President Chairman, Management Committee Multiplicity of Tests

SIR,-Drs. A. V. Hoffbrand and A. Lavoie are to be complimented on their paper "Megaloblastic Anaemia" (8 June, p. 550) for its lucidity, conciseness, and comprehensiveness. It illustrates the best in modern medicine, and also the worst. I would cavil with them on one point: they state that in order to make a diagnosis of megaloblastic anaemia it is necessary to carry out 14 tests and, to distinguish between vitamin B12 and folate deficiency, another four. It is the 14 tests that I auery. It may be that with some of the patients a diagnosis cannot be established until all these investigations have been completed, but I find it difficult to believe that most patients require more than a very few tests. It seems to me that the authors are somewhat confused about differences between research and clinical practice. In the former the information collected about each patient is that which is relevant to the research as a whole; in clinical practice the information collected is that which is relevant to the patient. Much research has been done which demonstrates that in various fields-for example, thyroid disease-the many tests available are unnecessary in a majority of cases since the additional information provided by more than a few tests is very small. This point is ignored in the teaching to medical undergraduates so that the present generation of physicians cheerfully orders innumerable tests which ultimately have no function other than to satisfy idle curiosity or to spend other people's money. The consequence of this is that when medical graduates leave research centres or go into general practice their inability to order innumerable tests makes them feel that they are not practising real medicine and this is one of the factors which leads to the lack of morale in the profession. I am not suggesting that we should go back to the days of Addison, but I do think that in a definitive paper such as this the need for tests should be given full justification.-I am, etc., MAX HAMILTON Department of Psychiatry, University of Leeds