Junior doctors. Be part of the deal

A survey of junior doctors in trusts in one English region found the majority did not know whether or not their post met Department of Health requirements on hours and conditions. Most did not know that average hours worked per week should not exceed 56. Most of the acute trusts had groups to implement these New Deal regulations. But almost two-thirds of junior doctors were unaware of these. Ignorance of the New Deal by junior doctors and other NHS personnel could hamper accreditation of trusts.     

Raw deal

Despite the New Deal, most junior doctors in Scotland work more than their contracted 83 hours a week without extra pay, writes Peter Bennie.     

Calman and the new deal--compromising doctor training and patient care

Since coming into line with European law in 1995 junior doctors are expected to work no more than 72 hours per week and the European commission is currently working to reduce the working week even further to a maximum of 48 hours. Many junior and senior doctors have expressed concern over the training opportunities which would be missed by junior doctors working a shift pattern to reduce hours. Using a confidential questionnaire we approached 136 trainees in a large teaching hospital for their views.     

An evaluation by doctors in training of a pilot programme of physician assistants

New grades of health-care workers have been introduced to support trainee doctors and facilitate the implementation of the New Deal and the European Working Time Directive. This study surveyed the views of junior doctors regarding their experience of one such new post, called a physician assistant, and found trainees generally positive, welcoming this innovation.     

Do we practise what we preach?

There are recommendations regarding many facets of lifestyle. We proposed to look at hospital doctors' habits in East Yorkshire. METHOD: A simple questionnaire was sent out to 574 doctors in the Hull and East Yorkshire Hospitals NHS Trust. Non-responders were re-mailed. Age, sex, grade, specialty, number of portions of fruit and vegetable per day, alcohol intake, smoking, exercise and hours worked. RESULTS: 301 doctors (238 males, 60 females) responded (response rate 58%). Approximately half of doctors who responded were consultants. Few respondents smoked (6.6%), and the mean alcohol consumption, 8.35 units per week (SE 0.54), was less than the recommended limits for men and women. Most doctors fell short of the "recommended" 5 portions of fruit and vegetables per day (median 3 per day) and nearly half worked more than 56 hours per week. Most respondents took at least the recommended amount of exercise per week (112 SE25 minutes) although 26% of doctors took no exercise at all.     

Do junior doctors take sick leave?

Nosocomial infections place a heavy burden on overstretched health services. An audit of junior doctors' sick leave behaviour was undertaken in 1993 and again in 2001. The object was to ascertain the level of common infectious illness and to investigate whether junior doctors were remaining at work inappropriately. The doctors were asked if any factors had influenced their decision to take sick leave or not. Between the two audits several initiatives have been introduced to improve the working conditions of junior doctors, including the New Deal to reduce hours of work. Eighty one junior doctors in a large teaching hospital participated in 1993 and 110 in 2001. The number reporting an infectious illness in the previous six months was similar (61.7% in 1993, 68.2% in 2001). There had been a significant increase in the percentage of infectious illness episodes for which the doctors took sick leave (15.1% in 1993, 36.8% in 2001, p < 0.001). The most common reason for taking less sick leave than was felt necessary was concern about colleagues having to do extra work (72% in 1993, 68% in 2001). Consultant pressure was cited by 26% (1993) and 20% (2001). Use of the staff occupational health unit was minimal, with none of the ill doctors contacting the department in 1993 and only three in 2001. Overall, despite the reduction in the number of infectious doctors not taking sick leave, the majority remained at work. Fundamental changes are needed if potentially infected doctors are not to present a risk of iatrogenic infection.     

Medical training and the hospital at night: an oxymoron?

