Junior Hospital Doctors Research Articles

Junior doctors oppose 48 hour limit for all Junior doctors want guidelines on study leave BMA warns Liberal Democrats about shortage of doctors More specialties move into new grade BMA NOTICES

# Junior doctors oppose 48 hour limit for all {#article-title-2} Junior hospital doctors have conceded that a limit of a 48 hour working week would be impractical for all doctors. At present doctors in training are excluded from the European Union's directive on working time, which specifies a 48 working week. The European Commission is expected to issue a white paper shortly setting out options for the excluded groups. Many junior doctors believe that they should be included but the BMA's Junior Doctors Committee has decided that its policy will remain the target set out in the new deal on hours of work—that is, that by 31 December no junior doctor should be working for more than 56 hours. The decision will please those surgical trainees who had criticised the new deal for reducing their training opportunities and believed that the JDC was not representing their interests. The JDC has already agreed to negotiate and promote the use of the “English clause” which enables trainees in appropriate specialties to be contracted for a maximum average of up to 83 hours a week—their hours of actual work should not, however, exceed 56. The deputy chairman for hours of work and manpower, Dr Andrew Hobart, supported a motion from a surgical research registrar—“This committee does not wish to see a 48 hour limit on hours of work to be applied to all junior doctors.” There was a case for limiting the hours of preregistration house officers but it would not, he said, “be in the best interest of doctors to restrict hours to …

BMA gives evidence to review body New groups will advise on medical manpower Universities are losing clinical staff Isolated areas need help to provide out of hours care GPs are concerned about checks on medical records

# BMA gives evidence to review body {#article-title-2} The BMA has given evidence to the Doctors' and Dentists' Review Body for the 1997 pay round, estimating that doctors need a pay increase of 53% to restore their comparative position to that of 1980 (p 769). The BMA has expressed concern at the problem of translating the NHS pay award for clinical academic staff—they have not yet received the 1996 award—and the review body has been asked formally to recommend to the government increases for clinical academics in line with NHS doctors. Junior hospital doctors are concerned about the discretionary nature of the top two points on the specialist registrar scale and want the review body to base the scale on the full range of registrar and senior registrar pay, but with seven incremental points. They have called for full shift additional duty hour rates to be paid to those doctors working full shift intensity on on call rotas or partial shifts. On behalf of doctors working in public health medicine and community health the BMA has asked the review body to maintain the link between the salary scales of clinical consultants and consultants in public health medicine; revise the supplements payable to directors of public health to take account of the major changes in the number and size of health authorities; recognise the increased workload resulting from the drastic shortfall in consultant posts in public health medicine; recommend an increase in the out of hours supplement for trainees in public health medicine; and maintain existing relativities between the salary scales of community health doctors and …

Junior hospital doctors' views on their training in the UK.

To ascertain the views of senior house officers and registrars on the educational and training component of their posts, a questionnaire was sent to all full-time doctors working in training posts in general and/or geriatric medicine at three district general and three teaching hospitals. Completed questionnaires were received from 64 (61%) of 105 doctors who were contacted. Most had a careers counsellor or tutor, although less than two-thirds thought they had benefited from this arrangement. The majority of doctors attended at least two medical tutorials or meetings per week; most wanted to attend more but were unable to because of other work commitments. Supervision by more senior staff on the ward was deemed by most to be satisfactory, but less so in out-patient clinics. Overall, one-third of doctors thought that training was inadequate and three-quarters wanted a greater amount of formal education. The majority of junior doctors' time was spent on routine work and most considered :training' constituted less than 10% of their working time. Doctors in training require more sessions designated as educational, with protected time to attend these.

Computer assisted learning for the interpretation of the chest radiograph

A multi-media computer assisted learning programme has been developed to instruct medical students, junior hospital doctors, nurses and other health professionals the principles of the interpretation of the chest radiograph. The software offers a highly interactive system that allows self-education and assessment.

The pitfalls in junior hospital doctors' contracts

The pitfalls in junior hospital doctors' contracts

Survey of surgical training in Europe.

