Andrew Elder

• Professor at University of Edinburgh

According to that old story, a local giving directions to a lost traveler says, “If I wanted to get there, I wouldn’t start from here.” Medicine finds itself far from the bedside,¹,2 seeking a way back, unsure where to begin.

At its most fundamental level, the clinical encounter between a patient and their doctor seeks to solve a mystery. Clinicians uncover clues through the history, physical examination, and ancillary tests to arrive at a diagnosis and develop a management plan. Despite advances in technology, the majority of clinical diagnosis are still reached throug...

Good clinical skills (history taking, physical examination, diagnostic reasoning, and the ability to explain complex medical problems) are pivotal to high-quality cardiovascular care because they instil confidence in the patient, aid accurate diagnosis, avoid wasteful and pointless investigation, and inform decision-making. The concept of ‘risk’ ca...

Clinical skills remain fundamental to the practice of medicine and form a core component of the professional identity of the physician. However, evidence exists to suggest that the practice of some clinical skills is declining, particularly in the United States. A decline in practice of any skill can lead to a decline in its teaching and assessment...

Abstract Background There is much discussion about the sex differences that exist in medical education. Research from the United Kingdom (UK) and United States has found female doctors earn less, and are less likely to be senior authors on academic papers, but female doctors are also less likely to be sanctioned, and have been found to perform bett...

Background: Fairness is a critical component of defensible assessment. Candidates should perform according to ability without influence from background characteristics such as ethnicity or sex. However, performance differs by candidate background in many assessment environments. Many potential causes of such differences exist, and examinations mus...

Background: There is much discussion about the sex differences that exist in medical education. Research from the United Kingdom (UK) and United States has found female doctors earn less, and are less likely to be senior authors on academic papers, but female doctors are also less likely to be sanctioned, and have been found to perform better acade...

A structured online survey was used to establish the views of 2,684 practising clinicians of all ages in multiple countries about the value of the physical examination in the contemporary practice of internal medicine. 70% felt that physical examination was ‘almost always valuable’ in acute general medical referrals. 66% of trainees felt that they...

Background: Atrial fibrillation increases stroke risk and adversely affects cardiovascular haemodynamics. Electrical cardioversion may, by restoring sinus rhythm, improve cardiovascular haemodynamics, reduce the risk of stroke, and obviate the need for long-term anticoagulation. Objectives: To assess the effects of electrical cardioversion of at...

The physical examination defines medical practice, yet its role is increasingly questioned, with statistical comparisons of diagnostic accuracy often the sole metric used against newer technologies. The authors set out to highlight seven ways in which the physical examination has value beyond diagnostic accuracy to reaffirm its place in the core sk...

Dizziness is a very common symptom in older adults. Its prevalence increases with age, with approximately one-third of elderly people experiencing it. It can be caused by true vertigo, of peripheral or central cause, presyncope, disequilibrium or a combination of these. A detailed history and examination are essential in distinguishing common cause...

Many high-stakes postgraduate examinations include assessments of the knowledge of ethical principles and the application of those principles to a clinical scenario. This article summarizes the approach to assessment in the MRCP(UK) Practical Assessment of Clinical Examination Skills (PACES) examination.

Physical examination of the cardiovascular system is central to contemporary teaching and practice in clinical medicine. Evidence about its value focuses on its diagnostic accuracy and varies widely in methodological quality and statistical power. This makes collation, analysis, and understanding of results difficult and limits their application to...

Background: International Medical Graduates (IMGs) are known to perform less well in many postgraduate medical examinations when compared to their UK trained counterparts. This "differential attainment" is observed in both knowledge-based and clinical skills assessments. This study explored the influence of culture and language on IMGs clinical co...

In today's hospital and clinic environment, the obstacles to bedside teaching for both faculty and trainees are considerable. As electronic health record systems become increasingly prevalent, trainees are spending more time performing patient care tasks from computer workstations, limiting opportunities to learn at the bedside. Physical examinatio...

The medical profession is global, and ambitious trainee physicians around the world are eager to attain internationally recognised postgraduate medical qualifications. The MRCP(UK) and specialty certificate examinations of the Federation of Royal Colleges of Physicians of the United Kingdom provide such qualifications, and between 2002 and 2013, th...

Sokol recently discussed the appeal process for medical royal college and faculty examinations.1 His historical reference to the Royal College of Physicians might lead readers to believe that the candidate described had taken an MRCP(UK) (membership of the Royal Colleges of Physicians of the United Kingdom) examination. This is not the case. MRCP(...

We read with interest the results of the British Thoracic Society's national survey related to the specialty certificate examination (SCE) in respiratory medicine.1 We are pleased that trainees felt the SCE to be appropriate in difficulty, content and duration, and that our test centres were fit for purpose. This correlates with the results of the...

