Caseload or workload? Scoring complexity of operative procedures as a means of analysing workload.

OBJECTIVE--To present a more realistic assessment of surgical workload than that provided by a case count. DESIGN--Prospective study of all the operative procedures performed in one year, classified according to the British United Provident Association''s schedule of procedures and scored by the "intermediate equivalent" value (taking the recommended fee value of an intermediate operation as 1.0) compared with the number of operations performed. SETTING--General surgical unit of Taunton and Somerset Hospital, comparing four consultant surgeons and their teams. PATIENTS--Inpatients and day patients admitted under the care of general surgeons during 1989. MAIN OUTCOME MEASURE--Difference between the apparent workload represented by simple case counting (caseload) and the actual workload represented by calculation of the total "intermediate equivalent" value. RESULTS--The workload assessed in terms of intermediate equivalent values was greater than that suggested by case counting for complex operations (12% v 4%), operations at the district hospital (82% v 74%), and operations performed by consultants (53% v 35%) and was lower for minor operations (20% v 42%), operations at the community hospitals (18% v 26%), and operations performed by surgeons in training grades and clinical assistants (47% v 66%). CONCLUSIONS--The use of the intermediate equivalent values as an indicator of complexity allows a more realistic assessment of the operative workload than a simple case count of the number of different operations and is recommended for comparing workload in different hospitals and departments.     

The hospital component of vocational training for general practice.

Trainees and educationalists in general practice have some grounds for suggesting that the hospital component of vocational training should be restructured and teaching improved. However, the implications for other trainees and secondary care have to be considered. Changes that are needed include a curriculum for senior house officers in each specialty; appointment of training consultants with the necessary skills; and a different attitude by everyone towards study leave, including arrangements for funding. The optimum duration of hospital posts for trainees in general practice might be shorter than now, but the effects on others must be considered and competencies guaranteed in a briefer training period. Changes in the regulations for vocational training could help to improve specialist experience if trainees in general practice were allowed to be supernumerary. Alternatively, senior house officer posts for trainees in general practice could be split between secondary and primary care, thus encouraging a broader perspective.     

Education and training of preregistration house officers: the consultants' viewpoint.

OBJECTIVE--To determine the opinions, attitudes, and requirements of consultants responsible for preregistration house officers in the light of the General Medical Council''s Recommendations on General Clinical Training. DESIGN--A questionnaire was piloted asking 28 questions under the headings professional details, present training arrangements, effectiveness of current training, and perceived help required for implementing the recommendations. SETTING--Two teaching hospitals and nine district general hospitals in the Yorkshire region. SUBJECTS--33 consultants (19 physicians, 14 surgeons) responded to an hour long interview. RESULTS--The traditional teaching ward round, with clinical meetings, was the main educational provision for house officers. Under a quarter of respondents provided specific teaching, which rarely exceeded 30 minutes weekly. Many delegated teaching to other junior or non-medical staff. Few consultants assessed the effectiveness of teaching, and feedback to juniors was rudimentary. There was strong support for the apprenticeship system and concern that it should not be downgraded. Appointing educational supervisors and introducing a structured educational programme were approved theoretically. Pressure on consultants to work faster, participate in audit and management, and accept financial responsibility for their clinical work, coupled with the reduction in junior doctors'' hours, were considered to militate against educational developments. Many respondents felt frustrated and powerless. They would welcome an increased educational role but considered there must be conceptual, contractual, and financial changes. CONCLUSIONS--Fundamental changes are required by both consultants and management before the preregistration year can have proper educational value. Training in educational methods for consultants and a structured curriculum and formative assessment for trainees require recognition and financial support.     

Senior house officers and their training. I. Personal characteristics and professional circumstances.

