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…