In this short blog, Aruni Sen shares his thoughts on a retrospective study he conducted with some of his colleagues around a 24/7 senior clinician delivered emergency care and the reactions from the profession.
The philosophy we strive for in the care we offer in the Emergency Department at Wrexham Hospital is that every patient, if needed, deserves to be seen by a consultant regardless of time of day; if a consultant emergency physician is needed at 9am then the need is no different at 2am. This view is ridiculed by many of our consultant colleagues in the United Kingdom; a throw away comment that we are ‘working like a glorified registrar all our life’ is cynical, insults both registrars and consultants and often comes from those who are not clinically active in hours – never mind out of hours.
We reject this cynicism; our working pattern now includes night shifts and we did so because of the risk to patients left to the care of junior doctors at night; instead of expecting the middle grade doctors to work an unsustainable number of night shifts, the consultants decided to share the burden.
Do consultants make a difference by delivering care at any time of day? The answer is unclear during the day (as there are many consultants, middle grades and juniors working) but at night (a consultant or middle grade doctor with a junior) it is more straightforward.
Our recent paper in the EMJ reports what we found – that a consultant is more efficient and does the job better than others. This should be no surprise to anyone; after all a registrar trains to improve as a clinician, and so if a consultant does not outperform a trainee we need to go back to the drawing board and ask what it is all about.
The benefits that we reported are quantitative; our next step is identifying the cost savings that a consultant service offers compared to that by juniors. A harder thing to measure accurately and in a reproducible way however, is the quality of care given, namely rapid decisions, focused investigations, admission avoidance and comprehensive counselling to name a few. We are not sure how to show this on paper.
One certainty that cannot be argued against is that our desire for respect from other specialties is unrealistic while we allow the bulk of service delivery to come from juniors. The hospital is not blind. For those of our colleagues who accuse us of committing self-destruction in writing this paper (like turkeys voting for Christmas) we must ask the question what our patients will think if they hear these negative comments.
We can only wonder…