Part-time medical training: 15 years' experience in the Oxford region.

Part-time training of doctors with domestic commitments has taken place successfully in the Oxford region since 1966; 249 doctors have now passed through such training schemes and a further 120 are currently training part-time. Two training schemes are now offered for doctors at senior house officer and registrar level: one of six to eight sessions a week for those undertaking recognised training aiming for consultant or principal in general practice posts, the other of one to two sessions a week providing ad hoc training for those unable for personal reasons to follow a recognised training programme. For doctors at senior registrar level, part-time training entails five to eight sessions a week. Of the 115 doctors who have left the schemes and are now in career posts in the United Kingdom, 19% are now consultants, 30% in other hospital posts, 27% in general practice, and 18% are clinical medical officers; overall, 71% of those in career posts are working part-time. This experience shows that part-time training can be successful and that there is a continuing need for part-time career posts.     

Senior house officers and their training. II. Perceptions of service and training.

Aspects of teaching and learning at senior house officer level in South East Thames region were investigated by analysis of the responses of consultants, senior registrars, registrars, and senior house officers to a postal questionnaire. Responses to sections about who teaches senior house officers, how senior house officers learn, and the relation between the service and training elements of these posts varied significantly, according to the status of the respondents; certain grades commonly overestimated their own contribution when compared with the estimates of the other grades. Although the replies of senior house officers showed that they were taught by various grades, 47% of this group did not regard the consultant as their main teacher. Senior registrars and registrars rather than consultants were regarded by senior house officers as best at teaching (63% v 48% respectively). Consultants and registrars were considered to require more commitment to training, personal educational training, and to be more approachable. Inquiry about teaching methods used most by senior house officers showed absence of a systematic approach to training. Only about half of senior house officers cited ward rounds with consultants. Views on the relation between training and service were significantly different among grades, but there was general dissatisfaction. Overall, the findings disclosed the ineffectiveness of senior house officer training posts. This arises from lack of a clear distinction between training and service elements, of educational training for teachers, of a clear contractual obligation to teach im the consultant grade, and of allotted time for training and study for the teachers and senior house officers respectively. Reversal of these current trends is needed for senior house officer posts to fulfil their main training function.     

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.     

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.     

Anaesthetic Staffing and Training Requirements in Scotland

In Scotland there is an average of 12 consultant vacancies and 14 Fellows qualifying per year, but these are insufficient to meet all the vacancies as several emigrate or return abroad. The existing registrar and senior registrar establishments are inadequate to meet the numbers of consultants required if full allowance is made for special factors, such as the high proportion of women graduates and the rising proportion of overseas trainees.A backlog of understaffing in Scotland relative to England and Wales is shown by comparison of the ratio of anaesthetists to surgeons. The existing rate of expansion of 6% per year must continue for many years or be increased if staffing levels are to come into line with those elsewhere in Britain.     

Counselling needs and experience of junior hospital doctors.

A sample of 106 senior house officers who had graduated from Nottingham University in 1987 was surveyed about their experience of and need for careers guidance, performance appraisal, and stress counselling. Of the 80 who replied, a quarter had received no careers guidance and a quarter no feedback about their work performance. Many reported having had difficulties in their post, but few had received help from senior staff or their consultant. The perceived needs for counselling were considerable. Careers counselling was thought to be essential in the preregistration year by all of the doctors and in senior house officer posts by three quarters. Nearly all would have chosen regular appraisal and nearly half wanted counselling for particular difficulties. Doctors in the training grades clearly believed that they needed counselling, but in most cases they did not receive it.     

"Short report" staffing in practice: five years' experience of a consultant based service in obstetrics and neonatal paediatrics.

Recent government plans include the concept of a core of doctors of intermediate grade providing 24 hour emergency cover in hospital departments. Hinchingbrooke Hospital has, since its opening in 1983, been run on a two tier basis, with consultants and a part time senior registrar supported only by senior house officers in their first post, usually on general practice vocational training schemes. With a planned rate of around 2000 deliveries per year all high risk obstetric and neonatal paediatric procedures, including ventilation of very small babies, have been carried out within the hospital. A study of the first five complete years of operation of the obstetric and paediatric departments showed that the perinatal mortality rate was low (hospital rate 4.7/1000 in 9149 deliveries during 1984-8 v district rate 5.1/1000 during 1986-8), and patient satisfaction seemed to be high. In a separate prospective study of out of hours work performed by consultants in paediatrics (four weeks) and obstetrics (20 days) three consultants in paediatrics spent 71 hours working out of hours; for the obstetricians, of the 56 request for advice and 38 interventions, only five and six respectively occurred between midnight and 9 am. Although successful at this hospital, the two tier system would be expensive under the Royal College of Obstetricians'' guidelines of one consultant to a maximum of 500 deliveries. An equal mixture of two tier and three tier systems might be the best solution for patient care and training of junior doctors.     