To assess the experience and perceptions of training of senior house officers in medicine a population survey of senior house officer training was conducted on senior house officers, registrars, senior registrars, and consultants in six medical specialties in South East Thames region by interview and postal questionnaire. The overall response rate was 72%, varying from 62% to 83% according to status and from 61% to 80% according to specialty. Although most of the 226 senior house officer respondents were aged 28 or under (168/225), had been qualified for four years or less (168/225) and were British (176/223), a quarter were older and had been qualified for five years or more; in all, 17 other nationalities were represented. Twenty two were aged over 33, and 17 had been qualified for more than 10 years. Thirty five senior house officers worked more than the mode of the distribution of duty rotas (one in three). Among postgraduate qualifications achieved or pursued, those related to general practice were highly represented (164 examinations); 111 senior house officers intended becoming general practitioners, 63 non-teaching hospital consultants, and 34 university or NHS teaching staff. Analysis of career progression showed that an appreciable number (31/221) had had more than three senior house officer posts. The findings indicate that the main implications for training and education are time for study, careers advice, and revision of educational programmes.     

Research ethics capacity development in Africa: exploring a model for individual success

The Johns Hopkins-Fogarty African Bioethics Training Program (FABTP) has offered a fully-funded, one-year, non-degree training opportunity in research ethics to health professionals, ethics committee members, scholars, journalists and scientists from countries across sub-Saharan Africa. In the first 9 years of operation, 28 trainees from 13 African countries have trained with FABTP. Any capacity building investment requires periodic critical evaluation of the impact that training dollars produce. In this paper we describe and evaluate FABTP and the efforts of its trainees. Our data show that since 2001, the 28 former FABTP trainees have authored or co-authored 105 new bioethics-related publications; were awarded 33 bioethics-related grants; played key roles on 78 bioethics-related research studies; and participated in 198 bioethics workshops or conferences. Over the past nine years, trainees have collectively taught 48 separate courses related to bioethics and have given 170 presentations on various topics in the field. Many former trainees have pursued and completed doctoral degrees in bioethics; some have become editorial board members for bioethics journals. Female trainees were, on average, less experienced at matriculation and produced fewer post-training outputs than their male counterparts. More comprehensive studies are needed to determine the relationships between age, sex, previous experience and training program outputs.     

Are the recommendations being met in the general practice year of vocational training? Trainees' views in the West Midlands region.

Vocational trainees in the West Midlands who were in their general practice year were sent a postal questionnaire to find out whether there were important differences between the criteria for training of the 1986 West Midland postgraduate education committee (based on national recommendations) and the perceptions of the trainees of their current trainers and practices. The response rate was 86.2% (75 out of 87). Sixty four per cent (48) of trainees reported that they received on average less than the recommended minimum of three hours of teaching time a week. They felt that experience was inadequate in paediatric surveillance (62.7%) and preventive medical care (37.3%). Most trainers gave topic teaching (90.7%), and few used role play (5%). Most of the trainees (52%) had not signed a contract, a third did not get help with recommended allowances, and 37% thought that their progress had not been reviewed. Several trainees commented on the excellence of their training practices, and most of the practices appeared to be keeping to the spirit of the recommendations. There are, however, discrepancies between what some trainees feel they receive and what is recommended.     

Grommets,tonsillectomies, and deprivation in Scotland.

OBJECTIVE--To see whether there is a relation between grommet insertion operation and tonsillectomy rates, otolaryngology services, and deprivation scores in Scotland. DESIGN--Analysis of routine 1990 NHS data on grommet insertions and tonsillectomies in Scottish children aged 0-15 years compared with data on general practitioner and otolaryngology services and Carstairs deprivation scores. SETTING--All 15 Scottish health boards. SUBJECTS--All children aged 0-15 (1,021,933). RESULTS--Tonsillectomy was more common than grommet insertion operations in Scotland (6182:4850). Health boards with high grommet insertion rates were more likely to have low tonsillectomy rates (Spearman''s rank correlation -0.59; 95% confidence interval -0.87 to -0.03). Grommet insertion rates varied fourfold (from 2.4/1000 to 9.2/1000) and tonsillectomy rates twofold (from 3.6/1000 to 8.0/1000) across Scottish health boards. Variation between health boards had changed over the 15 years 1975-90. Variation in grommet insertion rates did not reflect variation in the supply of otolaryngology consultants (Spearman''s rank correlation -0.25). There was a non-significant tendency for high general practitioner referral rates to be associated with high grommet insertion rates, low tonsillectomy rates, and less deprived areas (Spearman''s rank correlation coefficients 0.50, -0.53, and -0.43). Deprivation (measured by Carstairs scoring for each health board) was associated with higher tonsillectomy rates (Spearman''s rank correlation 0.41; 95% confidence interval -0.22 to 0.80) and significantly lower grommet insertion rates (-0.73; -0.92 to -0.28). CONCLUSION--Social factors as well as differences in disease prevalence and medical practice need to be considered when studying variation in childhood grommet insertion and tonsillectomy rates.     

