Knowledge and power in the clinical setting

In this paper we consider the three categories offered by Howard Brody for understanding power in medicine. In his book, The Healer's Power Brody separates out power in medicine into the categories of Aesculapian, Social, and Charismatic power. We examine these three categories and then apply them to a case. In this case set in an Obstetric ward, a junior member of the medical staff makes a clinical decision about a patient. This clinical decision is overruled by a senior medical staff member who then carries out his plan with disastrous consequences for the woman and her baby. This case challenges the three categories of power offered by Brody and highlights the need for a further category of Hierarchical power to be added to Brody's framework. We conclude by suggesting that there is a need to recognise the discrepancy in power not only between physician and patient but also between senior and junior staff in a clinical setting.     

Dying in hospital: the residents' viewpoint

A survey of residents'' (junior house officers'') experiences and attitudes to the terminal care part of their work in four Glasgow teaching hospitals showed that even a month after starting work one-fifth of the respondents had not actively managed a dying patient. Sixty-four per cent thought that they had received inadequate teaching in terminal care. Depression and anxiety had been the most difficult symptoms encountered. The residents thought that the ward nursing staff contributed much more than their senior medical colleagues to both the medical and psychological aspects of terminal care. The results indicate a need for more undergraduate education in the most relevant areas, such as coping with the psychological problems of dying patients and their relatives. Newly qualified residents require more support from senior medical staff in looking after the terminally ill.     

Effectiveness of out-of-hours biochemistry investigations.

A survey was carried out of doctors who used their out-of-hours biochemistry service to find out why requests for investigations were made, how often the results altered patient management, and whether they could define areas where investigations were unproductive. Of 107 questionnaires distributed, 147 (88%) were completed. In 86% the requests were for diagnosis or immediate patient management and in 35% the results actually altered management. Senior clinical staff were more efficient than their juniors in instigating biochemical investigations that proved to be effective. In no instance where the clinical staff predicted that it was unlikely that the results would alter management was management altered. It is suggested that joint reviews of case notes by junior and senior clinical staff would prove to be the most appropriate way to increase the effectiveness and efficiency of clinical investigation.     

Improving compliance with requirements on junior doctors' hours

Problem Compliance with UK regulations on junior doctors'' working hours cannot be achieved by manipulating rotas that maintain existing tiers of cover and work practices. More radical solutions are needed.Design Audit of change.Setting Paediatric night rota in large children''s hospital.Key measures for improvement Compliance with regulations on working hours assessed by diary cards; workload assessed by staff attendance on wards; patient safety assessed through critical incident reports.Strategies for change Development of new staff roles, followed by change from a partial shift rota comprising 11 doctors and one senior nurse, to a full shift night team comprising three middle grade doctors and two senior nurses.Effects of change Compliance with regulations on working hours increased from 33% to 77%. Workload changed little and was well within the capacity of the new night team. The effect on patient care and on medical staff requires further evaluation.Lessons learnt Reduction of junior doctors'' working hours requires changes to roles, processes, and practices throughout the organisation.     

Physician perspectives on resuscitation status and DNR order in elderly cancer patients

Aim

To evaluate the process of placing DNR order in elderly cancer patients in practice and analysis of physician perspectives on the issue.

Background

Decision not to resuscitate (DNR/DNAR) is part of practice in elderly cancer care. Physicians issue such orders when a patient is suffering from irreversible disease and the patient''s life is coming to an end. Modern practice emphasises the need of communication with the patients and their relatives while issuing a DNR. The decision making process of placing DNR can be quite daunting. The moral and ethical dimensions surrounding such a decision make it a contentious topic.

Materials and methods

We searched the literature to find relevant works that would help physicians and especially the junior health care staff in dealing with the complexities. In this article, we discuss the issues that physicians encounter whilst dealing with a DNR order in elderly cancer patients.

Results

There are no objective adjuncts or guidelines directed towards the approach of placing a DNR in elderly cancer patients. Better communication with the patients and relatives when making such decision remains a very important aspect of a DNR decision. Most health care staff find themselves ill equipped to deal with such situation. Active training and briefing of junior staff would help them deal better with the stresses involved in this process.

