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Rapid Responses: Rapid Responses published:
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Doctors don't need to do research but they need to understand it
- Shaun Treweek (11 August 2006)
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Dr Hunt's example
- mourad HABIB, CARLISLE-CUMBRIA (12 August 2006)
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Medicine and its representation
- Peter G. Davies (12 August 2006)
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We Need To Be More Than "Just" A Doctor
- Jonathan R. Benger (13 August 2006)
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Understanding the data.
- Richard G Fiddian-Green (14 August 2006)
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Clinical commitment must be acknowledged in our brave new world.
- Katie L Wittering (14 August 2006)
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Doctor to "Auditor/Researcher Extraordinaire" ?
- NOEL D COLLINS (15 August 2006)
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doctors and research
- Fairoz Abdul (16 August 2006)
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Glad that I am not the only one
- Kai Leong (17 August 2006)
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Just lip-service to Research
- Vinay P Rao (5 September 2006)
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Shaun Treweek, Research Fellow University of Dundee, DD2 4BF
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First, a disclaimer. I’m a researcher not a doctor. I teach a bit of evidence-based medicine to undergraduate medical students and one of the things I emphasise is that someone who ‘just wanted to be a doctor’ has absolutely no choice but to know something about, to use Dr Hunt’s example, cluster allocation, along with the difference between relative risk reduction and risk difference, the basics of systematic reviews, research design and much besides. The reason being that it would be hard to busy yourself keeping up-to-date with published best practice without understanding what these things are. A great deal of what is published is of dubious quality and doctors need the skills to sift the good from the bad. I see no reason why doctors should have to do research (or audit) if they want to concentrate on clinical practice but they need to have an understanding of research methods to be able to provide their patients with the best possible care. Knowing when researchers should use cluster allocation, for example, is a skill doctors need even if they never get involved in research themselves. Competing interests: None declared |
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mourad HABIB, GP Registrar CALDBECK SURGERY, CARLISLE-CUMBRIA
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Dr Hunt; thank you for this piece of art which I thoroughly enjoyed. Obviously your degree in Art benifitted you very much. As I'm in nearly the same level of trainning doing the VTS scheeme for General Practice I know exactly what you feel. Immagine doing a new Audit every 6 month in a new hospital post different branch every time ..well just to tick the right box. Added to that a big long one in the General Practice this one is a pass or fail. Many of my collaegues failed in it and had to accept extra trainning to re do the whole audit again. Oh I forgot.. if you forget a title or arrange them wrongly it is a fail straight away!! . Well thanks goodness that the RCGP will change all that starting from 2007 and will replace it with the new MRCGP. So do you like to come and join the General Practice then?! Competing interests: None declared |
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Peter G. Davies, GP Principal, Keighley Road Surgery, Illingworth, Halifax, HX2 9LL
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Tara Hunt (1) captures a key dynamic in modern medicine. At all levels we seem to have two jobs, firstly to do the job and see patients, and secondly to prove that we have done this activity, and to an appropriate standard. Doing the job is actually the core reason for doctors to exist. It is the hardest part of medicine. Meeting and dealing well with people with all their pathology and their personal particularities is hard work. By comparison with this going to meetings is far easier. To get to do our core job doctors now have to jump through multiple hoops of audit, quality assurance, clinical governance, appraisal, and now revalidation. There is no evidence that these time consuming activities do anything for patient care. There is no evidence that they measure what matters, or reliably discriminate good practice from poor practice. Indeed I propose that in their current form they could all be stopped and that no patient would be any worse off. However for Dr Hunt, and the rest of us, we currently need to throw some salt on the Altar of Audit and worship the Idols of Clinical Governance and Research. It is now quite possible to make a career doing this, and so rarely see any real patients at all. But never mind the numbers, feel the depth of the evidence based quality. Meanwhile the discharge summaries do not get written on time, and the readmission rate is going up. Competing interests: None declared |
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Jonathan R. Benger, Consultant in Emergency Medicine United Bristol Healthcare Trust