Improving the preregistration experience: the New Zealand approach.

There is currently much debate about how to improve undergraduate medical education, and in particular on how best to prepare students for clinical responsibility. For 20 years a period of trainee internship has formed part of New Zealand medical students'' undergraduate training, and the model could have much to offer the United Kingdom. Students take their final examinations at the end of the second clinical year; they spend their final year in a series of eight clinical attachments, during each of which they shadow a preregistration house officer or senior house officer. As trainee interns they are paid 60% of a house officer''s salary for their clinical work, which is supervised by the firm''s registrars and consultants under the overall responsibility of the head of the academic department. The order of the attachments is determined on educational, not service, grounds, and trainees have to attend educational sessions and pass assessments on each attachment. The trainee internship, funded jointly by the education and health departments, offers a more seamless transition from student to house officer and aims at improving both general medical education and clinical training.     

Overseas doctors and the staffing structure of hospitals.

The introduction of the new immigration rules will considerably reduce the number of overseas doctors available for junior hospital appointments over the next five years. To offset this sponsorship schemes should be offered by universities and colleges comprising training courses, entry to examinations, and hospital appointments, and training programmes should be adapted to make objectives attainable in the four years available to overseas doctors. Employment of overseas doctors can ease the transition within the staffing structure to fewer juniors and more consultants, but planning is urgently required, and in particular the service and manpower needs of the National Health Service must be considered.     

GP trainees' views on hospital obstetric vocational training.

OBJECTIVES--To examine the content of hospital obstetric vocational training for general practice, the beliefs of general practitioner trainees about this training, and their perceived competence at practical obstetric procedures and the effect of training. DESIGN--Confidential postal questionnaire. SUBJECTS--A random one in four sample of all general practitioner trainees in the United Kingdom on vocational training schemes or in training practices in Autumn 1990. MAIN OUTCOME MEASURES--Trainees'' competence and beliefs on Likert scale, numbers of procedures witnessed and performed, type of maternity care trainees intended to provide. RESULTS--Of 1019 trainees sent questionnaires, 765 (75.1%) replied; 517 had done some hospital obstetric training. After six months as a senior house officer 232/367 (63%) believed they were competent to perform a normal delivery unaided, 228 (62%) to manage a severe postpartum haemorrhage, and 227 (62%) to resuscitate a newborn infant. 272 (35.6%) trainees intended to provide intrapartum care and 56 (7.5%) to book home deliveries in the future. Hospital training increased confidence in performing most obstetric procedures in all trainees. However, a greater proportion of trainees who intended to provide full care than shared care felt competent at performing a normal vaginal delivery (63% (170/272) full v 45% (215/473) shared), low forceps delivery (38% (103) v 17% (79)), manual removal of placenta (24% (65) v 17% (82)), and intubating a neonate (42% (114) v 34% (161)). Trainees who had done any obstetric training were less likely to think that training encouraged future provision of intrapartum care (113/509 (22%) training v 65/213 (31%) no training). CONCLUSION--Hospital vocational obstetric training increases the perceived competence of trainees but fails to encourage them to use obstetric skills.     

Is communication improving between general practitioners and psychiatrists?