The Permanent Working Group of European Junior Hospital Doctors (PWG) conducted a survey among surgical trainees in member countries with the aim of describing postgraduate training in surgery throughout Europe. In each country, 10 trainees with surgical training of 2-5 years and 10 trainees with surgical training of 6-9 years answered a questionnaire, completed a diary and kept a log book of operations for 1 week. A total of 165 surgeons from 12 countries completed the survey. A trainee had to care for an average patient load varying from 30 to 80 patients at any one time. The average number of working hours ranged from 52 to 88 h per week, including up to 18 h of unpaid work. The different tasks carried out within these working hours varied considerably, as did the proportion of tasks with educational value. Trainees participated in four to 11 major operations each week, but the number of operations a week did not reflect the number of operations conducted under supervision. In some countries, the majority of the trainees stated that they received their training mainly through unsupervised experience. The average number of days spent on courses and congresses varied from 4 to 15 days per year, with great variation in the percentage of expenses paid. Countries with favourable working conditions, such as fewer working hours, shorter shifts and a day off after being on duty, seemed to have gained these advantages by a reduction in working hours with educational value, rather than by a reduction in routine work. It is concluded that conditions of surgical training vary greatly between the European countries in relation to duration, working hours, tasks undertaken, and resources used on training. Every country is capable of improving its surgical training.

Junior doctors deplore phasing of review body award Ministerial group on new deal should be recalled GPs will discuss their core services Patients get guidance on living wills

# Junior doctors deplore phasing of review body award {#article-title-2} Representatives of junior hospital doctors have unanimously deplored the government's decision to phase the implementation of the 1996 award of the Review Body on Doctors' and Dentists' Remuneration. Senior registrars, registrars, and specialist registrars were awarded a 5.3% increase and senior house officers and house officers a 6.8% increase from 1 April but 1% has been withheld until 1 December. The higher award for junior grades was made partly to compensate for a reduction in the rates for class 3 additional duty hours of 2.5% to 50% of basic pay. The Junior Doctors Committee welcomed the fact that the awards have partly addressed the relative deterioration in the pay of training grade doctors but at its recent meeting it also criticised the government for not funding the awards in full and insisting that they will have to be funded, in part, from local efficiency savings. “Hospitals will have to take our pay increases from patient care,” according to Dr Edwin Borman, an anaesthetic senior registrar in Birmingham. “It is quite wrong that the government is allowing hospitals to squeeze the service.” The representative from the General Medical Services Committee, Dr Ian Banks, pointed to the differential in pay—as much as £7000—between the salary of general registrars and hospital registrars. The review body had not accepted that there was a recruitment crisis in general practice. Specialist registrars should have automatic increments. The JDC also deplored “anything other than the automatic implementation” of the salaries of doctors in the new specialist registrar grade. The review body recommended …

Juniors will oppose all inclusive contract Low morale is linked to low recruitment Changes in medical education funding confirmed New support service will help GPs and their families

# Juniors will oppose all inclusive contract {#article-title-2} Representatives of junior hospital doctors say that they will resist proposals from the NHS Executive to introduce an all inclusive professional contract for doctors in the specialist registrar grade. The new grade was one of the proposals of the Calman report on specialist medical training, which called for a unified training grade as one way of shortening junior doctors' training. At the meeting of the Junior Doctors Committee last week the outgoing chairman of the negotiating subcommittee, Dr Paul Miller, reported that at a recent meeting with the NHS Executive it had been suggested that there would be no automatic annual increments for the new grade and that incremental progress would be linked to educational progression. The executive conceded that some form of add on payment to reflect work intensity might be considered. The JDC's representatives had protested at the proposed timetable—namely, that the specialist grade should start in radiology and general surgery on 1 December and that the doctors' and dentists' review body should be asked to price the grade. Junior doctors believe that the grade should not be introduced hastily to meet the review body's timetable or before agreement had been reached on terms and conditions of service. At the meeting of the JDC Dr Ed O'Neill from Northern Ireland strongly disapproved of the proposal for a new contract. “This is going back to the days before we had units of medical time. This is performance related pay by the back door. We are not negotiating on these terms.” The health minister, Mr Gerald malone, was due to meet representatives …

With nurse practitioners, who needs house officers?

