 CORRESPONDENCE Anesthesiology 2002; 97:278 © 2002 American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc. Are “International” Medical Graduates Second-class Anesthesiologists? To the Editor:—I read with keen interest the article published in the September 2001 issue of ANESTHESIOLOGY entitled “The Anesthesiologist in Critical Care Medicine,” 1 especially since I am currently enrolled in a critical care fellowship after having completed my anesthesiology residency. I agree for the most part with the positions of the authors, especially regarding the profound difference between the situation in the United States, where anesthesiologists have all but abandoned the field of critical care medicine, and that in Europe, where they are at the forefront of it. However, I was appalled to see that the main criterion used by the authors to evaluate the success of a discipline, such as otorhinolaryn- gology, is the reduction in the number of “international” medical graduates. This hypocritical denomination aside (what was wrong with “foreign”?), I feel that in a country whose success stems in great part from diversity and in which discrimination is illegal, residency candi- dates should be evaluated on their abilities and their character, not based on where they attended medical school. Evidence of discrimi- nation in resident recruitment has been found in other specialties. 2,3 I do not think that the education I received in a French medical school is in any way inferior to the one that students get in this country. If there are any objective data that show that “international” medical graduates are not as good physicians as their American-educated coun- terparts or that the patients they treat have worse outcomes, more complications, longer lengths of stay, or higher expenditures, I would like to be made aware of it. Until such time, I feel that it is unfairly biased to consider that a specialty fares better or worse based on the number of “international” medical graduates entering residency programs. Arthur Atchabahian, M.D., The Mount Sinai Medical Center, New York, New York. arthur1a@usa.net References 1. Hanson W III, Durbin CG Jr, Maccioli GA, Deutschman CS, Sladen RN, Pronovost PJ, Gattinoni L: The anesthesiologist in critical care medicine: Past, present, and future. ANESTHESIOLOGY 2001; 95:781– 8 2. Nasir LS: Evidence of discrimination against international medical graduates applying to family practice residency programs. Fam Med 1994; 26:625–9 3. Balon R, Mufti R, Williams M, Riba M: Possible discrimination in recruitment of psychiatry residents? Am J Psychiatry 1997; 154:1608 –9 (Accepted for publication February 15, 2002.) Anesthesiology 2002; 97:278 © 2002 American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc. In Reply:—Two of the authors of the article are international med- ical graduates, as are many of the leaders of critical care medicine in the US. The ability or inability of a medical discipline to attract grad- uates of American medical schools is a well-established indicator of the relative health of that discipline. It is not, in any way, an indictment of the quality of international or foreign medicine or physicians who trained outside of the US. C. William Hanson, M.D., University of Pennsylvania Health System, Philadelphia, Pennsylvania. hansonb@mail.med.upenn.edu (Accepted for publication February 15, 2002.) Anesthesiology 2002; 97:278 –9 © 2002 American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc. The Distribution of the Probability of Survival and Its Impact on Hypothesis Testing in Randomized Clinical Trials To The Editor:—We read with much interest the article of Riou et al. 1 The authors concluded that the bimodal distribution of probability of survival strongly impacts hypothesis testing in randomized trials by overestimating power. We would like to point out that statistical power depends only on the average probability of survival for each of the groups, 2 not the distribution of the probability of survival (Ps), as the authors claim. If we have understood the authors’ presentation, it appears that the reported results are a direct consequence of the assumptions that are used to construct their models, i.e., “if a drug is thought to increase Ps by 10%, when Ps was below 0.50, it was increased by 10% of Ps, and when Ps was greater or equal to 0.50, it was increased by 10% of 1 - Ps.” Their model does not increase the mean Ps by a predictable amount. We illustrate the lack of dependence on a bimodal distribution with a simplified example (table 1) in which there are patients with probability of survival of only 0.2, 0.6, and 0.8 of differing proportions and the treatment increases survival by 0.05 (e.g., from 0.2 to 0.25). In the left-hand example of table 1, the distribution has most of the patients with a 0.6 chance of survival, while the right-hand example has a bimodal distribution of patient survival with very few patients in the middle range. Yet, since both examples have the same mean Ps with and without treatment, the power is the same. We agree that the probabilities of survival would vary greatly in any given sample of trauma patients, between patients who face the great- est probability of mortality or survival regardless of the intervention. The effect size is necessarily minimal at the extremes of the survival probability continuum and can be larger in the middle of the distribution. Evaluating efficacy in a randomized clinical trial requires the appro- priate patient population in which the effect of the intervention can be observed. However, once the appropriate population has been identi- fied, the mean Ps will provide the correct sample size calculations, irrespective of the distribution of probabilities. Supported by PHS RO1 NS34949 and PHS K24 NS02091 (both William L. Young, M.D., P.I.). 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