Consultant Members Research Articles

A survey of consultants in the psychiatry of learning disability

Aims and MethodAll 208 consultant members of the Faculty for the Psychiatry of Learning Disability were contacted and asked to complete a questionnaire to provide qualitative and quantitative information about their work and experiences.ResultsOne hundred and thirty-six consultants responded, giving a 64% response rate. They reported a wide range of clinical, academic and management skills, with 72 having registration in other specialities. Insufficient in-patient provision and problems with discharge were cited by 85% of respondents. There was a wide disparity in the provision of mental health services for children and adolescents with learning disabilities and 12 areas reported no services from any source. Although most respondents showed satisfaction with clinical work and professional relationships, there were many concerns about management, commissioning and planning of services.Clinical ImplicationsConsultant psychiatrists in the field of learning disability are a broadly skilled group of clinicians with a wide range of responsibilities and areas of expertise, but many are working in services that they see as under-resourced and poorly managed, planned and commissioned. Overall levels of satisfaction are good, particularly in relation to clinical work, peer support and study/academic work.

A survey of consultants in the psychiatry of learning disability

Aims and Method All 208 consultant members of the Faculty for the Psychiatry of Learning Disability were contacted and asked to complete a questionnaire to provide qualitative and quantitative information about their work and experiences. Results One hundred and thirty-six consultants responded, giving a 64% response rate. They reported a wide range of clinical, academic and management skills, with 72 having registration in other specialities. Insufficient in-patient provision and problems with discharge were cited by 85% of respondents. There was a wide disparity in the provision of mental health services for children and adolescents with learning disabilities and 12 areas reported no services from any source. Although most respondents showed satisfaction with clinical work and professional relationships, there were many concerns about management, commissioning and planning of services. Clinical Implications Consultant psychiatrists in the field of learning disability are a broadly skilled group of clinicians with a wide range of responsibilities and areas of expertise, but many are working in services that they see as under-resourced and poorly managed, planned and commissioned. Overall levels of satisfaction are good, particularly in relation to clinical work, peer support and study/academic work.

Surgical management of primary hyperparathyroidism - results of a national survey.

During the last decade, the surgical management of primary hyperparathyroidism has been limited to those patients with symptoms or complications of the disease and most surgeons have advocated routine bilateral neck exploration. Several recent articles, however, have supported the role of early surgical intervention and minimally invasive surgery for these patients. The aim of this study was to define the current surgical management of primary hyperparathyroidism in the UK and Ireland. A postal questionnaire was sent to all consultant members of the British Association of Endocrine Surgeons in November 2000. The surgeons were asked about their current criteria for patient selection, methods of pre-operative localisation, imaging technique before re-exploration, operative technique and follow-up. Questionnaires were returned from 66 of 92 surgeons (response rate 71.7%) currently performing parathyroid surgery in the UK and Ireland, at an average of 23.1 parathyroidectomies performed per annum (range, 5-120). The majority of patients referred for surgery were either asymptomatic (12.1%) or minimally symptomatic (53%). There was marked variability among surgeons in the use of pre-operative imaging techniques before the initial operation (sestamibi used by 39.4% [26/66] and ultrasound by 39.4% [26/66] also, alone or in combination with other imaging techniques, while 39.4% (26/66) of surgeons used no imaging) and re-exploration. This survey demonstrates marked variation in pre-operative localisation and surgical management of patients with primary hyperparathyroidism. The majority of surgeons in the UK and Ireland currently perform bilateral neck exploration with or without pre-operative localisation.

Informed consent for middle ear operations: a United Kingdom survey.

Otorhinolaryngologists throughout the UK routinely perform middle ear operations. Although the risk of serious complications in the hands of a well-trained surgeon is very low, some of the complications of middle ear surgery are devastating to the patient viz. facial nerve palsy and complete hearing loss. The subject of informed consent is highly topical because of clinical governance and medico-legal implications. We have audited the practice of the Consultant members of the British Association of Otorhinolaryngologists-Head and Neck Surgeons via a postal questionnaire with regards to their consenting process prior to middle ear operations. Our study looked at the practice of discussing different complications and the complication rates, the person consenting, time spent on consenting, and the documentation. We found that wide variations exist in the consenting process. The implications of the results are discussed. This study is particularly pertinent at the present time with the implementation of the new consenting standards document published by the Department of Health.

