Sir Humphry Davy Department of Anaesthesia, Bristol Royal Infirmary, Marlborough Street, Bristol BS2 8HW, UK
* Corresponding author. E-mail: susan.underwood{at}ubht.swest.nhs.uk
Accepted for publication August 1, 2005.
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Abstract |
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Methods. We analysed data from operating theatres in our hospital looking at grade of anaesthetist, time of day, emergency category, and specialty for more than 50 000 cases.
Results. Although direct supervision of trainees increased from 32 to 37 to 47%, senior house officer (SHO) and specialist registrar (SpR) caseload reduced by 20 and 21%, respectively, while that of the consultants rose.
Conclusions. The reduction in total operating theatre cases for our trainees was evident across the epochs analysed, case numbers fell after introduction of the New Deal as well as more recently following the WTD, particularly for SHOs who are now doing a larger proportion of their work at night. SHOs and SpRs are doing more obstetric cases than in previous times but these are regional and not general anaesthetics.
Keywords: training ; trainee, supervision
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Introduction |
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In 1993 the Working Group on Specialist Medical Training set up by the then Chief Medical Officer Kenneth Calman, published its report Hospital Doctors Training for the Future, which introduced the Specialist Registrar grade. This was rolled out for anaesthesia in April 1996. Implementation of the New Deal, originally agreed in 1991 between the British Medical Association and the Departments of Health, began in practice when Additional Duty Hours were replaced by a Banding system for out-of-hours payments in December 2000. Maximum continuous duty periods were defined, as were weekly contracted hours, and all doctors should have been performing actual work tasks for a maximum of 56 hours per week on average. The high rates of pay awarded to doctors working outside the recommended limits forced changes in work patterns; on-call systems were replaced with partial and full shifts in the specialties with heavy emergency workload, including anaesthesia and intensive care. In August 2004, when the European Working Time Directive (as UK Health and Safety law) took effect for doctors in training, there was a further swing to full shift work as duration of continuous work and weekly hours were reduced. At present maximum shift duration is 13 h but doctors can be contracted to work up to 58 h on average per week under the Working Time Directive; in 2009 this total will be reduced to 48 h.
There is particular concern that altered shift patterns have reduced training and experience too far. If this is the case, the prospect of further reductions in hours is worrying and training may need to change in response. For these reasons, we were keen to examine whether the perceived reduction in numbers of cases performed, both directly and indirectly supervised, has actually occurred in our teaching hospital. Our analysis was designed to show changes in number, urgency, time, and subspecialty of cases and could not address the question of quality or outcome either of training or patient care. Using a computerized data entry system based in the operating theatre, we are able to extract information to demonstrate experience and training for each individual or group over a period of time, as well as revealing the local activity of the entire department.
We have published previously a detailed analysis of theatre training in our teaching hospital.4
In this paper, we will divide further data for the last 8 yr into epochs to see if there has been any change in training or service pattern for anaesthetists following the introduction of the specialist registrar grade following the Calman report, implementation of the New Deal or enforcement of the Working Time Directive (WTD).
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Methods |
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Data collection
All theatre-based information was entered into a commercially available, computerized data collection system (Swiftop EDS Healthcare, Bristol, UK) at the time of operation. The system was installed in our hospital in 1993 for routine direct data entry onto a computer terminal in the operating theatre by a member of the nursing team.
Data analysis
Information was downloaded from the theatre database as a series of spreadsheet files then imported into a modified copy of the Royal College of Anaesthetists Electronic Logbook (Hammond/McIndoe). Three sets of data were extracted for time periods: 19961997, 20012002, and 2004 following the introduction of changes recommended in the Calman report (1996), the implementation of the New Deal (2000), and the Working Time Directive (2004) respectively.
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Results |
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Trainees were allocated into two groups, Senior House Officers (SHO) and SpR. Thus, the cases were divided between consultants, who may be supervising or solo, and trainees who may be directly or indirectly supervised. Trainees were considered directly supervised if they were in theatre with a consultant or if they were SHOs working with an SpR. The combinations of anaesthetic personnel in theatre are shown in the Venn diagram (Fig. 1).
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The total number of SHO cases decreased over time showing the same change after introduction of the New Deal as following the recent implementation of the WTD. Total SpR case numbers initially remained constant; then fell by 25% following the implementation of the WTD. Consultant caseload rose markedly over the 8-yr period.
