Abstract
Patient safety became a fundamental priority for the National Health Service (NHS) in 2000 following the Department of Health's publication ‘Organisation with a Memory’ 1 and subsequent establishment of the National Patient Safety Agency in 2001. Despite this, most acutely ill patients are cared for by the most junior medical staff who have the least knowledge and experience. Moreover, their knowledge of basic science has fallen due to the practical elimination of Pathology and Laboratory Medicine from the curriculum in many medical schools. This has happened despite the recommendation from the General Medical Council (GMC). ‘Tomorrow's Doctors’ 2 states that medical graduates must have a knowledge and understanding of clinical and basic sciences; that they must be able to follow, safely and effectively, interpretation of results of commonly used investigations; and ‘make clinical decisions based on the evidence they have gathered’. At the present time the GMC Education Section is preparing to review that document to ensure that the guidance is fit for purpose. Formal consultation will take place in 2008.
The modernization of the NHS includes a plan to reduce the heavy reliance on junior doctors out-of-hours by implementing ‘Hospital at Night’. This relies on defining competencies rather than grade of staff. It is recognized that a core function is the recognition and management of the critically ill patient. This will require inter alia competence in prescribing and maintaining intravenous fluids, necessitating a clear basic understanding of fluid balance and its assessment. 3 The new National Institute for Clinical Excellence (NICE) Guidance ‘Acutely ill patients in hospital’ 4 states that routine monitoring should include biochemical tests (for example, electrolytes, lactate, glucose and arterial pH). In 2006, a number of child deaths were reported to the Coroner in Northern Ireland, in which hyponatraemia had played a significant part, and mismanagement of fluid and electrolyte balance was identified as a major factor.
How will our junior doctors become competent in requesting and interpreting investigations in laboratory medicine? The author's experience of Foundation Years 1 & 2 (FY1 & FY2) doctors is that they have a very poor understanding of simple electrolyte disturbance including hyponatraemia. Moreover, they appear to have little concept of how tests should be used, and the role of positive or negative predictive values.
There is very little literature to demonstrate the impact of the knowledge of basic sciences by junior doctors and its bearing on patient outcome. There is no shortage of anecdote and circumstantial evidence, but hard evidence is missing. The report by Khromova and Gray 5 in this issue is therefore timely and confirms the concerns of our profession. Interestingly, ‘most countries assume that an increase in the doctor training rates will improve health care, but the evidence indicates that national health-care funds are better spent on promoting ‘evidence-based care' directly’. 6 Surely, an understanding of clinical biochemistry is pivotal to that evidence-based care.
It should be appreciated that it is not only clinical biochemistry but also physiology, anatomy, therapeutics and clinical pharmacology where undergraduate training is deficient. A letter in BMA News in June 20077 described a FY2 doctor examining a patient with a broken forearm who did not know the anatomical name of the bone, but thought it began with ‘T’! The Academy of Medical Royal Colleges and the NHS Institute for Innovation and Improvement are planning to incorporate teaching of management and leadership skills to undergraduates. 8 Admirable in its way, but will it be to the further detriment of basic clinical science?
If we are unable to improve the undergraduate training or even training of junior doctors, the role of clinical validation and interpretive comments will become still more crucial in protecting patients, 9 and will need to be combined with foolproof decision support systems and effective interactive computerized physician order entry. Are junior doctors even aware the laboratories have staff who can help them, not only with interpretation, but also with advice on appropriate testing?
Khromova and Gray 5 review the sparse literature available, pointing out there is little evidence that the use of laboratory services can be improved by education. The authors‘ survey was implemented as a result of the frustration of laboratory staff who recognized the gaps in the knowledge of junior doctors when discussing significant results. This must be echoed all round the UK.
Annals readers will not be surprised in the report that junior doctors felt more confident in their knowledge of when to request tests than in their ability to interpret the results. Almost 20% junior doctors felt confident enough to request tests that they were not confident in interpreting. Many of the junior doctors did not feel confident in either requesting or interpreting laboratory test such as magnesium, phosphate, parathyroid hormone, urine sodium and osmolality and the short Synacthen test. They were also not confident in interpreting the results of liver function tests, proteins and haematinics. Very few were confident in interpreting the results obtained from a haemolysed sample. Up to 75% of those junior doctors felt they required teaching, particularly around those investigations that they were not confidently requesting or interpreting. The majority agreed that it should be done either in the final year of medical school and/or in their first year. Not surprisingly, the preferred teaching method would be small group seminars, and on-line tutorials would be a useful adjunct.
It has been recognized by the authors that the survey was designed as a pragmatic tool to answer a local question and has some limitations. It certainly poses the question as to whether the current training of this cohort of medical students is fit for the purposes outlined by the GMC. It points out that if we are unable to address the undergraduate curriculum or training at FY1, there is an urgent need for further development of clinical guidelines in the use of biochemical tests. The authors‘ proposal to refine the questionnaire and identify training needs from doctors from other medical schools using different teaching methods is a way forward. It is however, pertinent that Trevor Gray has spent much frustrating time in an effort to increase the amount of teaching of clinical biochemistry in Sheffield without any success.
At this time, the Royal College of Pathologists is reviewing the undergraduate curriculum for pathology and laboratory medicine. It is essential that the GMC, universities and medical schools take note to protect both patients and junior doctors.