The boundaries between the work of doctors and that of nurses are changing, with nurses taking over important parts of junior hospital doctors' clinical work. In 1993 an exploratory study was carried out to identify the professional, educational, and management issues that such developments raise. Interviews were carried out with a range of stakeholders in three innovatory posts in which nurses were doing much of the clinical work of house officers. A complex picture of perceived benefits and problems for patients, junior doctors, and nurses emerged. These seemed to be associated with (a) the extent to which the contribution of professional nursing was valued in the new role and (b) the amount of clinical discretion which the postholder was allowed, this depending on the type of preparatory education provided and the management of the post. The study points to the need for strategic issues--such as the development of appropriate education and the professional recognition of these new clinical roles--to be addressed at a national and regional level.

Minister urges reduction in juniors' working hours BMA says rabies rules should stay All career registrars will transfer to specialist registrar grade Community care is blocking beds, doctors say

# Minister urges reduction in juniors' working hours {#article-title-2} The minister for health, Mr Gerald Malone, has told chairmen of trusts, district health authorities, and family health services authorities that he will adhere to the target in the new deal on junior doctors' hours that all non-hard pressed on call posts contracted for more than 72 hours will be eliminated by December 1996. Although the target date for eliminating hard pressed posts contracted for over 72 hours was December 1994 the minister has admitted that 764 juniors were still in such posts in February. He has asked chairmen to concentrate on reducing the actual working hours of junior hospital doctors. He says in a letter earlier this month that doctors should not be asked to undertake hours of duty that made it inevitable that they would work longer than 56 hours a week--for example, through early starts and late finishes. He has asked chairmen to look at the arrangements and relationships of all the staff in a department to achieve this aim. Mr Malone points out that the only satisfactory way to ensure that juniors did not work too long was to secure proper rest periods, which were not constantly interrupted. The minister admits that partial shifts were unpopular with some doctors and managers but he suggests that this might be the appropriate working pattern to avoid unacceptable work intensity of on call rotas. Regional taskforces will be asked to work with chairmen to disseminate good practice on partial shifts. Mr Malone has emphasised the importance of involving juniors in monitoring, implementing, and developing new working practices. The minister has also pointed out that purchasers have a direct interest in …

Juniors call for renegotiation of flexible training Health secretary meets royal colleges over bed shortages Government will not climb down over nurses' pay Former Eastern Europe requests help BMA urges research in primary care Postgraduate deans should not be civil servants NHS Executive offers guidance on local pay for purchasers Pay must be linked to work intensity Correction

# Juniors call for renegotiation of flexible training {#article-title-2} Representatives of junior hospital doctors have called for an urgent renegotiation of the framework for flexible training in the wake of the proposals for a unified training grade. As a result of a recommendation in the Calman report, Hospital Doctors: Training for the Future, the NHS Executive published proposals last year for a new grade—the specialist registrar—to replace the present career and senior registrar grades (21 January, p 149). Proposing the motion, which was carried by 19 votes to 16, Dr Mark Porter, a registrar in anaesthetics in Coventry, told the Junior Doctors Committee last month that his motion was not limited to the new grade nor was there a time scale but there had been little reference to flexible training in the report of the working party on the unified training grade: “The specialist registrar grade should be flexible enough to accommodate those wishing to undertake training on a part time basis. The entry criteria and selection processes for all trainees should be the same, irrespective of the training patterns adopted during the training programme. Similarly, the standards for achieving the certificate for completion of specialist training should be the same for both full and part time trainees.” There was provision for only 5% of doctors to undertake flexible training, Dr Porter said, despite about 40% indicating that they would like it. Flexible training did not have to be double full time training but it had to be high quality, accessible, and attract appropriate remuneration. Although half the entrants to medical school are now women and many men would like to train part time, the chairman of the negotiating subcommittee, Dr Paul Miller, a psychiatric senior registrar in Liverpool, and other speakers urged the committee to vote against and wait until the broader issues of the grade had been …

Survey shows junior doctors are still overworked Government will commission research on NHS prescribing British tobacco curbs remain voluntary Health secretary promises blitz on practice paperwork Nurses can prescribe more medicines

