How easy is it to contact the duty medical doctor responsible for acute admissions?

OBJECTIVE--To ascertain ease or difficulty of contacting duty junior doctors responsible for acute medical admissions by telephone. DESIGN--Telephone survey of hospitals in six health regions in England and Wales. SETTING--70 Randomly selected hospitals, 15 of which were excluded because of non-acceptance of acute medical admissions. PARTICIPANTS--71 Duty doctors (duty house physicians, senior house officers, or registrars responsible for acute medical admissions) in 48 hospitals; seven duty doctors in seven hospitals were excluded (four declined to participate and three required a written explanation of the survey). 67 Doctors gave full information to all questions. MAIN OUTCOME MEASURES--Time taken for hospital switchboards and duty doctors to reply to telephone call, diagnoses of patients recently admitted, and on call rotas and hours of sleep of duty doctors. RESULTS--Hospital switchboards responded within 30 seconds in 87 (74%) calls, and in 76 calls (64%) the duty doctor requested was contacted within a further two minutes. Chest pain, possibly due to myocardial infarction, was the most common reason for acute medical admissions. Nearly half (48%) of the duty doctors in larger hospitals reported having 4-5 hours sleep or less on their nights on call. Most (30) were on a one in three rota; two were on a one in two rota. CONCLUSIONS--Despite impressions to the contrary contacting the duty medical team by telephone seemed fairly easy. Although most junior doctors were on a rota of one in three or better, insufficient recognition may be given to their deprivation of sleep during nights on duty.     

Preregistration house officers in the four Thames regions: II. Comparison of education and workload in teaching and non-teaching hospitals.

OBJECTIVE--To detect differences in the education and workload of preregistration house officers working in teaching and non-teaching hospitals. DESIGN--A postal questionnaire. SETTING--Teaching and non-teaching hospitals in the four Thames regions. PARTICIPANTS--1064 Preregistration house officers. RESULTS--Response rate was 61% for teaching hospitals and 73% for non-teaching hospitals. House officers in teaching hospitals had significantly fewer inpatients under their care (house physicians 16.9 v 22.9, house surgeons 17.9 v 20.3) and admitted fewer emergency patients per week (house physicians 7.7 v 12.7, house surgeons 6.5 v 9.8). More house officers in teaching hospitals reported that they had too few patients to provide adequate clinical experience. More of their time was consumed by administrative activities devoid of educational value. CONCLUSION--Preregistration house officer posts at teaching hospitals provide less clinical activity and are perceived as less educationally satisfactory by their holders than those elsewhere.     

Where have all the giants gone? Reconciling medical education and the traditions of patient care with limitations on resident work hours

The Accreditation Council for Graduate Medical Education recently approved regulations that would prohibit residents from working more than 80 hours per week and more than 24 hours at a stretch. These regulations are scheduled to take effect in all U.S. teaching hospitals on 1 July 2003. Those who approve of the proposed regulations argue that house staff fatigue is responsible for physician error, depression, anger, and a lack of compassion for patients. But critics point to the adverse effects on key goals of house staff training--the development of accountability and responsibility. Can the rigorous discipline of medical education and the long tradition of medicine as a profession be reconciled with the current calls for limiting resident duty hours and on-call schedules? The intensity of patient care in teaching hospitals today is far greater than it was in the past. These changes in medical care make it critical to develop new programs that will reconcile rigorous, scientifically based humanistic medicine with the needs of patients and physicians. This will require imaginative and creative solutions that take a larger view of medical education and medical care than mere manpower calculations and numerical solutions focused simply on compliance with an 80-hour work week.     

Doctors' use of electronic medical records systems in hospitals: cross sectional survey

ObjectivesTo compare the use of three electronic medical records systems by doctors in Norwegian hospitals for general clinical tasks.DesignCross sectional questionnaire survey. Semistructured telephone interviews with key staff in information technology in each hospital for details of local implementation of the systems.Setting32 hospital units in 19 Norwegian hospitals with electronic medical records systems.Participants227 (72%) of 314 hospital doctors responded, equally distributed between the three electronic medical records systems.ResultsMost tasks listed in the questionnaire (15/23) were generally covered with implemented functions in the electronic medical records systems. However, the systems were used for only 2-7 of the tasks, mainly associated with reading patient data. Respondents showed significant differences in frequency of use of the different systems for four tasks for which the systems offered equivalent functionality. The respondents scored highly in computer literacy (72.2/100), and computer use showed no correlation with respondents'' age, sex, or work position. User satisfaction scores were generally positive (67.2/100), with some difference between the systems.ConclusionsDoctors used electronic medical records systems for far fewer tasks than the systems supported.

