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1.  Consultant medical trainers, modernising medical careers (MMC) and the European time directive (EWTD): tensions and challenges in a changing medical education context 
We analysed the learning and professional development narratives of Hospital Consultants training junior staff ('Consultant Trainers') in order to identify impediments to successful postgraduate medical training in the UK, in the context of Modernising Medical Careers (MMC) and the European Working Time Directive (EWTD).
Qualitative study. Learning and continuing professional development (CPD), were discussed in the context of Consultant Trainers' personal biographies, organisational culture and medical education practices. We conducted life story interviews with 20 Hospital Consultants in six NHS Trusts in Wales in 2005.
Consultant Trainers felt that new working patterns resulting from the EWTD and MMC have changed the nature of medical education. Loss of continuity of care, reduced clinical exposure of medical trainees and loss of the popular apprenticeship model were seen as detrimental for the quality of medical training and patient care. Consultant Trainers' perceptions of medical education were embedded in a traditional medical education culture, which expected long hours' availability, personal sacrifices and learning without formal educational support and supervision. Over-reliance on apprenticeship in combination with lack of organisational support for Consultant Trainers' new responsibilities, resulting from the introduction of MMC, and lack of interest in pursuing training in teaching, supervision and assessment represent potentially significant barriers to progress.
This study identifies issues with significant implications for the implementation of MMC within the context of EWTD. Postgraduate Deaneries, NHS Trusts and the new body; NHS: Medical Education England should deal with the deficiencies of MMC and challenges of ETWD and aspire to excellence. Further research is needed to investigate the views and educational practices of Consultant Medical Trainers and medical trainees.
PMCID: PMC2397401  PMID: 18492261
2.  Knowledge, attitudes and practice of healthcare ethics and law among doctors and nurses in Barbados 
BMC Medical Ethics  2006;7:7.
The aim of the study is to assess the knowledge, attitudes and practices among healthcare professionals in Barbados in relation to healthcare ethics and law in an attempt to assist in guiding their professional conduct and aid in curriculum development.
A self-administered structured questionnaire about knowledge of healthcare ethics, law and the role of an Ethics Committee in the healthcare system was devised, tested and distributed to all levels of staff at the Queen Elizabeth Hospital in Barbados (a tertiary care teaching hospital) during April and May 2003.
The paper analyses 159 responses from doctors and nurses comprising junior doctors, consultants, staff nurses and sisters-in-charge. The frequency with which the respondents encountered ethical or legal problems varied widely from 'daily' to 'yearly'. 52% of senior medical staff and 20% of senior nursing staff knew little of the law pertinent to their work. 11% of the doctors did not know the contents of the Hippocratic Oath whilst a quarter of nurses did not know the Nurses Code. Nuremberg Code and Helsinki Code were known only to a few individuals. 29% of doctors and 37% of nurses had no knowledge of an existing hospital ethics committee. Physicians had a stronger opinion than nurses regarding practice of ethics such as adherence to patients' wishes, confidentiality, paternalism, consent for procedures and treating violent/non-compliant patients (p = 0.01)
The study highlights the need to identify professionals in the workforce who appear to be indifferent to ethical and legal issues, to devise means to sensitize them to these issues and appropriately training them.
PMCID: PMC1524795  PMID: 16764719
3.  'We'd like to have a family'--young women doctors' opinions of maternity leave and part-time training. 
Maternity leave and part-time training should facilitate the integration of the family and professional lives of young women doctors - whom the NHS cannot afford to lose as their numbers rise to half the number of the graduates of UK medical schools. Women doctors' planned professional activity is high, but to what extent do the maternity leave and part-time training arrangements assist them in fulfilling their plans? One hundred and forty-five young women doctors reported their experiences of and views on maternity leave and part-time training. Most had children between 6 and 10 years after qualification, to fit with career development. Seventy-one per cent of the confinements had qualified for maternity leave and pay, but there were complaints about the working of the regulations, particularly in relation to junior hospital doctors' short contracts. When asked to comment about part-time training, most (77%) expressed themselves as broadly in favour - only three actively opposing it. It was perceived as difficult to organize by 20% of respondents, as difficult to undertake by 29%, and as being of low status by 15%. This study concludes that the arrangements for maternity leave need to be improved and that the availability and status of part-time training need enhancing - especially to encourage women doctors to enter careers in hospital medicine.
PMCID: PMC1292296  PMID: 2795577
4.  UK doctors’ views on the implementation of the European Working Time Directive as applied to medical practice: a quantitative analysis 
BMJ Open  2014;4(2):e004391.
To report on doctors’ views, from all specialty backgrounds, about the European Working Time Directive (EWTD) and its impact on the National Health Service (NHS), senior doctors and junior doctors.
All medical school graduates from 1999 to 2000 were surveyed by post and email in 2012.
The UK.
