Since the May issue of the Annals, the following letters have been published on our website <http://www.rcseng.ac.uk/publications/eletters/>:
letter . 2006 Jul;88(4):353. doi: 10.1308/003588406X114767
letter Ann R Coll Surg Engl. 2006 Jul;88(4):353. doi: 10.1308/003588406X114767
Ann R Coll Surg Engl. 2006 Jul;88(4):353. doi: 10.1308/003588406X114767
We are disappointed to read the comments by Wraight regarding the role of surgical care practitioners (SCPs). His grievances are not reflected by the Papworth experience. At our institution there are four basic surgical training rotational SHOs and two specialist SHOs, supported by eight SCPs including two trainees. The SCPs participate fully in clinical team activities, assisting on ward rounds and chasing blood results in addition to operating responsibilities.
The philosophy of our SCPs is to aid in the training of junior surgeons rather than to compete with them. For the more junior SHO, the SCP has time to teach basic surgical skills during saphenous vein harvesting, offering valuable advice and feedback on technique. Furthermore, the SCP can free up the more experienced SHOs from leg duties, allowing them to venture up the table and participate in chest opening, mammary artery harvesting and cannulation for cardiopulmonary bypass. A recent study of all cardiac surgery SHOs in England showed that most found the presence of SCPs to be beneficial.1
SCPs have become an integral part of Papworth, fulfilling both service and training roles. Within a suitable regulatory framework,2 we believe SCPs can be of benefit to surgical trainees and enhance learning opportunities.
References
- 1.Shrivastava V. Surgical assistants affect SHO training in cardiac surgery. Ann R Coll Surg Engl (Suppl) 2004;86:238–241. [Google Scholar]
- 2.de Cossart L. SCPs – Healthcare-Lite, response. Ann R Coll Surg Engl (Suppl) 2005;87:326. [Google Scholar]
Ann R Coll Surg Engl. 2006 Jul;88(4):353. doi: 10.1308/003588406X114767
I am pleased that Papworth Hospital has developed an effective model for surgical care practitioners (SCPs) and I am sure others have done similarly. However, seeing the extent of the draft syllabus for SCPs1 and the sexing up by the Department of Health,2 I am not sure that everyone is coming at this from the same perspective.
Perhaps I should clarify my position. I have no objection to and, indeed, I fully support the concept of ‘physicians' assistants’, where paramedical staff assist on ward rounds, cannulate, take blood, arrange investigations and follow up results, for example.
My delineation is that to wield a scalpel and a suture (or any physician equivalents) one should have a medical degree and the breadth of knowledge and understanding that such confers. It is illegal for someone without a veterinary degree to operate on an animal. An NHS Modernisation Agency Report3 and a currently unpublished paper of mine would suggest that patients would like the same standard of care for humans.
With regard to Shrivastava et al's endorsement of SCPs,4 the conclusions cited are not so sound. Their data actually suggest that SHOs are put off a career in cardiothoracic surgery after working with SCPs for six months (41% wishing to continue with SCPs vs 61% without SCPs). Moreover, while they offer that SHOs with SCPs may be more frequently involved in initiating cardiopulmonary bypass and other procedures, it is not recorded in what capacity (surgeon or assistant) and the data do not even come close to statistical significance (p=0.3–0.8). Instead, SHOs with SCPs only performed half the number of saphenous vein harvests. For SHOs, particularly those not wishing to continue in cardiothoracics, one would have to wonder if single-handedly harvesting veins is not actually the more useful experience. Contrary to Drury et al, I cannot deduce from these data that SCPs are beneficial to SHOs.
I was taught saphenous vein harvesting by my consultant surgeon and registrars, so benefiting from their years of varied surgical experience. I still got to the ‘top of the table’ once I had completed the procedure or by swapping periodically with the registrars and the surgical consultant. At what stage will Mr Nashef allow his more experienced SCPs to venture up the table? And what then would happen to his SHOs' and SpRs' training? If he will not let SCPs to the top end of the table, how is an arbitrary delineation of above or below the pelvis any more valid than mine?
SCPs are only needed to operate if there are not enough doctors. Every time an SCP does this is a time that a junior doctor does not. We should not let all these educational opportunities go begging when we are in the extraordinary times of training jobs being abolished and doctors being unemployed.5 Why, really, is this happening? No one has yet managed to convince me of anything other than that, for now, it is cheaper. In the long run as doctors, patients and nurses we may pay dearly in many subtler ways.