Conclusion

There are complex psychosocial, medical, ethical and emotive aspects associated with placing a DNR order. Patients and their loved ones and the junior staff involved in the care of patient need early communication and briefing for better acceptance of DNR. Studies that could devise or identify tools or recommendations would be welcome.     

Medical manpower two years on.

Medical manpower in Britain, with particular reference to the NHS, was analysed for 1976 and 1977. The output of British medical schools increased. The total of doctors in the NHS rose by 2% between 1975 and 1976 and by 2.4% between 1976 and 1977. The highest and lowest growth rates were in junior and senior hospital staff grades respectively, while the highest growth rate in career grades seemed to be in community medicine and health. The inflow of overseas doctors remained high, though few tended to remain permanently in Britain. Continuous evaluation of the medical manpower position is needed before long-term predictions can confidently be made.     

Junior doctors' on call activities: differences in workload and work patterns among grades.

OBJECTIVE--To examine the workload and work patterns of junior doctors of all grades while on call. DESIGN--Pilot study of activity data self recorded by junior doctors, with the help of students during busy periods. SETTING--A general surgical firm and a general medical firm based at University Hospital, Nottingham. SUBJECTS--Four registrars, three senior house officers, and five preregistration house officers. RESULTS--Senior house officers and preregistration house officers spent nearly half of all their on call duty time working, but less than half of that time was spent in direct contact with patients. Registrars were on call more often than the house officers but spent less than one fifth of their on call duty time working, and almost two thirds of that time was spent in direct contact with patients. CONCLUSIONS--Workload while on duty is excessive for both senior and preregistration house officers. Changes in some administrative procedures and employment of more non-medical staff during on call periods might reduce the time spent on non-clinical activities, thereby reducing the overall workload and allowing more time for patient contact.     

Shift system for senior house officer on call duties on a neonatal intensive care unit

To reduce the number of hours that senior house officers in the neonatal department at Southmead Hospital, Bristol, have to work continuously a new on call rota was devised. The rota changed the traditional one in three system of 24 and 32 hour periods on call to one with two shifts each day, and it spread the workload more evenly among the personnel. The continuity of care of the patients was improved, no extra staff were recruited, and the new system was favoured by senior and junior medical and nursing staff.     

Programmed investigation unit.

The programmed investigation unit (PIU) is a inpatient unit where a full range of investigational medicine can be organised. It provides the basic minimum nursing care and is suitable for ambulant patients who can care for themselves. Requests for admission to the PIU at the Royal Victoria Infirmary, Newcastle upon Tyne, come directly from clinical units, and the staff of these units perform some of the tests and remain responsible for the patient while she is in the unit. At present the unit caters only for female medical patients. The average waiting time for admission is three weeks, and because the unit now deals with most investigations the waiting time for admission to the female general medical wards has fallen considerably. The staff of the unit have gained expertise in diagnostic methods, while the nurses of general medical wards have been free to concentrate on nursing those patients who need it. Separating patients who need investigations from those on general medical wards seems a logical way of using resources and staff to best effect.     

Obstetric accidents: a review of 64 cases.

