Aha! A chance to agree with Adrian and disagree with Matt!! Speaking as an
Educationalist Boffin (love it!!), I must take issue with a comment from
Matt. He states that SHOs teaching one another is "a useful means of
learning (self directed learning, small group work) if you believe our
educationalists." WRONG! Small group work is excellent, I agree, but it
needs to be moderated, supervised, and directed by an experienced teacher.
Therefore, SHOs teaching each other in this context can only be guaranteed
to be effective and correct if a senior is overseeing the discussion. The
benefit of this is that the SHOs work out the correct answer for themselves
(yippee, we like that) without the danger of coming to the wrong conclusion
(again, yippee) but the problem is that it ties up yet another doc into the
equation (boo).

Therefore I agree with Adrian (pause.......wipes sweat from brow) that a
vertical method of teaching is more labour efficient. Also, don't ever
forget that SHOs can teach us a thing or two! That is the beauty of working
in such a diverse specialty! Of course, we have developed the skills by the
time we get to the lofty heights of consultancy of "allowing them" to share
their wisdom with us whilst giving them the impression that we knew all
along and were just testing their knowledge before we scuttle off to the
text books to read up on it ;-)

Andy

-----Original Message-----
From: Accident and Emergency Academic List
[mailto:[log in to unmask]]On Behalf Of Adrian Fogarty
Sent: 04 January 2003 17:09
To: [log in to unmask]
Subject: Re: Induction of SHO's

----- Original Message -----
From: "Dunn Matthew Dr.
Subject: Re: Induction of SHO's


> What do you think about 2 consultants in the same speciality asking each
> other for advice? Is that OK?

A good question Matt, but it's not entirely comparable! With SHOs it's often
a case of "the blind leading the blind", especially if they're all first
years, and no individual has significantly more experience than his peers.
It's also unfair on the second SHO, who has no experience or training in the
art of supervision. This is crucial; individual clinical skill is very
different from supervisory clinical skill, and it's something one only
learns at SpR level.

It takes a lot of experience to be able to listen to an SHO's presentation,
to extract the relevant material from the "fluff", to scan the
investigations and data, and to rapidly drill down to the crux of the case.
It particularly takes experience to know which patients one needs to review
oneself, and which can be managed "remotely". OK it's safest to personally
review all patients but it's just not practical if the department's busy and
you're the only senior, sometimes fielding opinions from 6 or 7
"practitioners" at a time. Part of this skill is about knowing your juniors,
knowing which ones you can trust, and which ones need a more circumspect
approach.

Also you need to distinguish between "clinical" queries and "decision"
queries. In the former, the SHO cannot really assess the case clinically,
often it's something visual or palpable, and there's no point wasting time
talking about it, you've just got to go and see the patient yourself, for
example to visualise a wound or burn, or to feel a mass or lump etc. In the
latter however, the SHO has clearly and competently gathered all of his
"evidence", and is confident of his clinical findings, but he's just having
trouble integrating it into something meaningful, or else he has analysed
his case properly but he can't decide on "disposal". Finally there are many
cases where the SHO is confident of his clinical findings but he has
problems with data interpretation, for example an ECG or x-ray. In all of
these cases there's little to be gained by reviewing the patient again, and
it may actually be wasteful of resources. I'm not sure how it works in the
States and Australia where all patients must be "signed off" by the
attending physician or consultant, but I suspect not all patients are
physically reviewed, rather most of them are discussed and reviewed
"remotely"; I'm sure someone will correct me if I'm wrong.

At the end of the day, asking another SHO will rarely lead to a fresh review
of the patient, it almost invariably leads to a "remote" opinion, which
might be totally inappropriate for the situation. Finally it can also be
incredibly inefficient, with the first SHO taking the second SHO "out of
circulation" for several minutes, often to no avail, and the first SHO then
invariably asks someone else slightly higher up the "food chain" and so on.
On occasion I've observed three of them crowded around an x-ray viewing box
musing over something, but with no clear lines of responsibility. Eventually
a registrar or consultant gets asked. I don't understand this sort of
"avoidance behaviour", perhaps as I get older I'm getting more intimidating
or maybe the SHOs are getting meeker, or both. But it rarely happens in our
department, they know they'll get shouted at for this; our consultants have
an open door policy for SHO opinions, which they use very liberally indeed!

Sorry for the long reply, but supervision of SHOs is a whole subject in
itself, and it's quite distinct from your own personal clinical skills. So I
must agree with Rowley, vertical transmission is much healthier than
horizontal, whatever the educational boffins try to tell you!

Adrian Fogarty