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.     

Surgical training: an objective assessment of recent changes for a single health board.

The reduction in doctors'' hours and the introduction of specialist training have reduced general surgical training by 60%. This study assessed the implications for a single health board. A questionnaire listing 13 representative operations was sent to 44 trainees and 52 trainers to determine the number of operations a trainee should perform. The total number of operations required for training was compared against the total actually performed across the health board. Operating times for five representative operations were audited prospectively. Trainers and trainees recommended a similar and conservative number of operations. The total number of operations available for training (4913) was 38% less than the number recommended (7946). Trainees required 50-75% more operating time than consultants. To increase the proportion of operations undertaken by trainees from the current 30% to 70% would require an extra 270 theatre days (of pounds 1.3m) yearly. The minimum number of operations required for training must be defined and the proportion of supervised operations undertaken by trainees substantially increased. Service and financial implications will have to be addressed. Action is needed urgently, as the first trainees will become consultants in less than five years.     

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.     

The American General Practitioner in Hospital

In the U.S.A. and Canada full access of general practitioners to hospital beds and facilities is regarded as an essential privilege of their work. All hospital constitutions require a review of the credentials of staff applicants and continuing evaluation of their performance. Staff appointment carries administrative as well as clinical responsibilities and hospital work occupies a considerable proportion of the general practitioner''s day. The disciplinary machinery for safeguarding standards is strict by comparison with British hospital practice.This system produces an obvious excellence of clinical standards, postgraduate education, and communication between specialist and general practitioner and is attractive to the more able young British graduate. A pilot experiment of hospital staffing on North American lines in one of our new district general hospitals would be a worthwhile proposition.     

Pandemic Influenza Virus 2009 H1N1 and Adenovirus in a High Risk Population of Young Adults: Epidemiology,Comparison of Clinical Presentations,and Coinfection

Background

In 2009, pandemic H1N1 influenza virus (2009 H1N1) emerged worldwide, causing morbidity and mortality that disproportionately affected young adults. Upper respiratory infection (URI), largely due to adenovirus, is an endemic cause of morbidity in military training. Whether clinical presentations differ or excess morbidity results from coinfection is unclear.

Methods

The Center for Advanced Molecular Detection evaluates epidemiology and rapid diagnostics of respiratory pathogens in trainees with URI. From May 1, 2009, to November 30, 2009, demographic, clinical, and PCR data from throat and nasal specimens for adenovirus and 2009 H1N1 were prospectively collected.

Results

375 trainees with URI enrolled and were tested for both adenovirus and 2009 H1N1 by PCR (median age 20; 89% male). Adenovirus PCR was positive in 72% (96% serotype E-4) and 2009 H1N1 in 20%. Males were more likely to have adenovirus and females more likely to have 2009 H1N1 (p  =  0.047). Subjects with 2009 H1N1 presented an average of 1 week earlier in training, had shorter illness duration before enrollment, less sore throat, diarrhea, and fewer abnormal findings on throat exam. Coryza and cough were more common with 2009 H1N1 compared to adenovirus. Subjects with 2009 H1N1 were less likely to have adenovirus than those without, despite persistently high frequencies of adenovirus detections during peak 2009 H1N1 weeks (15% vs. 83%, p < 0.01). Coinfection with adenovirus and 2009 H1N1 was rare (4%). Rates of hospitalization and pneumonia did not differ between the adenovirus, 2009 H1N1, or coinfected groups.

Conclusion

Military trainees with 2009 H1N1 vs. adenovirus have differing clinical presentations, and males are more likely to have adenovirus. Despite high frequencies of adenovirus infection, coinfection with adenovirus and 2009 H1N1 is rare and apparently does not result in increased morbidity.     

