John,

I agree with much of what you say.

I don't think anyone, and certainly not me,  is suggesting that the only
criteria for assessing the impact of experienced staff in emergency care is
the clinical outcome in medical emergencies. My initial question was simply
to try and identify evidence around a very specific part of our work i.e.
management of acute medical emergency conditions for a project I'm involved
with.

Of course senior staff in A&E contribute much to the overall organisation of
their departments, the delivery of emergency care in general, research,
training, accident prevention etc. etc. I wasn't trying to find the evidence
base to support the effectiveness and cost/benefits of these contributions -
but now you mention it, such a body of evidence - if it exists - would be
very powerful in  support of the drive for more experienced staff in our
departments.

Mike Lambert. 


> -----Original Message-----
> From:	john ryan [SMTP:[log in to unmask]]
> Sent:	27 October 2000 14:09
> To:	[log in to unmask]
> Subject:	seniority of doctors
> 
> Mike,
> 
> Surely health planners, health authorities etc should be reminded about
> the 
> huge wealth of emergency medicine literature that has been produced by 
> 'senior doctors'.   What do we want to tell them ? That when a consultant 
> puts in a cannula and listens to the chest and takes the blood and writes 
> the x-ray form and prescribes the treatment that the outcome is always 
> better than when the SHO does it ?  Should'nt we be telling them that 
> senior A&E doctors have helped develop the modern emergency departments 
> where systems and processes may be just as important as the grade of
> senior 
> doctor seeing the patient.  You might have all consultants seeing patients
> 
> but without an appropriate triage system for example your MI patient could
> 
> still be delayed to thrombolysis.
> 
> Just take a look at any edition of JAEM for instance or take any edition 
> you like of Annals, Academic Emergency Medicine, Emergency medicine  or 
> Journal of Emergency Medicine.  Who is producing these papers ?  It cert  
> ainly aint SHOs in the majority of cases.  It is SpRs and Consultants. 
>  What are they writing papers about ?  Issues and system processes that 
> improve patient care in emergency departments.  They arent all RCTs but 
> they are about improving quality of care for emergency patients and they 
> are 'senior' initiated.  Would thrombolysis in A&E have occurred without 
> A&E consultants taking the lead in initiating/facilitating the process ? 
>  Would managing patients with primary care problems in an innovative way
> in 
> the emergency department have developed without senior A&E doctors ? What 
> about  Kevin and Simon's Bestbets ?   What about the role of seniors in 
> medical education ?  What about quality issues targeted at vulnerable 
> groups such as the elderly ?  and so on.
> 
> Sure it is intuitive that A&E seniors can impact on patient outcome by 
> dealing with their medical problems at a personal level but supposing all 
> those years ago Platt had'nt recommended appointing A&E consultants, do
> you 
> think a system of care provided by the most junior doctors in the hospital
> 
> responsible to absentee landlords would be positively effecting patient 
> outcome today ?  Have a look at some of the other countries in Europe
> where 
> emergency care is provided by the most junior doctors and see how good or 
> bad their systems are/
> 
> We need to give credit to the first generation of A&E consultants who 
> established our specialty and who created an environment which has allowed
> 
> us to develop systems and processes for improving patient outcome.
> Quality 
> emergency care with positive patient outcomes won't happen without 
>  clinical and administrative leadership by senior people who understand
> all 
> the variables involved in the provision of modern day emergency care. 
>  Others need to acknowledge the role that supervision and leadership at a 
> senior level in emergency departments plays in ensuring the best resources
> 
> and processes are available for patient care.  It would be nice to have 
> emergency medicine as a senior doctor based service (after all you want 
> your Granny to see the most senior doctor when she is sickest don't you ?)
> 
>  but we also have to have it as a senior doctor 'led' service.  The two 
> must go hand in hand.
> 
> John Ryan
> 
> 
> 
> 
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