General practitioner training in paediatrics in the Trent region.

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

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.     

Ignoring the obvious: doctors' wives as patients.

There is a widely held belief among doctors and nurses that when a colleague is in hospital, if anything can go wrong during the course of his illness it invariably will. To investigate this belief, we studied prospectively a group of pregnant doctors and doctors'' wives, comparing the number of obstetric, paediatric, and psychiatric complications with those in two control groups of similar social class, race, and parity. These were teachers and lecturers and a group of State registered nurses. The occurrence of obstetric and paediatric problems was similar in the three groups. Psychiatric problems, however, were more common among teachers and lecturers (p less than 0.001); this difference was due to the way the nurses on the postnatal wards failed to report mild psychiatric problems among doctors'' wives to their colleagues. This difference was not related to the amount of preferential treatment that doctors and doctors'' wives received while in hospital.     

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.     

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.     

GP trainees' views on hospital obstetric vocational training.

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

Some experience in an area health authority child health clinic.

Three years'' experience as a doctor taking two clinics a week in an area health authority child health clinic was reviewed. A wide range of clinical conditions was seen, including: problems associated with feeding in breast- and bottle-fed infants; minor developmental abnormalities (mental, behavioural, and physical); surgical and orthopaedic conditions requiring treatment; medical conditions, mainly respiratory and alimentary infections, skin conditions, and problems of over-treatment for minor ailments; and minor genetic abnormalities. Mothers asked for advice on a wide range of topics, risks and benefits of immunisation being the most common. The clinic doctor needs a wide experience in paediatrics to deal with such problems. It is suggested that all lecturers in child health and paediatric and senior registrars should take one clinic a week for six months, and all medical students should attend some clinics as part of their paediatric training. Health visitors have an important role in helping the clinic doctor, but their training should be more realistic and appropriate facilities should be provided to keep them up to date in their work.     

The safety of obstetric services in small communities in northern Ontario.

The safety of the obstetric care system in the small hospitals of northern Ontario was assessed by analysing the outcomes of all obstetric cases over a 2-year period. Information was retrieved by place of residence rather than hospital of delivery so that the overall perinatal system, including the referral patterns, would be assessed. There was little difference in perinatal loss rate (stillbirths and neonatal deaths up to 28 days per 1000 births) for residents of areas served by different levels of obstetric care. Areas served by units where cesarean sections are done regularly but which do not have specialists in obstetrics or pediatrics had a perinatal loss rate of 10.43, whereas areas served by units staffed with two or more specialists in both obstetrics and pediatrics and handling more than 1000 deliveries per year had a perinatal loss rate of 12.13. Although many of the smaller hospitals did not have the minimum capabilities suggested for obstetric units relatively safe care was being provided. These results do not support the need for further centralization of obstetric services in northern Ontario.     

General practitioner participation in intranatal care in the northern region in 1983.

In 1983 a quarter of general practitioners in the Northern region of England cared for obstetric deliveries and half of these for a minimum of 10 deliveries a year. Most expected their intranatal work to remain at the same level or increase in the next 10 years. Most participating general practitioners did their own forceps deliveries and initiated inductions. Most out of hours deliveries were attended by the mother''s own general practitioner or a partner. A quarter of all respondents had cared for planned and unplanned home births. Few were happy about attending them, but most would provide planned home care if urged to do so.     

Overseas doctors and the staffing structure of hospitals.

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

Stress,anxiety, and depression in hospital consultants,general practitioners,and senior health service managers.