References
- 1.Department of Health. The Curriculum Framework for the Surgical Care Practitioner. London: DoH; 2005. Mar, [Google Scholar]
- 2.Department of Health. Patients to get quicker care as American ‘ER’ style roles come to the NHS. London: DoH press release; 2005. Nov 4, ref 2005/0382. [Google Scholar]
- 3.NHS Modernisation Agency. Public Perceptions of Surgical Practitioners. London: Department of Health; 2004. Jul, [Google Scholar]
- 4.Shrivastava V. Surgical assistants affect SHO training in cardiac surgery. Ann R Coll Surg Engl (Suppl) 2004;86:238–241. [Google Scholar]
- 5.BMJ Careers, theme issue: What can you do if you are out of work? BMJ Careers. 2005. Oct 22,
Ann R Coll Surg Engl. 2006 Jul;88(4):353. doi: 10.1308/003588406X114767
I have followed the discussions regarding surgical training and the impact of surgical care practitioners (SCPs) with interest.1 Clearly, there are strong arguments for SCPs. Perhaps the most significant of these is ‘increasing NHS workforce problems and growing healthcare demand’.2
It is an unfortunate fact that the European Working Time Directive and Modernising Medical Careers are significantly reducing the availability of junior doctors to fulfil these demands. Training non-healthcare professionals to take on the role of surgical trainees is an ingenious and cost-effective solution to this problem of increasing demand with limited supply.
I am, however, quite surprised that the roles given to these non-healthcare professionals are those of operative surgery (the one area where surgical trainees are significantly missing out) and on of the more demanding areas of a trainee's work.
Here is a golden opportunity to use non-healthcare professionals to relieve surgical SHOs and PRHOs of the tedious repetitive chores generated by the daily ward round and free them up to get to theatre. Juniors could then begin the surgical training, which they can currently only start at SpR level. More time could be spent with their consultant trainers rather than with the nursing staff on the ward.
We have all heard the stories of how many appendicectomies, varicose vein procedures and hernia repairs our consultant surgeons performed when they were PRHOs. The money being used to provide SCPs should be used to provide ward-based ‘physicians' assistants’ to carry out ward work. This would free surgical trainees to make better use of their limited hours, by going to theatre and operating, as our consultants once did.
References
- 1.Costa M. Undermining surgical training. Ann R Coll Surg Engl (Suppl) 2005;87:144. [Google Scholar]
- 2.de Cossart L. SCPs – Healthcare-Lite, response. Ann R Coll Surg Engl (Suppl) 2005;87:326. [Google Scholar]
Ann R Coll Surg Engl. 2006 Jul;88(4):353. doi: 10.1308/003588406X114767
I fully agree that surgical assistants on the ward and in theatre offer invaluable assistance to surgeons and improve patient care. In contrast, surgical care practitioners (SCPs), as defined in Mrs de Cossart's article,1 will reduce the exposure of surgical trainees to the detriment of their training. Furthermore, the shortage of experienced theatre staff in many hospitals will only be made worse if senior nurses and operating department practitioners leave to become SCPs. It worries (and annoys) me that senior members of the College dismiss these issues and the genuine concerns of surgical trainees.
Reference
- 1.de Cossart L. Curriculum development for surgical care practitioners. Ann R Coll Surg Engl (Suppl) 2004;86:354–355. [Google Scholar]
letter Ann R Coll Surg Engl. 2006 Jul;88(4):353. doi: 10.1308/003588406X114767
Ann R Coll Surg Engl. 2006 Jul;88(4):353. doi: 10.1308/003588406X114767
We live in a time of financial constraint and limited resources. While magnetic resonance cholangiopancreatography (MRCP) is undoubtedly sensitive and specific in detecting common bile duct stones, it is also expensive, relies on highly specialised equipment, requires specialist interpretation and is purely diagnostic. Intra-operative cholangiography (IOC) is easy to perform, cheap, has similar sensitivity and specificity and can be interpreted by the operating surgeon.
The authors mention the radiation dose involved with IOC but this is minimal. They also mention the fact that MRCP is less invasive. This is obviously the case but, as all these patients are due to undergo surgery, it is irrelevant. IOC does not add to the morbidity or invasiveness of a laparoscopic cholecystectomy and, if positive, can be confirmed with intra-operative cholodocoscopy, which also allows for stone removal. As stated, IOC does increase operative time but with experience this can be reduced to a few minutes.
Routine MRCP certainly wastes a considerable amount of the patient's time with an extra trip to the hospital often involving time off work, etc. The authors also state that IOC may lead to damage of the common bile duct. In our experience of more than 1,000 consecutive IOCs this has never occurred. Routine pre-operative MRCP cannot currently be justified.
letter Ann R Coll Surg Engl. 2006 Jul;88(4):353. doi: 10.1308/003588406X114767
Ann R Coll Surg Engl. 2006 Jul;88(4):353. doi: 10.1308/003588406X114767
When the CRABEL score method of auditing medical records was first published in 2001,1 our general surgical department found it helpful as a benchmark with which to analyse the standard of note keeping.