British Association of Stroke Physicians: benchmarking survey of stroke services.

the National Service Framework for Older People requires every general hospital which cares for stroke patients to introduce a specialist stroke service by 2004. to describe the organisation and staffing of specialist hospital-based stroke services in the UK. a national postal survey of consultant members of the British Association of Stroke Physicians (BASP) seeking details of the provision of neurovascular clinics, acute stroke units (ASUs), stroke rehabilitation units (SRUs), and the organisation and staffing of these services. the response rate was 91/126 (72%). Fifty-four neurovascular clinics, 40 ASUs and 68 SRUs were identified. Neurovascular clinics used a number of strategies to maintain rapid access and 30 (56%) were run by a single consultant. Only 50% ASUs usually admitted patients within 24 h of stroke. As the number of beds available on ASUs and SRUs did not reflect the total number of stroke in-patients, 21 (53%) ASUs and 45 (79%) SRUs had admission criteria. Training opportunities were limited: 37% ASUs and 82% SRUs had no specialist registrar. The therapy sessions (1 session=half a day) available per bed per week on a SRU were: physiotherapy 0.8; occupational therapy 0.6; speech and language therapy 0.25. significant development is needed to achieve the NSF target for hospital-based stroke services as few Trusts currently have all components in place and even when available not all stroke patients have access to specialist care. Stroke specialists will be required to run these services but training opportunities are currently limited. Stroke unit therapy staffing levels were lower than was available in randomised controlled trials.

Current practices of cocaine administration by UK otorhinolaryngologists.

The aim of this study was to determine which anaesthetic and vasoconstrictor preparations UK Otorhinolaryngologists use for rhinological surgery, with particular reference to cocaine and adrenaline. The incidence and types of adverse reactions to cocaine were also recorded. A postal survey of all BAO-HNS consultant members was performed. Of the 360 consultant surgeons included in the survey, the majority still use peri-operative cocaine on a regular basis, 66 per cent use cocaine and adrenaline together and more than 40 per cent use cocaine in paediatric patients. Sixteen per cent of respondents did not use cocaine. Only 11 per cent of surgeons had experienced cocaine toxicity in their patients, with only one recorded case of mortality. Most surgeons in the UK use cocaine because of the superior operative field it provides and because they consider it to be safe even with adrenaline. The actual incidence of adverse reactions to cocaine is low, with serious complications being less common than the risks from general anaesthesia. Cocaine remains a valuable agent in the armamentarium of the rhinologist.

Arrangements for the management of urgent retinal detachments in the United Kingdom and Eire in the year 2000: results of a survey.

To ascertain the current provision of facilities for the management of vitreo-retinal (V-R) emergencies, and attitudes of V-R surgeons towards the management of V-R emergencies within the United Kingdom and Eire. To obtain this information, all 82 consultant members of the Britain and Eire Association of Vitreo-Retinal Surgeons (BEAVRS) were requested to complete a 14-part postal questionnaire in the year 2000. Seventy-eight questionnaires were completed and returned. Data from the questionnaires were collated on a Microsoft Access Database and then statistically analysed using SPSS. The Student's t-test was used to assess relationships between continuous variables, and the Chi-squared and Fisher's Exact tests were used to compare non-parametric data. Analyses of the first 13 parts of the questionnaire are presented in this report. The majority of V-R surgeons (59%) practise in teaching hospitals. There are greater numbers of V-R surgeons per unit in teaching hospitals as compared to District General Hospitals (DGHs). Ophthalmic theatre and ophthalmic theatre staff availability are theoretically high (92.3% and 84.6% respectively) and evenly distributed between teaching hospitals and DGHs, but in reality, access may be difficult. Most V-R surgeons take part in an on-call rota with general ophthalmology colleagues. This formal commitment may be infrequent. Only a small proportion of V-R surgeons (28.3%) officially provide a continuous fixed on-call V-R rota, though in practice, a larger proportion do seem to provide this type of cover informally. Most V-R fellows are located in teaching hospitals (89.5%), and are usually on either a formal or informal on-call rota. Only one unit has a formal continuous on-call rota for fellows allowing no more than 72 hours duty per week. The mean time given in response to the question as to the ideal time within which surgery of an acute macula on supero-temporal retinal detachment should be carried out was 29 hours. Most V-R surgeons would not support, in court, a colleague whose patient lost vision through delay in treating a macula on detachment. The findings of this survey have important implications for providing a reliable service and for proper cover for doctors in training.