OBJECTIVE--To study stress, anxiety, and depression in a group of senior health service staff. DESIGN--Postal survey. SUBJECTS--81 hospital consultants, 322 general practitioners, and 121 senior hospital managers (total 524). MAIN OUTCOME MEASURES--Scores on the general health questionnaire and the hospital anxiety and depression scale. RESULTS--Sixty five (80%) consultants, 257 (80%) general practitioners, and 67 (56%) managers replied. Of all 389 subjects, 183 (47%) scored positively on the general health questionnaire, indicating high levels of stress. From scores on the hospital anxiety and depression scale only 178 (46%) would be regarded as free from anxiety, with 100 (25%) scoring as borderline cases and 111 (29%) likely to be experiencing clinically measurable symptoms. The findings for depression were also of some concern, especially for general practitioners, with 69 (27%) scoring as borderline or likely to be depressed. General practitioners were more likely to be depressed than managers (69 (27%) v 4 (6%) scored > or = 8 on hospital anxiety and depression scale-D; P = 0.004) with no significant difference between general practitioners and consultants. General practitioners were significantly more likely to show suicidal thinking than were consultants (36 (14%) v 3 (5%); P = 0.04) but not managers (9 (13%)). No significant difference could be found between the three groups on any other measure. CONCLUSIONS--The levels of stress, anxiety, and depression in senior doctors and managers in the NHS seem to be high and perhaps higher than expected.     

Out of hours workload of a suburban general practice: deprivation or expectation.

The out of hours workload of a training practice in a suburban and semirural area on the south coast of England was studied for one year. An overall rate of contact of 273/1000 patients was found, which indicated a workload greater than that reported in most other studies. The duty doctor received over 35 telephone calls from patients during some Saturdays (1200 Saturday to 0800 Sunday) and Sundays (0800 to 0800 Monday), up to five being between 2300 and 0700. Of the patients who contacted a general practitioner, 44% were given advice by telephone and 4.9% were admitted to hospital. The admission rate was lower than that given in other studies. A considerable proportion of the workload arose from doctors covering the casualty department of a cottage hospital. Patients having a high expectation of 24 hour care by general practitioners in an area of comparative affluence (Jarman indices -13.8 to 1.7) may account for this aspect of the workload.     

Improving compliance with requirements on junior doctors' hours

Problem Compliance with UK regulations on junior doctors'' working hours cannot be achieved by manipulating rotas that maintain existing tiers of cover and work practices. More radical solutions are needed.Design Audit of change.Setting Paediatric night rota in large children''s hospital.Key measures for improvement Compliance with regulations on working hours assessed by diary cards; workload assessed by staff attendance on wards; patient safety assessed through critical incident reports.Strategies for change Development of new staff roles, followed by change from a partial shift rota comprising 11 doctors and one senior nurse, to a full shift night team comprising three middle grade doctors and two senior nurses.Effects of change Compliance with regulations on working hours increased from 33% to 77%. Workload changed little and was well within the capacity of the new night team. The effect on patient care and on medical staff requires further evaluation.Lessons learnt Reduction of junior doctors'' working hours requires changes to roles, processes, and practices throughout the organisation.     

Reduction of severe acute maternal morbidity and maternal mortality in Thyolo District, Malawi: the impact of obstetric audit

Background

Critical incident audit and feedback are recommended interventions to improve the quality of obstetric care. To evaluate the effect of audit at district level in Thyolo, Malawi, we assessed the incidence of facility-based severe maternal complications (severe acute maternal morbidity (SAMM) and maternal mortality) during two years of audit and feedback.

Methodology/Principal Findings

Between September 2007 and September 2009, we included all cases of maternal mortality and SAMM that occurred in Thyolo District Hospital, the main referral facility in the area, using validated disease-specific criteria. During two- to three-weekly audit sessions, health workers and managers identified substandard care factors. Resulting recommendations were implemented and followed up. Feedback was given during subsequent sessions. A linear regression analysis was performed on facility-based severe maternal complications. During the two-year study period, 386 women were included: 46 died and 340 sustained SAMM, giving a case fatality rate of 11.9%. Forty-five cases out of the 386 inclusions were audited in plenary with hospital staff. There was a reduction of 3.1 women with severe maternal complications per 1000 deliveries in the district health facilities, from 13.5 per 1000 deliveries in the beginning to 10.4 per 1000 deliveries at the end of the study period. The incidence of uterine rupture and major obstetric hemorrhage reduced considerably (from 3.5 to 0.2 and from 5.9 to 2.6 per 1000 facility deliveries respectively).

Conclusions

Our findings indicate that audit and feedback have the potential to reduce serious maternal complications including maternal mortality. Complications like major hemorrhage and uterine rupture that require relatively straightforward intrapartum emergency management are easier to reduce than those which require uptake of improved antenatal care (eclampsia) or timely intravenous medication or HIV-treatment (peripartum infections).     

