To the Editor: As a geriatrician in the subacute sector with hospital medical officers (HMOs) rotating from a major teaching hospital, I am acutely aware of the cost to all concerned of inappropriate diagnostic testing. Discussion stimulated by Stuart et al1 and the editorial by Hammett and Harris2 may help elevate this issue into its rightful arena — quality care and clinical accountability.

Donabedian,3 in looking at the assessment of quality care, describes "elements in the performance of practitioners", with technical performance defined as "knowledge and judgement used in arriving at the appropriate strategies of care". I believe that both these quality elements are deficient and that it is the responsibility of the senior clinicians to provide the necessary leadership in ensuring their acquisition.

While I agree with Hammett and Harris that there are systems failures and that, as an example, improved feedback of results (particularly given changing HMO work practices and shorter length of patient stays) will provide some of the answers, there appears little doubt that a significant knowledge deficit exists among junior doctors regarding the use and interpretation of common tests and how often they should be ordered. The unfortunate fact is that we have known about these issues for many years and have yet to develop a sustained response. At our hospital we have attempted to modify the use of diagnostic tests by HMOs during their geriatrics rotation, with tutorials from biochemists and haematologists which are reinforced during consultant ward rounds and meetings. This is, however, doomed to failure unless the process is continued by all other clinicians who supervise HMOs.

Emanuel and Emanuel4 define accountability in a number of domains. The least controversial of these, I suggest, is professional competence. It is incumbent on us as senior clinicians to "invoke, affirm and enforce professional standards",4 being accountable for the practices of those HMOs under our supervision. Appropriate use and understanding of diagnostic testing will reduce unnecessary patient discomfort while also reducing costs. As any geriatrician will tell you, additional years without insight simply provide grey hair, not improved clinical practice.