Should inexperienced trainees be delivering acute medical services?

• acute care
• trainee doctors

Earlier this year Smith and Poplett discussed the findings of a questionnaire that had been answered by newly qualified pre-registration house officers and senior house officers.¹ 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 patient 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 (the main Welsh broadsheet) for an article that appeared on the front page under the headline Doctor training “puts lives at risk”.² 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 where I made the following points³:

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 postgraduate training. Both the British Medical Association 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.