Doctors in training: How do we provide appropriate training, safe handovers and continuity of care?

This issue contains an article (Mukhopadhyay and China 2010) of relevance to some of the challenges that have been anticipated or identified, as the average hours worked by doctors in training has been reduced to 48 hours per week, under the New Deal limits and the European Working Time Directive (EWTD), dating from August 2009. For those who wish to consult ‘A guide to the implications of the European Working Time Directive for doctors in training’, a suggested website is: www.rcpe.ac.uk/training/files/guide-to-the-implications-of-ewtd.pdf. Some concerns can be judged in parallel with criticisms made of American surgical training, which has recently been reduced to 80 hours per week.

While the avoidance of overly-tired junior doctors, the risks of clinical mistakes, and the provision of a good work–life balance (although we perceive increasing disillusionment and sickness rates) are all commendable ideals, the impact of these changes on quality of patient care and improvement in patient safety are unproven (perhaps strangely inconsistent with the thesis that evidence provides a basis for medical practice). The changes do not apply to non-training doctors, i.e. consultants, associate specialists, staff and trust grade doctors, although surveys are showing that the knock-on effect of such regulations will have implications for them.

Training

The paper in this issue contains some thoughts on training in surgical procedures (Mukhopadhyay and China 2010). The learning of commonly performed O&G procedures, e.g. ventouse delivery, caesarean section, external cephalic version, uterine evacuation, diagnostic hysteroscopy and diagnostic laparoscopy can be introduced at a relatively inexperienced trainee level, but more complex procedures are less likely to follow such models, e.g. the management of placenta praevia accreta or CO₂ LASER excision and subsequent reconstructive vulval surgery (which may make a suitable topic for surgical workshops using animal skin, but such training opportunities are unlikely to be available to all trainees and such surgery is not suitable for the ‘see one – do one’ philosophy). As Williams (2009) described in a recent letter to the BMJ:

‘One of my wisest trainers told me that he could teach me how to do an operation in a few months, teach me when to do an operation in a year, but to teach me when not to do an operation would take many years’.

A joint statement by the Association of Surgeons in Training and the British Orthopaedic Trainee Association in August 2009 (ASiT 2009), reported that 68% had reported a deterioration in the quality of their training, and that 80% would choose to ‘opt-out’ of the EWTD if given the choice. One concern expressed is that a deterioration in training leads to a deterioration in patient care. A second concern is that training opportunities in performing emergency surgery are being diluted per trainee (which may lead to them failing RITA assessments and delay their completion of training), and decisions to perform surgery are not being made by the same trainee surgeon who performs the procedure, or who sees the patient in the ward or at a clinic for subsequent follow-up. A paper by Feanny et al. (2005) describes the behaviour of trainees on an emergency surgical take when a patient had to go back to theatre after developing a complication; the Senior Resident participated in 60% of these ‘take-backs’ during the 2 years before the introduction of the 80-hour week, but only 29% after the reduction of hours. Purcell Jackson and Tarpley (2009) describe the dilemma that arises when a complicated patient requires attention towards the end of a shift: the trainee can manage the problem beyond the handover time and then lie on the timesheet about the hours worked, manage the problem and document that they worked beyond the end of the shift (but thereby put their training programme's accreditation at risk or facing the training supervisor's displeasure), or transfer the care to the on-coming colleague who knows little or nothing about the patient.

Safe handovers and continuity of care

Reducing hours worked will require more frequent handovers and the challenge will be how to avoid the escape of patient information when the handover is given verbally, in restricted time or while on the move. Nursing staff and midwives have always had formal handovers and we can utilise some of their ‘handover skills’. They employ a ‘Do Not Disturb’ policy during handover. They have a formal handover sheet and handover takes place in a quiet room where no doctors can dare enter. However, what happens if the handover clinicians are occupied in theatre, in delivery, in A& E or in another ward and are unable to attend a formal handover?