What is already known on this topic

Electronic information systems in health care have not undergone systematic evaluation, and few comparisons between electronic medical records systems have been madeGiven the information intensive nature of clinical work, electronic medical records systems should be of help to doctors for most clinical tasks

What this study adds

Doctors in Norwegian hospitals reported a low level of use of all electronic medical records systemsThe systems were mainly used for reading patient data, and doctors used the systems for less than half of the tasks for which the systems were functionalAnalyses of actual use of electronic medical records provide more information than user satisfaction or functionality of such records systems     

Preliminary analysis of the care of injured patients in 33 British hospitals: first report of the United Kingdom major trauma outcome study.

OBJECTIVE--To measure the effectiveness of management of major trauma in the United Kingdom. DESIGN--Review of the care of all seriously injured patients seen over two years. SETTING--33 hospitals which receive patients who have sustained major trauma. SUBJECTS--14,648 injured patients admitted for more than three days, transferred or admitted into an intensive care bed, or dying from their injuries. MAIN OUTCOME MEASURE--Death or survival in hospital within three months of the injury. RESULTS--21% of seriously injured patients (1299) took longer than one hour to reach hospital. Time before arrival at hospital was not related to severity of injury. A senior house officer was in charge of initial hospital resuscitation in 57% (826/1445) of patients with an injury severity score > or = 16. More senior staff were commonly responsible for definitive operations, but only 46% (165/355) of patients judged to require early operation arrived in theatre within two hours. Mortality for 6111 patients sustaining blunt trauma and treated in the 14 busiest hospitals was significantly higher (actual 408, predicted 295.6, p < 0.001) than in a comparable North American dataset. Large differences in the 14 hospitals assessed could not be explained by variations in case load or facilities. In contrast, the outcome of the 4.1% (597) of patients with penetrating injuries was better than that of a comparable group in the United States. Analysis of the 415 penetrating injuries with complete data showed that 15 patients died (19.3 predicted; p = 0.04). CONCLUSIONS--The initial management of major trauma in the United Kingdom remains unsatisfactory. There are delays in providing experienced staff and timely operations. Mortality varies inexplicably between hospitals and, for blunt trauma, is generally higher than in the United States.     

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.     

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.     

Improving Community Based Pediatric Residencies by Local Affiliation: The Phoenix Experience

Community hospital graduate medical education programs have been judged deficient in several areas when compared with university programs. Generally community programs are smaller, they have a greater percentage of foreign house officers and unfilled house staff positions, and their graduates do less well on specialty board examinations. Difficulties may exist in offering a balanced and broad-based educational exposure. Four separate pediatric residencies in Phoenix became affiliated in 1972. The traditional deficiencies have been overcome, and a very popular and well-balanced program has ensued. Additionally, wasteful duplication has been avoided. Disadvantages have included complex scheduling and loss of continual close contact with house officers. Assigning patients to residents for continuity of care has been difficult. Experiences gained in this amalgamation may well apply to other hospitals facing similar problems. Local consortiums, such as this, fit well into university affiliated programs or statewide organizations.     

Preregistration house officers in general practice.

OBJECTIVES--To obtain from house officers who had rotated through general practice in their pre-registration year their views about their experience; and, separately, to compare the overall hours and type of work performed by hospital based and general practice based house officers. DESIGN--Postal questionnaire; and self recording of working hours and duties during four consecutive weeks. SETTING--Inner London teaching hospital and nearby general practice. PARTICIPANTS--28 preregistration house officers in general practice, 1981-91; and 12 preregistration house officers, four each in medicine, surgery, and general practice. RESULTS--26 out of 28 questionnaires were returned (response rate 93%). Twelve respondents were following or thinking of following a career in general practice. Twenty five respondents were satisfied with the clinical and educational aspects of the general practice rotation and would recommend the rotation, and 25 thought four months was about the right length of time in general practice. With regard to hours and type of work performed, hospital based house officers worked on average 55.5 hours a week (excluding on call), with an average of 12.5 hours (22.5%) spent in clinical activities; general practice based house officers worked about 41 hours a week, of which 24 hours (58%) were in clinical activities. House officers in hospital received less than one hour''s specific teaching a week; those in general practice received nearly three hours'' a week. CONCLUSIONS--A preregistration rotation in general practice is a popular alternative to the hospital based rotation. Although this is a limited study, other medical schools should consider introducing general practice options for preregistration house officers.     

