Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Failed evolution may lead to diktat
- Ian Callanan FRCSI (10 June 2005)
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Lesson from South Africa
- Martin J Dedicoat (10 June 2005)
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Junior Doctors - training vesus service
- Tahir A Mirza (13 June 2005)
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Hospital doctors need better training
- Shahid A Punwar (14 June 2005)
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Specialist Grade Can (still) Save The Day.
- Alfred P J Lake (16 June 2005)
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Ian Callanan FRCSI, Head of Medical Administration Beaumont Hospital Dublin
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Graham Reid makes some very valid and worrying points about the way that medical training has evolved. But his opening sentence says the most. Diktat is the likely outcome where systems have not changed voluntarily. Medical training for many of us was a hugely rewarding exposure to a vast array of varied situations, of interesting cases, of wonderful people and of many differing teaching styles and situations. However, we as a profession, steadfastly and with unerring conviction, refuse to see the risk associated with a training that involved long hours or excessive stress, of being faced with situations outside our experience and without the availability of help and guidance, in a fashion of training that could only be described, using that hopefully outdated phrase,as "the army way". And we have seen, but not accepted the evidence that this lifestyle destroyed both trainees lives and more importantly, patients' lives. There is a happy medium. Medical work should be consistently evaluated for its "training value". Effective learning should be the goal of every career programme and with effective learning will come a continued career satisfaction and an opportunity to develop skills, interests and expertise in whatever speciality one chooses. However, the profession needs to lead out on this. And from what I have seen, the profession is not leading on this. Many doctors (but thankfully not all)are moaning about diktats, about what the good old days were like and doing precious little about the evolution of medical training. Leading by example or by inspiration is left to a few and the remainder will be dragged kicking and screaming into the 21st century. And by way of illustration of this unwillingness to change, I would point out that infection control was a hot topic for Lister in the 1860's but we know that doctors are some of the worst culprits in the spread of MRSA. Likewise, the cardiac surgery events of Bristol have not lead to a root and branch systemisation of clinical audit. Let us celebrate, honour and emulate those amongst us who have evolved better training systems, better clinical management and better patient experience. And we must do this publically and vocally, telling all others what we are doing , why we are changing and the beenfit to medicla care that such changes will bring to our patients Competing interests: The author is President of the Irish Society for Quality and Safety in Healthcare, a voluntary organisation dedicated to its title |
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Martin J Dedicoat, Medical Manager Hlabisa Hospital, Hlabisa, KwaZulu/Natal, South Africa
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Dr Reid makes some very important and pertinent points with regard to the increasingly short time taken to become a consultant in the NHS,followed by lack of career progression on appointment. The thought of staying in the same post for over 30 years was one of the reasons I choose to come to South Africa following completion of specialist training in the UK. The public health system in South Africa has many challenges but one thing that seems to work very well is the career structure of consultants. Following specialist training a doctor is appointed as a specialist this is a junior specialist post often in a department with other more senior specialists. After a period of time or following further training you can apply for a senior specialist post which has increased responsibilities. Following this after a few more years you can progress to a principle specialist post which may be the most senior consultant post and head of department in many hospitals. But if you are still not satisfied you may then progress to chief specialist which is a post with regional responsibilities. All these posts are hands on clinical jobs with teaching responsibilities. Perhaps the NHS should take a look at this system. Martin Dedicoat Competing interests: None declared |
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Tahir A Mirza, SHO-Otolaryngology Frimley Park Hospital GU16 7UJ
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I agree with most of what Graham Read writes in his article; 'Hospital doctors need a new career structure', however, although as a Senior House Officer I am indeed in a ‘training post’, I certainly do not feel ‘above being required to do mere service work’. In fact I think most Senior House Officers would agree that the majority of their work is just this, service. This however is tolerable if the rewards in terms of training are sufficient. I have had the privilege of working in a plastic surgical unit where as a Senior House Officer I have had my own supervised half day list of minor operative procedures. I have also had the opportunity of working in a surgical unit where I have performed a variety of general surgical and breast procedures under direct consultant supervision; only after proper teaching and training, and when my consultant was happy with my level of competence and surgical expertise. I am sorry to say that in my experience and after discussion with many colleagues, such opportunities are few and far between these days. I recently submitted a manuscript for publication looking into how complications of above knee amputations varied with the grade of surgeon, amongst other variables. My results included a few such procedures performed by Senior House Officers. Alas the manuscript was rejected; one criticism being: ‘one would wonder what SHOs are doing performing above knee amputations in the modern Clinical Governance climate’. I fail to see how an appropriately educated, trained and supervised Senior House Officer performing this procedure contravenes any of the principles of Clinical Governance. Sadly I feel it is this sort of attitude that is counterproductive to the training of junior doctors today. It is quite clear that the Senior House Officers of yesteryear were often far more surgically proficient than many of the Registrars of today. Indeed the author is correct that there is a definite danger of ‘churning out consultants' with insufficient training and surgical expertise if things do not change. Competing interests: None declared |
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Shahid A Punwar, SHO ITU Charing Cross Hospital, London
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'What kind of doctors are we training who have never had to undertake a clinic unaided or cope alone with an unexpected event during surgery'. This quote from Dr Reads excellent article sums up the fears of myself and I would think many of my peers. As a post MRCS surgical trainee I am acutely aware that I am nowhere near as experienced as my predecessors were at the same level. However the problem does not merely lie in the EWTD and reduced training hours, but also from the attitudes of the trainers. SHOs are no longer deemed competent to perform surgery unaided or run clinics. This is poor for morale, especially when compounded by lack of training. If MMC is too work and we are to avoid a consultant provided service,dedicated time for training must be set aside. Targets must be set and competencies achieved, and then trainees must be allowed to progress. Only then will we avoid the situation above. Competing interests: None declared |
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Alfred P J Lake, Consultant in Anaesthesia and Pain Management Glan Clywd Hospital, Rhyl, Denbighshire LL18 5UJ.
