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House officers and surgical training – are we doing enough?

Over the recent years, exposure to training at the preregistration house officer (PRHO) grade has undergone a metamorphosis, due to restructuring of the undergraduate training curriculum and the implementation of the European Working Time Directive (EWTD) (Journal of the European Communities 1993) and the ‘New Deal’ on junior doctors’ working hours (Department of Health 1991). Using the EWTD as a catalyst, the emergency surgical-take in our hospital was re-organised to form a ‘hot week-on-take’ team consisting of a consultant, middle-grade, basic surgical trainee (BST) and PRHO-which was consistent throughout the daytime periods of the week on take. Using feedback proformas, we assessed the PRHOs for a 40-day period, both before and after implementation of this new system, regarding all patients seen and admitted by them. Data collected included details of patient handover, follow-up, involvement levels in operated cases and a visual analogue scale (VAS) for assessing the level of education, satisfaction and involvement from each patient contact episode. During the first part of the study, the PRHOs worked on a non-EWTD compliant rolling rota of early (8 am–2 pm) and late(2 pm–10 pm) shifts of emergency-take independent of the consultant, registrar or the BST on their elective firm. In the latter part of the study, when the new shifts had come into effect, this changed to the PRHOs working on a week of long day shifts (10 am–11pm), as part of the ‘hot week-on-take’ team. The emergency surgical patients seen by the PRHOs decreased from 35% (3.9 patients/day) to 33% (3.6 patients/ day) with the new shifts. Formal handover meetings, led by the consultant for the week, in the mornings and by the ‘hospitalat-night’ team, in the evenings saw an improved attendance by the trainees from 1% to 24% with the new shifts (p < 0.001). Follow-up of patients seen and admitted improved from 10% to 26% with a concurrent three-fold increase in the attendance of the PRHOs on the consultant-led post–take ward rounds (p1⁄4 0.002). No PRHO assisted or attended in any of the 114 same-shift emergency surgeries that were performed during the study period. The VAS scores showed a significant improvement in the perceived educational component of cases seen with the mean scores improving from 40 to 46 with the new shifts (p < 0.001). There was a similar change in the satisfaction scores from a mean of 51 to 54 while on the new shifts (p1⁄4 0.02). Reductions in the working hours of junior doctors have the potential to reduce the clinical experience and surgical exposure unless the structure of training is altered. The improvement in the subjective outcomes with the new hot ‘week-on-take’ system through which we attempted to re-create a traditional team structure could be a reflection of value added by working within a consistent team structure which had been lost in the old fragmented shift system.