OBJECTIVE--To identify the causes of obstetric accidents. DESIGN AND SETTING--Analysis of case records at the Medical Protection Society''s London office covering the five years 1982-6. SUBJECTS--Cases that had come to litigation which had resulted in stillbirth, perinatal or neonatal death, central nervous system damage to the baby, or maternal death and in which there was an opinion from a senior obstetrician consulted by the society. Of 147 cases reviewed, 64 met the criteria for the study. MAIN OUTCOME MEASURES--The principal findings of the expert reviewers. RESULTS--Three major topics of concern emerged common to most of the 64 cases. These were inadequate fetal heart monitoring, mismanagement of forceps, and inadequate supervision by senior staff. In 11 of the 64 cases cardiotocography was omitted, in 19 cases the trace was missing, in six cases the trace was unreadable, and in 14 of the remaining 28 cases signs of fetal distress went unnoticed or were ignored. In 31 cases forceps were used to aid delivery or were tried and abandoned in favour of caesarean section. In 16 cases two or more attempts to use forceps were made. Five infant deaths were directly attributed to mismanaged forceps. In 20 cases senior staff were criticised by the expert reviewer for failure to come to the labour ward. In many of these cases they may have given advice over the telephone, but the inadequacy of records made it impossible to tell. In these cases the labour and birth were managed by junior staff, usually a senior house officer. In six cases when senior staff did come they suggested that no action was needed. CONCLUSION--These few cases should not be dismissed as isolated incidents in obstetric practice in Britain. They reflect more general problems--namely, concerning the ability of junior doctors to interpret fetal heart traces accurately, their ability to use forceps, and the participation of senior staff in running a labour ward and delivery suite.     

Psychological and social evaluation in cases of deliberate self-poisoning seen in an accident department.

The outcome in 115 consecutive patients with mild self-poisoning seen by junior medical staff and discharged from the accident department was compared with that of 98 similar patients admitted to the medical wards. Psychiatrists saw only four patients in the accident department and 25 admissions. In making their assessments the junior medical staff considered psychosocial factors as well as the patients'' physical condition. Most patients recommended for further care, and discharged from the accident department, subsequently received it. Repetition rates were similar in the two groups and there had been no suicides when patients were followed up at one year. It is feasible for junior staff in an accident department to decide whether patients with self-poisoning need admission or may be discharged with or without subsequent referral for psychiatric or social work help.     

Ultrasonographic estimation of fetal weight--residents accuracy

The aim of this retrospective study was to evaluate the accuracy of gynecology and obstetrics residents when performing ultrasonographic estimation of fetal weight. The total of 400 ultrasonographic estimations of fetal weight and corresponding neonatal weight were collected and divided into 3 groups according to physicians' experience (junior and senior residents, staff physicians). The accuracy of fetal weight estimation correlated positively with the level of physicians'experience. The proportional difference between ultrasound estimation and actual birth weight varied from 8.45% to 6.88% (junior residents 8.45%, senior residents 6.95%, staff physicians 6.88%). The proportion of ultrasonograhic estimates that fell within 10% of birth weight varied from 59.09% to 79.21% (junior residents 59.09%, senior residents 78.44%, staff physicians 79.21%). Senior residents reach a highly acceptable accuracy in ultrasonographic estimation of fetal weight which is comparable to staff physicians.     

What did audit achieve? Lessons from preliminary evaluation of a year's medical audit.

OBJECTIVE--To evaluate the experience of a year''s audit of care of medical inpatients. DESIGN--Audit of physicians by monthly review of two randomly selected sets of patients'' notes by 12 reviewers using a detailed questionnaire dedicated to standards of medical records and to clinical management. Data were entered into a database and summary statistics presented quarterly at audit meetings. Assessment by improvement in questionnaire scores and by interviewing physicians. SETTING--1 District general hospital. PARTICIPANTS--About 40 consultant physicians, senior registrars, and junior staff dealing with 140 inpatient records. MAIN OUTCOME MEASURES--Median scores (range 1 to 9) for each item in the questionnaire; two sets of notes were discussed monthly at "general" audit meetings and clinical management of selected common conditions at separate monthly meetings. RESULTS--A significant overall increase in median scores for questions on record keeping occurred after the start of the audit (p less than 0.01), but interobserver variation was high. The parallel audit meetings on clinical management proved to be more successful than the general audits in auditing medical care and were also considered to be more useful by junior staff. CONCLUSIONS AND ACTION--Medical audit apparently resulted in appreciable improvements in aspects of care such as clerking and record keeping. Analysis of the scores of the general audits has led to the introduction of agreed standards that can be objectively measured and are being used in a further audit, and from the results of the audits of clinical management have been developed explicit guidelines, which are being further developed for criterion based audit.     

