Accident and emergency medicineBMJ 1998; 316 doi: https://doi.org/10.1136/bmj.316.7140.2 (Published 25 April 1998) Cite this as: BMJ 1998;316:S2-7140
Jim Wardrope outlines the essential attributes of a consultant in A&E
- Jim Wardrope, Consultant in A&E Medicine
Accident and emergency is a young specialty. It is only 25 years since the first ‘experimental' posts were established, with full time consultants being responsible for the proper running of accident and emergency departments.1
There are now about 350 posts, and the specialty is still expanding. Perhaps the major challenge facing the NHS is the rising tide of emergency work, especially in acute medicine. The A&E department is in the front line, leading initiatives to provide the best and most appropriate management for the sickest of patients.
What does a consultant do?
From cardiac arrest to sprained ankle, from multiple trauma to a child with a wheezy chest, the variety of clinical problems is huge. The A&E department sees more new patients than any other clinical department. An average A&E department will see 40,000-60,000 new patients each year.2 Half of these will have minor injury or illness requiring no further follow up or medical care, 10% will have fractures, and 10-20% will need admission to hospital. The department will be led by two or three consultants, and they have a responsibility to ensure that each patient receives an accurate assessment of their condition, proper initial treatment, and appropriate ongoing care.
To meet these responsibilities, A&E medicine demands structure and organisation. If there is one attribute of successful A&E consultants then it is organisational ability, both of their department and of themselves. Most clinical days start with routine review processes. This may be of patients admitted the previous day to the observation ward, a review clinic, or going through case notes. Quality control and audit are daily routines, with x ray reports to review, blood results to check, and notes and electrocardiograms to review. The rest of the day may include seeing routine new patients, moving the large mountain of mail, and administrative tasks that are a part of any consultant's workload. Meetings, teaching sessions, and continuing medical education all have to be fitted into the week's work.
However, a unique demand on A&E consultants is the need to be available at short notice to give help, especially in the resuscitation room. ‘Resus' is one area that A&E consultants claim as their own, with special expertise, training, and experience. Cardiac arrest, major trauma, a severely ill child, an unstable cardiac case, and severe asthma are all part of the working week for an A&E consultant. Such expertise does not come easily, and considerable training in many facets of medicine and surgery is developed during specialist training. Advanced trauma life support, advanced life support, and advanced paediatric life support are now essential parts of this training.
At the other end of the spectrum is the assessment and treatment of ‘minor' injury, a challenging mix of orthopaedics, physiotherapy, sports medicine, and rheumatology demanding a high degree of diagnostic skill if substantial morbidity is to be prevented. A&E consultants have to be generalists, and at a time of increasing specialisation they may be the last generalists left in the hospital.
However many A&E consultants do have special interests and responsibilities within the department structure. Some may have extra training and experience in paediatrics (the A&E department will see more children as new patients than paediatric outpatients); some may have interest in acute medicine, an increasing demand on all A&E departments; some may have training in intensive care; and some may have in- terest in sports medicine and musculoskeletal medicine.
Attributes of a consultant
Adaptability, clinical acumen, planning and organisational skills, teamwork and leadership, communication, teaching'the list of necessary skills is large, but they need to be part of your character or acquired during training if you are to become a good consultant.
Adaptability is an essential characteristic: 95% of the work is predictable and routine, but a surprise is always just around the corner and it often occurs when you have three other things to do at that time. Switching mindset from paediatric resuscitation to an elderly patient with multiple social problems to filling the gap in the rota of senior house officers requires a high degree of mental and emotional agility. The ability to think on the run and to react to changing conditions are the hallmarks of a good A&E specialist.
Clinical acumen- What is it and who needs it in these days of high tech medicine? Is it a sixth sense that only a few can have? Probably not; it is the ability to observe, extract meaningful information, and to synthesise this into a working plan of management. Conan Doyle's training in medical diagnosis was the basis of Sherlock Holmes' skills.3
Experience develops a sixth sense for unusual and worrying symptoms: ‘A history noted to differ markedly from the typical arrests the listener's attention and puts him on his guard … against a condition with which the physician is so far unfamiliar.'4
The volume and breadth of A&E work means that you have to develop clinical skills to a high standard. Clinical assessment is all important as there are neither the time nor resources to subject every patient to rigorous investigation.
Most A&E departments have a close team identity. The ability to work flexibly within the team is of great importance. There will be a time quietly and efficiently to take up the leadership role in the most difficult and challenging situations, but equally there will be a time when your role will be to make the tea. An awareness of the team allows you to adopt the correct role at the right time.
An A&E department's reputation depends on its consultants' skills in organisational and strategic planning.
It might seem impossible to predict what will happen in an A&E department, and this might be true from minute to minute. Over the medium term most events and demands are predictable, and a capacity to think ahead is one of the keys to successful practice. Dealing with waiting times, planning for major incidents, or predicting the next problem in a critically ill patient'to be one step ahead of any emergency situation is the secret of retaining control. Teaching is part of any consultant post but it is of major importance in A&E medicine.