Context Attempts to reduce doctors’ working hours and streamline postgraduate medical training may mean junior doctors’ out‐of‐hours experience is reduced. It is also proposed that, in the UK, compulsory clinical (Foundation Programme) competencies are to be accomplished in 1 year rather than 2 years as they are at present. This observational study was performed to examine the scope of opportunity available to junior doctors to achieve such competencies while working on a ‘Hospital at Night’ (H@N) team. Methods A database of electronic requests made to the H@N team was used to tabulate the number and type of tasks requested and to define differences between specialties, using local hospital admissions rates to contextualise the data. These requests were then compared with a list of compulsory clinical competencies to assess the scope of opportunity available to trainees to achieve these competencies when working on the H@N team. Results A total of 8268 referrals were made to our H@N team between 1 October 2007 and 31 January 2008 using the electronic Hospital Information System^® (HIS^®). The predefined, online HIS^® request list included eight of the 20 tasks that represent compulsory competencies and showed that on average there were 247 opportunities per week of night shifts to perform them. Medical wards generated more requests than surgical wards (4767 versus 3170) and afforded greater opportunity to attain compulsory competencies (139 opportunities/week versus 96 opportunities/week; extra requests could not be attributed to either medical or surgical wards as original request did not include ward number). Conclusions The H@N initiative provides adequate opportunities for junior doctors to attain important clinical (Foundation) competencies. There appears to be sufficient opportunity to achieve these competencies within 1 year rather than the 2 years currently allowed in the UK Foundation Programme.     

海岛医院多渠道推进诊间结算的实践与成效

目的探索多渠道推进诊间结算的策略和经验,为进一步提升诊间结算执行率提供借鉴。方法①人员培训,对全院医生开展诊间结算的宣传动员和学习培训、年长医生重点培训、行政干预,提高医生开展诊间结算的积极性;②设备保障,对现有电脑系统升级改进,细化支付清单提供便捷查询,为医生诊间结算工作的顺利进行提供物质保证;③患者方面,利用各种宣传形式和传播渠道向公众宣传诊间结算的社会效益、使用方法,以及从年轻患者到老年患者的分阶段逐步普及,增加患者知情权,改善患者对诊间结算的接受能力;④协调管理,由诊区服务台对患者接受诊间结算的能力进行筛查,改善医生执行诊间结算的体验,提高效率。结果实施诊间结算后,病人的就诊过程比原先省去了就诊后排队付款的环节;医院诊间结算执行率,专家门诊从第1周的1.55%提高到第19周的69.20%,普通门诊从第1周的0.87%提高到第19周的38.26%,合计门诊从第1周的1.24%提高到第19周的55.15%,差异均有统计学意义(P<0.01);在此期间,患者就诊满意率从诊间结算第1周时的63.5%提高到第19周时的87.4%,差异有统计学意义(P<0.01)。结论诊间结算节省了患者的就诊总时间,提高了就诊满意度,缓解了人工收费窗口的工作压力,值得在各级医院推广应用。     

Work patterns and fatigue-related risk among junior doctors

Background

To reduce fatigue‐related risk among junior doctors, recent initiatives in Europe and the USA have introduced limits on work hours. However, research in other industries has highlighted that other aspects of work patterns are important in generating fatigue, in addition to total work hours. The Australian Medical Association (AMA) has proposed a more comprehensive fatigue risk management approach.

Objectives

To evaluate the work patterns of New Zealand junior doctors based on the AMA approach, examining relationships between different aspects of work and fatigue‐related outcomes.

Methods

An anonymous questionnaire mailed to all house officers and registrars dealt with demographics, work patterns, sleepiness, fatigue‐related clinical errors, and support for coping with work demands. Each participant was assigned a total fatigue risk score combining 10 aspects of work patterns and sleep in the preceding week.

Results

The response rate was 63% (1366 questionnaires from doctors working ⩾40 hours a week). On fatigue measures, 30% of participants scored as excessively sleepy (Epworth Sleepiness Score >10), 24% reported falling asleep driving home since becoming a doctor, 66% had felt close to falling asleep at the wheel in the past 12 months, and 42% recalled a fatigue‐related clinical error in the past 6 months. Night work and schedule instability were independently associated with more fatigue measures than was total hours worked, after controlling for demographic factors, The total risk score was a significant independent risk factor for all fatigue measures, in a dose‐dependent manner (all p<0.01). Regular access to adequate supervision at work reduced the risk of fatigue on all measures.

Conclusions

To reduce fatigue‐related risk among junior doctors, account must be taken of factors in addition to total hours of work and duration of rest breaks. The AMA fatigue risk assessment model offers a useful example of a more comprehensive approach.     