Among other questions, in a multipurpose survey on medical careers and career intentions, doctors were asked to respond to three statements about the EWTD on a five-point scale (from strongly agree to strongly disagree): ‘The implementation of the EWTD has benefited the NHS’, ‘The implementation of the EWTD has benefited senior doctors’ and ‘The implementation of the EWTD has benefited junior doctors’.
The response rate was 54.4% overall (4486/8252), 55.8% (2256/4042) of the 1999 cohort and 53% (2230/4210) of the 2000 cohort. 54.1% (2427) of all respondents were women. Only 12% (498/4136 doctors) agreed that the EWTD has benefited the NHS, 9% (377) that it has benefited senior doctors and 31% (1289) that it has benefited junior doctors. Doctors’ views on EWTD differed significantly by specialty groups: ‘craft’ specialties such as surgery, requiring extensive experience in performing operations, were particularly critical.
These cohorts have experience of working in the NHS before and after the implementation of EWTD. Their lack of support for the EWTD 4 years after its implementation should be a concern. However, it is unclear whether problems rest with the current ceiling on hours worked or with the ways in which EWTD has been implemented.
PMCID: PMC3918994  PMID: 24503305
Health Services Administration & Management; Medical Education & Training
5.  Application of airline pilots' hours to junior doctors. 
BMJ : British Medical Journal  1989;299(6702):779-781.
OBJECTIVE--To determine the staff required if the rules for airline pilots' hours of work are applied to junior doctors. DESIGN--Junior anaesthetists recorded their workload from 1 March 1988 to May 31 1988. SETTING--District general hospital. SUBJECTS--Two groups of three junior anaesthetists sharing a one in three rota to provide continuous emergency cover. INTERVENTIONS--By using the guidelines published by the Civil Aviation Authority in The Avoidance of Excessive Fatigue in Aircrews schedules were drawn up to cover the hours that junior doctors had been on duty. RESULTS--Each anaesthetist provided emergency and routine cover for 48-112 (mean 75) hours each week. To cover the work of six junior anaesthetists on an annual basis would require 26 doctors if they were working within the Civil Aviation Authority's guidelines. CONCLUSIONS--Junior anaesthetists' hours are much longer than those of airline pilots. Both professions entail considerable periods of monitoring interspersed with episodes of high demands on physical and cognitive skills. Errors induced by fatigue made by anaesthetists and pilots could result in death. The medical profession should define rules similar to those of the aviation authority to prevent junior doctors having to work unsafe numbers of hours.
PMCID: PMC1837606  PMID: 2508922
6.  Post-exposure prophylaxis for human immunodeficiency virus: knowledge and experience of junior doctors 
Sexually Transmitted Infections  2001;77(6):444-445.
Objective: To assess the level of knowledge and experience of post-exposure prophylaxis (PEP) against human immunodeficiency virus (HIV) among junior doctors.
Methods: A questionnaire was sent to all junior doctors working in two major teaching hospitals in London.
Results: Most junior doctors had heard of PEP (93%) but fewer were aware that it reduced the rate of HIV transmission (76%). Only a minority of doctors (8%) could name the drugs recommended in recent national guidelines and a significant proportion (43%) could not name any. Almost one third (29%) did not know within what period PEP should be administered. This was despite the fact that the majority of respondents (76%) had experienced high risk exposure to potentially infective material at some stage in their careers and that a significant proportion (18%) had sought advice about PEP following potential exposures.
Conclusions: This study demonstrates that the junior hospital doctors in our survey had inadequate knowledge of PEP against HIV despite being at risk of occupational exposure.
Key Words: HIV; post-exposure prophylaxis; needlestick injuries
PMCID: PMC1744409  PMID: 11714945
7.  Views of junior doctors about whether their medical school prepared them well for work: questionnaire surveys 
BMC Medical Education  2010;10:78.
The transition from medical student to junior doctor in postgraduate training is a critical stage in career progression. We report junior doctors' views about the extent to which their medical school prepared them for their work in clinical practice.
Postal questionnaires were used to survey the medical graduates of 1999, 2000, 2002 and 2005, from all UK medical schools, one year after graduation, and graduates of 2000, 2002 and 2005 three years after graduation. Summary statistics, chi-squared tests, and binary logistic regression were used to analyse the results. The main outcome measure was the level of agreement that medical school had prepared the responder well for work.
Response rate was 63.7% (11610/18216) in year one and 60.2% (8427/13997) in year three. One year after graduation, 36.3% (95% CI: 34.6, 38.0) of 1999/2000 graduates, 50.3% (48.5, 52.2) of 2002 graduates, and 58.2% (56.5, 59.9) of 2005 graduates agreed their medical school had prepared them well. Conversely, in year three agreement fell from 48.9% (47.1, 50.7) to 38.0% (36.0, 40.0) to 28.0% (26.2, 29.7). Combining cohorts at year one, percentages who agreed that they had been well prepared ranged from 82% (95% CI: 79-87) at the medical school with the highest level of agreement to 30% (25-35) at the lowest. At year three the range was 70% to 27%. Ethnicity and sex were partial predictors of doctors' level of agreement; following adjustment for them, substantial differences between schools remained. In years one and three, 30% and 34% of doctors specified that feeling unprepared had been a serious or medium-sized problem for them (only 3% in each year regarded it as serious).
