I used to be dead against proformas - loss of clinical freedom, loss of
initiative, loss of the power to think, etc. But I have changed my mind
over the last few years as I've seen the quality of our juniors change,
especially the SHOs who are still the supposed backbone of the department.
We use clinical questions at interview as we have found them to be the only
method that allows us to weed out the absolutely incompetent junior doctors
who were the utter banes of our lives some years ago. We have found that
the doctors' levels of theoretical knowledge are often very good indeed.
Sadly, when it comes to putting this knowledge into practice, things are
different and our doctors now are very poor at making good clinical
decisions. They do every possible investigation as a way of delaying or
avoiding decisions and now are seeing an average of one to one and a half
patients per hour. We have introduced protocols for chest pain, PE, and
DVT, for example and they even seem to have difficulty following these at
times. Nevertheless, more often than not, they manage to do so and patients
are managed in a reasonably sensible way. We are now looking at protocols
for UGIH, TIA, and query appendicitis and I believe the appropriate use of
such methods will lead to an improvement in patient care, where the correct
patients are admitted and the others are safely discharged. I cannot see
why we should worry about giving juniors experience of decision-making in
our departments when this leads to a poorer standard of patient care.
Cheers,
Rocky
PS - OK for the spelling and grammar, AF?
-----Original Message-----
From: Accident and Emergency Academic List
[mailto:[log in to unmask]] On Behalf Of Prescott Mark (RLZ)
Sent: 21 December 2005 13:43
To: Laurence Rocke
Subject: Re: Proformas
This forum has now been described as a "so-called academic mailing list"
Today I have experienced my own worst nightmare of observing petty bickering
and "parent behaviour" which has clogged my already overfull inbox and has
contributed nothing to academic progress.
Perhaps it is now time to grow up and consider the issue raised - ie do
proformas help either the patient or the doctor?
I think the answer is probably "some"
I am sure that I have seen a study showing that the use of a structured
assessment of patients with RIF pain did result in better diagnosis of
appendicitis, but have not seen a parallel study of the doctors skills and
development as a result of use of this tool.
My own department has found that current juniors seem to have less basic
knowledge and confidence than say 10 years ago, and are working slower, with
individual doctors seeing fewer patients per hour. Their patients may indeed
benefit from their use of proformas!
The underlying question is when do juniors learn to make decisions and this
seems to being put back and back (medical SHOs not discharging patients
etc). How do doctors gain that confidence? (obviously by seeing more
patients!)
I suggest that A&E is one of only a few specialities that still have SHOs
discharging a patient on their own initiative. In the West Midlands there
are still several A&E departments where an SHO will work at night without a
resident Senior. For how long will this be continue to be acceptable and
what is the alternative - do we limit which patients they should see
(downgrading the department) or try and pay for middle grade docs - oh and
by the way where do they come from?
MP
> -----Original Message-----
> From: Paul Bailey [SMTP:[log in to unmask]]
> Sent: 21 December 2005 13:17
> To: [log in to unmask]
> Subject: Re: Proformas
>
> I have read the original post and actually had no trouble whatsoever
> understanding it.
>
> Kind regards
> Paul Bailey
>
> -----Original Message-----
> From: Accident and Emergency Academic List
> [mailto:[log in to unmask]] On Behalf Of Adrian Fogarty
> Sent: Wednesday, 21 December 2005 6:51 PM
> To: [log in to unmask]
> Subject: Re: Proformas
>
> Fine if we're talking about simple errors, although in this case they did
> make the post incomprehensible. But it was the incorrect use of the
> adjective "loose" in place of the verb "lose" that was the final straw!
> I'm
> afraid, this habit is becoming "de rigueur" among the "chav set" in this
> part of the world (and before anyone corrects me; yes, there is a verb "to
>
> loose" but this is used very rarely nowadays and certainly not in the
> context intended below) so I cannot bear to see it being used on a
> so-called
>
> academic mailing list.
>
> AF
>
> ----- Original Message -----
> From: "McCormick Simon Dr, Consultant, A&E"
> <[log in to unmask]>
> To: <[log in to unmask]>
> Sent: Wednesday, December 21, 2005 8:24 AM
> Subject: Re: Proformas
>
> Dear Adrian,
>
> Thanks for feeling the need to pick up upon my grammar/spelling in a
> reasonably public forum, this is of course something you have done to
> others
>
> in the past but usually in a less aggressive and condescending way. You
> are
>
> quite right, there are problems with this e-mail, which are clearly
> visible
> to me now, but as this was the third time I'd tried to type it (my e-mail
> server and spell checker kept crashing) at the end of what was already a
> particularly frustrating day, I guess I missed them. Terribly sorry to
> have
>
> irritated and depressed you but perhaps cutting a colleague some slack was
>
> beyond you yesterday.
>
> Merry Christmas
>
> Simon
>
> -----Original Message-----
> From: Adrian Fogarty [mailto:[log in to unmask]]
> Sent: 20 December 2005 18:26
> To: [log in to unmask]
> Subject: Re: Proformas
>
> I'm sorry, it's been a long time since I had a whinge about grammar, but
> the
>
> email below has completely lost me. The third sentence finishes with a
> clause: "and even if they do follow them." but then ends abruptly just
> when
> I was expecting something to follow! Later, the sixth sentence finishes
> with: "something I'm convinced proformas will do" which doesn't appear to
> make any sense given the overall context of the post. There are numerous
> other minor stylistic issues that bother me but none of these appear to
> affect the meaning, so I won't mention them here, apart from the
> irritating
> habit of using the word "loose" when the author clearly means "lose": a
> depressing but increasing "trend" over the last few months.
>
> AF
>
> "McCormick Simon Dr, Consultant, A&E" <[log in to unmask]>
> wrote:
>
> Folks,
>
> We are continuing to face the problem of increasingly junior staff trying
> to
>
> see increasing numbers of patients, whilst their supervision is by junior
> or
>
> locum middle grades and only a few consultants. This inevitably leads to
> errors. We already have guidelines available but you cannot guarantee
> staff
> read them, and even if they do follow them. Audit just highlights the
> problem but by then they have moved on to another job. A suggested
> solution
> is the use of proformas but this just makes my heart sink as it seems a
> cheap alternative to good (continuing) education, supervision and
> experience. Surely we need to encourage free thinking and understanding of
>
> the subtleties of medicine, something I'm convinced proformas will do.
> I've
> seen similar things used before and juniors either loose sight of the big
> picture or shoe horn cases that don't quite fit in to these systems. I can
>
> see the short term financial, time and clinical risk gains but aren't the
> loss of developing good clinical skills and that 6th sense inevitable and
> unwanted? Or am I being an old fashioned fuddy duddy and worrying about
> nothing.
>
> Simon McCormick
>
>
> Rotherham
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