According to that old story, a local giving directions to a lost traveler says, “If I wanted to get there, I wouldn’t start from here.” Medicine finds itself far from the bedside,1,2 seeking a way back, unsure where to begin.That we have wandered far afield is plain to see. Core bedside skills of history taking and physical examination—still vital...

Bias of clinical examiners against some types of candidate, based on characteristics such as sex or ethnicity, would represent a threat to the validity of an examination, since sex or ethnicity are 'construct-irrelevant' characteristics. In this paper we report a novel method for assessing sex and ethnic bias in over 2000 examiners who had taken pa...

Dizziness is a very common symptom in older adults. Its prevalence increases with age, with approximately one-third of elderly people experiencing the symptom. It may be caused by true vertigo, of peripheral or central cause, pre-syncope, disequilibrium or a combination of these. A detailed history and examination are essential in distinguishing co...

As a consequence of change in medical, educational and regulatory practice, MRCP(UK) successfully modified the international PACES examination in 2009. This brief paper explains the rationale for change and summarises the development and implementation process.

The MRCP(UK) PACES examination has been sat by almost 40,000 candidates in 10 countries around the world since its introduction in 2001. The examination assesses skills of relevance to the practice and delivery of high quality clinical care and is the leading international postgraduate summative assessment of this kind. In 2009, the examination was...

Epilepsy is most likely to develop in later life. The burden of this disorder on health-care resources will rise further as the world's population continues to age. Making a secure diagnosis can be challenging because the clinical manifestations of seizures and the differential diagnoses and causes of epilepsy can be different in older individuals...

IntroductionThe Prevalence of ComorbiditiesThe Implications of ComorbiditySpecific Comorbidities in Heart FailureReferences

Supplementary Information. Additional statistical analyses and graphs for individual medical schools.

The UK General Medical Council has emphasized the lack of evidence on whether graduates from different UK medical schools perform differently in their clinical careers. Here we assess the performance of UK graduates who have taken MRCP(UK) Part 1 and Part 2, which are multiple-choice assessments, and PACES, an assessment using real and simulated pa...

This is the protocol for a review and there is no abstract. The objectives are as follows: The primary aim is to determine whether a strategy of rhythm control compared with rate control reduces the risk of thromboembolic events, strokes and mortality. The secondary aims are to evaluate whether rhythm control reduces the rate of cognitive decline,...

Background: Atrial fibrillation increases stroke risk and adversely affects cardiovascular haemodynamics. Electrical cardioversion may, by restoring sinus rhythm, improve cardiovascular haemodynamics, reduce the risk of stroke, and obviate the need for long-term anticoagulation. Objectives: To assess the effects of electrical cardioversion of at...

Which benchmarks for age discrimination in acute coronary syndromes? 'NHS services will be provided, regardless of age, on the basis of clinical need alone.' [1] 'NHS Trusts should put in place hospital-wide systems of care so that patients with suspected or confirmed coronary heart disease receive timely and appropriate investigation and treatment...

Clinical, social and survival outcomes in elderly patients undergoing bowel cancer surgery were studied to explore the justification for the current upper age limit in colorectal cancer screening programmes. Scottish national data were analysed to determine age-specific population survival following a diagnosis of colorectal cancer. Detailed analys...

To analyse access by age to exercise testing, coronary angiography, revascularisation (percutaneous transluminal coronary angioplasty/stent insertion and coronary artery bypass graft surgery) and receipt of thrombolysis, where indicated, for hospital patients with diagnosed cardiovascular disease. Retrospective case note analysis, tracking each cas...

Objectives To analyse access by age to exercise testing, coronary angiography, revascularisation (percutaneous transluminal coronary angioplasty/stent insertion and coronary artery bypass graft surgery) and receipt of thrombolysis, where indicated, for hospital patients with diagnosed cardiovascular disease. Method Retrospective case note analysis...

Atrial fibrillation increases the risk of stroke, increases the risk of cognitive impairment, and adversely affects cardiovascular haemodynamics. Electrical cardioversion for atrial fibrillation has been in use since the 1960s; the rationale is that restoration of sinus rhythm improves cardiovascular haemodynamics, reduces the risk of stroke, and o...

To investigate the clinical management of heart disease and determine whether there was age- and sex-related bias in the use of investigations and interventions. Retrospective analysis of individual patient records against criteria of appropriateness based on published guidelines, clinical practice and literature relevant to the 1996-7 study period...