The vast knowledge base of clinical practice makes full preparation impossible. Our statement about feeling prepared is simple yet discriminating and identified some substantial differences between medical schools. Medical schools need feedback from graduates about elements of training that could be improved.
PMCID: PMC3020650  PMID: 21070622
8.  Junior doctors' hours: what do they really think? 
Junior doctors' hours are one of the most controversial topics under debate in the health service today. We undertook a detailed postal questionnaire of hospital doctors in training within a major teaching unit in order to assess the awareness and perceived implications of the incipient changes and to elucidate how it was felt these changes would affect both the doctors and patients. The questionnaire focused specifically on the effect of the changes on quality and continuity of patient care, junior training and socio-economic factors relating to the medical staff. The questionnaire was entirely anonymous and carried only the first author name but provision was made to determine current grade, specialty, age, sex and career plans of the respondents. Importantly, space was included at the end for pertinent comments. All junior staff in training in all specialties in the Cardiff area were circulated. Three hundred and twenty-six questionnaires were sent out and 202 were returned of which 192 were properly completed (59%). Almost everyone was au fait with the proposed changes. There was a surprisingly high level of support for changes among non-surgical trainees, and half felt that quality of care would improve, though the more senior the trainee, the less enthusiastic they were in all aspects. Many felt that far too little consultation with junior staff had taken place and there was generalized criticism of general practitioner trainees by their specializing counterparts, partly because of a perceived lack of commitment and partly because of blame of this group for the inception of the changes.(ABSTRACT TRUNCATED AT 250 WORDS)
PMCID: PMC1294562  PMID: 7632195
9.  What drives the ‘August effect’? A observational study of the effect of junior doctor changeover on out of hours work 
JRSM Short Reports  2013;4(8):2042533313489823.
To investigate whether measurements of junior doctor on-call workload and performance can clarify the mechanisms underlying the increase in morbidity and mortality seen after junior doctor changeover: the ‘August effect’.
Quantitative retrospective observational study of routinely collected data on junior doctor workload.
Two large teaching hospitals in England.
Task level data from a wireless out of hours system (n = 29,885 requests) used by medical staff, nurses, and allied health professionals.
Main outcome measures
Number and type of tasks requested by nurses, time to completion of tasks by junior doctors.
There was no overall change in the number of tasks requested by nurses out of hours around the August changeover (median requests per hour 15 before and 14 after, p = 0.46). However, the number of tasks classified as urgent was greater (p = 0.016) equating to five more urgent tasks per day. After changeover, doctors took less time to complete tasks overall due to a reduction in time taken for routine tasks (median 74 vs. 66 min; p = 3.9 × 10−9).
This study suggests that the ‘August effect’ is not due to new junior doctors completing tasks more slowly or having a greater workload. Further studies are required to investigate the causes of the increased number of urgent tasks seen, but likely factors are errors, omissions, and poor prioritization. Thus, improved training and quality control has the potential to address this increased duration of unresolved patient risk. The study also highlights the potential of newer technologies to facilitate quantitative study of clinical activity.
PMCID: PMC3767064  PMID: 24040495
10.  The Effect of Modernising Medical Careers on Foundation Doctor Career Orientation in the Northern Ireland Foundation School 
The Ulster Medical Journal  2010;79(2):62-69.
Modernising Medical Careers (MMC) emerged in response to acknowledged problems in training in the Senior House Officer grade. The objective of this study was to assess the effect of the Foundation Year 2 (F2) training programme on career orientation in the Northern Ireland Deanery.
A prospective survey-based study was conducted for all F2 doctors participating in the Northern Ireland Foundation Programme. Career orientation was investigated using the Specialty Choice Inventory 45 (SCI45) at the start (Q1) and end (Q2) of the F2 year. Specialty choice was collated after the outcome of specialty recruitment in 2008.
There were 231 F2 doctors in programme during the first F2 year in 2006–2007. 147 (M=65, F=82) and 106 (M=55, F=51) completed questionnaires at Q1 and Q2. Male F2 doctors scored significantly higher in the action orientation (54.0 vs. 50.0, p<0.001) and need for assertiveness (53.0 vs. 48.0, p=0.005) subscales at both time points as well as Q1 detail is crucial (57.0 vs. 51.0, p=0.014) and Q2 independent specialty (53.0 vs. 46.0, p=0.016). Female F2 doctors scored significantly higher in the educating patients subscale at both time-points (44.0 vs. 46.0, p=0.009 and 46.0 vs. 47.0, p=0.03). Analysis of SCI45 subscale scores suggested that males tended to favour the surgical specialties while females favoured the care of the elderly and paediatric specialties. Overall only 29% of doctors were successfully appointed to a specialty in which they had expressed an interest at Q1 whilst 47.8% were selected to specialist training for their declared specialty interest at Q2.