Review of cases of nosocomial Lassa fever in Nigeria: the high price of poor medical practice.

OBJECTIVE--To investigate two hospital outbreaks of Lassa fever in southern central Nigeria. SETTING--Hospitals and clinics in urban and rural areas of Imo State, Nigeria. DESIGN--Medical records were reviewed in hospitals and clinics in both areas. Patients with presumed and laboratory confirmed Lassa fever were identified and contracts traced. Hospital staff, patients, and local residents were questioned, records were carefully reviewed, and serum samples were taken. Serum samples were assayed for antibody specific to Lassa virus, and isolates of Lassa virus were obtained. RESULTS--Among 34 patients with Lassa fever, including 20 patients, six nurses, two surgeons, one physician, and the son of a patient, there were 22 deaths (65% fatality rate). Eleven cases were laboratory confirmed, five by isolation of virus. Most patients had been exposed in hospitals (attack rate in patients in one hospital 55%). Both outbreak hospitals were inadequately equipped and staffed, with poor medical practice. Compelling, indirect evidence revealed that parenteral drug rounds with sharing of syringes, conducted by minimally educated and supervised staff, fuelled the epidemic among patients. Staff were subsequently infected during emergency surgery and while caring for nosocomially infected patients. CONCLUSION--This outbreak illustrates the high price exacted by the practice of modern medicine, particularly use of parenteral injections and surgery, without due attention to good medical practice. High priority must be given to education of medical staff in developing countries and to guidelines for safe operation of clinics and hospitals. Failure to do so will have far reaching, costly, and ultimately devastating consequences.     

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.     

Alberta euthanasia survey: 2. Physicians' opinions about the acceptance of active euthanasia as a medical act and the reporting of such practice.

OBJECTIVE: To ascertain the opinions of Alberta physicians about the acceptance of active euthanasia as a medical act (the "medicalization" of active euthanasia) and the reporting of colleagues practising active euthanasia, as well as the sociodemographic correlates. DESIGN: Cross-sectional survey of a random sample of Alberta physicians, grouped by site and type of practice. SETTING: Alberta. PARTICIPANTS: A total of 2002 (46%) of the licensed physicians in Alberta were mailed a 38-item questionnaire in May through July 1991; usable responses were returned by 1391 (69%). RESULTS: Although only 44% of the respondents considered active euthanasia morally "right" at least 70% opted to medicalize the practice if it were legal by restricting it to be performed by physicians and to be taught at medical sites. Even though active euthanasia is criminal homicide in Canada, 33% of the physicians stated that they would not report a colleague participating in the act of anyone, and 40% and 60% stated that they would not report a colleague to medical or legal authorities respectively. Acceptance or rejection of active euthanasia as a medical act was strongly related to religious affiliation and activity (p < 0.01). CONCLUSIONS: This survey about active euthanasia revealed profound incongruities in the opinions of the sample of Alberta physicians concerning their ethical and social duties in the practice of medicine. These data highlight the need for relevant modifications of health education policies concerning biomedical ethics and physicians'' obligations to society.     

Introduction of a partial shift system for house officers in a teaching hospital.

OBJECTIVES--(1) To introduce a partial shift system to reduce the hours of work of preregistration house surgeons to an average of 64 a week to comply with the New Deal for junior doctors; (2) to test linking the partial shift concept to an existing structure of "on call" firms. DESIGN--Formal assessment after three months of a pilot partial shift system for eight house surgeons on three firms instituted on 1 November 1991, followed by questionnaire and interview evaluation at three and six months of a revised system implemented on 1 February 1992. SETTING--Department of general surgery at St Bartholomew''s Hospital, London. SUBJECTS--24 house surgeons attached to three surgical firms. RESULTS--In eight weeks each house surgeon worked one week (five shifts) of night duty, one week of "cover" (afternoon and evening) duty, and six weeks of normal daytime hours. Each weekday a house surgeon from the firm on call worked an extended daytime on call shift until 10 pm. Weekend duties were split between two house surgeons from the firm on call. A computer generated graphical display of the rota was used to facilitate leave planning. Average working hours were reduced to below 64 per week, including prospective cover, without detriment to patient care and educational standards. Within the shift system individual house surgeons could be on call with their own firm by day and at weekends. Opinions were equally divided among junior staff as to their preference for either on call or partial shift systems. CONCLUSIONS--The principles of this partial shift system are generally applicable and the model can readily be adopted by district general hospitals.     