Pain management services in palliative care: a national survey.

The effective management of pain requires a multidisciplinary approach. Previous studies have suggested that around 8% of cancer patients will require interventional techniques from an anaesthetist with special interest in pain management to maximize pain control, although this percentage may increase in the cohort of patients with difficult pain syndromes under the care of specialist palliative care services. We wished to determine the experiences and views of other palliative care physicians with regard to input from specialists in pain management. A postal questionnaire was sent to the consultant members of the Association of Palliative Medicine. Most respondents had access to 'as-required' anaesthetist consultations with 72% of respondents feeling that the frequency of consultation was adequate. However, over half of the respondents had used the services of a pain management specialist less than four times in the past year and a quarter of respondents had not been involved in a joint consultation with an anaesthetist in the past year. All respondents felt that the pain management specialist's role included advice on technical procedures but less than 25% felt that their role should extend to advice on prescribing analgesics. There are likely to be several reasons for this apparent underutilization of specialist anaesthetist/pain management services. This survey has identified possible factors including lack of formal arrangements, lack of suitable experience and the attitudes of palliative medicine consultants.

Venous thromboembolic prophylaxis for transurethral prostatectomy: practice among British urologists

Venous thromboembolism (VTE) is an occasional cause of death after transurethral prostatectomy but there are no established guidelines for its prevention in relation to this operation. We assessed practice in the UK by mailing a questionnaire to 460 consultant members of the British Association of Urological Surgeons. 362 (79%) completed questionnaires were received. 280 of 362 (77%) respondents routinely used VTE prophylaxis with transurethral prostatectomy; 82 (23%) did not. 230 of the 280 urologists who took precautions used mechanical methods; 50 used low dose heparin, either with stockings or alone. This survey indicates that, despite a lack of clear evidence, most British urologists favour some form of precaution against VTE in patients undergoing transurethral prostatectomy.

Venous thromboembolic prophylaxis for transurethral prostatectomy: practice among British urologists.

Venous thromboembolism (VTE) is an occasional cause of death after transurethral prostatectomy but there are no established guidelines for its prevention in relation to this operation. We assessed practice in the UK by mailing a questionnaire to 460 consultant members of the British Association of Urological Surgeons. 362 (79%) completed questionnaires were received. 280 of 362 (77%) respondents routinely used VTE prophylaxis with transurethral prostatectomy; 82 (23%) did not. 230 of the 280 urologists who took precautions used mechanical methods; 50 used low dose heparin, either with stockings or alone. This survey indicates that, despite a lack of clear evidence, most British urologists favour some form of precaution against VTE in patients undergoing transurethral prostatectomy.

Geriatricians and active euthanasia

A study into UK geriatricians' attitudes towards voluntary euthanasia and physician-assisted death has been published in Age and Ageing. A postal questionnaire was sent to 742 consultant members of the British Geriatrics Society, and 82% considered active voluntary euthanasia never to be ethically justified, while 23% supported legalization in some situations and 13% would be willing to administer active voluntary euthanasia in some situations.