When a physician and a clinical ethicist collaborate for better patient care

Bioethics is a relatively new addition to bedside medical care in Arab world which is characterized by a special culture that often makes blind adaptation of western ethics codes and principles; a challenge that has to be faced. To date, the American University of Beirut Medical Center is the only hospital that offers bedside ethics consultations in the Arab Region aiming towards better patient‐centered care. This article tackles the role of the bedside clinical ethics consultant as an active member of the medical team and the impact of such consultations on decision‐making and patient‐centered care. Using the case of a child with multiple medical problems and a futile medical condition, we describe how the collaboration of the medical team and the clinical ethics consultant took a comprehensive approach to accompany and lead the parents and the medical team in their decision‐making process and how the consultations allowed several salient issues to be addressed. This approach proved to be effective in the Arab cultural setting and indeed did lead to better patientcentered care.     

Computer-aided decision support in clinical medicine

This paper reviews the problems and prospects involved in providing computer-aided decision support in clinical medicine. First, the evaluation of medical innovation is discussed. It is suggested that there are three criteria by which an innovation may be judged, namely (1) a need for the innovation, (2) the ability of the innovation to fulfil that need and (3) the ability to do so without transgressing practical, ethical or legal boundaries. These problems are addressed in turn. The paper suggests, taking one area of clinical medicine as an example (acute abdominal pain) there is a clear need for decision support — since the area is not handled well by doctors in current practice. Evidence is adduced to suggest that the computer can provide decision support and do so without transgressing professional, ethical or legal boundaries. The obstacles to progress, which stand in the way of widespread implementation are briefly discussed. These are lack of medical terminology, poor man-machine interface and above all a lack of co-ordination. Finally, it is suggested that the most valuable facet of current systems is the discipline and precision in data collection they impose upon practicing doctors.     

Teaching in accident and emergency medicine: 10 commandments of accident and emergency radiology.

One of the many attractions of accident and emergency medicine is the wide and varied opportunities it provides for education. This is because of the acute nature of the work, which necessitates prompt and accurate decision making. However, in many instances the decisions have to be made by inexperienced senior house officers. Departments therefore need a safe system of practice that can be remembered and adhered to under stress. The 10 commandments is one such system for analysing emergency radiographs of all the regions of the body. This system lays down guidelines to protect both staff and hospitals from the inevitable mistakes that inexperienced doctors will make.     

Performance changes following a field conditioning program in junior and senior rugby league players

This study investigated training loads, injury rates, and physical performance changes associated with a field conditioning program in junior and senior rugby league players. Thirty-six junior (16.9 [95% confidence interval: 16.7-17.1] years) and 41 senior (25.5 [23.6- 27.3] years) rugby league players participated in a 14-week preseason training program that included 2 field training sessions each week. Subjects performed measurements of standard anthropometry (height, body mass, and sum of 7 skinfolds), muscular power (vertical jump), speed (10-, 20-, and 40-m sprint), agility (L run), and maximal aerobic power (multistage fitness test) before and after training. Improvements in agility, muscular power, and maximal aerobic power were observed in both the junior and senior players following training; however, the improvement in maximal aerobic power and muscular power were greatest in the junior players. Training loads and injury rates were higher in the senior players. These findings demonstrate that junior and senior rugby league players adapt differently to a given training stimulus and that training programs should be modified to accommodate differences in training age.     

Clinical skills of medical residents: a review of physical examination.

Students are introduced to techniques of physical examination at medical school. However, their skills are deficient at the time of graduation, and with the increasing shift of clinical teaching away from the bedside and into the conference room it is expected that these skills will weaken in succeeding generations of physicians. A practical and satisfactory method of addressing this problem during internship and residency training has not been forthcoming because of the lack of a regular forum for the teaching of clinical skills in busy tertiary referral hospitals and the shortage of teachers with the necessary skills and commitment to teaching a large number of house staff. We describe a program whose unique hierarchical approach has permitted a detailed ongoing review of physical examination. One clinician was able to teach 24 residents by instructing a small group of senior residents, who in turn, after practising with clinical clerks, taught groups of junior residents.