The preliminary results from the BMA's nationwide survey of junior hospital doctors shows that 300 are still contracted to work more than 83 hours a week—the ceiling that should have been achieved by 1 April 1993. The Department of Health maintains that there are only four posts in Britain over 83 hours. The survey was conducted so that comparisons could be made with the results from the regional task forces. By 31 December 1994 no junior doctor on an on call rota in a hard pressed specialty should have been working more than 72 hours. The survey shows that 22.8% of juniors are still contracted to work above 72 hours. The preliminary results are based on a random sample of 3500 responses spread across all specialties and all regions. The survey showed that 2.2% of senior registrars, 1.5% of registrars, 0.3% of senior house officers, and 1.3% of house officers were contracted to work more than 83 hours a week. Almost 60% of junior doctors are working longer than their contracted hours. The majority of these extra hours are unpaid. The department's official data do not take account of these extra hours. The results show that the take up rate of partial shifts, a working pattern introduced to help to reduce hours, has been low. Most doctors (68.5%) remain on the traditional working pattern of on call rotas; only 5.4% are on partial shifts. The survey asked about intensity of work and the results show that juniors are not receiving adequate periods of rest. …

Locum doctors protest at strike breaking

Doctors have been flown from Australia to fill the places of striking junior doctors at Whakatane Hospital in New Zealand's North Island. Ten of the hospital's junior doctors are on a three and a half week strike. They want a return to hourly rates of pay and claim that they were being called back after a full day's work to perform duties normally done by other staff. Eastbay Health Crown Health Enterprise hired the locum doctors after placing advertisements in Australian newspapers …

Junior doctors asked for more data on hours worked

The BMA's Junior Doctors Committee is asking all hospital junior doctors to supply details of the actual hours they work and the intensity of work so that comparisons can be made with the returns from regional task forces. The committee, which is asking for questionnaires to be returned by 30 November, believes that there are still major problems in reaching the target set for 31 December. The government's figures are based on the hours for which junior doctors are contracted to work and do not, according to the JDC, reflect the hours doctors are working once time spent on early starts, late finishes, and cover for colleagues' absences is taken into account. Under the new deal on doctors' hours no doctors should be on their feet and working for more than an average of 56 hours a week after that date. The hours should be reduced to 64 hours for those on a partial shift and to 72 hours for those on an on call rota. One of the questions asks for information about the amount of rest doctors get when on call to show whether or not the majority of doctors are working an appropriate working pattern and being paid at an appropriate rate. If they are able to do so the JDC would like doctors to name their base hospital or NHS trust so that details of problem posts and specialties can be sent to the relevant task force. A new subcommittee of the BMA's Central Consultants and Specialists Committee has been formed to represent clinical and medical directors. …

Do clinicians accept the role of Helicobacter pylori in duodenal ulcer disease: a survey of European gastroenterologists and general practitioners.

To examine to what extent clinicians in Europe accepted the theory of the casual role of Helicobacter pylori (H.pylori) in duodenal ulcer disease in the year 1992, and to what extent the theory had influenced their diagnostic and therapeutic habits in the management of duodenal ulcer patients at that time. Postal questionnaire. Three European countries: the UK, the Netherlands, and Denmark. Three hundred and three gastroenterologists, 250 general practitioners, 83 junior hospital doctors. Number of doctors believing H. pylori to be a significant cause of duodenal ulcer disease, use of diagnostic tests for detection of H. pylori and therapeutic regimens for eradicating H. pylori. Four hundred and forty-two doctors replied. Eighty-four per cent of the British doctors, 73% of the Dutch doctors, and 47% of the Danish doctors accepted the role of H. pylori in duodenal ulcer disease. The rates were higher among gastroenterologists than among general practitioners. Eighty-four per cent of the British doctors, 80% of the Dutch doctors, and 48% of the Danish doctors used diagnostic tests for H. pylori, most frequently histological examination (64%). In patients with duodenal ulcer disease, H. pylori eradication was undertaken by 93% of the British doctors, 89% of the Dutch doctors, and 60% of the Danish doctors. A triple therapy (a bismuth salt, metronidazole, and either amoxicillin or tetracycline) was used by 57% (181/315) of the doctors. H.pylori treatment is frequently used in some countries. However, the role of H. pylori in duodenal ulcer disease has not been accepted to the same extent in different European countries.