Clinical Practice 07

Aims: To assess the views of the consultant surgical community regarding the role of research in surgical training post-Calman. Methods: A postal survey of consultant members of ASGBI was performed to assess views on desirability, timing, duration and method of assessment of research in surgical training. The results were compared with a similar survey conducted pre-Calman in 1995. Results: A 50 per cent response rate was achieved compared to 71 per cent in the 1995 survey. Eight-two per cent of respondents had themselves obtained a higher degree by thesis. Overall, 89.7 per cent thought that research in training was either essential or desirable, compared to 89 per cent in the previous survey. Only 1.4 per cent felt that research should be conducted during BST (Basic Surgical Training) compared to 8 per cent previously. Forty-seven per cent indicated that research should be performed between BST and HST (Higher Surgical Training). Thirty-six per cent felt research during HST was most appropriate. Sixty-one per cent felt 1 year and 36 per cent 2 years of research was sufficient (91 and 9 per cent, respectively, in 1995). A total of 27.5 per cent thought that a thesis was the most appropriate method of assessment (33 per cent previously), while 35 per cent were supportive of an MSc (33 per cent previously). Eighty per cent of consultants with a higher degree thought research carried out as a trainee was worthwhile, both for their own education and career. There were no significant differences based on either age or specialist interest of the respondents. Conclusions: Even in the post-Calman era, 90 per cent of surgeons still regard research as either essential or desirable, although 1 year is regarded as adequate by the majority.

Clinical standards for specialist community rehabilitation services in the UK.

To develop a set of clinical standards for specialist community rehabilitation services in the UK and to undertake a preliminary survey of consultants who provide those services. The proposed set of standards was adapted from the previously published standards for inpatient services, by a working party of the British Society for Rehabilitation Medicine (BSRM). Consensus was then achieved by an iterative consultation process in five rounds. A postal survey was conducted on behalf of the BSRM amongst its consultant members providing community rehabilitation services in the UK, who were asked to assess their services in relation to these standards, and to comment on the standards themselves, their usefulness and applicability. Fifty consultants who ran specialist community rehabilitation services agreed to participate, of whom 29 (58%) actually responded. Overall, the standards appeared to be acceptable to most, and mainly struck the right level, being attained by the majority of services. Twenty-five (89%) felt the standards were helpful and 26 (93%) felt that they covered the main aspects of specialist community rehabilitation services: 23 (79%) found them at least partially applicable to their own service. Proposed clinical standards have been developed for specialist community rehabilitation services in the UK. It is likely that they will require further refinement with time, and modification is required to adapt them to different subspecialities and settings.

Who cares for the patient with head injury now?

Objective—A recent report on head injury management from the Royal College of Surgeons of England suggests that surgeons are unsuited to the inpatient care of head injuries (ICHI) and should...

UK geriatricians' attitudes to active voluntary euthanasia and physician-assisted death.

To describe the views of British geriatricians on active voluntary euthanasia and physician-assisted death. Postal questionnaire to 742 consultant members of the British Geriatrics Society. 81% considered active voluntary euthanasia never to be justified ethically, although 23% supported legalization in some situations and 13% would be willing to administer active voluntary euthanasia in some situations. With regard to physician-assisted death, 68% opposed it on ethical grounds and 24% supported its legalization in some instances, with 12% stating they would be willing to provide such assistance in some situations. Free text comments frequently cited good palliative care as an important response to such issues in clinical practice.

The use of central venous cannulae in neuroanaesthesia. A survey of current practice in the UK.

A postal questionnaire was sent to all UK consultant members of the Neuroanaesthesia Society to ascertain whether there was any consensus on indications for use and route of insertion of central venous cannulae in elective neuroanaesthetic practice. Five brief clinical scenarios were presented. Of 179 respondents, 98% indicated that they would insert a central venous cannula into patients requiring excision of an acoustic neuroma in the sitting position, 76% for clipping of an intracranial aneurysm and 75% for resection of an arteriovenous malformation. The antecubital fossa was the preferred route of insertion for 43.5% of respondents with 36.5% preferring the internal jugular approach. The subclavian (17%) and femoral (3%) routes were unpopular first-choice approaches. A significant proportion of respondents (43.5%) do not routinely order a chest X-ray at any stage following pre-operative central venous cannulation. The indications for use and advantages and disadvantages of each route of insertion, with reference to neuro-anaesthetic practice, are discussed.