Despite introducing MMC with a coordinated UK wide specialty application process (MTAS), a detrimental effect on their career orientation was not evident. Pragmatic career choices based on lifestyle may be the reason why female doctors expressed a preference for care of the elderly and paediatrics while their male colleagues favoured acute, more surgically biased specialties.
PMCID: PMC2993148  PMID: 21116421
Career; Choice; Doctor; Junior; Specialty
11.  Junior hospital doctors' views on their training in the UK. 
Postgraduate Medical Journal  1996;72(851):547-550.
To ascertain the views of senior house officers and registrars on the educational and training component of their posts, a questionnaire was sent to all full-time doctors working in training posts in general and/or geriatric medicine at three district general and three teaching hospitals. Completed questionnaires were received from 64 (61%) of 105 doctors who were contacted. Most had a careers counsellor or tutor, although less than two-thirds thought they had benefited from this arrangement. The majority of doctors attended at least two medical tutorials or meetings per week; most wanted to attend more but were unable to because of other work commitments. Supervision by more senior staff on the ward was deemed by most to be satisfactory, but less so in out-patient clinics. Overall, one-third of doctors thought that training was inadequate and three-quarters wanted a greater amount of formal education. The majority of junior doctors' time was spent on routine work and most considered :training' constituted less than 10% of their working time. Doctors in training require more sessions designated as educational, with protected time to attend these.
PMCID: PMC2398578  PMID: 8949591
12.  Are today's junior doctors confident in managing patients with minor injury? 
Emergency Medicine Journal : EMJ  2006;23(11):867-868.
To assess the confidence of junior doctors in managing minor injuries, compared with other common acute conditions.
A questionnaire designed to elicit areas of confidence and subjective competence was distributed to junior doctors working in the emergency department in December 2004.
Junior doctors felt most competent and confident working with medical trolley patients and least competent working with patients with minor injury. A lack of teaching and experience in handling minor injuries (which are seen by nurse practitioners in a separate unit during the day) was highlighted.
Nurse‐led minor injury units may have an effect on junior doctors' experience and confidence in minor injury care. Further effort needs to be made to increase the training of junior doctors in minor injury care.
PMCID: PMC2464387  PMID: 17057141
13.  Survey of the use of epinephrine (adrenaline) for anaphylaxis by junior hospital doctors 
Postgraduate Medical Journal  2007;83(983):610-611.
Anaphylaxis is a life threatening reaction where prompt and appropriate management can save lives. Epinephrine (adrenaline) is the treatment of choice; however, the recommended dose and route of administration of epinephrine used in the management of anaphylaxis is different from that used in the management of cardiac arrest.
To investigate how junior doctors would administer epinephrine in a case of anaphylactic shock in an adult patient.
Junior medical staff in two district general hospitals were assessed with a short questionnaire.
95 junior hospital doctors were assessed. The majority (94%) would administer epinephrine as the life saving drug of choice, but only 16.8% would administer it as recommended by the UK Resuscitation Council Guidelines.
Junior doctors may be called to make immediate management decisions in patients with anaphylaxis; however, widespread confusion exists regarding the dose and route of administration of epinephrine. Strategies to improve education and access to appropriate drugs are needed. A labelled “anaphylaxis box” on every resuscitation trolley, containing the dose of epinephrine with clear labelling for intramuscular use, may be one solution.
PMCID: PMC2600009  PMID: 17823230
14.  Nurses taking on junior doctors' work: a confusion of accountability. 
BMJ : British Medical Journal  1996;312(7040):1211-1214.
The number of hospital based posts in which nurses take over clinical work previously done by junior doctors is growing. Accountability for the scope of such new roles and the standards of practice which apply to them are still unclear. When analysed together and compared, the regulations arising from the professional bodies (GMC and UKCC), civil law concerning certain wrongs to patients, and employment law are sometimes contradictory and hard to interpret. The resulting uncertainties about appropriate management for clinical roles evolving between the professions, coupled with an increasingly litigious public, put the nurses and consultants involved at risk of complaints and of disciplinary and legal action. Drawing on our current research into changing clinical roles at the medical-nursing interface, we suggest strategies to reduce risk. Doctors and nurses should be equal partners in planning and managing these new posts, patients should be informed adequately about the nature of the postholder's role and training, significant changes in the work of such postholders should be formally acknowledged by the employer and relevant insurers, individuals taking up new roles should have access to legal advice and support to cover legal risk, and national regulatory bodies need to work together to harmonise their codes of practice in relation to changing clinical roles between the professions.
PMCID: PMC2350937  PMID: 8634568
15.  Is cocaine use recognised as a risk factor for acute coronary syndrome by doctors in the UK? 
Postgraduate Medical Journal  2007;83(979):325-328.
