Intended for healthcare professionals


Experience is paramount for successful management of disease

BMJ 1998; 316 doi: (Published 13 June 1998) Cite this as: BMJ 1998;316:1828
  1. Martin Dumskyj, Specialist registrar in general medicine, diabetes, and endocrinology
  1. Kingston Hospital, Kingston upon Thames KT2 7QB

    EDITORőEarlier this week the medical firm on which I am registrar was on general medical intake. After a quiet day things began to get busy around 11 pm. Two patients with suspected oesophageal varices and haematemesis arrived almost simultaneously. Both had signs of cardiovascular compromise. Around midnight a woman with an anterior myocardial infarct was given thrombolysis. At 2 30 am the same patient developed transient complete heart block and pulmonary oedema, then ventricular tachycardia followed by atrial fibrillation. Too short of breath to lie flat for transvenous pacing, she was successfully managed with an external pacing device, followed by intravenous amiodarone and carefully titrated doses of intravenous nitrates.

    Our firm comprises one house officer, two senior house officers, and a registrar, and at the time of writing it had a third senior house officer funded from the contingency money that we received from the government to deal with a potential winter crisis. To comply with the new deal for junior doctors' hours the house officer goes to bed at midnight and the senior house officers split the night, only one being up at a time. Accordingly I, as the duty registrar, managed all of the ill patients described above. The duty senior house officer was clerking patients who had taken overdoses or had other less acute problems for most of the night and was therefore unable to be present with me. As a fairly experienced registrar I have managed similar cases countless times before. I am experienced at staying awake and managing patients “hands on” when needed, as was no doubt the case here.

    What is disturbing is that not one of the four doctors junior to me on the firm learnt anything about the management of patients with acute serious illness that night. In three years from now I might be a consultant. Those doctors, deprived of experience by the new deal, may be medical registrars. My own mother will be approaching the same age as the patient with the infarct. From the time of Hippocrates experience has been recognised as paramount for the successful management of disease. Are our mothers and fathers to be managed by inexperienced doctors?