Survey of medical training in cytopathology carried out by the journal Cytopathology

Anshu, A. Herbert, B. Cochand‐Priollet, P. Cross, M. Desai, R. Dina, J. Duskova, A. Evered, A. Farnsworth, W. Gray, S. S. Gupta, K. Kapila, I. Kardum‐Skelin, V. Kloboves‐Prevodnik, T. K. Kobayashi, H. Koutselini, W. Olszewski, B. Onal, M. B. Pitman, ?. Marin?ek, T. Sauer, U. Schenck, F. Schmitt, I. Shabalova, J. H. F. Smith, E. Tani, L. Vass, P. Vielh and H. Wiener
Survey of medical training in cytopathology carried out by the journal Cytopathology This report of the Editorial Advisory Board of Cytopathology gives the results of a survey of medical practitioners in cytopathology, which aimed to find out their views on the current situation in undergraduate and postgraduate training in their institutions and countries. The results show that training in cytopathology and histopathology are largely carried out at postgraduate level and tend to be organized nationally rather than locally. Histopathology was regarded as essential for training in cytopathology by 89.5% of respondents and was mandatory according to 83.1%. Mandatory cytopathology sections of histopathology were reported by 67.3% and specific examinations in cytopathology by 55.4%. The main deficiencies in training were due to its variability; there were insufficient numbers of pathologists interested in cytology and a consequent lack of training to a high level of competence. Pathologists without specific training in cytopathology signed out cytology reports according to 54.7% of responses, more often in centres where training was 3–6 months or less duration. Although 92.2% of respondents thought that specialist cytology should not be reported by pathologists without experience in general cytopathology, that practice was reported by 30.9%, more often in centres with small workloads. The survey report recommends that 6–12 months should be dedicated to cytopathology during histopathology training, with optional additional training for those wanting to carry out independent practice in cytopathology. Formal accreditation should be mandatory for independent practice in cytopathology. When necessary, temporary placements to centres of good practice should be available for trainees intending to practise independently in cytopathology. There should be adequate numbers of pathologists trained in cytopathology to a high level of competence; some of their time could be released by training cytotechnologists and trainee pathologists to prescreen cytology slides and assess adequacy of fine‐needle aspiration samples when immediate diagnosis was not required. The survey demonstrated a clear need for European and international guidelines for training in cytopathology.     

Costs and benefits of a community special care baby service

Between January 1981 and December 1986 3829 low birthweight (<2500 g) infants and 1980 other high risk infants were cared for at home after they were discharged from hospital by a specialist neonatal nursing service. Of the infants who were referred to this service, 720 (12%) weighed under 2000 g and 1919 (33%) under 2250 g at the time of discharge home. The infants were visited by the community neonatal sisters on an average of 11 occasions, but the number of visits varied from six to over 100 depending on the needs of the child and parents. There was close liaison with other community and hospital staff. Two hundred and thirty (4%) referred infants were readmitted to hospital while under the care of the specialist nursing service. In 1985 the cost of the service was £127 000, or £123 for each infant referred. Providing this specialist support at home allowed much earlier discharge of low birthweight infants from hospital. When compared with the cost of providing continuing inpatient neonatal care earlier discharge was estimated to have saved roughly £250 000 in 1985.Low birthweight infants have an increased risk of serious illness or death that extends beyond the neonatal period. Many are born to young and socially disadvantaged parents who can benefit from expert guidance and support at home. A community neonatal nursing service has advantages for high risk infants and their parents, is cost effective, and allows more efficient use of limited hospital resources.     

Effectiveness of out-of-hours biochemistry investigations.

A survey was carried out of doctors who used their out-of-hours biochemistry service to find out why requests for investigations were made, how often the results altered patient management, and whether they could define areas where investigations were unproductive. Of 107 questionnaires distributed, 147 (88%) were completed. In 86% the requests were for diagnosis or immediate patient management and in 35% the results actually altered management. Senior clinical staff were more efficient than their juniors in instigating biochemical investigations that proved to be effective. In no instance where the clinical staff predicted that it was unlikely that the results would alter management was management altered. It is suggested that joint reviews of case notes by junior and senior clinical staff would prove to be the most appropriate way to increase the effectiveness and efficiency of clinical investigation.     

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.     

Hospital training for general practice: views of trainees in the North Western region.

Vocational trainees in the North Western region who were in their general practice year completed a questionnaire concerning the hospital component of their training. Replies were received from 125 trainees, providing information about 451 hospital posts. In a total of 372 posts (85%) less than two hours of formal teaching a week was provided. Trainees stated that they received no informal teaching in nearly one third of posts. The orientation of teaching towards general practice was reported as greatest in the posts that were not part of a vocational training scheme. Study leave was applied for by doctors in only 163 (37%) posts, usually to prepare for or to sit an examination. There seem to be serious educational deficiencies in hospital posts that are used to train both general practitioners and other specialists. Improvements in both the quantity and quality of in service teaching are therefore needed urgently.     