Cocaine is a sympathomimetic agent that can cause coronary artery vasospasm leading to myocardial ischaemia, acute coronary syndrome and acute myocardial infarction (ACS/AMI). The management of cocaine‐induced ACS/AMI is different to classical atheromatous ACS/MI, because the mechanisms are different.
Knowledge study—Junior medical staff were given a scenario of a patient with ACS and asked to identify potential risk factors for ACS and which ones they routinely asked about in clinical practice. Retrospective study—Retrospective notes reviews of patients with suspected and proven (elevated troponin T concentration) ACS were undertaken to determine the recording of cocaine use/non‐use in clinical notes.
Knowledge study—There was no significant difference in the knowledge that cocaine was a risk factor compared to other “classical” cardiovascular risk factors, but juniors doctors were less likely to ask routinely about cocaine use compared to other “classical” risk factors (52.9% vs >90% ,respectively). Retrospective study—Cocaine use or non‐use was documented in 3.7% (4/109) and 4% (2/50) of clinical notes of patients with suspected and proven ACS, respectively.
Although junior medical staff are aware that cocaine is a risk factor for ACS/AMI, they are less likely to ask about it in routine clinical practice or record its use/non‐use in clinical notes. It is essential that patients presenting with suspected ACS are asked about cocaine use, since the management of these patients is different to those with ACS secondary to “classical” cardiovascular risk factors.
PMCID: PMC2600067  PMID: 17488862
16.  Specialty choice in UK junior doctors: Is psychiatry the least popular specialty for UK and international medical graduates? 
In the UK and many other countries, many specialties have had longstanding problems with recruitment and have increasingly relied on international medical graduates to fill junior and senior posts. We aimed to determine what specialties were the most popular and desirable among candidates for training posts, and whether this differed by country of undergraduate training.
We conducted a database analysis of applications to Modernising Medical Careers for all training posts in England in 2008. Total number of applications (as an index of popularity) and applications per vacancy (as an index of desirability) were analysed for ten different specialties. We tested whether mean consultant incomes correlated with specialty choice.
In, 2008, there were 80,949 applications for specialty training in England, of which 31,434 were UK graduates (39%). Among UK medical graduates, psychiatry was the sixth most popular specialty (999 applicants) out of 10 specialty groups, while it was fourth for international graduates (5,953 applicants). Among UK graduates, surgery (9.4 applicants per vacancy) and radiology (8.0) had the highest number of applicants per vacancy and paediatrics (1.2) and psychiatry (1.1) the lowest. Among international medical graduates, psychiatry had the fourth highest number of applicants per place (6.3). Specialty popularity for UK graduates was correlated with predicted income (p = 0.006).
Based on the number of applicants per place, there was some consistency in the most popular specialties for both UK and international medical graduates, but there were differences in the popularity of psychiatry. With anticipated decreases in the number of new international medical graduates training in the UK, university departments and professional associations may need to review strategies to attract more UK medical graduates into certain specialties, particularly psychiatry and paediatrics.
PMCID: PMC2805648  PMID: 20034389
17.  Current dilemmas in overseas doctors' training 
Postgraduate Medical Journal  2005;81(952):79-82.
International medical graduates (IMGs) are a remarkably successful professional group in the United Kingdom making up to 30% of the NHS work force. Their very success and media publicity about general practice and consultant shortages, has led to a large influx of inexperienced doctors seeking training opportunities in competitive specialties. In 2003 a record 15 549 doctors joined the medical register of which 9336 doctors were non-European Economic Area citizens. The number of candidates sitting PLAB part 1 and part 2 in 2003 rose by 267% and 283% respectively compared with 2001. Changes to Department of Health, Home Office, and deanery regulations with expansion of medical schools, implementation of European Working Time Directive, Modernising Medical Careers, and the future role of the Postgraduate Medical Education and Training Board, will have an important impact on IMGs' training. Dissemination of realistic information about postgraduate training opportunities is important as the NHS for some time will continue to rely on IMGs.
PMCID: PMC1743197  PMID: 15701736
18.  Factors Influencing Performance of Cardiopulmonary Resuscitation (CPR) by Foundation Year 1 Hospital Doctors 
The Ulster Medical Journal  2012;81(1):14-18.
Foundation Year One (FY1) doctors are often the first medical staff responders at in-hospital cardiac arrests. The study objectives were to assess the cardiopulmonary resuscitation (CPR) skills of FY1 doctors at a Belfast teaching hospital and to highlight factors that influence their performance.
A group of FY1 doctors working in a Belfast teaching hospital were asked to participate in this study. These junior doctors were regularly on-call for acute medical emergencies including cardiac arrest. Participants were instructed to perform two, 3 minute sessions of CPR on a skills reporter manikin. Each session was separated by a 5 minute rest period, one session using a compression-to-ventilation ratio of 15:2 and the other using a ratio of 30:2. Performance was gauged both objectively, by measuring the depth of chest compressions, and subjectively by a panel of 5 Advanced Life Support (ALS) instructors who reviewed the tracings of each CPR session.