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.     

Career and parenting satisfaction among medical students,residents and physician teachers at a Canadian medical school

BACKGROUND: Studies of career and parenting satisfaction have focused separately on medical students, residents and practising physicians. The objective of this study was to compare satisfaction across a spectrum of stages of medical career. METHODS: A survey of incoming medical students, current medical students, residents and physician teachers at the University of Saskatchewan was conducted in the spring of 1997. Response rates were 77% (43/56), 81% (177/218), 65% (134/206) and 39% (215/554) respectively. Factors assessed in the stepwise regression analysis were the effect of sex, parenting and level of training on the likelihood of recommending parenting to medical students or residents, and on parenting dissatisfaction, job dissatisfaction, career dissatisfaction and the importance of flexibility within the college program to accommodate family obligations. RESULTS: More male than female physician teachers had partners (92% v. 81%, p < 0.01) and were parents (94% v. 72%, p < 0.01). Female physician teachers spent equal hours per week at work compared with their male counterparts (mean 52 and 58 hours respectively) and more than double the weekly time on family and household work (36 v. 14 hours, p < 0.01). Physician teachers were the most likely respondents to recommend parenting to residents and their peers. Residents were the most dissatisfied with their parenting time. At all career stages women were less likely than men to recommend parenting, were more dissatisfied with the amount of time spent as parents and were more likely to regard flexibility within the college program as beneficial. There were no sex-related differences in job dissatisfaction and career dissatisfaction. However, married women were more dissatisfied with their jobs than were married men. Job dissatisfaction was greatest among medical students, and career dissatisfaction was greatest among residents. INTERPRETATION: The optimal timing of parenthood appears to be upon completion of medical training. Women were less likely to recommend parenting, less satisfied with the time available for parenting and more likely to value flexibility within the college program to accommodate family needs. These differences did not translate into women experiencing more job or career dissatisfaction.     

医院输血安全管理现状分析与对策

目的：通过对某省七家三级医院输血科管理现状调查,了解医院在输血管理制度的制定与实施、技术操作的规范性、输血流程的安全性、输血科人员配置等方面存在的问题,明确今后医院输血安全管理工作的重点,并提出相应的管理对策,旨在为医院及政府职能部门制订有关医院输血安全相关策略提供科学的佐证。方法：1、文献法：对CNKI、维普数据库近五年相关文献进行系统回顾;2、现场调查：对某省7家三级医院输血安全管理现况调查。结果：所调查的7家医院输血安全管理制度知晓率较低,储血冰箱未按照正确的时间进行监测,医务人员对病人输血反应观察不到位,输血前医患沟通较好,输血差错自愿报告系统超过60%的医院尚未建立,输血不良事件发生后,只有14%的医护人员愿意主动上报,输血科医务人员30岁以上的不到30%,专科以下学历占66%,专业背景37%为检验专业,无学历的占8%。结论：医院输血安全管理存在许多问题：管理制度知晓率低、执行不到位,储血过程未按相关要求进行监测,输血科医务人员过于年轻化,学历层次较低,专业背景单一。建议医院应根据存在的问题,采取应对策略。     

Patients' responsibilities in medical ethics

Patients have not been entirely ignored in medical ethics. There has been a shift from the general presumption that 'doctor knows best' to a heightened respect for patient autonomy. Medical ethics remains one–sided, however. It tends (incorrectly) to interpret patient autonomy as mere participation in decisions, rather than a willingness to take the consequences. In this respect, medical ethics remains largely paternalistic, requiring doctors to protect patients from the consequences of their decisions. This is reflected in a one–sided account of duties in medical ethics. Duties fall mainly on doctors and only exceptionally on patients. Medical ethics may exempt patients from obligations because they are the weaker or more vulnerable party in the doctor–patient relationship. We argue that vulnerability does not exclude obligation. We also look at others ways in which patient responsibilities flow from general ethics: for instance, from responsibilities to others and to the self, from duties of citizens, and from the responsibilities of those who solicit advice. Finally, we argue that certain duties of patients counterbalance an otherwise unfair captivity of doctors as helpers.     

