Have the BBC Missed The Point?

This story appeared quietly and with little fuss over the weekend. Afterall, unless its about £100,000 salaries or patients dying, nobody seems to care what happens to doctors.


The BBC story highlights an important point, although I can't credit the BBC as the remark originally came from a professor at the Royal College of Physicians. With the complete introduction of the European Working Time Directive (EWTD) from 2009, all professions, including doctors will be limited to working 48hours a week down from the current 56 hour limit. Now I don't know about other professions but this has some pretty serious consequences for doctors and perhaps more so for patients.


The BBC article states that patient care will suffer because there will be less staff available, this clearly makes sense as if all doctors are working 48 hours rather than 56 each doctor is working 8 hours less. Who is going to cover those lost hours? Patients are still going to get ill 24 hours a day, 7 days a week. Who is going to be there when Mr Jones arrests but Drs Smith, Brown and Wood have all worked their 48 hours this week? Of course, everyone knows that the vast majority of doctors are still going to work more than 48 hours a week, they just won't get paid for it as it is effectively 'illegal'. When it comes to auditing hours, these doctors will be 'encouraged' to lie about their hours to make the trust EWTD compliant. So patient care probably will suffer in the short term, but Dr Smith and his colleagues won't leave Mr Jones to die, they will ignore the EWTD, safe in the knowledge that what they are doing is illegal and they're not getting paid for it. Another solution to this problem is the use of night nurse practitioners and such like. I'm sure Dr Crippen wouldn't approve and to be honest, I know who I'd rather be looked after in the middle of the night during an emergency.


Anyway, I think the BBC have missed the point, it isn't the short term, immediate care of patients which is at risk. I'm far more worried about the implications for the future in terms of training. Talk to a doctor who qualified 5, 10, 20, 30 years ago and they'll tell you about the 'good times', the 100-120 hour weeks, the 48 hour shifts without sleep. Strangely, most of them will tell you they enjoyed it in a sadistic kind of way. Not because they get a kick out of working more hours than there are in a week, but because of the experience they gained. Most doctors will tell you that on call, during the night is where they learnt the most.


Lets consider for a second Mr Bone, a consultant orthopaedic surgeon. He became a consultant within about 11 years of graduating from medical school. When he qualified, he worked 100 hour weeks as a house officer and similarly throughout his training. That is about 50,000 hours or so of training.

Next, lets consider me (or equally one of my colleagues) who, having studied a PBL course doesn't know all that much to start with. If I were to become an orthopaedic surgeon about 11 years after qualifying having worked no more than 48 hours a week. I would have received about 25,000 hours of training. About half that of today's consultants. It certainly won't be considered acceptable to double the length of time it takes to become a consultant and so we're left with one scenario.

In 10, 15, 20 years time, the 'consultant led' NHS is going to be staffed by doctors with roughly half the amount of training their predecessors had.

Who would you want to replace your hip?

New Firm, New World

I've not done a medical firm for a while and it was a bit of a shock to the system when I started my new firm this week. I've been used to the relatively relaxed surgical specialties for a while. Surprisingly I'm loving it! Although its only been 2 days, I'm already getting quite into it despite the long days that I'm not really used to.

Yesterday was my first day, the registrar is off on holiday, the SHO was off sick and the consultant was busy. It was left to the F1 to do a ward round so I tagged along with him. The F1 is really nice, I learnt lots and found it really interesting. There weren't too many patients on our list though each one had their own complex issues. Its supposed to be a gastro firm so why one of our patients is a myeloma patient i've got no idea, it was certainly interesting the two of us trying to take care of this guy (neither of us know much about myeloma) trying to arrange an MRI for query cord compression was a challenge, and I ended up getting shouted at down the phone by a neurologist who didn't want to do his MRI. I left at 5pm, having not even had a 2 minute break all day, I was knackered, god knows how the F1 was feeling, he didn't leave till 7 and he'd done a 14 hour shift the day before.