Overall, 85% of medical FY1's working in the hospital participated in the study. Objective results determined that males performed significantly better than their female counterparts using both the 15:2 and 30:2 ratios. The male FY1 doctors performed equally well using both 15:2 and 30:2 ratios, in comparison to female doctors who were noted to be better using the 15:2 ratio.
Individuals with a Body mass index (BMI) greater than the mean for the group, performed significantly better than those with a lower BMI when using the 30:2 ratio.
BMI was an important factor and correlated with chest compression depth. Females with a low BMI performed less well when using a ratio of 30:2. Overall, expert opinion significantly favoured the 15:2 ratio for the FY1 doctor group.
CPR performance can be influenced by factors such as gender and BMI, as such the individual rescuer should take these into account when determining which compression to ventilation ration to perform in order to maximise patient outcome.
This study showed that males and those females with a BMI of >24 performed satisfactory CPR when using the recommended Resuscitation Council guidelines. Females with a BMI <24 performed CPR more effectively when using the 15:2 ratio. FY1 doctors should be fully assessed prior to performing CPR at in-hospital cardiac arrests. Remedial teaching should be given to those less than satisfactory until they are shown to be competent.
PMCID: PMC3609676  PMID: 23536733
19.  Will our junior doctors be ready for the next major incident? A questionnaire audit on major incident awareness across three NHS Trusts in Wales 
BMJ Open  2011;1(1):e000061.
The aim was to assess junior doctors' understanding of their role in the Major Incident Contingency Plan at their hospital, and to evaluate the effectiveness of a teaching intervention on increasing awareness.
In this audit, ‘junior doctor’ refers to the first 2 years of work after qualifying from medical school. Once a major incident is confirmed, junior doctors should go to their ward, contact the senior nurse in charge and compile a list of the patients who could safely be discharged from the hospital. This action is standard across NHS Trusts in Wales.
A questionnaire was given to 89 junior doctors across three NHS Trusts in Wales. It involved general aspects of a major incident, as well as ascertaining perceptions of their role as junior doctors. They then received formal teaching by Emergency Planning Faculty. Following this, a repeat questionnaire was completed.
91% felt they did not know what would be expected of them during a major incident; 47% would initially go to the Emergency Department; 27% were unclear where to go; 31% were unaware who to contact on hearing of a major incident; and 16% would telephone switchboard. Junior doctors believe their primary role would be triage (16%); clerking in the emergency department (36%); clerking in Medical Assessment Unit/Surgical Assessment Unit (17%); and practical work (15%). Only 3% would first go to their ward; 12% believe their primary role would involve patients on the ward; and only 1% would list patients for discharge. 90% of completed questionnaires included a request for teaching. Following teaching, 97% knew who to call, where to go and what to do during a major incident.
Junior doctors' awareness of major incidents within Wales was near absent prior to teaching. This teaching is vital to help ensure smooth running of the hospital on the day.
Article summary
Article focus
Are junior doctors aware of their role during a major incident?
How effective is a teaching intervention on improving awareness?
Key messages
This audit is the first of its kind to assess the understanding of major incident roles within Wales.
Awareness of major incidents was near absent prior to teaching.
Teaching is highly effective, and the vast majority of junior doctors wish to learn about it.
Strengths and limitations of this study
Three of the seven NHS Trusts in Wales were included in the audit. These Trusts were located in both the north and the south of Wales, giving a good reflection of major incident awareness across the country.
A limitation of the audit was that the second questionnaire was completed within one day of the teaching; it did not assess the longer-term retention of this knowledge.
PMCID: PMC3191403  PMID: 22021743
20.  Improving compliance with requirements on junior doctors' hours 
BMJ : British Medical Journal  2003;327(7409):270-273.
Problem Compliance with UK regulations on junior doctors' working hours cannot be achieved by manipulating rotas that maintain existing tiers of cover and work practices. More radical solutions are needed.
Design Audit of change.
Setting Paediatric night rota in large children's hospital.
Key measures for improvement Compliance with regulations on working hours assessed by diary cards; workload assessed by staff attendance on wards; patient safety assessed through critical incident reports.
Strategies for change Development of new staff roles, followed by change from a partial shift rota comprising 11 doctors and one senior nurse, to a full shift night team comprising three middle grade doctors and two senior nurses.
Effects of change Compliance with regulations on working hours increased from 33% to 77%. Workload changed little and was well within the capacity of the new night team. The effect on patient care and on medical staff requires further evaluation.
Lessons learnt Reduction of junior doctors' working hours requires changes to roles, processes, and practices throughout the organisation.
PMCID: PMC1126659  PMID: 12896942
21.  Well prepared for work? Junior doctors' self-assessment after medical education 
BMC Medical Education  2011;11:99.