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How right Dr. Read is to highlight the anachronism that the consultant grade of today has become and how inappropriate that it should be the only “approved” permanent career post for specialists in hospital practice. I can only agree that it is (past) high time to adjust the career structure for hospital doctors to allow varying degrees of specialisation, responsibility and out of hours working, indeed, I first wrote about this more than 20 years ago when a senior registrar myself (up to date with the most immediate hands-on experience) (1) and subsequently represented(2,3,4). All doctors are concerned about any changes to the training arrangements that may adversely affect their ability to appropriately discharge the duties required of them. In relation to reduced hours of working due to the New Deal for junior doctors and the EWTD they were, indeed, highlighted in a British Medical Journal editorial (5). The feared ‘dumbing down’ of training is, rightly, worrying when the end of that training programme is considered to be to the level ‘where the buck stops’. The reason why we need to be concerned is because there is only the one service grade for those who have completed a training programme here or in rest of EU to enter, the Consultant, little changed since the inception of the NHS, and, unfortunately, subject to less than adequate control and supervision. All worries about doctors of reduced training, experience and competence entering the workforce at a senior level either by acquisition of the CCST in this country or through equivalence from the new EU accession countries, for example, can be addressed by introducing the career grade of Specialist which would be the point of entry for all and allow the essential provision of the required support and supervision during the period of necessary further development with expanding training and broadening experience before achieving a consultant post. The proposal is not new but is resisted in large part because it interferes with individuals’ personal agendas and private practice aspirations. The Specialist would not be 'some sort of consultant' but exactly as stated with the necessary skills; do we not at the moment let doctors with other titles deal with patients in accordance with their competencies? Are we not, anyway, moving to team-based activity with many of the duties performed by doctors hertofore now undertaken by others in many guises? The future service needs to be Specialist based but Consultant led and an appropriate hierarchy for any specialty in the future could be as follows, identified for mine: Trainee Anaesthetist - Resident or Registrar. Assistant Anaesthetist - the physician's assistant/non-physician anaesthetist of the future, as already proposed, at a junior or senior (equivalent to the present inappropriately named nurse consultant) level. Associate Specialist (Anaesthetist) - broadly our current SASs in a single grade. Specialist (Anaesthetist) - appointment following award of CCST. Consultant (Anaesthetist) - a senior position attainable after a period as a Specialist. Clinical Director - the Head of Service with the necessary increased control over all other grades. The future may well be part-time for many which easily fits into the above structure but full-time Consultants with a commitment not only to 'train for ten years' but also to their department will be a necessary and valuable commodity. Not only should a CCST cease to 'qualify' the holder as a Consultant but it is right to examine the skills that need to be brought to any role. The doctor's primary role is in diagnosis and organising the appropriate management and/or referral to those with the necessary skills to treat who do not need to be medically qualified which, indeed, can be applied most particularly to surgical practice. 1. Lake APJ. Chances of Promotion Essential to Viable Post. Hospital Doctor 1983; 18th. August. 2. Lake APJ. Road to Success Lies in Consultant Posts. Hospital Doctor 1985; 6th. June. 3. Lake APJ. Specialist Grade Can Save the Day. Hospital Doctor 1995; 6th. April: 14. 4. Lake A. Welcome shift in roles (Specialist Grade). Hospital Doctor 2004; 18th. March: 20. 5. Chikwe J, de Souza AC, Pepper JR. No time to train the surgeons. British Medical Journal 2004; 328: 418-9. Competing interests: None declared |
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