General practitioners and psychiatrists communicate mainly by letter. To ascertain the most important items of information that should be included in these letters ("key items") questionnaires were sent to 80 general practitioners and 80 psychiatrists. A total of 120 referral letters sent to psychiatric clinics in 1973 and 1983 were studied, together with the psychiatrists'' replies, and these were rated for the inclusion of "key items." General practitioners'' letters contain less information about the family but more about psychiatric history than they did a decade ago. Overall, psychiatrists'' letters have not changed. Registrars, however, now include noticeably more "key items" than they did 10 years ago, but their letters remain twice the length of those written by consultants. It is suggested that letter writing skills are vital to good patient management and should be taught to postgraduate trainees in general practice and psychiatry.     

Clinical audits in a postgraduate general practice training program: an evaluation of 8 years' experience

Background

Clinical audit can be of valuable assistance to any program which aims to improve the quality of health care and its delivery. Yet without a coherent strategy aimed at evaluating audits'' effectiveness, valuable opportunities will be overlooked. Clinical audit projects are required as a part of the formative assessment of trainees in the Family Medicine Residency Program (FMRP) in Kuwait. This study was undertaken to draw a picture of trainees'' understanding of the audit project with attention to the knowledge of audit theory and its educational significance and scrutinize the difficulties confronted during the experience.

Methodology/Principal Findings

The materials included the records of 133 audits carried out by trainees and 165 post course questionnaires carried out between 2004 and 2011. They were reviewed and analyzed. The majority of audit projects were performed on diabetic (44.4%) and hypertensive (38.3%) care. Regarding audits done on diabetic care, they were carried out to assess doctors'' awareness about screening for smoking status (8.6%), microalbuminuria (19.3%), hemoglobin A1c (15.5%), retinopathy (10.3%), dyslipidemia (15.8%), peripheral neuropathy (8.8%), and other problems (21.7%). As for audits concerning hypertensive care, they were carried out to assess doctors'' awareness about screening for smoking status (38.0%), obesity (26.0%), dyslipidemia (12.0%), microalbuminuria (10.0%) and other problems (14.0%). More than half the participants (68.48%) who attended the audit course stated that they ‘definitely agreed’ about understanding the meaning of clinical audit. Most of them (75.8%) ‘definitely agreed’ about realizing the importance of clinical audit in improving patients'' care. About half (49.7%) of them ‘agreed’ that they can distinguish between ‘criteria’ and ‘standards’.

Conclusion

The eight years of experience were beneficial. Trainees showed a good understanding of the idea behind auditing the services provided. They demonstrated their ability to improve the care given in health centers in which these projects were undertaken.     

General practitioner training in paediatrics in the Trent region.

A total of 259 postal questionnaires were sent to all final year vocational trainees and new principals in general practice in the Trent region to find out how much training in paediatrics they had had. Questionnaires were returned by 105 trainees and 139 principals (244; 94%). Overall 72% (175) had taken up a hospital post in paediatrics during training, but among the 138 doctors who were on or had completed a three year vocational training scheme the proportion was slightly higher (82%; 115) (p = 0.01). Among the 175 who had had a post in paediatrics 108 (62%) had been given teaching sessions every week, and for half of these doctors the sessions lasted over one hour a week. Seventy five (54%) of the 139 principals reported that in their training in a general practice they had received no teaching about child health and a fifth said that they had not attended a clinic for children; 47 (34%) had received no training on procedures for dealing with cases of child abuse. The doctors who had held posts as senior house officers in paediatrics were more likely to report that they had adequate skills in paediatrics than those who had not, but overall only 62 (44%) reported that they could run a preschool child health surveillance programme. Extra paediatric posts in hospital are needed, but in the mean time improvements can be made to the teaching content in hospital and in the general practice attachment and postgraduate training in paediatrics provided for all general practitioners.     

Psychiatric training: the consultants' view.

All consultants in general psychiatry appointed between 1 October 1972 and 30 September 1975 were sent a questionnaire asking about their training experience in various aspects of psychiatric practice. The results showed that the standards of training in 13 areas of psychiatry were generally poor, although psychiatrists who had trained at the Maudsley Hospital had generally had better training than those who had worked in psychiatric hospitals. Perhaps the most alarming feature was the general lack of improvement over the past nine years. It will be several years before the effects of the visist of approval made by the Royal College of Psychiatrists can be seen and assessed. Meanwhile, the demands for a fairer share of experience for all trainees can perhaps be met by introducing rotational programmes that include both teaching and psychiatric hospitals.     