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Dr Hunt articulates the feelings of many doctors on discovering that the effective practice of modern medicine requires a range of skills beyond the provision of direct clinical care.[1] Her slightly delayed entry into medicine may explain why this issue is troubling her now, rather than later in her career: certainly these are sentiments I hear more commonly from consultant colleagues than juniors. However, to imagine that good medical practice is confined to the delivery of care one patient at a time is to overlook the role of doctors in organising healthcare systems and delivery in the wider context. It is disappointing that Dr Hunt’s appraiser chose to frame the process in terms of her Trust’s participation in the Clinical Negligence Scheme, since most junior doctors value well-conducted appraisals. Nevertheless, cheaper insurance premiums for hospitals mean more money to spend on healthcare, and also indicate that organisations that carry out effective appraisal make less clinical errors: presumably these are both outcomes that Dr Hunt would approve of. Furthermore, research and audit without the active participation of doctors will soon become clinically irrelevant or ineffective. We have a wider responsibility for patient care that is served by informed participation in these and many other activities, such as teaching and continuous quality improvement (which also seem to get irritatingly in the way of a narrowly focussed approach to patient care). However, all is not lost. Dr Hunt appears well placed to fall into the “Modernising Medical Careers” vacuum that currently threatens to swallow those junior doctors who are too old for a foundation programme yet too young to have secured a specialist registrar post. If this does indeed curtail all opportunities for career progression she may end up as “just” a doctor after all. 1. Hunt T. I just wanted to be a doctor. BMJ 2006;333:359. Competing interests: None declared |
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Richard G Fiddian-Green, FRCS, FACS None
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My research mentor, Professor Michael Hobsley, FRCS, MChir, PhD,DSc (Med)(1), taught me to play with the data by plotting it and considered this the real fun in research. That he believed, and I agree, was the best way of understanding the data. The editorial board of the NEJM appears to have a different view: the means of analysis must be decided prospectively for any retrospective analysis runs the risk of introducing an unacceptable bias. What is more they have taken a strong stand on the issue retracting at least one landmark study for this reason and rejecting another which was subsequently accepted by the Lancet. Olshansky and Dossey have considered the issue in a different context (2). "Leibovici", they wrote, "published an intriguing study questioning conventional notions of time, space, prayer, consciousness, and causality. The randomised, controlled, double blind, parallel group study (prayer versus no prayer) included 3393 septic patients and considered the hypothesis that "retroactive" prayer, offered 4-10 years later, affects outcomes. Of the preselected outcomes, mortality was similar in both groups, yet length of stay in hospital and duration of fever were shorter with prayer (P = 0.01 and P = 0.04). Leibovici, with humour befitting his style, concluded that remote, retroactive intercessory prayer should be considered for clinical practice". Might the target of Leibovici's paper on the effect of retroactive prayer have been the editorial board of the NEJM? Might the whole issue even have been manufactured for political or even legal reasons? If so by whom and for what reason. 1. www.gastrohep.com/profiles/default.asp?person=mhobsley 2. Brian Olshansky and Larry Dossey Retroactive prayer: a preposterous hypothesis? BMJ 2003; 327: 1465-1468 Competing interests: Two or papers rejected by the NEJM |
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Katie L Wittering, Foundation Year 2 South Manchester University Hospital Trust M23 9LT
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Editor – As I wait with bated breath for details of the MMC (Modernising Medical Careers) run-through training recruitment, Dr Hart’s desire to be credited for her clinical role strikes a serious chord. The publish or die culture not only distracts trainees from clinical care, but also fails to produce high quality research and audit. I fear that national, on-line selection will reward those who cobble together references regardless of substance and at the expense of concentration on the wards. This is unlikely to recruit the best doctors. Clinical commitment and the quality of research or audit undertaken must be acknowledged in our brave new world. The Foundation Programme clinical assessment tools (CBD, DOPs, and mini-CEX) are time-consuming and yet, in their current format, of questionable value and no long-term consequence. Could they not be refined to reliably differentiate trainees’ clinical capability and contribute towards interview selection? kwittering@doctors.org.uk Competing interests: None declared |
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NOEL D COLLINS, SHO (Psychiatry) St Ann's hospital, St Ann's Road, London N153TH
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I agree that Tara Hunt has realistically captured the feeling of current frustration with many trusts' obsession with select principles of clinical governance. I am currently stuck in the chasm between SHO and SPR grades after having my medical career 'modernised' (ie paralysed) by current NHS training initiatives. I too fully understand and respect the importance of audit and research, but have noticed how much current application forms for jobs are heavily weighted towards these honorable concepts. I regard myself as a dedicated and careful clinician but now feel these qualities are very much trumped in favour of involvement in token audit and research. But, like many prospective SPRs with a 'modernised career', I have learnt what is valued by prospective employers and I am now fully prepared to transform into a researcher/auditor extraodinaire. I do hope, that Tara Hunt is also able to undergo a similar transformation in preparation for future employability. Competing interests: None declared |