Our specialty led the way in providing protected teaching time and high quality teaching programmes for senior house officers. It had to, given the huge range of conditions that junior doctors have to treat. A wide ranging and highly stimulating teaching programme is essential, and many A&E consultants have formal training in teaching and educational method. There is a vast amount of teaching to be provided every six months in settings as diverse as the formal departmental teaching programme, the ‘resus' room, or over a sprained ankle.
A&E specialists are one of the largest groups involved in training in advanced life support. Communication should be one of your strengths, as it is a key part of the consultant role. Patients, relatives, primary care workers, other members of the department team, other parts of the hospital, the emergency services, managers and purchasers'as the ‘middle man' in so many episodes of care, you must have the ability to liaise effectively with most of the world.
Becoming a consultant
General professional training£1 year in A&E, 1 to 3 years in acute specialties
Objectives: to obtain A&E experience, to pass a higher qualification, and gain clinical experience in other acute specialties.
The mix of posts will depend on the interests of the individual. Acute general medicine, paediatrics, anaesthetics, and orthopaedics would be the most relevant jobs. A&E has room for a wide range of secondary interests; a year or more of full time research in medicine, paediatrics, anaesthetics, or orthopaedics and rheumatology might provide the basis of this special expertise.
Higher qualification AFRCS (A&E), MRCS, MRCP
Some candidates for specialist registrar jobs have more than one higher qualification, although this is not essential
Higher specialist training 5 years, 1 year acute specialties: A&E training Management training Education training
Objectives: to become proficient in the clinical, academic, and managerial skills that are needed for independent practice.
Jobs will rotate between at least two A&E departments. During this time clinical skills are refined, formal training in teaching skills is often obtained, and management skills are learnt and practised. Time will be spent on secondments to òcoreó specialties of medicine, anaesthetics, orthopaedic trauma, surgery, and paediatrics, with opportunity for minor attachments to other specialties such as ophthalmology, general practice, and neurosurgery.
Sit Fellowship of the Faculty of Accident and Emergency Medicine
Gain certificate of completion of specialist training
Pay and prospects
There is a national shortage of A&E consultants, with many unfilled consultant posts.
There are very few single handed consultant posts, with the trend being for departments to have two, three, or more consultants. In such departments the main clinical responsibilities are shared, but each consultant may have a ‘special interest' and take responsibility for delivery of key clinical, managerial, or teaching objectives. A&E clinical work is highly ‘sessional,' with few long term responsibilities for individual patients. This makes flexible working, job sharing, and part time working more feasible than in some acute clinical specialties.
The clinical sessions may be very busy, but there should be time to develop interests as diverse as academic research, working as a police surgeon, work in pre- hospital or disaster care, sports medicine, or medicolegal aspects of personal injury. A&E medicine will never be an easy career, but it will provide constant challenge and diversity and enormous potential for individual consultants to develop their own clinical, academic, or managerial interests.
Some of us even have an interest in our family.
I thank Dr Roger Evans and Mr Gautam Bodiwala for their help with this article.
Further information British Association for Accident and Emergency Medicine tel 0171 831 9405 fax 0171 405 0318, emailFaculty of Accident and Emergency Medicine tel 0171 405 7071 fax 0171 405 0318 Joint Committee on Higher Training in Accident and Emergency Medicine tel 0171 405 3474 fax 0171 973 2133 email All based at: 35-43 Lincoln's Inn Fields, London WC2A 3PN
Medical emergencies through the winter have affected surgical training, as routine lists were cancelled to make way for patients admitted urgently, according to the Royal College of Surgeons of Edinburgh. Its survey of surgical trainees found that one quarter had missed training opportunities because of cancellation of elective lists or patients being transferred to other sites when their own hospital was full. The College's president Professor Arnold Maran expressed concern that such interruptions are in addition to the recent shortening of surgical training. He added that the senate of the four surgical colleges has set up a group to examine ways in which surgical competence can be tested on practical experience rather than time in post.
The number of people volunteering with Voluntary Service Overseas (VSO) has slumped dramatically in the last two years, says the charity (http://www.oneworld.org/vso/news). Although the worst affected areas are teaching and engineering (down 50%) healthcare professionals, and especially doctors, are also in short supply. The charity says it could place more than five times the number of applicants it actually receives, and is continuing with a programme designed to make VSO more attractive. One solution is to have shorter contracts than the traditional two years: postings of as little as six months are increasingly available.
If VSO takes your fancy, one way to prepare might be to book yourself on to International Health Exchange's introductory course for health workers in developing countries, which runs from 22 - 26 June 1998, and costs £300.
Details from: IHE, 8-10 Dryden Street, London NW1 2BJ