我国西北地区康复治疗师的现状调查及分析

目的:调查我国西北地区康复治疗师的现状,为规范康复治疗师培养的改革提供依据。方法:采用抽样调查的方法,向西北五个省区部分康复医疗单位发放调查问卷共200份,由单位负责人填写,调查内容包括该单位康复治疗师的数量、专业、学历、从业时间、职称、持证情况和对培训的需求情况等,填写完成后进行数据统计分析。结果:康复治疗师中从事神经康复方向的治疗师比例最高,约为45.04%。大部分的治疗师从业时间都在5年以内,从业时间大于5年的比例只占13.68%。77.60%的治疗师为医学相关专业毕业,多数治疗师为本科以下学历,硕士和博士学历仅占0.48%,而获得康复治疗师资格证书的人员比例仅为39.35%。治疗师的职称也大多为初、中级(92.49%),高级职称治疗师仅占7.51%,78.81%的治疗师希望得到高水平的培训或进修。结论:西北地区康复治疗师整体从业时间较短,学历较低,缺乏高职称的治疗师,康复治疗师人才队伍培养体系亟待改善。     

Competencies required for the practice of geriatric medicine as a consultant physician.

Geriatric medicine in Canada is now being viewed not merely as an academic specialty but, rather, more broadly as a service specialty providing consulting support to other physicians. Any redesigning of training programs will have to be done with this fact in mind. We drew up a list of competencies required for consultant practice in the field and presented them to other practitioners of geriatric medicine and members of the Canadian Society of Geriatric Medicine for feedback. We believe that the resulting list of competencies can be used as a starting point for redesigning training programs in geriatric medicine.     

Careers of medical women.

In autumn 1977 91% of the women who had graduated from United Kingdom medical schools in 1949-51 (early cohort) and 1965 (late cohort) were practising medicine. Over the first 12 years after qualification the late cohort was marginally more active in medicine and had more members in career and training posts than the early cohort. On the survey date 1 October 1977 (26-28 years after qualification) the participation index of the early cohort was 0.73 and of the late cohort (12 years) 0.65. Both cohorts show the bimodal career pattern characteristic of British women''s occupational experience.     

Obstetrics and Gynecology: Considerations in Career Selection

Current training programs in obstetrics and gynecology are not producing an excess of specialists in view of future manpower needs. In addition to being specialists and consultants, obstetrician-gynecologists also function as providers of primary care for women. During the last decade, three formal sub-specialties of obstetrics and gynecology have evolved: gynecologic oncology, maternal-fetal medicine and reproductive endocrinology. These have improved patient care and have altered the structure of resident education. With more American medical school graduates entering this specialty, the quality of resident applicants has improved, creating intense competition for desirable training positions. Those inclined toward a career in obstetrics and gynecology can be assured that it will provide an increasingly favorable and challenging environment for professional activity in the future.     

Senior house officers in medicine: postal survey of training and work experience.

OBJECTIVES: To describe working conditions for senior house officers in medicine in Scotland and to relate these to the quality of clinical training they receive. DESIGN: Postal questionnaire survey. SUBJECTS: All senior house officers in medicine and related specialties in post in Scotland in October 1995 (n = 437); 252 (58%) respondents. MAIN OUTCOME MEASURES: Questionnaires covered hours, working patterns, measures of workload, an attitudes to work scale, and experience of education and training. RESULTS: In the week before the questionnaire, doctors on rotas had worked a mean of 7.4 (95% confidence interval 5.8 to 9.0) hours in excess of their contracts, compared with 3.7 (2.0 to 5.5) hours for those on partial shifts. The most common reason for this was "the needs of the patients or the service." Those on partial shifts reported significantly less continuity of care with patients than those on rotas (Mann-Whitney U test, z = -4.2, P < 0.0001) or full shifts (z = -2.08, P = 0.03). Doctors in general medicine reported significantly higher measures of workload (number of acute admissions, number of times called out, and fewest hours'' uninterrupted sleep) than those in subspecialties. Consultants'' clinical teaching and style of conducting a ward round were significantly related to factors extracted from the attitudes to work scale. CONCLUSIONS: The quality of senior house officers'' training is detrimentally affected by a variety of conditions, especially the need for closer support and supervision, the need for greater feedback, and the lack of time that consultants have to dedicate to clinical training. Efforts should be made to improve these conditions and to reinforce a close working relationship between trainee and supervising consultant.     