Education and the working patterns of junior doctors in the UK: a review of the literature

OBJECTIVE: To identify and review UK research relating to the effects of patterns of work on the education of junior doctors, describe the trends in the research, contextualise the progress of the UK in reducing the number of hours worked by junior doctors alongside that of other countries and identify areas for future research. METHOD: A total of 77 research studies, mostly written after 1995, were identified as relevant from approximately 900 references generated by searching Medline and using a 'snowball' technique. The articles identified were qualitatively reviewed to identify their key research conclusions and/or the main points of argument. These were collated and presented in a qualitative review. RESULTS: Research in the UK is contradictory regarding the effects of working patterns and the views of doctors towards them. Further research is needed to examine in depth the differences in the effects of working patterns on education between hard-pressed and non hard-pressed specialties, hospitals and regions. When viewed in an international context, the UK ranks among a number of countries with similar medical systems that are moving towards reducing the hours worked by doctors in training, all of which are at different points in the process. CONCLUSION: The literature review has helped to identify the popular wisdom surrounding the debate on junior doctors' hours, the progress of the UK when compared to that of other countries and gaps in research. Further research is needed to refine understanding of this area.     

Consultants' hours. A day in the life

Many NHS consultants are working more than their contracted hours. Diaries kept by 32 consultants in one trust revealed an average working week of 50 hours. A pilot scheme rescheduling the work patterns in a haematology department to include a rest day has reduced the number of hours worked. The scheme is popular with consultants and could be transferable to other teams.     

宁波市海曙区居民饮食与运动知识行为分析

目的　了解宁波市海曙区居民饮食运动行为现状 ,为在社区范围内开展饮食营养和运动的教育和干预活动提供依据。方法　采用两阶段整群抽样方法 ,抽取海曙区 5个街道 2 0 43名 1 5岁以上常住居民 ,其中 ,92 9名男性 ,1 1 1 4名女性 ;3 5 0 %的人为初中文化 ,2 5 2 %的人为高中文化 ,并对他们进行问卷调查。结果　海曙区居民人均每日盐摄入量是 1 4 8克 ,高脂饮食率为 9 3 % ,3 3 8%能基本保证每日奶制品摄入 ,规律运动仅占 1 6 7%。 66 4%的人不知道正确的每日摄盐量 ,3 0 9%的人不知道低盐食物能够预防高血压 ,3 6 7%的人不知道高脂、高糖饮食是糖尿病的危险因素。仅 5 4 7%的人知道肥胖是糖尿病危险因素之一。结论　食盐摄入过高与运动缺乏是海曙区居民最主要的问题 ,是今后海曙区开展慢性病控制行为干预的重点     

Impact of a 10-year nation-wide alcohol campaign on knowledge of sensible drinking limits in Denmark

In Great Britain and in Denmark, strong efforts have been made to influence knowledge on upper threshold for hazardous drinking. In Denmark, a campaign has been repeated every week 40 from 1990 to 2000 with information on the sensible drinking limits of 21 drinks per week for men and 14 drinks per week for women. The aim of this study was to examine the effect of this ongoing campaign on the level of knowledge of sensible drinking limits for men and women. Random representative samples of 1030 adult Danes were telephone interviewed each year during 1994–1999. Our main finding was that the level of knowledge of sensible drinking limits for own sex increased in all subsets of the population throughout the period. However, at the end of the study period (1999) a total of 80% of highly educated young (18–25 years) men knew sensible drinking limits for own sex, while only 35% of uneducated older (more than 65 years) men had knowledge on sensible drinking limits. The proportions were similar among women. Subjects admitting an intake higher than sensible for own sex, i.e. 21 and 14 drinks per week, respectively, had the highest knowledge of these drinking limits. We conclude that public health campaigns, such as the sensible drinking limit campaign, certainly has an impact on level of awareness in the general population. Furthermore, those drinking more than 21 and 14 drinks per week, respectively, are reached by these campaigns.     

Working hours. Minute stakes

The working time directive has major implications for NHS employers. Many NHS employers believe current systems for recording hours worked will not meet the directive's requirements. The introduction of leave entitlement for bank and agency nurses is likely to cost the NHS an extra 40 m Pounds or more a year. The directive does not currently apply to junior doctors. But if, as expected, they are brought within it, the implications for the NHS are huge.     