I agree with the authors that a large weighting is attached to the ‘subsequent entries’ section. If this is not recorded consistently well it has a large negative effect on the score. In fact, I think this has disproportionately high marks attached to it and a modification in the allotted marks would be appropriate.
I was interested to see in this latest paper that the notes were audited only once every six months. In our series this was performed monthly and presented at the audit meetings. The advantage to this was that all firms were aware of the process and criteria required to score well. As a by-product of this it became competitive between firms, which drove the standard up further. Over the initial three-month period of the audit the overall CRABEL score rose from 81% to 91% and in the worst performing firm from 77% to 98%.
I think this audit has done well to highlight the often poor note keeping that occurs. Nevertheless, in order to be most effective it should be repeated on a more regular basis. Once established it is easy to collect the data and regular presentation would remind all staff to document their entries in a satisfactory and medicolegally acceptable manner.
Reference
- 1.Crawford JR. The CRABEL score – a method for auditing medical records. Ann R Coll Surg Engl. 2001;83:65–68. [PMC free article] [PubMed] [Google Scholar]
Ann R Coll Surg Engl. 2006 Jul;88(4):353. doi: 10.1308/003588406X114767
We were pleased to hear from Mr Mutimer that others have found the CRABEL score a useful tool for driving up the quality of medical records. He and other colleagues would be aware that the quality of case notes now forms a fundamental part of the assessment of Trusts by the Clinical Negligence Scheme for Trusts programme. This process requires case note audit.
We have been struck by the ease with which the CRABEL score can be used and by the impact, as reported by Mr Mutimer, of feedback to colleagues and clinical firms, following which the performance does tend to improve.
No tool is likely to prove perfect but we have found the CRABEL score to be a useful part of the armamentarium of clinical governance.
letter Ann R Coll Surg Engl. 2006 Jul;88(4):353. doi: 10.1308/003588406X114767
Ann R Coll Surg Engl. 2006 Jul;88(4):353. doi: 10.1308/003588406X114767
This article leaves a lot unsaid about the system of x-ray interpretation currently widely used in emergency departments across the UK. The emphasis in foot injury assessment lies not in automatic x-rays by a junior doctor but in noting the exact mechanism of injury and good clinical examination, which helps x-ray interpretation enormously. An x-ray is not always needed. Like many things in emergency departments, this requires senior input.
The ‘ABCS’ system was described in 19951 and has been in wide use since then for all limb, spine and pelvis x-rays. ABCS represents adequacy and alignment, bone, cartilage and soft tissue. Alignment is applicable to TMTJ between the first metatarsal/medial cuneiform, the second metatarsal/intermediate cuneiform as well as the base of the fifth metatarsal/cuboid in two views. There are a few more alignments to be aware of in foot x-rays for completeness.
It is important that the ABCS method of plain film interpretation is taught and practised correctly in the emergency departments and is best done by emergency consultants.
Reference
- 1.Nicholson DA. ABC of Emergency Radiology. London: BMJ Books; 1995. [Google Scholar]
Ann R Coll Surg Engl. 2006 Jul;88(4):353. doi: 10.1308/003588406X114767
We agree that clinical assessment guides interpretation of radiographs. Consequently, as stated in our article, we took care to provide the doctors involved in the validation process with the history and examination findings that were documented in the clinical case notes. We agree that an automatic radiograph is not required in all cases of foot injury. In our experience, significant injuries may result from trivial mechanisms and the correct interpretation of radiographs is important if misdiagnosis of serious injuries is to be avoided.
Our simple, systematic method of assessing foot radiographs was developed independently and not with reference to the system of Nicholson and Driscoll. We believe alignment is best assessed by looking at the five lines described in our paper. Of note, neither the medial nor the lateral margin of the fifth metatarsal aligns with either margin of the cuboid. However, there is congruity between the articular surfaces of the base of the fifth metatarsal and the cuboid.
Education of junior doctors in emergency medicine should be the responsibility but not the exclusive domain of emergency consultants as other specialists have much to offer. Our motivation for writing this paper was to help reduce the number of patients presenting to our foot and ankle clinic with problems related to missed diagnoses in emergency departments. Before we developed our method, we tested a group of junior doctors with no prior accident and emergency or orthopaedic experience using the same set of radiographs and clinical findings at the start of their attachment and 24 weeks later. We found no significant improvement in diagnostic accuracy and the probability of recognising Lisfranc injuries hardly improved (from 0 to 0.1). We have shown that our simple method improves diagnostic accuracy (particularly of the Lisfranc injury) of junior doctors in accident and emergency.