Recruitment of doctors to non-standard grades in the NHS: analysis of job advertisements and survey of advertisers

Objectives To estimate the proportion of advertised non-consultant hospital posts that do not conform to nationally recognised terms and conditions of service and to investigate why these posts exist, who fills them, and what the doctors in such jobs do.Design Analysis of job advertisements and a cross sectional survey of advertisers.Setting Job advertisements in one of the leading UK publications listing hospital doctor vacancies (BMJ Careers).Results Nearly a quarter of non-consultant posts advertised in the two study periods (23% and 21%) were for non-standard grade posts. A questionnaire was sent to the medical staffing officer for each post. Of 430 questionnaires sent out 192 (45%) were returned. 98 trusts said they advertised non-standard grades because there was no more funding from the deanery for approved posts and 75 because service needs could not be met by doctors in training grades. In 132 posts (69%) the post holder would be required to do on-call work, and 50 advertisers (26%) required on-call duty for 1 in 5 or more frequently, which would conflict with the European Working Time Directive. 131 advertisers (68%) expected the posts to be filled by doctors from outside the European Economic Area.Conclusions Non-standard grade posts are mostly being created to meet service requirements when there is no more funding for standard training posts and are expected to be filled by doctors from overseas. Doctors in such posts can be more easily exploited and their careers hindered. The Department of Health''s annual census should include non-standard grade doctors.     

Postgraduate clinical education — the Canadian experience

To obtain a quantitative measure of the extent to which graduate education and qualification for specialty practice have become an integral part of the total educational experience, samples of the graduating classes of 1960, 1964, 1968 and 1970 of Canadian medical schools were tracked through postgraduate educational training and into specialty certification. From the 1960 cohort 65% chose a career recognized by special certifying exams in Canada and/or the United States, entered a residency, completed it and achieved certification of special competence. From the 1970 cohort, by the end of 1972 approximately 50% had entered a recognized specialty training program leading to certification. The diminishing trend toward specialty practice is demonstrated by reviewing the comparative figures in the 1964 and 1968 cohorts. Evidence garnered in this study indicates a continuing strong motivation for specialty practice although family medicine and/or general practice appear increasingly attractive as career choices. Strong provincial educational forces as well as social and other forces will probably continue to modify career selection and may lead an increasing number of Canadian medical graduates into family practice.     

Measuring readmission rates.

OBJECTIVE--To assess the feasibility of extracting data on readmissions and readmission rates from Körner data for use as health service indicators. DESIGN--Retrospective analysis of inpatient Körner data for January 1988 to April 1989. SETTING--Three districts in North East Thames region. MAIN OUTCOME MEASURES--Number of readmissions after index discharge for all acute specialties combined and by specialty (general medicine, general surgery, gynaecology, trauma and orthopaedics, and geriatrics); readmission rates at 28 days after index discharge; and rates standardised for age group and sex by specialty and by consultant. RESULTS--All specialties showed an early peak in number of admissions, which levelled off by 28 days. Readmission rates at 28 days were appreciably lower in surgical specialties than in medical specialties (for example, general surgery 4.1% v geriatric medicine 15.1%). They were related to age and sex of the patient. Rates standardised for these variables did not significantly differ by district. Likewise, significant differences in standardised rates were not obtained for consultants within a specialty in one district. CONCLUSIONS--Readmission rates may be measured with Körner data. The pattern of readmissions with time means that readmission rates should be measured at not more than 28 days after the index discharge; the rates require standardisation for age and sex. Annual comparisons of standardised rates may be made among districts for combinations of specialties; those among individual consultants or specialties are unlikely to be statistically valid.     

Was Rodney Ledward a statistical outlier? Retrospective analysis using routine hospital data to identify gynaecologists' performance

Objectives To investigate whether routinely collected data from hospital episode statistics could be used to identify the gynaecologist Rodney Ledward, who was suspended in 1966 and was the subject of the Ritchie inquiry into quality and practice within the NHS.Design A mixed scanning approach was used to identify seven variables from hospital episode statistics that were likely to be associated with potentially poor performance. A blinded multivariate analysis was undertaken to determine the distance (known as the Mahalanobis distance) in the seven indicator multidimensional space that each consultant was from the average consultant in each year. The change in Mahalanobis distance over time was also investigated by using a mixed effects model.Setting NHS hospital trusts in two English regions, in the five years from 1991-2 to 1995-6.Population Gynaecology consultants (n = 143) and their hospital episode statistics data.Main outcome measure Whether Ledward was a statistical outlier at the 95% level.Results The proportion of consultants who were outliers in any one year (at the 95% significance level) ranged from 9% to 20%. Ledward appeared as an outlier in three of the five years. Our mixed effects (multi-year) model identified nine high outlier consultants, including Ledward.Conclusion It was possible to identify Ledward as an outlier by using hospital episode statistics data. Although our method found other outlier consultants, we strongly caution that these outliers should not be overinterpreted as indicative of “poor” performance. Instead, a scientific search for a credible explanation should be undertaken, but this was outside the remit of our study. The set of indicators used means that cancer specialists, for example, are likely to have high values for several indicators, and the approach needs to be refined to deal with case mix variation. Even after allowing for that, the interpretation of outlier status is still as yet unclear. Further prospective evaluation of our method is warranted, but our overall approach may be potentially useful in other settings, especially where performance entails several indicator variables.     

