Whatever happened to bedside teaching?
Zoya Arain investigates the impact of the EWTD on clinical teaching
The practice of bedside teaching has evolved from the dawn of clinical medicine and is considered crucial in the development of a clinician who can integrate theory, practical skill and empathy. Under the close scrutiny of a formidable consultant, small groups of junior doctors learn how to correctly perform the physical exam, become proficient in applying clinical ethics, and take a patient history.
However, with the European Working Time Directive (EWTD) and the potential consequences of the health bill proposed by Andrew Lansley this year, can this age-old practice survive the ever-changing face of the modern NHS?
For surgical trainees and junior doctors, who routinely worked between 60-75 hours weekly, the EWTD had a significant impact on available training hours. Since its arrival, the EWTD has invited a barrage of criticism from surgical trainees and junior doctors themselves, to the senior most members of the Royal Colleges.
In response to the complaints, the government commissioned an independent review assessing the impact of the EWTD on training, headed by Sir John Temple published on ninth of June 2010, entitled ‘Time for Training’. It concluded that it is possible to deliver high-quality training in a 48-hour week on the condition that trainees do not have a major role in out-of-hours services, are well supervised and have full access to learning opportunities.
In an out-of-hours care system, most shifts occur in the evening or at night, and there are often gaps in the rota, filled by junior doctors. However, with the 48 hour weekly cap, the doctors find themselves sacrificing planned daytime training sessions for poorly-supervised night time shifts, with consequent repercussions on the quality of training they receive.
As a solution to this problem, Sir Temple states that ‘it is imperative that the NHS moves towards a consultant delivered service’ with the foundation of a ‘24 hour presence or ready availability for direct patient care responsibility’. Despite a 60% expansion in consultant numbers over the past ten years, it has been observed that junior doctors are still being heavily relied upon to fill rota gaps in out-of-hours services. Sir Temple argues that ‘there are over 15,000 hours available to trainees on a 48hr contract in a seven year training programme but these are not being used effectively’. Furthermore, planned reductions in trainees by the year 2015 will only serve to amplify this problem.
Although the proposal of further expansion in consultant numbers is an attractive one, there are two real limitations to its viability. Firstly, the ability of the NHS to finance this endeavour is questionable, with 53,150 posts due to be lost across 155 hospitals in a bid to cut down on expenditure. Secondly, with the progressively managerial responsibilities of consultants who are the principle force behind ‘target-driven healthcare’;; training junior doctors may no longer be considered a priority.
Despite the admonitions of the EWTD by Sir John Temple, the report was conclusively supportive for its future in the NHS, though this sentiment has not been echoed by much of the medical profession. John Black, President of the Royal College of Surgeons, stated that ‘even in the most modest of aims, the EWTD have not delivered for
surgery’. Surgery is an acute specialty with a need for ‘24-hour cover’, which is completely incompatible with the seemingly arbitrary 48-hour cap. We ask whether we wish to be operated on in ten years’ time by a consultant which the BMJ themselves acknowledge would have some 3,000 hours less experience than their predecessors.
This year, the liberating NHS White Paper proposed by the Health Secretary, Andrew Lansley, has been the new focus of media attention. The bill recommends the involvement of the private sector in the provision of health care. However, one of the major concerns being expressed in response to this idea is the subsequent effect this will have on medical training. The Professor of General Medicine at Manchester University, David Metcalfe, explains that the NHS has made allowances for the training of junior doctors with higher staffing levels to allow consultants and registrars to teach at the bedside;; ‘will the NHS... be able to compete on price and support education this way?’. Another point he raises is that a ‘hands-on’ approach is essential in clinical learning. The patient’s case needs to be wide enough to ensure that it is representative and will enable doctors to make ‘informed career choices’. Should private companies ‘cream off’ the most profitable illness, students in orthopaedics, for example, may see a greater share of trauma cases and far fewer hip replacements.
With the availability of simulators and computer software enabling students to develop practical skills in their own time, supervised training may not be the sole means of gaining competence in particular skills. An example of this is the laparoscopic surgical stimulator, which is becoming more frequently sighted in teaching hospitals. However, without the presence of a patient, there is little clinical context upon which technical detail can be hung.
It is difficult to fully anticipate the extent of the repercussions that a reduction in training time will have on the doctors of tomorrow. However, the dissatisfaction and anger being expressed so soon after the reforms have taken place, offer a bleak window into the future if nothing is changed.
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