessly in its objective and has little value in assessing the clinical acumen of practising physicians. The examination consists of 30 clinical encounters, with many actors playing the roles of patients. A few examples of the cases presented will highlight the absurdity of this approach for assessing clinical skills. A middle-aged diabetic man presents with abdominal pain. The arterial blood pH is 7.22 (normally 7.35 to 7.45), the partial pressure of carbon dioxide 25 (normally 35 to 45) mm Hg and the levels of bicarbonate 10 (normally 22 to 28) mmol/L and of glucose 25 (normally 2.8 to 4.4) mmol/L. The "patient" breathes normally (10 breaths/min), and there is no Kussmaul's sign or ketoacidosis odour. The patient is not dehydrated and denies a history of polyuria or thirst. In my experience as a critical care physician I have yet to see a patient with ketoacidosis present in this manner. Another case is a 22-year-old woman with a history of easy bruisLE 15 MAI 1994