The average annual caseload for an individual SHO fell from 496 in 19967 to 449 in 20012 and will be about 400 for 20045. SpR average annual caseload rose from 395 to 424 and will be approximately 316 for 20045. For consultants, the individual annual caseload has increased from 313 to 328 to nearly 400 (Fig. 2).
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Discussion |
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Another aspect of training is working in the operating theatre under indirect supervision and the gathering of experience over time, which provide the trainee with confidence and consolidate the skills enabling him/her to become an independent practitioner. Concentrating only on the direct supervision rate, risks losing sight of total caseload and, therefore, experience. Over the three time periods studied we saw a reduction in caseload for SHOs from an average of around 500 to 450 to 400 cases per SHO per year. The SpRs did an average of 400 cases per year when the specialist registrar programme started, and approximately 316 annually following the introduction of the WTD. This represents a reduction of 20% in annual case numbers for our trainees. The reduction in SHO caseload occurs primarily during the daytime, with night numbers increased. Perhaps surprisingly, this does not appear to have affected the emergency/elective balance which has remained remarkably constant. It is well known that performance at night is not as good as in the day and it has been the aim in our hospitals to reduce night-time theatre work where possible.6 7
The increase in obstetric cases seen in SHO and SpR practice is as result of increased regional anaesthesia, in keeping with national obstetric practice. General anaesthesia for obstetric patients is rarely performed by trainees. Our analysis mirrors the national picture where lack of training in obstetric anaesthesia airway management is a concern.8
We were primarily looking for trends in junior doctors' training, but it is interesting to note that the individual consultant caseload appears to be increasing, even though the number employed has risen. For consultants, as for trainees, calculating an average number of cases oversimplifies the situation. It does not take account of sessions spent outside theatres in pain management, preoperative assessment, intensive or perioperative care, nor of the duration of theatre lists. Of the current 52 consultants, 20 have timetabled sessions in intensive care units or the pain service. It may be, that with lower numbers of training cases, consultants are able to do more solo cases without increasing the length of theatre lists, a statement which might equally apply to our surgical colleagues. Although the total number of consultant-supervised cases has increased, the consultant-teaching load has reduced from 45 to 22% of their in-theatre caseload; the unused training capacity has increased from 4835 to 10 431 to approximately 16 000 cases per year.
Our data suggest that theatre caseload for trainees in anaesthesia has been declining over the last 8 yr as junior doctors hours have been reduced. It is thought widely that the WTD is the major cause, but this analysis shows that much of the change occurred before its introduction, and may have been a consequence of changing work patterns to suit the New Deal. Whatever the cause, there is reason to be concerned as there may come a point at which lack of experience will reduce safety for our patients. With the introduction of the 48-h working week in 2009, we can expect further reductions in trainee case numbers. Even with improved structured teaching, use of simulation for rare event management and focused in-theatre training we may need to change our training programme.
We have looked at the quantity of anaesthetic training over 8 yr but can make no measure of quality from our data. A fully trained anaesthetist should be able to work unsupervised within his/her area of expertise as well as supervising others more junior. Perhaps the move to competency rather than time-based training and assessment will provide a safety net, enabling extension of training time to those who need it. Planning training programmes on this basis will pose practical difficulties but it may become essential if present standards are to be maintained.
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Acknowledgments |
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Footnotes |
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References |
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2 NHS Management Executive. Junior DoctorsThe New Deal. London, July 1991
3 Parliament. Guidance on the Working Time (Amendment) Regulations 2003 (Statutory Instrument 2003 No. 1684). London, July 2003
4 McIndoe AK, Underwood SM. The current state of anaesthetic traininga detailed analysis of activity in a UK teaching hospital. Br J Anaesth 2000; 84: 5915
5 Royal College of Anaesthetists. A Manual for Trainees and Trainers, Section 5.2 Grades of Clinical Supervision. The CCST in Anaesthesia. London, April 2003
6 Joint Consultants Committeee. Staffing Acute Hospitals at Night and at Weekends: the Role of Competences-based Multidisciplinary Teams. London: JC33, 20023
7 Paice E. Hospital at NightThe original concept. Hospital at Night Implementation Resource Pack. NHS Modernisation Agency 2004; 1.4.1
8 Confidential Enquiry into Maternal and Child Health. Why Mothers Die 20002002: The Sixth Report of the Confidential Enquiries into Maternal Death in the United Kingdom. London: RCOG Press, 2004