成都市二级以上综合性医院医务人员手卫生执行情况及影响因素调查

目的 了解成都市二级以上综合性医院医务人员手卫生执行状况及影响因素.方法 现场观察医务人员手卫生执行情况和手卫生设施,调查医务人员手卫生知识.结果 医务人员手卫生执行率为17.8％(接触患者前执行率为12.8％、接触患者周围物品及环境后执行率为21.0％、接触患者后执行率为27.3％,脱手套后执行率为31.5％);2.2％的医疗室有脚踏或感应式水龙头、24.5％有洗手产品,6.3％有干手物品;92.8％的医务人员知道六步洗手法,对手掌、手背、手指和指背等洗手部位的认知率均在90.0％以上,仅22.8％的人知道搓手时间为≥15s.副主任以上医师(14.6％)、主治医师(9.2％)和医师(15.6％)以及主管以上护师(25.0％)、护师(26.3％)和护士(20.5％)之间手卫生执行率差异均无统计学意义(P＞0.05).副主任以上医师平均知识得分(12.4±3.2)、主治医师(13.6±3.3)和医师(13.4±2.9)以及主管以上护师(15.2±2.0)、护师(14.8±2.1)和护士(14.3±2.6)之间差异亦无统计学意义(P＞0.05).护士的手卫生执行率(22.7％)明显高于医生(13.6％);≥50岁者(7.4％)明显低于＜50岁各年龄组(17.1％～25.0％);女性(19.5％)显著高于男性(13.8％);差异均有统计学意义(P＜0.05).护士的平均知识得分( 14.7±2.3)显著高于医生(13.2±3.1);50～ 59岁年龄组平均知识得分(12.2±3.8)显著低于20～29岁(14.0±2.6)、30～39岁(14.3±2.9)和40～ 49岁(13.8±2.7)组;女性(14.5±2.5)得分显著高于男性(12.7±3.2);差异均有统计学意义(P＜0.05).结论 成都市二级以上综合性医院医务人员手卫生知识水平相对较高,但手卫生执行率偏低,医院手卫生设施不完善.应通过进一步加强培训,改善手卫生设施,以进一步提高手卫生执行率.     

Views of junior doctors about their work: survey of qualifiers of 1993 and 1996 from United Kingdom medical schools

OBJECTIVE: To investigate the views of junior doctors about their work. DESIGN: Postal questionnaire surveys. SETTING: United Kingdom. SUBJECTS: Doctors who graduated from medical schools in the United Kingdom in 1996, surveyed at the end of their preregistration year (2926 respondents), and graduates of 1993 surveyed 3 years after qualification (2541 respondents). RESULTS: Almost 70% of the 1996 qualifiers felt that they worked excessive hours and 80% felt that they undertook too many routine non-clinical duties. Only 24% agreed that their postgraduate training was of a high standard and 22% felt they were being asked to perform clinical tasks with inadequate training. A total of 70% were dissatisfied with arrangements for cover for absent doctors. Senior doctors and nurses were regarded as supportive by most respondents, but hospital management was not. Although 65% were satisfied with their future prospects, only 36% had been able to obtain useful careers advice. Job enjoyment was reasonably high, with two-thirds scoring 6 or more on a scale from 1 (not enjoying at all) to 10 (greatly enjoying), but 70% of respondents felt that they had insufficient time for family and social activities. A briefer questionnaire sent to the 1993 qualifiers in 1996 showed similar results. CONCLUSIONS: More needs to be done to ensure that junior doctors are trained appropriately for the tasks they undertake, to ensure that they regard their training highly, to reduce excessive non-clinical work, and to provide reasonable working hours and cover.     

宁夏地区中学校医和健康教育教师预防艾滋病知识与态度

目的 了解宁夏地区中学校医预防艾滋病知识、态度及健康教育状况,为中学开展预防艾滋病健康教育提供决策依据。方法 以不记名问卷方式对宁夏4市92名中学校医进行调查。结果 有35.3%的教师曾接受过预防艾滋病健康教育方面的培训,90%以上的教师对艾滋病三大传播途径的知识掌握较好,但对于非传播途径、预防及治疗的基本知识回答正确率较低。分别有95.7%和98.9%的校医赞同在初中和高中开展预防艾滋病健康教育;但几乎所有的回族校医（96.8%）都反对在初中阶段讲解有关避孕套的知识,有49.2%的回族教师反对在高中阶段讲解正确使用避孕套知识。接受过培训的教师预防艾滋病知识得分、对在学校开展预防艾滋病教育态度总得分等均高于未受过培训的教师,且差异有统计学意义。回族教师对在学校开展预防艾滋病教育态度总得分明显低于汉族教师（P〈0.01）。校医预防艾滋病知识主要来自书籍、报刊、杂志（76.9%）,其次为电视、广播（45.2%）,培训在各种来源中居第5位（23.6%）。结论 应加强对民族地区中学校医和健康教育教师进行学校预防艾滋病健康教育的培训;尽快编写符合民族地区情况的学校预防艾滋病健康教育大纲及教师教学参考书。     