Psychiatric training in the UK: the next steps

Postgraduate education and training in the UK is undergoing tremendous change. In this paper the changes affecting psychiatry are described, with an account of the drivers. Patients, their carers and politicians all expect psychiatric service providers to have certain characteristics. Psychiatric training is becoming more competency focused and it is right that assessments of competencies also occur at the place that trainees work. There are key competencies that trainees need to take into account while learning and working. These are described along with the way forward     

Individual and collective responsibility to enhance regulatory compliance of the Three Rs

Investigators planning to use animals in their research and the Institutional Animal Care and Use Committee (IACUC) members who review the research protocols must take personal responsibility for ensuring that they have the skills and knowledge to perform their duties, applying the Three Rs principles of Russell and Burch. The two Korean laws introduced in 2008 and 2009 regulating animal use for scientific purposes in line with the Three Rs principles have been revised a total of 11 times over the last 6 years. Both regulatory agencies, e.g., the Animal and Plant Quarantine Agency and the Ministry of Food and Drug Safety, provide regular training based on the legal requirements. Based on the amended Animal Welfare Act, the IACUC appointment framework has been upgraded: appointments are now for two-year terms and require a qualified training certificate issued by the Animal and Plant Quarantine Agency since 2012. The authors reviewed the current curricular programs and types of training conducted by the two governing agencies through Internet searches. Our Internet survey results suggest that: a) diversity should be provided in training curricula, based on the roles, backgrounds and needs of the individual trainees; b) proper and continued educational programs should be provided, based on trainees’ experiences; and c) active encouragement by government authorities can improve the quality of training curricula. [BMB Reports 2014; 47(4): 179-183]     

Organisation of vascular surgical services: evolution or revolution?

The trend towards subspecialisation in hospital services is likely to lead to the development of vascular surgery as a separate specialty. If vascular surgery is to emerge as a high quality service then vascular emergencies--a substantial component of the workload--should be dealt with by surgeons with adequate training, and all patients should have equal access to the service. A specialist vascular surgical unit would have to be large enough to make efficient use of other services that it needs, such as radiology, and so may require the amalgamation of smaller health district units. Because of the differing local degrees of subspecialisation, national or regional strategies for vascular surgery must be developed.     

Medical staffing in Ontario neonatal intensive care units.

Advances in technology have improved the survival rates of infants of low birth weight. Increasing service commitments together with cutbacks in Canadian training positions have caused concerns about medical staffing in neonatal intensive care units (NICUs) in Ontario. To determine whether an imbalance exists between the supply of medical personnel and the demand for health care services, in July 1985 we surveyed the medical directors, head nurses and staff physicians of nine tertiary level NICUs and the directors of five postgraduate pediatric residency programs. On the basis of current guidelines recommending an ideal neonatologist:patient ratio of 1:6 (assuming an adequate number of support personnel) most of the NICUs were understaffed. Concern about the heavy work pattern and resulting lifestyle implications has made Canadian graduates reluctant to enter this subspecialty. We propose strategies to correct staffing shortages in the context of rapidly increasing workloads resulting from a continuing cutback of pediatric residency positions and restrictions on immigration of foreign trainees.     

Referrals to hospital by general practitioners: a study of compliance and communication.

To determine the extent of non-attendance at first hospital appointments 269 hospital referrals made in one practice over 14 weeks were analysed retrospectively. Non-attendance was more likely among patients referred to outpatient departments than to casualty or for admission. Fifteen per cent (41/269) of all patients and 20% (33/167) of outpatients failed to keep their initial appointments. Prolonged waiting times from referral to appointment were significantly related to non-attendance. Twenty weeks after the last referral had been made no communication had been received by the practice for 24% (61/252) of all referral letters received by the hospital. Minimum delays to appointments and improved communication between hospitals and general practitioners would help general practitioners to make appropriate referrals and improve compliance.     

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.     