Preregistration house officers in the Thames regions: changes in quality of training after four years.

OBJECTIVE--To measure changes in the training and workload of preregistration house officers over four years. DESIGN--Postal questionnaire. SETTING--The Thames health regions. PARTICIPANTS--1049 preregistration house officers. RESULTS--Response rate was 69% (725 replies). The proportion of house officers officially on duty > 83 hours a week fell from at least 42% to 21%, and the proportion officially on duty < or = 72 hours rose from no more than 9% to 40%. Adequate guidance in breaking bad news increased from 25% to 46% (p < 0.0001; 95% confidence interval for difference, 16.2% to 25.8%) and guidance in pain control increased from 36% to 46% (p < 0.01; 5.0% to 15.0%). The number of house officers attending an induction course increased from 61% to 94% (p < 0.001; 28.9% to 37.1%). There was no change in the proportion unable to attend formal educational sessions because of clinical commitments or in levels of satisfaction with consultants'' educational supervision. The median number of inpatients under house officers'' care fell from 20 to 17, but the numbers of patients clerked in an average week showed little change. House officers were less satisfied with the clinical experience their post provided (proportion dissatisfied rose from 30% to 39%; p < 0.01; 4.2% to 13.8%) and less enthusiastic about recommending their post to a friend (proportion neutral or not recommending rose from 30% to 42%, p < 0.0001; 7.9% to 16.9%). CONCLUSION--Despite progress in reducing hours of duty and providing induction courses, the training that hospitals and consultants provide for house officers is still unsatisfactory and inconsistent with the General Medical Council''s recommendations.     

Recall of an oral health education programme by nursing personnel in special housing facilities for the elderly

Objectives: To investigate the recall of oral health knowledge and confidence by nursing personnel in special housing facilities for the elderly, three years after an education programme. Design: A cross sectional design using a questionnaire. Sample: All nursing personnel, a total of 2,901 subjects, in five municipalities in south‐western Sweden; of whom 950 had attended the programme. The response rate was 67% (1930 subjects). Intervention: An oral health education programme consisting of four one‐hour lessons. Results: The oral health education programme still had an effect on the participants' attitudes towards oral health three years later. When comparing the trained group (OHEP+) which attended the programme with those who did not have training (OHEP‐), the perceived ability, opportunity and the knowledge of oral health were significantly better in the former group, p<0.01 Eurther, within the OHEP‐ group who did not attend the programme there was a significant difference in the perceived ability, opportunity and the knowledge of oral health between those with a higher level of health care education, p<0.01. Conclusions: The effect of an oral health education programme on the participants' attitudes towards oral health persists at least for three years. The data indicate that trainees with a low level of health care education benefit most.     

Devolving authority for health care in Canada's provinces: 3. Motivations,attitudes and approaches of board members

OBJECTIVE: To obtain information from the members of the boards of devolved health care authorities on their motivations, attitudes and approaches, to evaluate their relative orientations to the expectations of provincial governments, local providers and community members, and to evaluate the influence of members'' being employees in health care or social services and being willing to stand for election. DESIGN: Mail survey conducted in cooperation with the devolved authorities during the summer of 1995. SETTING: Three provinces (Alberta, Saskatchewan and Prince Edward Island) with established boards and 2 provinces (British Columbia and Nova Scotia) with immature boards. PARTICIPANTS: All 791 members of the boards of devolved authorities in the 5 provinces, of whom 514 (65%) responded. OUTCOME MEASURES: Respondents'' declared motivations, levels of confidence in board performance and attitudes toward accountability; differences between members who were willing to run for election to boards and others and differences between members who were employees in health care or social services and others. RESULTS: The main motivations of board members were an interest in health care and a desire to be part of decision-making and their main concern was inadequacy of data for decision-making. Almost all (93%) felt that they made good decisions, and 69% thought that they made better decisions than those previously made by the provincial government. Most (72%) felt that they were accountable to all of the local citizens, although nearly 30% stated that they represented the interests of a specific geographic area or group. Attitudes toward their provincial governments were polarized, with half agreeing and half disagreeing that provincial rules restrict the board members. The board members who were employed in health care and social services and those who were willing to stand for election did not differ substantially from their counterparts, although potential electoral candidates were less likely than others to feel accountable to provincial-level constituencies (such as taxpayers and the minister of health) and more likely to represent the interests of a specific geographic area or group. Only a modest number of differences were found among members from different provinces. CONCLUSIONS: Board members'' strong feelings of accountability to and representation of local citizens could counteract the structural influences leading board members to favour the interests of provincial governments and providers.     

