Sir.—Allow me to comment on your trenchant observations regarding "standard practice." As a nonacademic practitioner of many years looking at the problem from the other side of the mirror, I find the following thoughts come to mind.
The crux of the problem may be that the tools used to determine standard care are designed for and function best when applied to tertiary care and may not be ideal for studying primary care situations. This could well arise partly because of the hierarchical structure of academic medicine. Most of us, especially professors, assume that a conclusion reached by a professor is probably correct. A practicing physician may not wish to differ openly with the chief of his or her service and thus may modify the primary care pattern without making an issue of it.
While we may agree that anecdotal observations are not a sound basis on which to determine