The efficacy of three gastric restriction operations were compared in a prospective randomized study of 310 morbidly obese subjects. The median patient age was 34 years (range, 18 to 62 years). They were predominantly female (13:1) and had a median pre-operative weight that was 198% of their ideal weight (range, 160% to 318%). There was an equitable dispersion of perceived risk factors between the groups under study and there were no deaths during the perioperative period. Compliance with follow-up at 3 years was 91%. When success was defined as a loss of more than 50% of excess weight or a current pregnancy, the success rates at 3 years were 17% for gastrogastrostomy, 48% for vertical gastroplasty, and 67% for Roux-en-Y gastric bypass (p less than 0.001). Although the gastric bypass operation took longer to perform, there were similar outcome patterns for the three groups during the postoperative period. We conclude that the Roux-en-Y gastric bypass is the preferred procedure for the surgical treatment of morbid obesity.

This paper reports a study which compared the performance of different groups of students and doctors on identical and equivalent tests set in an objective-type format and in a free-response format. The tests were designed to ensure that the content was relevant to clinical practice at the hospital intern level. In all test situations candidates' scores were significantly higher in the objective tests than in the free-response tests. This difference was greater for the more junior and less competent students than for the more competent doctors. The cueing effect of the options was thought to be the main factor responsible for the difference in performance. The results of a questionnaire survey demonstrated that students were aware of the deficiencies in multiple-choice tests. A large majority of the students believed that the free-response tests gave a more accurate assessment of their clinical ability. It was found that in these tests, aimed at measuring aspects of clinical competence, multiple-choice questions appeared to overestimate the candidate's ability to an extent that made them less suitable than free-response questions for this purpose. It was also found that free-response tests, of the type used in this study, provide a suitable alternative to multiple-choice tests for use in the written section of clinical examinations. It was concluded that the written component of the final examination in the medical course should have a preponderance of free-response items over multiple-choice items.

Gastric restrictive procedures for morbid obesity are frequently performed to reduce problems arising from the physical limitations and social isolation of massive obesity. Numerous reports have described changes in weight after gastric restrictive operations. yet few studies have documented changes in the secondary effects of obesity. This report deals with changes in psychosocial status and physical activity occurring in 240 patients who remained in the study 3 years after surgery. These patients were members of a group of 310 patients who were entered into a prospective randomized trial to assess the relative benefits of three forms of gastric restrictive procedure. Prior to operation, and at yearly intervals after operation, the physical activities and psychosocial status of each patient was assessed by a standardized semi‐structured interview. At the time of the three‐year interview the median weight loss for these patients was 29.5 kg which represents 53% of excess weight lost. This weight loss was associated with a marked reduction in the amount of food eaten. There was a significant increase in the number of patients smoking more than 20 cigarettes a day and a mild increase in alcohol intake. There were significant improvements in the level of self‐image and state of happiness. The social lives and sex lives of the majority of patients were improved and a significantly greater number of patients reported being in a stable emotional relationship at 3 years after operation than did so pre‐operatively. There was a marked increase in the number of patients in full‐time or part‐time employment from 38% prior to surgery to 60% at 3 years after operation. We conclude that, in association with significant weight loss after gastric restrictive procedures for morbid obesity, there is a broad improvement in physical and psychosocial factors at 3 years after opeation.

In a previous study we described a problem-based criterion-referenced test of the clinical competence of medical students which was felt to offer advantages over the traditional final-year examination. This paper reports the validity and reliability studies on which it is possible to judge the value of this new test when compared to the traditional approach. The results demonstrate a high level of content validity and provide evidence of the construct validity of the test. Efforts to obtain measures of concurrent and predictive validity were thwarted by a failure to attain reliable assessments of ward performance from resident and consultant staff. Satisfactory levels of internal consistency were established for the whole test. Marker reliability was satisfactory in all sections of the test except for those requiring examiners to rate practical clinical skills. This was so despite the use of simulated patients, behavioural check-lists and rater training. Possible solutions to this problem are discussed. It is concluded that this new approach overcomes many of the measurement problems inherent in the traditional final examination. It has been shown to be feasible to construct and administer in the medical school setting without the need for the allocation of additional resources.

and The Royal Infirmary, Cardiff EDITORIAL SYNOPSIS There are interesting similarities between the handling of electrolytes by the intestine and by the renal tubules. These studies suggest that in states of increased adrenocortical activity, potassium losses into the intestinal lumen may be high, and go unrecognized clinically.