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.     

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.     

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.     

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.     

A general practitioner in an ophthalmology accident and emergency department.

After a short period of intensive training, a general practitioner successfully replaced a senior house officer (SHO) in the accident and emergency department of an eye hospital on one morning a week for a year. An unbiased observer compared the performance of the general practitioner after one year with that of a full-time SHO who had had 17 months'' experience; their performances were about equal. Although a sessional general practitioner costs about 28% more than an SHO, the real cost is much less because undue length of service as an SHO or change to another specialty (because of the SHO surplus) delays achievement of a permanent grade. Continuity is a great advantage of the general practitioner. Replacement of some SHOs by general practitioners would reduce the surplus of SHOs with poor promotion prospects. The commonest diagnoses were Meibomian cysts (18%), corneal foreign bodies (20%), corneal abrasions (12%), and conjunctivitis (8%).     

X-Ray Pelvimetry

The results of x-ray pelvimetry performed on 66 pregnant women, with a view to predicting the outcome of pregnancy, were reviewed. It was concluded that such pelvimetry was most valuable in cases in which it indicated a normal pelvis or gross bony disproportion. It was least effective in those with a “borderline” pelvis, in which the correct management of the patient requires an adequate trial of labour. The authors believe that pelvimetry in the later stages of pregnancy has no ill effects on the unborn baby or the mother.Indications for use of x-ray pelvimetry in obstetrics, the technique employed, the various types of female pelvis and the relation of these to the course of labour are considered. Pelvimetry findings are compared with the eventual outcome of labour in women with suspected cephalopelvic disproportion. It is emphasized that the pelvic assessment should be made jointly by the radiologist and obstetrician.     

Routine neonatal screening for phenylketonuria in the United Kingdom 1964-78. Medical Research Council Steering Committee for the MRC/DHSS Phenylketonuria Register.

From 1964 to 1968, despite a general policy of routine neonatal screening for phenylketonuria that was usually carried out using the Phenistix nappy test, half to one-quarter of all cases reported to the register had been missed in the screening programme and had not been detected before the age of 4 months. In about two-thirds of the "missed" cases no screening test had been carried out, and in one-third a urine test had been performed but had given a false-negative result. In 1968-9 the screening programme was reorganised according to recommendations made in a Government circular (HM (69) 72), which proposed that a specimen of blood should be obtained by heel prick from all newborn infants between the 6th and 14th day of life and be tested in a central laboratory for the presence of raised blood phenylalanine concentrations. The senior medical officers of the various regions were made responsible for ensuring that all infants were tested. By 1974 only 1 to 2% of surviving infants were not being tested for phenylketonuria in the neonatal period, and only five of the 357 cases born between 1974 and 1978 and notified to the register had been diagnosed after the age of 3 months.     

Missed injuries of the spinal cord.

Damage to the spinal cord had not been recognised initially in 15 patients out of a consecutive series of 353 admitted over a decade to the National Spinal Injuries Centre with paralysis due to trauma to the cord. In some patients the missed diagnosis led to mismanagement and a greater neurological deficit. Missed injuries of the spinal cord are seen in patients with multiple injuries and head injuries and in those without any paralysis. Various radiological errors contribute to the failure to recognise the vertebral injury. In addition to causing severe disability to the victim these missed and mismanaged injuries of the spinal cord cost the National Health Service large sums in compensation. A careful evaluation of the history of each accident, with greater awareness of the potential of certain types of accidents to cause spinal cord injury, should reduce the incidence of missed injuries of the spinal cord.     

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.     

Radioisotopic Bone Scintigraphy with the Gamma Camera in the Investigation of Prostatic Cancer