Apart from objective exam results, the overall feeling of preparedness is important for a successful transition process from being a student to becoming a qualified doctor. This study examines the association between self-assessed deficits in medical skills and knowledge and the feeling of preparedness of junior doctors in order to determine which aspects of medical education need to be addressed in more detail in order to improve the quality of this transition phase and in order to increase patient safety.
A cohort of 637 doctors with up to two years of clinical work experience was included in this analysis and was asked about the overall feeling of preparedness and self-assessed deficits with regard to clinical knowledge and skills. Three logistic regression models were used to identify medical skills which predict the feeling of preparedness.
All in all, about 60% of the participating doctors felt poorly prepared for post-graduate training. Self-assessed deficits in ECG interpretation (aOR: 4.39; 95% CI: 2.012-9.578), treatment and therapy planning (aOR: 3.42; 95% CI: 1.366-8.555), and intubation (aOR: 2.10; 95% CI: 1.092-4.049) were found to be independently associated with the overall feeling of preparedness in the final regression model.
Many junior doctors in Germany felt inadequately prepared for being a doctor. With regard to the contents of medical curricula, our results show that more emphasis on ECG-interpretation, treatment and therapy planning and intubation is required to improve the feeling of preparedness of medical graduates.
PMCID: PMC3267657  PMID: 22114989
22.  Perceptions of nurse practitioners by emergency department doctors in Australia 
The Australian Medical Association is strongly opposed to the nurse practitioner (NP) role with concerns that NPs may become doctor substitutes without the requisite training and education that the medical role demands. Despite this, NPs have been heralded by some as a potential solution to the access block, workforce shortage and increased demand affecting emergency departments (EDs).
The purpose of this study was to determine the perception of NPs by medical staff working in Australian EDs.
Semi-structured telephone interviews were conducted with closed and open-ended questions. Participants were drawn from a representative stratified sample of two city, two metropolitan and two provincial hospitals of each State/Territory.
A total of 95 doctors from 35 EDs participated in this study including 36 Departmental Directors; 36% of participating Directors indicated having an NP on staff. Doctors were strongly opposed to the statement that NPs could replace either nurses or other prevocational doctors; 71 interviewees commented on the role of NPs in the ED. Thematic analyses revealed polarised views held by doctors. Eight major themes were identified, the most common being that there is a lack of clarity of the NP role definition, their scope of practice and differentiation from the medical role.
Although ED NPs represent a highly skilled professional group their role is poorly understood by ED doctors. Opposition to the NP role is a significant barrier to the introduction of great numbers of ED NPs as a strategy to overcome the medical workforce shortage.
Electronic supplementary material
The online version of this article (doi:10.1007/s12245-010-0214-8) contains supplementary material, which is available to authorized users.
PMCID: PMC3047829  PMID: 21373292
Nurse practitioner; Intern; Emergency medicine; Supervision
23.  Deliberate self harm assessment by accident and emergency staff--an intervention study. 
OBJECTIVE: To examine the impact of specific training for accident and emergency (A&E) staff on the quality of psychosocial assessment of deliberate self harm patients. METHODS: A non-randomised intervention study that compared the psychosocial assessment of deliberate self harm patients before and after a one hour teaching session for the A&E departments nursing and junior medical staff. Adequacy of psychosocial assessment was judged by examining A&E case notes. The records of the hospital's parasuicide team were examined to assess administrative changes. Staff attitude to and knowledge of deliberate self harm were also measured before and after the intervention. RESULTS: 45 of 52 nurses and all 15 junior medical staff attended the teaching session. Sixteen (13%) of 125 sets of records before and 58 (46%) of 127 sets of records after the intervention were judged to be adequate. In the postintervention period, notes were more likely to be judged adequate when a proforma was used as part of the assessment (52 of 66 with a proforma and six of 61 without a proforma, chi2 = 60, p < 0.01). Following the intervention, communication between A&E staff and the hospitals parasuicide team improved. CONCLUSIONS: An intervention that provides teaching to A&E staff can lead to improvements in the quality of psychosocial assessment of patients with deliberate self harm.
PMCID: PMC1343001  PMID: 9475216
24.  Implementing a 48 h EWTD-compliant rota for junior doctors in the UK does not compromise patients’ safety: assessor-blind pilot comparison 
Background: There are currently no field data about the effect of implementing European Working Time Directive (EWTD)-compliant rotas in a medical setting. Surveys of doctors’ subjective opinions on shift work have not provided reliable objective data with which to evaluate its efficacy.
Aim: We therefore studied the effects on patient's safety and doctors’ work-sleep patterns of implementing an EWTD-compliant 48 h work week in a single-blind intervention study carried out over a 12-week period at the University Hospitals Coventry & Warwickshire NHS Trust. We hypothesized that medical error rates would be reduced following the new rota.
Methods: Nineteen junior doctors, nine studied while working an intervention schedule of <48 h per week and 10 studied while working traditional weeks of <56 h scheduled hours in medical wards. Work hours and sleep duration were recorded daily. Rate of medical errors (per 1000 patient-days), identified using an established active surveillance methodology, were compared for the Intervention and Traditional wards. Two senior physicians blinded to rota independently rated all suspected errors.
