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.     

Time for change in traditional working practices?

Consultants in Britain are under pressure to change the way they organise their work. Many rely on formal, but unwritten, rules and a culture of "learning by doing." Unlike their counterparts in Sweden, they are often not well integrated into the management systems of their hospitals. The result is wide differences in the NHS workloads of individual consultants and, for a minority, conflicts of interest with their private work. The training received by junior doctors varies because it is largely left to individual consultants. Clinical directorates should provide a more effective mechanism for consultants to influence trust policies and for consultants to implement these policies. Consultants must not only recognise the need for change but also seize the initiative.     

Professional societies and industry support: what is the quid pro quo?

Professional medical societies have become increasingly dependent on pharmaceutical, device, and biotechnology companies for ongoing support of their programs, but the internal influence of this financial largesse on medical societies' practices is well hidden. Many examples exist in which societies' educational products, including clinical practice guidelines and professional publications, have been tainted by involvement by industry-paid individuals. These examples show that professional judgments of organizations can be affected in ways that are not in the best interests of our patients. Society leaders should develop policies that leave critical decisions, especially those that affect patient care, in the hands of members without financial ties to industry. Society leaders should not accept funds designated for specific industry-recommended projects unless such programs are already part of their planned agenda. These leaders, who typically serve for only a year or two, should delve into arrangements that salaried society executives make with industry, and insure that no promises are made that compromise an organization's professional goals. Professional societies should also find ways of reducing the vast, embarrassing industry involvement at their national meetings, especially the vulgar circus-like displays and the drug company-sponsored symposia. We must reduce commercialism and restore professionalism to our medical meetings.     

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.     

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.     

Why general practitioners and consultants change their clinical practice: a critical incident study.

OBJECTIVE: To describe the complete range of factors which doctors recognise as changing their clinical practice and provide a measure of how often education is involved in change. DESIGN: Interviews using the critical incident technique. SETTING: Primary and secondary care. SUBJECTS: Random sample of 50 general practitioners and 50 consultants. MAIN OUTCOME MEASURES: Categories of reasons for change in clinical practice. RESULTS: Doctors described 361 changes in clinical practice, with an average of 3.0 reasons per change. The three most frequently mentioned reasons were organisational factors, education, and contact with professionals, together accounting for 47.9% of the total number of reasons for change. Education accounted for one sixth (16.9%) of the reasons for change and was involved in one third (37.1%) of the changes. Education was seldom mentioned as a reason for change in referral practice but was more often mentioned in management and prescribing changes. Consultants were influenced by medical journals and scientific conferences, while general practitioners were more influenced by medical newspapers and postgraduate meetings. CONCLUSIONS: Education is involved in about a third of changes in clinical practice. The wide range of other factors affecting changes in practice need to be taken into account in providing and evaluating education. The role of education in the numerous changes in clinical practice that currently have no educational component should also be considered.     

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.     

Editor's column: Directories as scientific catalysts

International funding of scientific activities is mostly of catalyst size only. Systematic efforts to track down the catalysing situations in these activities are made by the funding organizations. Great attention is devoted to meetings, while the catalysts of current activities between meetings are neglected. Regular primary publications are the closest counterparts in the current work of meetings but are out of size and inconvenient in structure for catalytic support. Circulars, newsletters and annotated directories (many hybrids occur) are very important catalysts of more manageable size. Taken together they represent considerable amounts of largely concealed labour and costs. Standards are badly needed for making the organization of information elements in directories efficient. Each entry in a directory should add a research profile to the scientists' identity and address. Directories may remain a jungle product, but scientists' considerable efforts in producing them merit a reconsideration of the organization of their contents and the provision of advice for their production and distribution.     

International scientific meetings: relation between structure and function.

Increasing pressure is being placed on the scientific community to evaluate research activities. Scientific meetings consume a small but important fraction of the research budget. Audit of a well established series of scientific meetings showed that they met their immediate objectives in that they were international and multidisciplinary and provided a forum in which all participants actively contributed to discussion. The meetings had a positive outcome for the participants, leading in many cases to the subsequent exchange of research material (60% of participants) and to the establishment of collaborative research projects (31%). The impact of the meetings on the scientific community at large was assessed by citation analysis, which showed that the proceedings were cited early, often, and over a substantial period.     

The use of Ethics Decision‐Making Frameworks by Canadian Ethics Consultants: A Qualitative Study

In this study, Canadian healthcare ethics consultants describe their use of ethics decision‐making frameworks. Our research finds that ethics consultants in Canada use multi‐purpose ethics decision‐making frameworks, as well as targeted frameworks that focus on reaching an ethical resolution to a particular healthcare issue, such as adverse event reporting, or difficult triage scenarios. Several interviewees mention the influence that the accreditation process in Canadian healthcare organizations has on the adoption and use of such frameworks. Some of the ethics consultants we interviewed also report on their reluctance to use these tools. Limited empirical work has been done previously on the use of ethics decision‐making frameworks. This study begins to fill this gap in our understanding of the work of healthcare ethics consultants.     

The dorsal, unpaired, median neurons of the locust metathoracic ganglion

Neurons having large cell bodies in the anterior dorsal median cluster in the metathoracic ganglion of the locust Schistocerca gregaria and the grasshopper Romalea microptera were studied by direct dye injection and reverse filling combined with elyctrical stimulation and recording. Eight, possibly nine, are of the unpaired type, with a T branch leading into left and right axons that leave the ganglion to terminate in muscles. Another six are probably paired, and may be interneurons. Five of the 8 or 9 unpaired neurons have one axonal branch in both N4 and N5, on both sides: the others have but a single branch. One of the nine, DUMETi, has left and right axons exclusively innervating the jumping muscles, and another, DUMDL, has left and right axons exclusively innervating the dorsal longitudinal flight muscles. Neither the locations, sizes or numbers of somata, nor their locations were as constant as is the case for ordinary ventral motoneurons.     