To assess whether patients with heart disease in a single UK hospital have equitable access to exercise testing, coronary angiography, and coronary artery bypass graft surgery (CABG). Retrospective analysis of patients' medical case notes (n = 1790), tracking each case back 12 months and forward 12 months from the patient's date of entry to the stu...

To study the safety and benefit of mitral balloon valvotomy (MBV) in patients aged > or =80 years. A tertiary cardiac centre A retrospective study of 20 octogenarians (mean age 83, range 80-89 years) in whom percutaneous MBV was performed as a definitive or palliative treatment for severe mitral stenosis. All were in New York Heart Association (NYH...

To assess the immediate haemodynamic improvement and long term symptomatic benefit of percutaneous mitral balloon valvotomy in patients aged over 70 years. Pre- and postprocedure haemodynamic data and follow up for 1 to 10 years by clinic visit or telephone contact. Tertiary referral centre in Scotland. 80 patients age 70 and over who had mitral ba...

Atrial fibrillation (AF) increases the risk of stroke and also has adverse haemodynamic consequences. Cardioversion of AF to sinus rhythm may obviate the need for long-term anticoagulation and improve cardiovascular haemodynamics, but is probably underused. We therefore investigated the views of hospital consultants about cardioversion for AF. 336...

Background: Angiotensin converting-enzyme (ACE) inhibitors used for the treatment of heart failure relieve symptoms, increase exercise performance, reduce hospital admissions and prolong life. The large survival studies have used higher doses of ACE inhibitors than those commonly used in clinical practice. NETWORK was set up to compare the effect...

Editor—The articles by Barry Cookson and E L Teare and S P Barrett on methicillin resistant Staphylococcus aureus (MRSA)1 2 added to the nationwide debate between clinicians, infection control teams, trusts, and purchasers. Recently, after a large outbreak of MRSA in our local teaching hospital, all colonised patients were treated and followed up b...

Fatal dwelling-house fires account for 10% of all accidental deaths in the United Kingdom with one-quarter of the deaths being of elderly people. No study had described the characteristics of elderly individuals who die in fires. We report results from a retrospective review of all fatal dwelling-house fires in Scotland from 1980 to 1990. Of 1096 p...

Angiotensin converting enzyme (ACE) inhibitors are of proven value in patients with severe chronic heart failure (CHF). Studies of the effects of ACE inhibitors on exercise capacity and quality of life in mild CHF have produced conflicting results. We have studied the effects of quinapril, a new ACE inhibitor with a relatively short plasma half-lif...

Each new study builds on its predecessors, providing new information, which aids the fine tuning of treatment. In the case of hypertension in elderly patients this includes the blood pressure levels at which to treat, the target blood pressure, upper age limits, how to manage other cardiovascular risk factors, and the use of newer drugs such as cal...

To assess the effects on haemodynamic function and symptoms of percutaneous balloon dilatation of mitral stenosis in patients unable to undergo surgical treatment because of associated medical/cardiac problems. A review of clinical outcome in 28 patients (of 108 undergoing balloon dilatation of the mitral valve) who were unsuitable for surgery. A t...

We have investigated the effect of varying sodium intake on the renin-angiotensin system, ADP-induced patelet aggregationin vitro, and blood 5-HT concentrations in 9 male volunteers. Systolic blood pressure was slightly reduced during a low sodium diet, whereas the diastolic pressure remained unchanged. Plasma renin activity and aldosterone concent...

To determine the effect of watching a game of Scottish football on heart rate and blood pressure. Prospective study. Two Scottish Premier League football grounds. 10 healthy men, each a supporter of one of two clubs. Systolic and diastolic blood pressure and heart rate at home, while walking, and during the match. Systolic blood pressure and heart...

To establish and compare the characteristics of older (greater than or equal to 70 years) and younger patients with chest pain selected to undergo coronary angiography and by analysis of their subsequent management to assess the value of coronary angiography for older patients with chest pain. Retrospective analysis of clinical case notes and coron...

We report the results and one-year follow-up of 20 elderly patients (age range 70–82 years) with severe rheumatic mitral stenosis treated by mitral balloon valvuloplasty (MBV). All 20 were breathless at rest despite treatment with diuretics and digoxin. At cardiac catheterization, successful dilatation was achieved in 17 patients: mean transvalvula...

A case of sudden death, attributed at post mortem to aspiration of an antibiotic capsule into the larynx, is described and the literature alluding to this phenomenon and its treatment briefly reviewed.

A case of cerebral malaria in a young British traveller, successfully treated by exchange transfusion of whole blood, is reported and the literature regarding the use of this technique in P. falciparum malaria is briefly reviewed.

A fatal case of Stevens-Johnson syndrome associated with Fansidar and chloroquine is reported in a 5-year-old boy.

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