New deal issues at Pinderfields

The conflicting pressures created by Achieving a Balance, the new deal on junior doctors’ hours, and the Calman report on specialist training all impinge on the quality of life that consultants can expect in the future, but the immediate impact is on junior hospital doctors. Concern has recently been expressed about the difficulties of introducing 72 hour limits by December 1994. In addition to these direct changes the impact of the internal market and the purchaser and provider divide could lead to large numbers of dissatisfied and demoralised junior doctors. Indeed, a recent survey suggests that up to half of doctors have considered leaving medicine. Perhaps the most frustrating part of a junior doctor's life is the belief that you have no control over events which shape hospital life and even your future career prospects. But my recent experience as a higher surgical trainee at Pinderfields Hospitals NHS Trust in Wakefield, Yorkshire, has prompted me to write this account. Within a short time of arriving it was apparent that there were considerable problems with accommodation, catering, postgraduate teaching, and hours of work. Indeed, the regional task force had described conditions as among the worst in Yorkshire. …

Psychodynamic supervision for junior hospital doctors

This paper describes a supervision group for senior house officers which focused on the psychodynamics of their working relationships with patients. The SHOs worked in a variety of hospital specialties as well as general practice. The description includes details of how such a group was set up and some of the practical difficulties in maintaining the SHOs' attendance. Brief details are given of the types of cases the SHOs were most eager to discuss, and the nature of the leading anxieties connected with the cases. The SHOs found this type of supervision supportive and enlightening as they developed and improved their clinical skills.

Use of intravenous cannulae by junior hospital doctors.

One hundred junior hospital doctors were surveyed to investigate their use of intravenous cannulae. Anaesthetists inserted more cannulae per day than non-anaesthetists and were more likely to use local anaesthetic and wear gloves, although most doctors never or rarely did so. Anaesthetists were also more knowledgeable than non-anaesthetists about the sizes of cannulae they used and the sizes available, although there was considerable ignorance overall in this regard. Many doctors regularly place themselves at risk and expose their patients to unnecessary pain during intravenous cannula insertion, and have little knowledge about the cannulae they use.

Doctors' understanding of the specialty of Public Health Medicine: a survey of general practitioners and junior hospital doctors.

The Acheson report recommended that the new name for Community Medicine should be Public Health Medicine and that a new group of doctors with responsibility for communicable disease control be established. Three years after the report, general practitioners and junior hospital doctors in one health district were surveyed regarding their understanding of the specialty. This study identified some confusion about the titles and functions of doctors in Public Health Medicine. It is important to understand this problem and make efforts to rectify it.

Prescribing and dispensing of insulin: margins for error?

To investigate recent anecdotal reports of incorrect insulin dispensing, we compared retail pharmacists' and doctors' understanding of commonly used insulin brands. Eighty pharmacists, 29 general practitioners (GPs), and 31 junior hospital doctors were interviewed and completed a questionnaire concerning the duration of action and formulation of 17 insulins. Views on dispensing of alternative insulins were sought from the pharmacists. Fifteen insulin pairs in two columns, 'insulin prescribed' and 'dispense instead', were presented and pharmacists and doctors asked if substitution was appropriate. Mixtard, Penmix and Actrapid were the best understood insulins, Insulatard, Humulin Zn and Protaphane the worst. Both GPs (p = 0.014) and hospital doctors (p < 0.001) scored better than pharmacists. No pharmacist stated that they would routinely dispense alternative insulin, 27 out of 80 not even in an emergency, though 37 were prepared to do so in such a situation after checking, usually with a doctor or in the relevant literature. Sixteen pharmacists, 24 GPs, and all 31 hospital doctors completed the section on insulin pairs but accuracy at identifying appropriate substitutions was poor. These findings coupled with confusing insulin nomenclature may lead to dangerous dispensing errors.