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Re: Knowledge but not useful knowledge

Dear Editor

It is not clear in this article how the conceptual leap from some of the knowledge tested to inability to care for critically ill patients has been made. Does not knowing the survival rate of patients suffering a cardiac arrest, for example, or the role of the bag attached to a non-rebreathing oxygen mask really compromise patient care?

From the limited results presented, there is no data whatsoever to suggest that any of the specific areas of knowledge tested have any bearing on safety. The fact that SHOs seem to know even less in some respects than PRHOs supports this.

Send letter to journal:
Re: Knowledge of acute care is subacute

Dear Editor

This article has correctly pointed out the deficit in todays training system. There is no lack of knowledge but the lack of skills and inability to use them in acute situations. There are various reasons like shortage of doctors,long working hours, doctors providing phlebotomy services.

A more formalised and structured approach to training in acute situations and procedures should be provided. This might be achieved by appointment of local training officers to ensure that these skills and knowledge are acquired; such a system has been adopted for resusitation training with considerable success.

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Re: Should inexperienced trainees be delivering acute medical services?

Dear Editor

Earlier this year your journal published an article by Smith and Poplett [1] which discussed the findings of a questionnaire that had been answered by newly qualified pre-registration house officers and senior house officers. The questions concerned various aspects of basic acute medical care. The results suggested significant gaps in knowledge and understanding of both the signs and immediate management of these conditions. The authors concluded that medical graduates are poorly prepared to identify and treat critically ill patients and felt that "these deficits have the potential to contribute to error and to influence medical outcome". The authors did not, at any point, consider whether such young and inexperienced doctors should be assessing and treating such acutely ill patients in the first place.

At the time of publication, this article was reported widely by the UK print media and I was interviewed by The Western Mail[2] (the main Welsh broadsheet) for an article that appeared on the front page under the headline Doctor training 'puts lives at risk'. I was unhappy with the paper's interpretation of Smith and Poplett's research, and because of the potential for public confusion I responded with a long letter to the editor[3] where I made the following points:

1. The findings of the research did not surprise me and the situation is actually much better now than it was in 1993 when I qualified as a doctor. At the time, there was virtually no preparation for the realities of working in the NHS, with very little instruction on how to assess and treat sick people, prescribe drugs, take blood or resuscitate collapsed patients. Instead, we learned very quickly "on the job" and many of us recall with horror our first few weeks as house officers, the pressure we were under and the mistakes we must have made.

2. There has been a recognition of these deficits over the last few years and the medical school courses across the UK have evolved appropriately. There has been a move away from the traditionally theoretical and highly academic approach to a more "hands on" and integrated course that concentrates on knowledge together with the practical and communicative skills needed to actually work as a doctor. Unfortunately, this paper suggests the process has still not gone far enough.

3. Improving the training of medical students is only part of the answer and it must be remembered that the doctors interviewed were at the beginning of their post graduate training. Both the BMA and the Government are committed to a health service that is delivered by 'competently trained doctors' rather than 'doctors in training'. It is essential that we move away from the traditional model of care where patients are first seen by the most junior doctors in the hospital. These doctors do not have the experience, training or basic skills to properly assess, diagnose and treat patients with complicated and life threatening diseases.

4. Patients should be seen at a much earlier stage in their admission by consultants. This would not only provide better levels of individual care but would also ensure more efficient service delivery.

This article highlights the fact that inexperienced trainees lack the competence to deal with much of their workload and supports the argument that we should have a consultant delivered service.

Dr Ieuan Davies
Specialist Registrar in Paediatrics
(Immediate Past) Chair BMA Wales JDC

References

(1) Smith GB , Poplett N. Knowledge of aspects of acute care in trainee doctors. Postgrad Med J 2002;78:335-338.

(2) Livingstone T. Doctor training 'puts lives at risk'. The Western Mail (19th June 2002) p.1.

(3) Davies I. We need more consultants. The Western Mail (2nd July 2002). Letter to the Editor.