Cardiac magnetic resonance imaging in daily practice in a peripheral medical centre: description of the first 383 patients

Background. Cardiac magnetic resonance (CMR) imaging has evolved over the last decade into an indispensable diagnostic instrument. CMR imaging noninvasively provides structural, functional and morphological information with high spatial resolution and an unlimited field of view. Since October 2006 the VieCuri Medical Centre in Venlo has a CMR scanner at its disposal.Objectives. The goal of this study was to analyse the impact of CMR imaging on diagnosis and treatment in daily practice in the setting of a medium-volume peripheral hospital.Methods. All patients who underwent CMR imaging between October 2006 and November 2008 were included in this analysis. The medical history before and after the CMR scan, the application form for CMR imaging and the outcome of the scans were reviewed. CMR images, obtained using a 1.5-T magnetic resonance imaging system, were reviewed by a multidisciplinary team.Results. In 235 patients CMR imaging demonstrated one or more abnormalities, whereas CMR imaging did not identify any abnormalities in 148 patients. CMR imaging confirmed an expected finding in 166 cases, identified an unexpected condition in 69 cases, ruled out an expected finding in 59 cases and ruled out a suspected condition in 89 cases. Due to better insight into diagnosis, CMR imaging resulted in a change of treatment in 166 of the total of 383 CMR scans (43%).Conclusion. In a relevant number of cases CMR imaging leads to a change in the treatment of a patient, proving the value of CMR imaging as a diagnostic modality. Therefore, CMR imaging is an excellent opportunity for peripheral medical centres to improve efficiency and the standard of patient care. (Neth Heart J 2010;18:524–30.)     

Factors influencing the emigration of physicians from Canada to the United States.

OBJECTIVE: To determine whether location of postgraduate medical training and other factors are associated with the emigration of physicians from Canada to the United States. DESIGN: Case-control study, physicians were surveyed with the use of a questionnaire mailed in May 1994 (with a reminder sent in September 1994), responses to which were accepted until Dec. 31, 1994. PARTICIPANTS: Physicians randomly selected from the CMA database, 4000 with addresses in Canada and 4000 with current addresses in the United States and previous addresses in Canada. OUTCOME MEASURES: Sex, age, location of undergraduate and postgraduate medical training, qualifications, practice location, opinions concerning residence decisions, current satisfaction and plans. RESULTS: The overall response rate was 49.6% (50.0% among physicians in the United States and 49.2% among those in Canada). Age and sex distributions were similar among the 8000 questionnaire recipients and the nearly 4000 respondents. Physicians living in the United States were more likely to be older (mean 53.2 v. 49.6 years of age), male (87% v. 75%) and specialists (79% v. 52%) than those practising in Canada. Postgraduate training in the United States was associated with subsequent emigration (odds ratio 9.2, 95% confidence interval 7.8 to 10.7). However, in rating the importance of nine factors in the decision to emigrate or remain in Canada, there was no significant difference between the two groups in the rating assigned to location of postgraduate training. Professional factors rated most important by most physicians in both groups were professional/clinical autonomy, availability of medical facilities and job availability. Remuneration was considered an equally important factor by those in Canada and in the United States. Six of seven personal/family factors were rated as more important to their choice of practice location by respondents in Canada than by those in the United States. Current satisfaction was significantly higher among respondents in the United States. Most physicians in each group planned to continue practising at their current location. Of Canadian respondents, 22% indicated that they were more likely to move to the United States than they were a year beforehand, whereas 4% of US respondents indicated that they were more likely to return to Canada. CONCLUSIONS: Factors affecting the decision to move to the United States or remain in Canada can be categorized as "push" factors (e.g., government involvement) and "pull" factors (e.g., better geographic climate in the US). Factors can also be categorized by whether they are amenable to change (e.g., availability of medical facilities) or cannot be managed (e.g., proximity of relatives). An understanding of the reasons why physicians immigrate to the United States or remain in Canada is essential to planning physician resources nationally.