Diagnosis and treatment of venous thromboembolism by consultants in Scotland.

A questionnaire was sent to 508 consultants in Scotland likely to encounter deep vein thrombosis and pulmonary embolism to assess their current standard practice in diagnosis and treatment of these disorders. Replies were received from 358 (70.5%). In deep vein thrombosis 47% and in pulmonary embolism 33% of consultants usually depended on clinical observation alone for diagnosis. In deep vein thrombosis 37% used venography to supplement clinical diagnosis and in pulmonary embolism 13% used angiography and 53% used isotopic scanning. Almost all consultants treated deep vein thrombosis (95%) and pulmonary embolism (99%) with anticoagulants. Most consultants (81%) gave heparin by intravenous infusion. Although many consultants gave intravenous heparin for more than three days (49.5% in deep vein thrombosis and 61% in pulmonary embolism), 25% of these consultants did not use any laboratory monitoring of heparin''s effect. Large numbers of consultants gave warfarin for more than three months (20% in deep vein thrombosis and 47% in pulmonary embolism). There was a significant tendency to give heparin (p less than 0.01) and warfarin (p less than 0.001) for longer periods in pulmonary embolism than in deep vein thrombosis. This survey shows a widely varying practice and underlines the need for further controlled studies to provide clear guidance in the management of deep vein thrombosis and pulmonary embolism.     

Physicians' perceptions of the effect on clinical services of an alternative funding plan at an academic health sciences centre

BACKGROUND: In July 1994 an alternative funding plan for clinical services (global funding instead of fee-for-service payment) was established at the Southeastern Ontario Health Sciences Centre, Kingston, Ont. This study describes the perceptions of the referring physicians and consultants of the effects of the alternative funding plan 2.5 years after it was initiated. METHODS: A questionnaire was mailed to all physicians in the Kingston area in November 1996. Information was collected on demographics, referring physicians'' perceptions of the funding plan''s impact on their practices, consultants'' perceptions of its impact on their activities, perceptions of referring and consultant physicians of its impact on services provided by consultants, and attitudes toward alternative funding in the context of the Ontario health care system. RESULTS: Of the 772 physicians 531 (68.8%) returned a completed questionnaire (323 referring physicians and 208 consultants). A sizeable proportion of the referring physicians (126 [39.0%]) indicated that they were referring fewer patients to consultants at the study centre. They did not think that their practice volume had increased, but they did report spending more time on complex cases and on patient care after referral or hospital stay, and more time coordinating community care after hospital stay. Of the consultants 81 (38.9%) believed that their time spent on patient care had increased. No consistent impact on time spent on research or teaching activities was perceived. A total of 54 (26.0%) of the consultants were concerned about the impact of the alternative funding plan on quality of care. A significant proportion of the respondents (399 [75.1%]) believed that outpatient waiting times had increased, and 116 (35.9%) of the referring physicians believed that consultants were not as available by telephone. Most (220 [68.1%]) of the referring physicians believed that the funding change had had a negative effect on health care services in the region, and 87 (41.8%) of the consultants agreed. Nevertheless, the respondents believed that other factors such as funding cuts, hospital bed closures and staff layoffs were much more responsible than the alternative funding plan for their negative perceptions. INTERPRETATION: The alternative funding plan appears to have had an impact on the practices of individual physicians. However, it was not the focus for significant opposition or support from either consultants participating in the funding plan or referring physicians.