Several studies in the American literature have shown an increased risk of adverse events dependent on the number and quality of handovers (Pellegrini et al. 2005; Browne et al. 2009). As an example, Browne et al. (2009) reviewed patient outcomes following the reduction in working hours. The morbidity of 48,340 patients over the age of 55 with hip fractures was documented; there was a significant increase in perioperative respiratory, cardiac and renal complications following the reform, together with an increased length of stay and increased inflation-adjusted costs.

Within the Department of Obstetrics and Gynaecology at Norfolk and Norwich University Hospital, handovers have been based on the mnemonic SHARING (E. Toeima, personal communication). The information given at handover is written on to a proforma, where S is for available Staff and acknowledgement of their seniority or experience; H is for High risk patients and their location; A is to list those Awaiting theatre; R is for Referrals to be seen or taken over; I for Induction (and high vs low risk), N is for the status of the neonatal unit, and G for the bed occupancy in gynaecology. This structured system has much to recommend it.

Any handover can only be effective if the doctors involved have the requisite knowledge, experience and interest to gather, process and prioritise information about patients and the problems which they face. It is now commonplace in some surgical specialties, including gynaecological cover in some hospitals, to encounter an inexperienced SHO (in one of its many guises, ‘FY2’, ‘CT’, or ‘ST’), out-of-his/her-depth on a night shift, anxiously cross-covering multiple specialties. In most cases, the specialties covered at night fail to match those in which they cover during their normal working day. In a few cases, these specialties have never been taught formally to the doctor as a medical student.

Patients are no longer always found in a defined gynaecology ward and ‘outliers’ may be in ward areas where the passage of a second trimester fetus or the ischaemic changes in a torting ovarian cyst are not easily recognised. The patient prepared for emergency theatre more than 12 hours ago may still be waiting in her place in the queue. Gynaecology or obstetric patients sitting in an intensive care unit should be reviewed on every ‘shift’, but it will be difficult to interpret improvement or deterioration unless the patient is familiar to the ‘on-coming’ junior. The problems may be amplified by decreasing opportunities to discuss, by phone, cases of interest, or for the out-going junior doctor to be available to attend service or teaching ward rounds with consultant input the following morning (although many post-take consultant rounds are conducted at speed, before the more formal activities of the day begin; a sessional commitment is usually not given to the consultant to allow post-take teaching ward rounds, as happens for some physicians).

The Royal College of Surgeons of England has recently performed an online survey on the impact of the EWTD to reduce the average hours worked by doctors in training, and obtained responses from nearly 400 consultants and more than 500 trainees. Only 30% of those who replied were actually working 48 hours or less, and Mr John Black, President of the Royal College of Surgeons, concluded that the 48-hour week for surgeons in the NHS cannot be delivered (Black 2010). Many of those who were working more than 48 hours were doing so to provide some continuity of care of their patients.

What of the Royal College of Obstetricians and Gynaecologists and its response to EWTD? In a statement dated 23 September 2009, Dr Maggie Blott, Vice President for Education, commented that many Trusts will be only able to reduce the hours that junior doctors worked to 48 hours by increasing reliance on middle-grade ‘Trust doctors’ and staff grade posts, and that ‘out-of-hours’ cover and continuity of care would be provided by a large number of locums (Blott 2009). This brings with it all the uncertainty of the experience of the locum doctor (whether they have ever worked in the hospital before and know its geography, access to laboratory and theatre facilities, or computerised patient records or investigation requests) and whether the locum is ‘moonlighting’ from their day job, e.g. in research (which may be equally draining of concentration and enthusiasm) and covering the shift not because extra clinical training is necessary but because they are driven by the need for the extra cash/supplementary salary.

It is our anecdotal experience that continuity of care since EWTD has become a much greater challenge in the surgical environment. Handovers are known to be problematic in patient care. I invite correspondence or articles from others who have identified ‘handovers’ as an area where we must perform better. I would welcome further articles on training advantages or disadvantages as experienced with our new working patterns.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.