Use of SPRAT for peer review of paediatricians in training

Objective To determine whether a multisource feedback questionnaire, SPRAT (Sheffield peer review assessment tool), is a feasible and reliable assessment method to inform the record of in-training assessment for paediatric senior house officers and specialist registrars.Design Trainees'' clinical performance was evaluated using SPRAT sent to clinical colleagues of their choosing. Responses were analysed to determine variables that affected ratings and their measurement characteristics.Setting Three tertiary hospitals and five secondary hospitals across a UK deanery.Participants 112 paediatric senior house officers and middle grades.Main outcome measures 95% confidence intervals for mean ratings; linear and hierarchical regression to explore potential biasing factors; time needed for the process per doctor.Results 20 middle grades and 92 senior house officers were assessed using SPRAT to inform their record of in-training assessment; 921/1120 (82%) of their proposed raters completed a SPRAT form. As a group, specialist registrars (mean 5.22, SD 0.34) scored significantly higher (t = – 4.765) than did senior house officers (mean 4.81, SD 0.35) (P < 0.001). The grade of the doctor accounted for 7.6% of the variation in the mean ratings. The hierarchical regression showed that only 3.4% of the variation in the means could be additionally attributed to three main factors (occupation of rater, length of working relationship, and environment in which the relationship took place) when the doctor''s grade was controlled for (significant F change < 0.001). 93 (83%) of the doctors in this study would have needed only four raters to achieve a reliable score if the intent was to determine if they were satisfactory. The mean time taken to complete the questionnaire by a rater was six minutes. Just over an hour of administrative time is needed for each doctor.Conclusions SPRAT seems to be a valid way of assessing large numbers of doctors to support quality assurance procedures for training programmes. The feedback from SPRAT can also be used to inform personal development planning and focus quality improvements.     

Audit of 26 years of obstetrics in general practice.

To assess the feasibility and quality of general practitioner obstetrics an audit of 1223 consecutive obstetric deliveries over 26 years was carried out with standard clinical records. The perinatal mortality of 9.0 per 1000 births was significantly better than the national average of about 19.0 per 1000 for the overall period. During the audit home deliveries virtually stopped. The proportion of consultant bookings and deliveries more than doubled because of more stringent booking arrangements despite relocation of the previously isolated general practitioner unit to beneath the consultant unit. Abnormal deliveries also rose significantly. A "steady state" was achieved during the final 11 years in which 73% of women booked to be delivered by their general practitioner, 64% were admitted to the general practitioner unit, and 54% were delivered by their general practitioner. Though this is enough to sustain obstetric experience, the proportion might safely be increased.     

Modified paediatric resuscitation chart.

OBJECTIVES--To determine whether a modified paediatric resuscitation reference chart improves the speed and accuracy of calculation of doses of drugs in simulated paediatric cardiopulmonary arrests when compared with the chart devised by Oakley. DESIGN--A prospective study in which a series of randomly assigned questions was used to compare the performance of doctors using the two charts. SETTING--Accident and emergency departments in two hospitals. SUBJECTS--31 senior house officers. MAIN OUTCOME MEASURES--The speed and accuracy of calculation of volumes of drugs to be administered. RESULTS--The modified chart significantly increased the accuracy of the calculations (62/62 v 43/62, p < 0.01 [corrected]), the speed of correct calculations (6.8 v 36.0 s, p < 0.0001), and the number of calculations that were completed (62/62 v 50/62, p < 0.001). CONCLUSIONS--The modified paediatric resuscitation chart should supersede the existing chart.     

Cost of achieving a balance in the anaesthetic department of a district general hospital.

In Achieving a Balance the Department of Health published requirements for medical staffing in hospitals. To review the effect that these would be likely to have a study was undertaken in the anaesthetic department of a district general hospital. The results were then validated with staffing levels in a new district general hospital with only one tier of junior staff. It was found that over the next 10 years a massive expansion in the numbers of consultants would be needed at a cost of 108,000 pounds in salaries and employer''s contributions alone.