Ann R Coll Surg Engl. 2006 Jul;88(4):353. doi: 10.1308/003588406X114767
Though I congratulate the authors on their attempt to simplify the interpretation of foot radiographs, I do not think that they have shed any new light on the subject. It is well documented that not only should the medial margin of the second metatarsal be in line with the medial margin of the middle cuneiform on the AP view but also that the medial margin of the base of the third metatarsal should be in line with the medial margin of the lateral cuneiform on the oblique view.1 It is this latter fact that is omitted from the study (to its detriment). Armed with these two facts, most junior doctors should be able to confidently identify a Lisfranc fracture dislocation.
I also disagree with the statement that ‘the medial and lateral margins of the metatarsals align with the margins of the corresponding tarsal bones’ as, for example, how does the lateral border of the fifth metatarsal align with the lateral border of the cuboid? Due to the considerable bony overlap, it is the two constant relationships previously described that are the most accurate markers of serious injury in the forefoot.
Reference
- 1.Raby N. Accident and Emergency Radiology: a survival guide. 2nd edn. Bailliere Tindall; 2005. [Google Scholar]
Ann R Coll Surg Engl. 2006 Jul;88(4):353. doi: 10.1308/003588406X114767
We agree that the base of the third metatarsal usually aligns with the medial aspect of the lateral cuneiform. However, on routine radiographs the position of the metatarsal is often difficult to assess because of overlapping shadows. This conclusion was also reached by Foster and Foster,1 who examined 200 foot radiographs in order to determine normal variations of the tarsometatarsal joint complex.
We agree that the lateral border of the fifth metatarsal does not align with the lateral border of the cuboid and, although this is not stated explicitly in our paper, it is implicit in the absence of a ‘sixth line’ in the alignment section of our article.
Reference
- 1.Foster SC. Lisfranc's tarsometatarsal fracture dislocation. Radiology. 1976;120:79–83. doi: 10.1148/120.1.79. [DOI] [PubMed] [Google Scholar]
letter Ann R Coll Surg Engl. 2006 Jul;88(4):353. doi: 10.1308/003588406X114767
Ann R Coll Surg Engl. 2006 Jul;88(4):353. doi: 10.1308/003588406X114767
I read with great interest the article Flying doctors from Guy Hirst. The answer is simply: yes. This article highlights the need for training of those who have the position of team leaders in whatever field of medicine they chose to pursue.
As an emergency medicine (EM) trainee it is imperative that my ‘team’ is in tune with the requests of the leader and the leader in tune with the team. However, it is not simply in EM that this is required.
Cockpit resource management was deficient at the time of the Everglades crash and has prompted the development of this strategy to prevent reoccurrence of such tragedies. The crew became fixated on the failure of a landing gear light prior to landing. As a result no one realised the auto pilot was off and that no one was actually flying the plane until the ground proximity warning lit up.
The cockpit recorder for this flight is played in the opening ‘lecture’ of the Sedation in Emergency Training (SET) course, which is designed and run from the six simulator centres in the UK (Bristol, Cambridge, Sterling and in London at Chelsea and Westminster Hospital, Bart's and St George's Hospital). The course is aimed at trainees in the early part of their SpR training to teach the crisis resource management ethos. It advertises ‘safe sedation’ within the emergency department but additionally augments your team leading skills; instead of saying, ‘Can someone quickly bleep the anaesthetist?’ and either no one or three people doing so, you should say, ‘Joe Bloggs, quickly bleep the anaesthetist and come back and tell me when you've done it’. A more advanced SET course is also available, aimed at higher surgical trainees from year 3 onwards.
This may seem an obvious way of approaching crises but in times of anxiety and stress it is the simple lines of communication that can result in failures of the system, thus putting patients at risk.
It is an invaluable skill and can be extrapolated to other courses and emergencies with critically ill patients on wards, in intensive care and operating theatres. I would commend similar simulator courses to all SpRs within surgery, EM and indeed all areas of medicine.
For information on the Chelsea and Westminster Hospital courses visit www.chelwestsimcentre.co.uk.
letter Ann R Coll Surg Engl. 2006 Jul;88(4):353. doi: 10.1308/003588406X114767
Ann R Coll Surg Engl. 2006 Jul;88(4):353. doi: 10.1308/003588406X114767
Macadam et al report an abdomino-perineal resection rate of 33.9% in their district general hospital study of 120 patients with curable rectal cancer. This rate is consistent with that achieved by low volume surgeons in a contemporary large national study of 523 patients with rectal cancer.1 However, the rate achieved by high volume surgeons in that national study was 14%. This negates the conclusion of Macadam et al that case volume does not affect surgical outcomes.
Reference
- 1.Spigelman AD. The National Colorectal Cancer Care Survey. Melbourne: National Cancer Control Initiative; 2002. pp. 38–39. [Google Scholar]