From :  Rowley Cottingham <[log in to unmask]>

>Of course the job isn't what we signed up for! Like any job it has to 
>change with the times, and one of the things I have written about before 
>here is exactly what we need to be doing in terms of selecting and training 
>juniors as the job has changed.

--> I agree that we should expect the job to change. Like any other aspect 
of medicine has and always will. You're on the spot there! However, I'd like 
to add that, as I completely accept what you say and I was repeatedly 
advised of this by my consultants at the start of my training, I "signed up" 
for what I expected the job to be NOW, NOT for what it was when I trained. I 
now advise my juniors, as you do here, to assess what ANY specialty will be 
like when they get to cpnsultant stage, not what it is now.

>I predicted 5 years ago that in 3 years time we wouldn't be doing any minor 
>injury work; the ENP would become like the midwife and do all of that work. 
>It hasn't quite come to pass yet, but it is certainly going that way with 
>primary care doing primary care work as well - and we can hardly grumble 
>about that as we have been begging for it for ages!

--> We have ENPs in cardiology, NOT for minors. I love working with ENPs 
(we've had this discussion before). If you get enough ENPs and get them to 
see minors, then, as you say, there will be none left for "us". If you get 
enough in-house specialty juniors to accept ED through-put as a sorting 
service, then we will not get to see many other cases. For example, many 
departments see no paediatrics and others no gynae cases. Most departments 
divert STDs, etc... Some departments use Staff Grade docs to blitz through 
the minors and this has the same effect as ENPs would have as far as the 
SHOs are concerned. So, it is up to whoever decides the staffing mix - the 
ENPs do not "invade" EDs and kidnap patients - they are sought after and 
hired. One should not hire them if one wishes to see these minor cases, or 
just hire "a few" to see SOME of the minors...

>Again, I wrote of this before and was dismissed, "Oh, there'll still be 
>plenty of work for us!". People are now coming to realise what I meant, and 
>we need to do two things.

--> Seems they were right - I understand most departments are seeing more 
cases each year, not less.

>Firstly, we need to be moving into the community; why can't one be a 
>Community Consultant in Emergency Medicine guiding ECPs and paramedics as 
>well as juniors who could be working on ambulances SAMU style?

--> Sorry. Don't like working on the road that much. Happy with the 
"community" moving to my ED, as it does now, in greater and greater numbers. 
I happen to find the current patient mix to my liking. I also like to 
multi-task, depite being X-chromosome-deficient... Seems to me that ED 
consultants are becoming more and more necessary every day and I expect the 
need for ED care to accelerate, 'cause we do just about everything we do 
more efficiently!

>Secondly, we need to look at what we do well; before the 4 hour standard we 
>all got very skilled at looking after medical patients for 12 to 48 hours. 
>So let's do that, and look after patients for that time; this is acute 
>medicine, if you like, and we have a good service up and running. In fact 
>it is so efficient that the PCT is querying our huge number of zero length 
>stays and we aren't using all the beds in our short stay facility. Once 
>they get over two days and go to the 'ologists things are very different.

--> On the money there!!! Agree! We see and admit under us a huge variety of 
cases, including not just the obvious ones (head injury, ?SAH, cellulitis, 
?PE, chest pain, etc.) but also pneumonia, asthma, collapses, anaemia, 
pylonephritis, etc...

>As a Consultant you should relish multi-tasking.

--> YES!

>I remember from my youth a man who used to do a stage act with plates and 
>bamboo poles;
about 50 of each and he'd set a plate spinning atop each pole.

--> Also remember him. Saw him in ED the other day with hypertension and 
stress-related symptoms... Dx: Multi-task-itis (just kidding - I agree with 
you)

>Of course this all goes out of the window if minors gets wall-to-wall as 
>ours has recently

--> ... Ahh... Sounds like you are a few ENPs short... But get only as many 
as leave the right amount of minors for the docs, according to how YOU and 
your colleagues like it to be... It's not a zero or 100 ENP situation...

From :  McCormick Simon Dr, Consultant, A&E <[log in to unmask]>
>...but doesn't the problem come when a department has to try and work in a 
>'standard' way which doesn't suit one type of colleague or another.

--> You're right. The "average" is often not the "mode" and even when it is, 
there are many who fall on either side...

>Take the idea of 48 hour care of patients, it is quite clear that some 
>people think this is great and is the way forward, whilst there are also 
>some (perhaps the low
boredom threshold group - me included) who find this concept the antithesis 
of what they want.  The challenge for the future will be in finding space 
for both sets of people.

--> You could not have been more right. I am in EM for a number of reasons, 
one of them being that I hate seeing any patient more than once and I hate 
ward rounds even more. Like you, probably. And yet, I am very happy to be in 
a department that admits under itself that variety mentioned above. This is 
not a contradiction. I have colleagues who DO like the ward rounds... They 
also seem to dislike the multi-tasking bits I like. So we share the load 
fairly but UNEQUALLY - they do more rounds and I do less and focus on the 
plate-juggling a bit more... Of course, you need a big department with 
multiple consultants...