Training for general practice: a national survey.

OBJECTIVES--(a) To compare current vocational training in general practice with that ascertained by a survey in 1980; (b) to compare the training of trainees in formal training schemes with that of trainees arranging their own hospital and general practice posts. DESIGN--National questionnaire survey of United Kingdom and armed services trainees who were in a training practice on 1 April 1989. Questionnaires were distributed by course organisers. SETTING--Research project set up after an ad hoc meeting of trainees at the 1988 national trainee conference. SUBJECTS--2132 Of the 2281 trainees (93%) known to be in a training practice on 1 April 1989. RESULTS--1657 Trainees returned the questionnaires, representing 73% of all trainees known to be in a training practice on 1 April 1989. Between 1980 and 1989 there were significant improvements in the trainee year, and there was also evidence of improvements in general practice study release courses. There was no evidence of improvement in other aspects of training. General practice trainees spent an average of three years in junior hospital posts, which provided very little opportunity for study related to general practice. Training received during tenure of hospital posts differed significantly between trainees in formal schemes and those arranging their own hospital posts. During the trainee year training was almost the same for those in formal schemes and those arranging their own posts. Regions varied significantly in virtually all aspects of general practice training. CONCLUSIONS--The trainee year could be improved further by enforcing the guidelines of the Joint Committee on Postgraduate Training for General Practice. The poor training in junior hospital posts reflected the low priority that training is generally given during tenure of these posts. A higher proportion of general practice trainees should be attached to vocational training schemes. More hospital trainees could attend general practice study release courses if these were designed specifically with the needs of hospital doctors in mind.     

Perceptions of family medicine and career choice among first year medical students: a cross-sectional survey in a Turkish medical school

Public attitudes to family medicine in Turkey have lagged behind its rapid academic development. The effect of undergraduate training in primary care on medical students' attitudes to family medicine has not been assessed. Objectives of this study were to assess the attitudes of first year medical students at Uludag University School of Medicine in Bursa, Turkey to family medicine and to determine their career aspirations. The study was a survey of the first year medical class in 2003-2004. The response rate was 95% (248/261 students). Students were positive about their choice of medicine as a career but had negative opinions of general practice. Female students were more positive in this respect. Initial preference was for specialization in fields other than general practice with little knowledge of the academic specialty of family medicine. Greater undergraduate exposure to family medicine is needed in order to increase knowledge of the field and influence student career choices.     

General-practitioner Hospital Beds: A Review

This paper reviews literature related to general-practitioner hospital beds. In England and Wales 21% of all maternity beds are controlled by general practitioners rather than consultants, and the proportion has increased considerably since 1955. Nearly one in five of these 21% are sited in the wards of a consultant hospital. General-practitioner beds, other than maternity, represent 3% of all hospital beds (excluding psychiatric beds) and this proportion has remained constant over the past 15 years. Only about 1% of these general-practitioner beds are located in a consultant hospital.In the discussion three questions are raised: Will general-practitioner inpatient care have a useful function in the future? What might that function be? Where should the care be located? The broader issue of the future role of the general practitioner needs to be considered before these questions can be satisfactorily answered. Unless a “hospital orientated” role of the general practitioner prevails there seems little place for practitioner inpatient care in urban areas. In the more rural areas, however, whatever the role of the practitioner becomes, certain groups of patients might advantageously receive inpatient care from their practitioners. Firmer answers to the questions raised cannot be given until a co-ordinated programme of research and development concerning different patterns of care is started.     

Where medical science and human behaviour meet.

Although we may be wrong about the details, we should try to imagine what the future holds for hospital consultants. The days of the independent consultant in the same post for 30 years are over, and there will be a change from "the" consultant to a few tiers of senior staff. Patients will increasingly demand to see specialists, so more specialists will be needed. As patients and their advocates become better informed the traditional rationing of clinical care to patients in Britain, such as restricting access to specialists, cannot continue. There is a current trend for evidence based health care, but the idea that each element of medical practice can be dictated by systematic evidence based research will prove to be naïve--such research informs practice rather than dictates it. Science will continue to act as the guide to medical practice but specialists will not be turned into a set of logical operators running programs designed by health planners.