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Fairoz Abdul, FY 2 Walsall PCT Lichefield street, Walsall WS1 1TE
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When i started my career as a junior doctor i had the similar kind of thoughts and perceptions about audit and research activities as that of Dr. Hunt's. I felt that i just want to be a good clinician, spend more and more time in wards, with patients, attend maximum out patient clinics, make spot diagnosis and work up a management plan. I was happy with it. When i did my first clinical audit, i was less enthusiastic at the start and later i realised that this process is making sense to my practice. If an audit is done in the field of your practice or interest, you would enjoy it most and you would be fascinated with the data or information you have and it will be complementing your work and also gives you an opportunity to be better doctor. Similarly research. I understand the importance of audit, research and publication. It is essential for junior doctors to learn and have knowledge of research and publications. But it should not be a cyclical obligatory requirement to progress as a clinical or "doctor only". These cyclical research activities should best done on one own interest. I believe that the concept of doing an audit, publishing in every rotation we go, would take us away from our wards, clinical responsibility. This would compromises the patient’s care and our clinical learning. Hence i feel that every doctor should have a practical experience in audit research and publications for being a better doctor, and understanding the research activities done by others. At the same time continuing to do these activities should be left to one own interest rather than assessment of professional progress. Competing interests: None declared |
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Kai Leong, BST New Cross Hospital
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Two recent excellent 'Personal View' articles, one by Mr G Williams and the other by Dr Hunt just summarised perfectly what the current batch of SHOs aka 'The lost tribe' need to do for career progression. Unless of course, if one chooses to take time out to do research, provided that one has sufficient savings to fund one's lifestyle during the interim, then theoretically, that will put one in a much better position to capture a registrar job. Well, that was it at least what it used to be. But in the advent of MMC (Modernisng Medical Career), many including my clinical tutor remain sceptical about diverging out from our career path to do research. That does not leave us with much options other than to try to publish materials of whatever sorts be it audits, letters, personal views or ideally scientific papers. Being a third year SHO, I have had my fair share of doing and presenting audits. I must admit, though, I did not derive much pleasure or satisfaction from audits but I know they are necessary to 'jazz' up my curriculum vitae. Having said that, my sense of responsibility ensured every audit I have done would ultimately benefit the patients. This did not interfere with my clinical duties which I still regard as the utmost important but unfortunately, it is not something that could be objectified and measured for points in an interview. I have yet to come across an SpR application form which asks us how many lives we have saved or improved but instead how many publications we have under our belts. My final advice is that the next time one walks into the hospital compound, between seeing patients, during breaks or whilst walking out of the hospital after work, think of anything that could possibly be audited ie from floor cleaning (Health and Safety audit) to talking to patients (Consent audit). The CPD (Continuing Professional Development) sessions should be used to develop the audit rather than being used as 'me' time. If still unsuccesful, at least one should know that one is not alone. 1. Williams G. Call for papers. BMJ 2006;333:207 2. Hunt T. I just wanted to be a doctor. BMJ 2006;333:359 Competing interests: None declared |
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Vinay P Rao, Unemployed following a Research Fellowship (recently at) Mayo Clinic, USA
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Sir, I completely empathise with the views of Dr Hunt regarding audit and clinical research. Perhaps she could take heart from the fact that there are doctors (myself included), who have completed a dedicated period of research overseas and have returned to the NHS only to be told that research is not so important after all. Trainees who have remained in clinical surgery to learn operative skills are now walking all over those with post-graduate degrees thanks largely to the fact that Consultant surgeons (and indeed the RCS)are incapable of making up their minds over the real role of research expertise in surgical training. It's less about research than a desperate attempt to justify whimsical trainee appointments not based on any clear criteria. Vinay P Rao Competing interests: None declared |
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