Experience with x-rays, strontium-87m scintigraphy, and technetium-99m polyphosphate scintigraphy in the identification of bone metastases in 201 patients with prostatic cancer is reviewed. About 40% of the patients had demonstrable metastases in bone at the time of first presentation.Comparative studies of 247 x-ray and ^87mSr surveys indicated that x-rays failed to detect metastases in 10% of cases where they were identified by ^87mSr but that the isotopic survey similarly failed to detect radiologically evident deposits in 7% of cases.Similar studies comparing ^99mTc polyphosphate surveys with x-ray scans showed that x-rays missed isotopically detected metastases in 12% of cases, but in only one survey out of 67 did the isotope miss radiologically evident deposits. In a series of 32 patients investigated by both isotopic techniques ^99mTc polyphosphate did not fail to detect any metastases and identified deposits in one patient in whom they were missed by ^87mSr scintigraphy. About 15% of both x-ray and ^87mSr surveys gave equivocal results, but only 3% (2 out of 67) of ^99mTc polyphosphate surveys were equivocal.We concluded that ^99mTc polyphosphate bone scintigraphy with the gamma camera was the most reliable of the techniques used for the identification of bone metastases in patients with carcinoma of the prostate. The results of scintigraphy with ^87mSr suggested that serial surveys may provide early evidence of hormone resistance in prostatic cancer.     

Cost effectiveness of treating primary care patients in accident and emergency: a comparison between general practitioners,senior house officers,and registrars.

OBJECTIVES--To compare outcome and costs of general practitioners, senior house officers, and registrars treating patients who attended accident and emergency department with problems assessed at triage as being of primary care type. DESIGN--Prospective intervention study which was later costed. SETTING--Inner city accident and emergency department in south east London. SUBJECTS--4641 patients presenting with primary care problems: 1702 were seen by general practitioners, 2382 by senior house officers, and 557 by registrars. MAIN OUTCOME MEASURES--Satisfaction and outcome assessed in subsample of 565 patients 7-10 days after hospital attendance and aggregate costs of hospital care provided. RESULTS--Most patients expressed high levels of satisfaction with clinical assessment (430/562 (77%)), treatment (418/557 (75%)), and consulting doctor''s manner (434/492 (88%)). Patients'' reported outcome and use of general practice in 7-10 days after attendance were similar: 206/241 (85%), 224/263 (85%), and 52/59 (88%) of those seen by general practitioners, senior house officers, and registrars respectively were fully recovered or improving (chi2 = 0.35, P = 0.840), while 48/240 (20%), 48/268 (18%), and 12/57 (21%) respectively consulted a general practitioner or practice nurse (chi2 = 0.51, P = 0.774). Excluding costs of admissions, the average costs per case were 19.30 pounds, 17.97 pounds, and 11.70 pounds for senior house officers, registrars, and general practitioners respectively. With cost of admissions included, these costs were 58.25 pounds, 44.68 pounds, and 32.30 pounds respectively. CONCLUSION--Management of patients with primary care needs in accident and emergency department by general practitioners reduced costs with no apparent detrimental effect on outcome. These results support new role for general practitioners.     

Rationalising requests for x-ray examination of acute ankle injuries.

Radiographs of injured ankles represent about 1 in 50 of all radiological examinations. The notes and radiographs of 100 patients with ankle injuries were reviewed, and the films of a further 93 patients who had ankle fractures treated by immobilisation were also scrutinised to assess the presence of absence of soft tissue swelling over the malleoli. Any accompanying radiographs of the foot requested at the same time were also studied. In 65 of the 100 cases of ankle injury there was no soft tissue swelling, and none of the patients had a major fracture, while 92 of the 93 patients with a major fracture had soft tissue swelling at the level of the malleoli. In 32 of the 100 cases of ankle injury foot radiographs had also been requested, but only three foot injuries were found. If the simple maxim of "No swelling adjacent to a malleolus, no radiographs" were applied radiography of twisted ankles could be reduced by as much as two-thirds. Moreover, if this maxim included the rider "and no routine foot films" the total casualty radiographic work load could be reduced by 8%.     

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.     

Comprehensive Department of Psychological Medicine: Three-year Review of Inpatients Referred for Aftercare Visits

All inpatients discharged in 1967 from a comprehensive department of psychological medicine who were referred for aftercare visiting by a mental welfare officer or psychiatric social worker were reviewed after a period of three years. Over this period half the patients had not been readmitted and only 6·3% of those below retirement age had been unemployed for 75% or more of the total time involved. Altogether 76% were assessed as socially integrated, though there had been a drift away from living at home.It is probable that case conferences made the process of referral for aftercare more discriminating and that the follow up conferences contributed substantially towards the care, supervision, and maintenance of these patients in the community. Measures of this kind are essential if a general hospital psychiatric service is intended to cope with the total problem involved.     

Home care for patients with suspected myocardial infarction: use made by general practitioners of a hospital team for initial management.