This morning, I arrived promptly and helped out the F1 by doing some of his jobs, before 9am I'd done all the blood forms and spoken to a nursing home to find out the normal condition of one of our patients. The SHO turned up shortly after 9 and I'd been forewarned about her by the F1, he wasn't wrong, she wasn't the friendliest person in the world but there is always one bad egg isn't there? The consultant came along and it was decided that I should just shadow the F1 for most of my time on the firm which I'm really happy to do as I've already learnt plenty, including lots of tips about being an F1 which will come in handy. I enjoyed the ward round and after lunch (fortunately we had time for lunch today which was kindly bought for me by the F1) I stayed and helped with the jobs. To round the day off, I did an ABG on an old lady with annoyingly mobile arteries, fortunately I hit it, which is surprising as I've not done it for since early in 3rd year!

I'm really enjoying this medical firm, despite yesterday's 8 hour ward round. I'm even surprising myself. I'm looking forward to getting stuck in over the next 4 weeks and getting some really good experience shadowing the F1. I just hope when the F1s change in December that I get a decent replacement...

Problem Based Learning aka DIY Medicine.

I've been promising a post on Problem Based Learning (PBL) for a while now. A few people in particular have emailed me to ask about it, and medical school in general (Unfortunately I think I've terrified at least 3 people who might be coming to my medical school - oops.)

I wrote about PBL before...early in my blogging days in a post titled Learning Based Problem. Due to my developing interest in medical education, I approached the Dean to see if I could do a 3 week SSC on PBL. Fortunately he agreed and I spent most of the 3 weeks in bed reading various books and journals. It was a fairly relaxing SSC (although that's not the reason I requested to be allowed to do it!) but it was really rather interesting (I realise it probably makes me quite sad but I quite enjoyed reading about learning theory and the evidence behind PBL.) My 4500 word write up, again under the title Learning Based Problem was in the end quite good, although I didn't feel it really summarised my thoughts very well.

Despite having experienced 4 years of PBL, whenever anyone asks what I think of it I’m never quite sure what to say. Fundamentally I can see what the concept of PBL has to offer and I think the theory which supports PBL is sound; however most of the time, in practice, I don’t think PBL works. A successful PBL experience is dependent on too many variables which are rarely all fulfilled at the same time and as a result the process falls down, for example, a poor group dynamic or ineffective tutor can almost instantly render the whole process useless.

One important question is what are the most important qualities a doctor should posses? The GMC’s answer to that (Tomorrow's Doctors) is that more emphasis should be placed on the acquisition of general competencies rather than retention of facts. To a certain extent I agree but it is also important that doctors have the knowledge as well as general competency to be a successful doctor.

The evidence behind PBL is rather muddled, there is evidence to suggest it has benefits and weaknesses. Little has been done to compare PBL directly with more traditional courses due to the difficulties in assessing students from different courses. PBL is based on educational various educational theories. (I can't be bothered to go into this here. If you're really interested email me at imamedicalstudentgetmeoutofhere[AT]hotmail.co.uk and I'll send you a copy of my SSC.) In summary; the evidence that is available tends to suggest that PBL students have less basic science knowledge but have better clinical knowledge and basic competencies such as communication skills and team work. The latter could be explained by the fact that PBL curricula tend to have more communication skills teaching, Rather than attributing the improvement on PBL alone.

PBL is here to stay for the foreseeable future, and until someone devises an appropriate method of comparing students from both types of course the evidence base behind PBL will remain somewhat vague.

PBL does stimulate curiosity but in order to learn one must be very motivated all of the time, this is a hard concept to grasp when one is used to didactic teaching methods. PBL seems to have been taken up with some enthusiasm; however one of the main reasons for its failure in my opinion is that after the initial effort and outlay, some courses seem to be neglected, without constant update and maintenance the curriculum becomes neglected and ineffective.

In my opinion the benefits of PBL do not justify the resources required to implement such a drastic change in the curriculum. I do believe that both PBL and traditional methods of medical education have something to offer, but perhaps a combination of the two or even an entirely new approach to medical education would be best.

To be honest, I really dislike PBL. I enjoyed it in my first year (even though I had no idea what I was doing then) because it worked. Now it has just become a waste of my time, i'd be better off spending 2 hours reading a book than engaging in the pointless task that is PBL. After all, it is do it yourself medicine. Even most of my tutors are unsure about it, so what chance do we have? Saying that, I do like the freedom a PBL course gives you to learn what you want, when you want. I would have hated a completely traditional course.

Meh...that was just a muddled rant. I can never really explain PBL very well. Oh well, I hope some of you found it useful. I should just go back to moaning!