Options for change in the NHS consultant contract.

The lead negotiators for the management and consultant sides in an NHS trust in northern England responded to debate in their trust about consultant contracts by offering to research the attitudes of their peers towards a variety of contract options. The options tested included the current contract; models already examined in the trust and elsewhere, such as time sensitive and mild performance related contracts; and some more radical and speculative possibilities, including consultants franchising their services to the trust. Beyond the predictable conclusion that consultants would prefer no change while managers desired it, a time sensitive contract emerged as having potential for successful negotiation. On the other hand, neither consultants nor managers favoured a strict performance related contract or a fee for service contract. There was a strong similarity of opinion between the two groups on the relative salary values of the options, though the consultants consistently priced these higher than the managers.     

Exemplary family physicians and consultants: empirical definition of contemporary medical practice.

To identify the characteristics of exemplary family physicians and consultants, we interviewed 25 family physicians and 25 consultants (5 each in the specialties of internal medicine, obstetrics and gynecology, pediatrics, psychiatry and surgery) selected by their peers as being exemplary in their own practice setting. The results indicated that the participants had well-formulated concepts of exemplary practitioners, defining five main categories of performance: clinical competence, relationship with patients, availability, family physician-consultant relationship and a fifth category that included organizational ability and personality attributes. The family physicians and the consultants placed different values on these categories and indicated that these values might change under different clinical circumstances. Their concepts appear to be compatible with, but not restricted to, a model of contemporary medical practice based on an ethic specific to medicine.     

SURVIVAL OF MANX SHEARWATERS PUFFINUS PUFFINUS

The breeding success of Manx Shearwaters at Skokholm Island, Pembrokeshire, was followed in study burrows, and data on survival of the young were augmented by ringing large numbers as they were about to leave the island and recapturing them in later years.
The weight of the young at fledging and the date at which they leave affect their chances of survival; overall, as many as 30% of the young birds may survive to reach breeding age, which is thought to be normally about 5–6 years. Adult mortality varies between wide limits of about 5 and 20%, but juvenile survival appears to be of about the right order to balance adult losses.
The significance of the one-egg clutch is discussed. At the normal time of laying the female may not be able to obtain sufficient food to form a second egg. A two-egg clutch, laid at a later date, would not produce more surviving young since these would fledge too late in the season to have a good chance of survival.
The advantage of leaving the island at a heavy weight is discussed, and it is concluded that the fat stores laid down give heavy young a greater chance than light young of migrating a long distance without food. It is possible that the young may even reach their winter quarters (off Brazil) without having to feed on passage if they depart with enough stored fat.     

Colposcopy services in the West Midlands region.

A survey of all 72 consultant gynaecologists in the West Midlands region was carried out to determine their views on colposcopy services. All districts provided a colposcopy service and 47 consultants practised colposcopy. The consultants differed considerably in their views on criteria for referring women for investigation after smears. All but one thought that a positive smear result was an indication for immediate referral but whereas 55 thought that women with one or more inflammatory smear should be referred, 17 did not believe this to be necessary. Sixty seven consultants thought a preoperative colposcopic assessment desirable, but 10 had to ration referrals because of limited resources. Four forms of treatment were used: 17 districts had a carbon dioxide laser, eight used low voltage diathermy loop excision, two had only a cold coagulator, and one used only cold cautery. There was widespread dissatisfaction with resources and about the increasing amount of time spent on the service at the expense of other work. Consultants were also concerned about the relevance of much of what was done to the aim of the screening programme--reducing mortality from cervical cancer. Although additional resources are needed in some districts, referral policies, indications for colposcopic assessment, training, choice of treatment, and the value of follow up need to be reviewed if the service is to be improved.     

Older Adults Looking for a Job through Employment Support System in Tokyo

MethodsWe conducted 6 waves of longitudinal mail surveys over 38 weeks to 235 older job seekers (146 males and 89 females, average age 63.7, SD 5.6), who visited two ASESCs for the first time, to clarify their living situation, health condition, and changes in their job seeking process.ResultsThese older job seekers tended to be at a relatively low education level and on low income, as well as tended to seek jobs for earning living expenses rather than for well-being. Half of them found employment in 35.0 days; however, 23.8% couldn’t find any job in 38 weeks, especially those who were younger and with higher education.ImplicationsASESCs are functioning to assist older job seekers who are mainly seeking jobs for earning living expenses, which can be attained in a short time span and enable them to earn some money. These facilities are expected to be consulting services, not only for employment support but also for general living, because it is important to maintain contact with people who are at risk of social isolation, serious financial difficulty, or suicide. We consider it very helpful to encourage and re-activate these mismatched people, by supporting them to engage in highly contributional services to our society and the next generation, such as providing child-care support or daily life support, the demands for which are rapidly increasing due to recent governmental policies.     

Plant molecular biology in Argentina and Chile

We report here on 32 laboratories from Argentina and Chile that include 55 research scientists. Most of these groups were constituted in the last ten years, usually by investigators returning from their postdoctoral training abroad. Some groups are based in institutions with a long tradition in plant biochemistry that are seeking to update their research. Others are organized under the National Institutes for Agronomic Research (INTA in Argentina and INIA in Chile) with the aim of introducing the techniques of molecular biology in their plant breeding programs. Several laboratories sharing similar research interests maintain collaborative links, and many of them participate in binational or multinational research programs. An interesting level, of coordination is provided by REDBIO, the Latin American Network on Plant Biotechnology, which organized national and international meetings in both Argentina and Chile to promote biotechnological research. As a whole, the academic production of these groups has been steadily increasing.