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The survey reported by Gompels and colleagues showing the incorrect use of adrenaline in anaphylaxis by over 50% of junior doctors reveals sobering but perhaps not startling statistics.1 Their study serves as an audit reflecting the quality of contemporary medical education in that it compares prevailing practice with established guidelines in the management of a given medical problem. Having spent 18 seamless months as a casualty officer recently and worked in two accident and emergency departments in large cities, I wish to highlight the observation that teaching on anaphylaxis was remarkably cursory in didactic sessions, as well as in the standard cardiorespiratory training workshops. When combined with the reality that moderate to severe anaphylaxis is seen infrequently, it is easy to appreciate how any superficial knowledge that exists passes into further obscurity over time.
The inability to tackle emergencies adequately results from inexperience, but the large gaps in basic medical know-how (in over 50% of graduates in this study) is a direct testament to their undergraduate and early postgraduate training. Medical curricula are ever expanding with concepts that the freshly minted doctor of the 21st century must absorb, but it appears that in this enormous amount of information the crucial elements are becoming indistinguishable.
Since this study is an audit perhaps we ought to “close the loop” by reappraising undergraduate training in earnest, especially now that many medical schools favour the submission of course work in monitoring progress at the exclusion of formal examination strategies. A specific and formal examination structure (perhaps a viva voce or written short answer questions) dedicated to the management of emergencies would be a useful adjunct to the traditional emphasis on the detection of signs in relatively stable patients. This arrangement would produce a preregistration doctor who is more confident and less dangerous under the onslaught of acute presentations and better primed for the senior house officer days. This plea for an improvement in our undergraduate and postgraduate education is particularly justified in the context of British medicine, where ironically, at the grassroots, the most junior doctors enter accident and emergency departments to find themselves managing (often independently) patients who are seriously unwell.
We would like to thank Dr Gandhi for his views on undergraduate and postgraduate training, which I am sure are also a reflection of other people's views as well.
The purpose of our paper was to highlight the difficulties that are experienced in the differential diagnosis of acute anaphylaxis, and the management thereof. This study arose from the perception in our allergy practice that significant numbers of patients were referred who had inappropriate treatment. The purpose of this publication was to promote further education and debate, which hopefully it has achieved.