Confidence, the demise of the SHO, and lung cancer screening.

I have been on call this weekend. Recently in an RCPE survey the consultant body was asked specifically “Do you frequently carry out duties previous carried out by more junior roles”, or words to that effect. Many a time do I hear my colleagues saying “I do the same job today as I did xx years ago as a house officer”. I certainly saw plenty of patients today, rewrote a number of treatment charts, prescribed analgesia, night sedation, and the like, looked up blood results, and requested radiology tests. So perhaps not much has changed since 2000.

One of the tasks today was the removal of a chest drain that was not working, mainly because it wasn’t actually in the thoracic cavity any more. I asked the house officer to do it, which seemed reasonable enough to me (and the registrar trudging around after me). 2 hours later I got a call from the FY1 telling me that they didn’t feel confident to pull the drain; could I come and do it?

We used to have a sea of SHOs in hospitals – I remember being one. The SHOs ran the show – they knew the patients, they did the ward rounds, they did the jobs, saw the relatives, and kept the hospital running. We don’t seem to have SHOs any more. FY2 – ST2 should be the group of Doctors who run everything. But there’s been a change. I’m not sure when registrars started doing all the work, no that’s not right, I don’t think FY2 – ST2 doctors don’t do any work, they do seem very busy, but they don’t seem to make decisions any more, that’s what the registrars and consultants do. Perhaps our hospital is different from everywhere else, but I suspect not. Consultants do what the registrars did, registrars do what the SHOs did, so perhaps the SHOs are doing what the house officers used to do? House officers seem to have an awful lot of paperwork to do these days.

I’m sure everyone across the land has had similar conversations. Our juniors seem to lack the confidence to make decisions – perhaps that’s appropriate, perhaps the every increasing senior cover is the correct way to go, but I do worry about how the future consultant body will get to the point of making decisions, or at least being confident in the decisions they make.

The most recent edition of Thorax runs an editorial on being confident about our diagnosis of ‘meaningful’ lung cancer in screening programs. Overdiagnosis is reported as common most screening programs, lung cancer included. But we ‘know’ that some patients have a lung cancer that doesn’t progress, at least not dramatically, so they die “with” lung cancer, not “from” lung cancer. But identification of these patients is difficult. Dr Frank C Detterbeck, Division of Thoracic Surgery, Yale, muses that overdiagnosis can only be defined in retrospect, looking back in a population after a long period, yet the clinician has to make decisions prospectively about an individual patient, not a population. He concludes that the article by Patz in JAMA doesn’t help to determine the benefits of screening, but does suggest how to minimise harm, stating that intervention in non-Broncho-Alveolar-Carcinoma NSCLC is very rately unnecessary, but for BAC we should be more circumspect, and wait for the right time to intervene. Of course our biggest dilemmas come for patients who have isolated lung cancers, early stage, with no pathological confirmation of malignancy, never mind a sub-type. Perhaps these cases are more straightforward – excision biopsy is indicated. But how confident can we be that these lesions are malignant? How much functional loss will occur due to the lobectomies carried out to find out? I don’t think we’re looking at the same situation found in breast and prostate cancer screening, with many unnecessary procedures, but with more widespread use of CT screening, we might get close.

The ECLS lung cancer screening study is underway in East and West Scotland – too early to see what the screening will lead to, in terms of surgical procedures, but we’ve already seen a lot of people with advanced disease who only presented as they answered the call for volunteers for the study: same patients, a bit earlier, but not early enough. Time will tell if lung cancer screening does save lives.

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