> A little too low. I've been asking this question with
> colleagues for some time now.
>
> The question being, "what is the minimum number of new
> patients that a Consultant should see per year in order to
> maintain clinical skills and maintain street credibility with
> the staff". The number seems to be about 1,000 seeing
> patients across the case mix.
>
> Of course it might be fairer if there was a point system for
> New Patients depending on the Triage Code e.g. 10 points for
> a resus case and 1 for a Green Category


We've been talking about this. My own view is that a total across the skill
mix just doesn't work. Point system by triage code doesn't really work
either. The case mix is just too varied. I'd reckon that you'd be wanting a
certain number of each diagnostic group (trouble with code by triage
category even if modified is that you won't maintain your skills in
resuscitation of critically ill patients by signing off a few CPR in
progresses; and you'll maintain your skills at management of complex soft
tissue injuries better by seeing a couple of dozen complex cases than by
seeing a couple of hundred unselected cases- even if the triage category
remains the same).
Of course, this is one of the problems with consultant expansion: although
the number of patients seen by each consultant may remain constant or even
rise; there is a risk of decreasing the complexity. Looking at major trauma-
from the TARN data there has been a drop in the proportion of patients seen
by a consultant; and given the drop in major trauma and the rise in
consultants, the decrease in cases per consultant must be considerable. I
have seen no data on critically ill medical patients, but suspect there may
be a similar picture (mitigated somewhat by the rise in cases of severe
sepsis and septic shock). It is a problem if this issue is hidden by
consultants dealing with minor soft tissue infections, clearing cervical
spines after simple rear end shunts and applying the Ottawa ankle rules.

Much of our departments' workload involves exclusion of pathology. While
this is useful experience up to a point, it is not on a par with treating
and treating serious pathology. For example: in major trauma there is some
benefit- particularly to the team as whole rather than individuals- in
running trauma alerts as a trauma team; but this is no substitute for
actually treating major trauma, and if done too much may create the wrong
mindset (one expects there to be nothing serious, and so treats each patient
as though there is nothing serious). Similarly, with minor injuries, there
is some benefit in examining minor ankle sprains (fixes the Ottawa rules in
one's head), but one has to actually see a few peroneus tendon subluxations,
tibialis posterior tears or osteochondral fractures of the talus to learn
and maintain skills in their diagnosis.

If you break down the casemix needed by actual cases, then you might get a
very different picture (and one that poorly reflects the workload). For
example a consultant may need to see:
50 trauma resus cases including 10 with ISS over 15
100 physiologically unstable medical patients with at least 20 each of
septic shock, cardiogenic shock and lower airway obstruction
40 ankle injuries including at least 5 each of peroneus tendon subluxation,
tibialis posterior tear, osteochondral fracture, Potts fracture and minor
sprain
40 shoulder injuries- 20 dislocations, 10 acute rotator cuff tears and 10
proximal humeral fractures.
etc.
I'd reckon you could get a lot of experience (probably more relevant
experience than many consultants currently get- and particularly with the
sicker patients the workloads suggested above are considerably higher than
the total number of cases per consultant coming to many departments) keeping
within the 800 cases; just you'd be seeing a lot fewer undifferentiated
minors than many consultants see.

Good stuff. Well worth debating. The debate may become a little
uncomfortable, though as at the end of the day there's only a certain amount
of pathology out there. This puts an upper limit on the number of
consultants per head of population. In some cases I suspect we're close to
that upper limit.

Matt Dunn
Warwick


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