北京市平谷区职业人群健康素养状况调查

目的了解平谷区职业人群健康素养水平、健康知识知晓率、健康行为形成率,为采取适宜的健康教育方式、策略提供依据。方法采用分层整群抽样方法,抽取全区农林牧渔业、住宿餐饮业、其他服务行业三类职业人群共计650人,使用市疾病预防控制中心统一制作问卷进行健康素养状况调查。结果职业人群健康知识总体知晓率为63.0%;健康行为形成率为62.5%。文化、性别、年龄等多因素影响健康素养水平。三大职业人群对与医学相关的健康知识知晓率较低,尤其是紧急救护知识最低为28.5%;在职业防护知识中,比较关注职业危害的防护培训、设施、用品,而对《职业病防治法》了解甚少,为27.6%;对于健康基础指标、吸烟危害、农药安全等知识人群知晓率相对较高,分别为85.1%、86.2%、91.7%。在健康行为指标中,食用加碘盐知晓率最高,其次是每年体检,知晓率最低的依然是看病就医,分别为94.7%、85.1%、27.9%;拨打"120"、触电急救等基本技能知识知晓率相对较高,为94.5%和78.1%。结论应根据职业人群不同特征采取适宜的健康教育方式,加强健康知识宣传力度。尤其应增加紧急医疗救护、职业防护等相关知识储备,提高人群健康素养水平。     

Regulation of junior doctors' work hours: an analysis of British and American doctors' experiences and attitudes

Regulations of junior doctors' work hours were first enacted in the United States (US) and United Kingdom (UK) over a decade ago, with the goals of improving patient care and doctors' well-being while maintaining a high quality of medical training. This study examines experiences and attitudes regarding the implementation of these regulations among physicians and surgeons at two teaching hospitals, one in South-East England, and the other in New England, US. This paper presents the findings of a survey questionnaire and a series of in-depth interviews administered to a sample of junior doctors and the consultants responsible for their supervision. The study finds that the different policy mechanisms employed in the two countries have had different degrees of success in reducing the work hours of junior doctors. The results also indicate, however, that even in settings in which hours have been reduced significantly, the regulations have only had limited effects on the quality of medical care, junior doctors' well-being, and the quality of medical education. A number of barriers to the success of the regulations in achieving their objectives are identified, and the relative merits of political action and professional self-regulation are discussed. This research suggests that recently enacted policies requiring further reductions in junior doctors' hours in both the US and UK may face similar barriers when implemented. Understanding the lessons that emerge from implementation of the original regulations is essential if future reforms are to succeed and a high-quality system of health care is to be sustained.     

Practices and knowledge regarding prevention of tetanus among doctors in Delhi

A cross-sectional study was conducted in Delhi to study immunisation practices regarding prevention of tetanus among doctors and their knowledge regarding its prevention. Delhi was divided into five zones, and from each zone two hospitals and five dispensaries were selected, giving due representation agency-wise. All the doctors posted for casualty duty in the selected hospitals, all doctors posted in the selected dispensaries and two private practitioners selected randomly from the nearby area of the selected dispensaries were included in the study. Only 7% of doctors had received their last dose of tetanus toxoid to complete the immunisation schedule and majority had received it following injury. As much as 38.3% of doctors favoured TT after every injury. Out of the remaining who opposed it only 59.5% could provide the correct reason for this. Less than half of the doctors knew the indications of anti-tetanus serum. There is a need for the doctors to take TT immunisation more seriously and adopt recommended immunisation practices, because if they themselves are not following the guidelines, it is likely to be reflected in their advice and motivation to patients.