Two hundred and sixty three general practitioners were offered the use of a hospital based service consisting of a medical senior house officer, a nurse attached to a coronary care unit, and a specially equipped ambulance estate car to help with the initial management of patients with suspected myocardial infarction who might be suitable for home care. One hundred and sixty nine general practitioners registered as potential users of this service; during 22 months they called the hospital team to see 271 patients, 235 of whom the team suspected had indeed suffered a myocardial infarction. During the same period, however, these general practitioners also admitted 317 patients with suspected myocardial infarction directly to hospital. Other general practitioners admitted 323 patients and deputising doctors 258. A further 529 patients with suspected infarction were admitted without the intervention of a general practitioner. Of the patients seen by the team, 54 required immediate admission to hospital; 17 of the remaining patients who initially appeared suitable for home care later required admission to hospital. In a large city such as Nottingham the provision of hospital based facilities to help general practitioners with home management is unlikely to make an appreciable impact on the overall pattern of care of patients with suspected myocardial infarction.     

RIGHT DIAPHRAGMATIC HERNIA SECONDARY TO TRAUMA—With Report of Two Cases

With automobile accidents at high speed on the increase, some previously rare injuries are becoming more common. Rupture of the left diaphragm is fairly common. On the right, it has been believed rare. The diagnosis has often been missed for many years after the causative injury.Any suspicious x-ray film shadow at the base of the right lung field after injury such as those that occur in accidents of great impact should arouse the physician''s suspicions. A mushroom-shaped mass on the lateral x-ray view is characteristic.Introduction of pneumoperitoneum may help in diagnosis. Only if the peritoneal and pleural cavities communicate will this procedure produce a pneumothorax.Surgical correction is indicated in all cases. This is best done through the chest. The right lobe of the liver usually must be reduced. In general the results are excellent.     

A survey of koala road kills in New South Wales.

Between 1984 and 1990, 75 koalas (Phascolarctos cinereus) from the central northern coast of New South Wales (Australia) were presented for necropsy due to motor vehicle accidents. The koalas consisted of 44 males and 31 females. Fifty one of these were between 2 and 7 yr (39 males and 12 females). The greater proportion of koalas, especially males, were struck by vehicles between June and December. The main injuries detected were head injuries (44), hemoperitoneum (16), limb injuries (16), hemothorax (15) and spinal injuries (7). Nine koalas were not dead at the time of the accident but died later following complications from the trauma. Twelve koalas had evidence of underlying disease at the time of accident. Ten of these had either conjunctivitis, cystitis, prostatitis, periovarian cysts, endometritis or a combination of the diseases. All 10 koalas still had good body condition. It is suggested that healthy young to middle-aged males are particularly prone to vehicular accidents during the mating period. This has implications for the management of local koala populations.     

A poliomyelitis survey the simple way: the Tanzanian experience.

A simple cost effective survey to assess the need for a rehabilitation service for individuals disabled by poliomyelitis was carried out making the maximum use of the existing government administration. The field team consisted solely of a medical officer and a health officer. The prevalence rate for paralytic poliomyelitis in the Mbeya region of Tanzania was 2.95/1000 persons. The rate for children under 10 years was 1.15/1000, suggesting that the expanded immunisation programme started in 1977 was being successful. With approximately 4000 cases of paralytic poliomyelitis in the Mbeya region a rehabilitation service would seem to be justified. If poliomyelitis surveys are required for rehabilitation purposes they must include all age groups. In this survey, had only school children been considered, as recommended by the World Health Organisation, two thirds of the cases would have been excluded, thereby hardly justifying a rehabilitation service.     

Difficulties in diagnosing and managing congenital dislocation of the hip.

In a 10-year retrospective study of 25 921 consecutive deliveries in a neonatal unit in Newcastle upon Tyne 271 cases of congenital dislocation of the hips were identified. Of these, the outcome was unsatisfactory in 12: four diagnoses were missed at birth and eight children required further surgical treatment. Radiological abnormalities were detected in a further five children at long-term follow-up examination. From the results of this study and other published series it was concluded that lack of attention to detail was the main cause of inadequate diagnosis and management of congenital dislocation of the hips. More detailed instruction of junior staff, confirmation of the diagnosis by senior staff, the use of a non-removable splint early in treatment, and thorough follow-up by senior staff are all important.