Functional consequences of trophic specialization in pufferfishes

1. Trophic breadth may be correlated with behavioural and functional versatility or flexibility (Liem 1984), such that species with limited diets would be predicted to be less versatile or flexible in their feeding capabilities than would trophic generalists. The relationship was examined between the trophic breadth of a species and the degree to which muscle activity is influenced by prey type in two species of pufferfishes: Chilomycterus schoepfi, a specialist on hard-shelled prey, and Sphoeroides nephalus, a generalist predator. It was predicted that the specialist would show a decreased ability to alter its motor pattern in response to prey type and an increased amount of motor-pattern variability when feeding on different prey.
2. Electromyographic recordings of five feeding muscles were made from five individuals per species feeding on four prey types that differed in their hardness and escape abilities. Muscle-activity duration, relative onset and integrated rectified area were analysed for prey capture and manipulation behaviours for each prey type.
3. Prey-type effects on mean motor-pattern variables for capture were limited to one of 14 variables in each species. Prey effects on buccal manipulation were not significant for any of the 14 variables for C. schoepfi, but S. nephalus exhibited prey effects for seven out of 14 variables. No differences in motor-pattern variation were found for the strike, but species differed significantly in overall motor-pattern variability during buccal manipulation; C. schoepfi, the dietary specialist, exhibited greater motor variability than S. nephalus, the dietary generalist.
4. The results therefore support a direct relationship between the trophic breadth of a species and its functional versatility for buccal manipulation. In contrast, prey capture was a relatively stereotyped behaviour for both species, as few prey-type effects were found.     

London after Tomlinson. Care in the capital: what needs to be done.

One of the aims of the Tomlinson report is to shift more care from the secondary to the primary sector in London. But the primary sector is already underresourced and overloaded. The capital has a heterogeneous population which often makes inappropriate demands on general practitioners. Many premises are inadequate and there are insufficient support staff. David Metcalfe emphasises that London is special and that the shift will not become a reality unless these problems are tackled. He suggests the establishment of different models of practice centres which could treat some of the patients who now go to accident and emergency departments. Some would be the night emergency service base, some would have primary care beds, and each would have a different mix of specialist support.     

Abortion Act in Somerset

A survey conducted with a sample of 20% of general practitioners over six months in 1972 disclosed a request rate for termination approaching 10% of all pregnancies. The attitude and performance of the practitioner were considered to be important in the patient''s requests for this, and patients were thought to know about these. This implies that in three-quarters of the practices there was a sizeable demand for abortion which remained latent.Altogether, 20% of specialist consultations were made privately and in none of these cases was abortion refused. Under the Health Service the refusal rate was 19%, but 7 of the 12 women refused N.H.S. abortions subsequently obtained it privately.     

Fine needle aspiration cytology: a survey of current European practice

Fine needle aspiration cytology (FNAC) is practised widely throughout Europe. The majority of countries have dedicated cytopathologists as well as histopathologists practicing cytology. Despite this, FNAC is performed mostly by clinicians and radiologists except in the larger centres with dedicated staff with a special interest in cytopathology. The advent of One-Stop diagnostic services and image-guided procedures are prompting further development of FNAC clinics where cytopathologists take their own samples, issue reports in the same clinical session and take extra material for ancillary tests to complete the diagnosis. The volume of FNAC work varies accordingly; in dedicated centres FNAC represents up to 80% of the workload whilst, in the majority of countries, it represents one quarter or less. Hence, the rate of inadequate FNAC varies widely, depending on the local sampling policies and the organ, but does not exceed 25% in any of the countries. The most sampled organs are breast and thyroid, followed by lymph nodes. Most countries have dedicated training in cytopathology for pathology trainees, the duration varying between 6 months and 2 years of the total training time. This discussion, focusing on European practices, highlights the heterogeneity of FNAC activity but also its success in many centres where it is practiced to a high standard, particularly in breast, thyroid and lymph node pathology. The relatively high rate of inadequate material in some centres reflects local policies and calls for greater uniformity of FNAC practice, particularly specimen sampling. To achieve this, the future direction should concentrate on specialist training, to include performing as well as interpreting FNAC, as part of the curriculum. Current emphasis on web-based training may not provide first hand experience of the FNAC procedure and should be supplemented by attending FNAC clinics and developing the technique to its full potential.