Results: Average scheduled work hours were significantly lower on the intervention schedule [43.2 (SD 7.7) (range 26.0–60.0) vs. 52.4 (11.2) (30.0–77.0) h/week; P < 0.001], and there was a non-significant trend for increased total sleep time per day [7.26 (0.36) vs. 6.75 (0.40) h; P = 0.095]. During a total of 4782 patient-days involving 481 admissions, 32.7% fewer total medical errors occurred during the intervention than during the traditional rota (27.6 vs. 41.0 per 1000 patient-days, P = 0.006), including 82.6% fewer intercepted potential adverse events (1.2 vs. 6.9 per 1000 patient-days, P = 0.002) and 31.4% fewer non-intercepted potential adverse events (16.6 vs. 24.2 per 1000 patient-days, P = 0.067). Doctors reported worse educational opportunities on the intervention rota.
Conclusions: Whilst concerns remain regarding reduced educational opportunities, our study supports the hypothesis that a 48 h work week coupled with targeted efforts to improve sleep hygiene improves patient safety.
PMCID: PMC2659599  PMID: 19174502
25.  GP recruitment and retention: a qualitative analysis of doctors' comments about training for and working in general practice. 
BACKGROUND AND AIMS: General practice in the UK is experiencing difficulty with medical staff recruitment and retention, with reduced numbers choosing careers in general practice or entering principalships, and increases in less-than-full-time working, career breaks, early retirement and locum employment. Information is scarce about the reasons for these changes and factors that could increase recruitment and retention. The UK Medical Careers Research Group (UKMCRG) regularly surveys cohorts of UK medical graduates to determine their career choices and progression. We also invite written comments from respondents about their careers and the factors that influence them. Most respondents report high levels of job satisfaction. A noteworthy minority, however, make critical comments about general practice. Although their views may not represent those of all general practitioners (GPs), they nonetheless indicate a range of concerns that deserve to be understood. This paper reports on respondents' comments about general practice. ANALYSIS OF DOCTORS' COMMENTS: Training Greater exposure to general practice at undergraduate level could help to promote general practice careers and better inform career decisions. Postgraduate general practice training in hospital-based posts was seen as poor quality, irrelevant and run as if it were of secondary importance to service commitments. In contrast, general practice-based postgraduate training was widely praised for good formal teaching that met educational needs. The quality of vocational training was dependent upon the skills and enthusiasm of individual trainers. Recruitment problems Perceived deterrents to choosing general practice were its portrayal, by some hospital-based teachers, as a second class career compared to hospital medicine, and a perception of low morale amongst current GPs. The choice of a career in general practice was commonly made for lifestyle reasons rather than professional aspirations. Some GPs had encountered difficulties in obtaining posts in general practice suited to their needs, while others perceived discrimination. Newly qualified GPs often sought work as non-principals because they felt too inexperienced for partnership or because their domestic situation prevented them from settling in a particular area. Changes to general practice The 1990 National Health Service (NHS) reforms were largely viewed unfavourably, partly because they had led to a substantial increase in GPs' workloads that was compounded by growing public expectations, and partly because the two-tier system of fund-holding was considered unfair. Fund-holding and, more recently, GP commissioning threatened the GP's role as patient advocate by shifting the responsibility for rationing of health care from government to GPs. Some concerns were also expressed about the introduction of primary care groups (PCGs) and trusts (PCTs). Together, increased workload and the continual process of change had, for some, resulted in work-related stress, low morale, reduced job satisfaction and quality of life. These problems had been partially alleviated by the formation of GP co-operatives. Retention difficulties Loss of GPs' time from the NHS workforce occurs in four ways: reduced working hours, temporary career breaks, leaving the NHS to work elsewhere and early retirement. Child rearing and a desire to pursue interests outside medicine were cited as reasons for seeking shorter working hours or career breaks. A desire to reduce pressure of work was a common reason for seeking shorter working hours, taking career breaks, early retirement or leaving NHS general practice. Other reasons for leaving NHS general practice, temporarily or permanently, were difficulty in finding a GP post suited to individual needs and a desire to work abroad. CONCLUSIONS: A cultural change amongst medical educationalists is needed to promote general practice as a career choice that is equally attractive as hospital practice. The introduction of Pre-Registration House Officer (PRHO) placements in general practice and improved flexibility of GP vocational training schemes, together with plans to improve the quality of Senior House Officer (SHO) training in the future, are welcome developments and should address some of the concerns about poor quality GP training raised by our respondents. The reluctance of newly qualified GPs to enter principalships, and the increasing demand from experienced GPs for less-than-full-time work, indicates a need for a greater variety of contractual arrangements to reflect doctors' desires for more flexible patterns of working in general practice.
PMCID: PMC2560447  PMID: 12049026

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