Service, safety and training – a tricky trio.

The National Health Service is more than a health service, is is perhaps one of the biggest postgraduate universities in the world.  Within the corridors, operating theatres, and wards of the hospitals in the UK, healthcare professionals are learning.

They are taught by example every day, and increasingly are allocated time out of the service to learn at dedicated teaching days / seminars and courses.

This key role of the state-funded health service in the UK can sometimes be forgotten, or hidden away under the demands to provide a service to the sick and needy that are entering hospitals in ever-increasing numbers.  But ask patients who are in any of the teaching hospitals in the UK, and I am sure that they will be familiar with the request for a student to practice taking a history, or performing a clinical examination.   Alongside students, there are many more trainees of different levels of seniority who also ask permission to learn from patients: patients consent to procedures where a trainee will be carrying out the procedure, under the supervision of a colleague who is fully qualified.

This type of learning is essential to ensure that the next generation of doctors is suitably skilled and qualified to deal with the problems they are to encounter during their careers.  These procedures might be simple – like inserting a cannula, or a urinary catheter, or far more complex.

Recently there have been pressures on this style of training.  Opinions differ on the relative impact of each development, but the European Working Time Directive, competency based curricula, formalised workplace-based assessments and streamlining of the training career ladder have all affected how we train teh next generation of Consultants.

The increasing concern for patient safety, and the increasing awareness of patients about potential complications have resulted in less invasive procedures being carried out by general teams, but instead by specialists in more controlled environments – conferring undoubted benefits to the individual patient receiving the treatment.

This situation leaves us with a tension – trainees need to train, patients require a service, and patients need to be safe.  To train safely, trainees require willing patients, supervision, and opportunities to learn techniques in a safe, supervised environment. Increasing pressures on services have led to a situation where taking time off the ward to attend such opportunities seems beyond reach, and negatively impacts on the care of other patients within the same service.

BUT – emergencies happen, our trainees are usually the first on the scene, and will need skills usually developed in elective procedures to deal with the emergency confronting them.

So, in the modern world, are we balancing this tension – are we giving trainees the chances to develop the skills we expect of them, whilst ensuring the patients who kindly offer the opportunity to trainees to learn are safe – both electively and in the emergency setting?

A paper published recently online in the PMJ takes a look at this question in one area that sits right in the middle of this conundrum – the insertion of intercostal chest drains.

This core skill for general physicians is increasingly becoming the preserve of respiratory specialists, and even then, is becoming the preserve of sub-specialists.

The paper looked at attitudes, experience, and training in chest drain insertion.  The results are interesting, and pose very important questions for those who train general physicians, or any trainees where procedures are considered a core skill.

Overall, there was consensus that general medical registrars (general physicians) should be able to place chest drains, and that the procedure should not become a specialist only activity.

So – general medical trainees should be trained… but how much did they think was required?

Overall, trainees and consultants agreed that to be considered competent, an individual must place at least 5-10 chest drains, and to maintain this competency, must place 5-10 per year thereafter.

And… how did they do compared with their own standards?

Higher trainees (senior residents) who are most likely to be the ones called on to perform these procedures urgently had, in the main acquired the suggested number of drains to be called competent.

But only 5% of those who weren’t Respiratory trainees had been able to maintain their competency – as defined by their own standards.

So – as the authors conclude, chest drain insertion is a vital procedure for a service to be able to provide, but those we rely to provide this service – by their own admission, cannot maintain the necessary competence.

This is a worrying admission to make, and should ring alarm bells for those managing acute medical services, and those charged with the education of doctors within the university that is the NHS.

The solution will not be a quick fix, but it seems that the relationship between training, service and safety has changed in recent years.

This tripod is a tricky one to balance, but if one leg grows out of proportion to the others, something is bound to fall over…

Picture by RetSamys

  • Natalie Blencowe

    What about surgical patients requiring chest drains? Should we call the medical team to put them in – as we would never expect to put in 5-10 per year – adding to their already large workload……

    • Toby Hillman

      In some centres there are pulmonary intervention teams that would do this. Others rely on radiology departments to service the whole hospital. This survey only explored seldinger type drains, so it would depend on why your patient needs a drain… However, one could see an advantage in having a medical team come to provide an overall evaluation as well as helping with the technical procedure.

      I think this is an incredibly difficult nut to crack. Increasing reliance on medical teams to provide cover for surgical patients is perhaps pointing the way towards the hospitalist model of care, rather than the traditional med/surg split that we maintain in our on-call and training schemes…

    • Fiona Moss

      You should call whoever is competent to put the drain in. Perhaps the radiologist? Or one of the senior surgeons?
      Or the respiratory SpR? Who would you like to put a chest drain in you or one of your relatives – that question usually gives the answer to these sort of questions.

      • Natalie Blencowe

        I agree that the radiologist would be the ideal person; however, in many hospitals there is no funding for the gold standard of ‘image guided drain insertion.’
        I think ]there may often be a situation – particularly out of hours – where no doctor on duty has put in the required number of drains to maintain their competency. I’d say that the average surgical registrar puts in 1-2 per year – but may well still be competent to do so. ‘Competency’ means different things to different people, and is acquired at different rates. Assigning numbers to the acquisition of procedural skills might perhaps be unhelpful?

        • Fiona Moss

          Agree re numbers and competency. But every hosptial should know who is competent to undertake such a procedure. “Having a go” – when you have only one 1 or 2 should not be allowed to happen – particularly “out of hours” – when there is not one to supervise. This is when and how mistakes and errors happen.