Major complications and consent prior to endoscopic sinus surgery.

The endonasal endoscopic approach to the paranasal sinuses is no longer exclusively practised by a small number of dedicated super-specialists and has gained widespread acceptance in the UK. We have audited the practice of the Consultant members of the BAO-HNS via a confidential postal questionnaire with regards to the consent of their patients prior to surgery, and to the complications they have experienced. The overall rate of complications following endoscopic sinus surgery (ESS) was 0.69%, with the incidence of major complications 0.25% and of minor complications 0.44%. Wide variations in the practice of informed consent were found to exist, and this is discussed with reference to a suggested template for preoperative discussion with the patient.

Table of Contents

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The use of prostate-specific antigen testing in the detection of localized prostate cancer. Current opinion and urological practice in the United Kingdom

Background: The prostate-specific antigen (PSA) test and its interpretation plays a crucial role in the detection of early localized prostate cancer. However, inaccuracy of the test, inability to predict the aggressiveness of the disease and the lack of evidence about the comparative effectiveness of treatments have led to major dilemmas in considering whether to employ the PSA test and which cut-off points to use in interpreting its results. The aim of this study was to evaluate current urological practice in the UK regarding the use of PSA testing. Methods: A postal questionnaire survey of all consultant urologist members of the British Association of Urological Surgeons was conducted. Statistical analysis included proportional odds regression models to examine factors associated with urologists' preferences for different definitions of ‘normal’ PSA cut-off levels. Results: The survey response rate was 60%. The majority of consultant urologists applied the PSA test routinely. There was a high level of agreement amongst UK urologists on normal PSA cut-off points (<4.0 ng/ml) for asymptomatic men under 60 years of age. There was very wide variation in the definition of normal PSA cut-offs for older (≥60 years) asymptomatic men. A preference for lower cut-off points, leading to investigation with ultrasound and biopsy, was significantly associated with larger urology department size, the presence of a prostate cancer subspecialist in the department and relatively short length of specialization in urology. Conclusions: Prostate cancer screening and early detection practices and reported incidence rates of the disease are likely to be influenced by variation in urologists' interpretations of PSA. Despite increasing evidence in favour of lower PSA cut-off levels, particularly for younger men (<60 years), urologists in the UK are divided over their interpretation. Men, particularly over age 60 years, have varying chances of further investigation following PSA testing. Any trial of prostate cancer screening or treatment should take this potential variation into account. Standard protocols for PSA interpretation should be implemented.

Clinical standards for inpatient specialist rehabilitation services in the UK.

To develop a set of clinical standards for specialist inpatient rehabilitation services in the UK and to undertake a preliminary survey of consultants who provide those services. The proposed set of standards was developed by group consensus followed by an iterative consultation process. A postal survey was conducted on behalf of the British Society for Rehabilitation Medicine (BSRM) amongst its consultant members in the UK (n = 163), who were asked to assess their services in relation to these standards, and to comment on the standards themselves, their usefulness and applicability. The response rate was 61%, of which 81 respondents ran an inpatient rehabilitation service. Overall, the standards appeared to be acceptable to most, and mainly struck the right level, being attained by the majority of services. Specific suggestions were incorporated into the revised standards. Further work is required to establish agreed outcomes that are systematically measured and recorded: only half the respondents (50%) routinely recorded a standardized outcome measure, and only a quarter (26%) routinely reviewed patients to record long-term outcome. Clinical standards have been developed for specialist inpatient rehabilitation services in the UK. The BSRM proposes to adopt these standards for a test period of 2-3 years in the first instance. It is likely that they will require further refinement with time, and modification is required to adapt them to different subspecialities and settings.