I guess my concern amongst others about senior sign off is
1. the evdidence base from which this was constructed - scanty
2. the choice of patient and reasons for doing this 
3. the ability of CEM to 'enforce' this as a standard in EDs - surely those of
us who will fail at this (we are one of those) will just politely ignore it?
The EDs who are therefore the most 'at risk' from a safety perspective will not
benefit, at least in the short term.
Whilst the aim of improving quality and safety in the specialty is laudible, I
think we need to be sure that this direction is the right one before embarking
on it. This will probably apply to all the new set of indicators that there
seems to be great difficulty over agreeing at the moment. I have asked for a
robust evaluation and opportunity to develop some good evidence for the future
shape of indicators to go alongside all of this, and I hope that we will have
that opportunity. The risk here is that CEM will introduce these standards
without the evidence for impact and then be blamed when it all goes wrong - I
would not wish that scenario.
Best Wishes
Sue Mason

Professor of Emergency Medicine
University of heffield

Quoting Doc Holiday <[log in to unmask]>:

> 
> From: [log in to unmask]
> > Having had 20 yrs at the Alamo ED...
>  
> --> Well, I have never even lived in any one country for 20 years, nevermind
> worked at one place... I have not worked at the Alamo, although I have worked
> at a couple of places which bore a remarkable resemblance to Stonehenge in
> the modernity of their methods...;-)
>  
> > I believe I should have the Lead Acting role as John Wayne
> http://www.imdb.com/title/tt0053580/smile
>  
> --> You can have that John; I see Emergency Physicians more like another
> John...
> http://www.youtube.com/watch?v=g25G1M4EXrQ&feature=related
> Listen in particular from time-mark 1:41...
> In the words of JFK: "We choose to... not because they are easy, but because
> they are hard..."
>  
> > As my own son jumped ship from ST3 EM to Anaesthetics ST2
>  
> --> Well then... I guess he can play a Leonard instead of a John where he's
> going 'cause "it's life, Jim, but not as we know it..."
>  
> ;-)
>  
> Best wishes to your son on his future career. I can't imagine he made such a
> decision without the required thought.
>  
> I switched a couple of times before landing in EM and I only wish for your
> son that he's as happy enetually in his career choice, as I am. That when he
> has been a consultant for a few years, for longer than he has been a trainee,
> he can look back and be happy with his choice, as I am.
>  
> Happiness is what it's about.
>  
> I also happen to see things quite positively as I look at the future. I have
> probably more experience with ships than most on this List and I can tell you
> quite certainly that, although rats do leave a sinking ship, any good captain
> and any solid crew will tell you that making their ship comfortable for the
> rats is not their role in life...;-) And this is what goes through my mind
> when I come across VTS trainees who misunderstand things like those you have
> described, after a mere few weeks in the ED... while I praise them on their
> career choice of being a salaried GP...
>  
> I have not yet had a look at the "sign off thing" which started this debate -
> anyone have a link? But I do have quite an interest in American EM, which has
> been mentioned already. While it is true that they have sign-offs and
> night-shifts, I would like to point out that their system is so vastly
> different from ours that these two things are a mere drop in the ocean. I
> have had the opportunity to taste work in American EM and I have a couple of
> dozen friends (mostly those I teach ATLS with) who are American EPs. THEY ARE
> NOT HAPPY!!!
>  
> I would caution strongly anyone who wants to make our system "more like the
> USA".
>  
> For those who are not aware, sign-offs by seniors only happen in the minority
> of American EDs. In most there are no trainees whatsoever. It takes 3 years
> to train through an EM residency, out of medical school, and as of year 4 one
> is one the shop floor, with an approximate split of 1:1:1 between
> days:evenings:nights and quite often 2:5 weekends... Most EPs work where
> there is no-one to teach and spend most shifts being the only doc or one of
> two docs in the ED at the time, doing nothing more than seeing one patient
> after another. In a world which revolves around money, they are the specialty
> which does not make much of it for their business/hospital. Burn-out is rife.
> Happiness is not. In-fighting within EM is a huge problem.
>  
> This is not tough to understand, if one looks more deeply. In the USA the
> people you see in EM all signed up and committed to do it when they were
> students, having never worked a day as a doctor. No way could they have as
> much to base that decision on as your son would have!!! And those who guessed
> wrong about what they thought they'd like - they are STUCK! By the time they
> have done 3 years of residency and are in, say, year 1-2 of EM proper and
> realise they hate it, they are just beginning to dig into around $200-300K
> debt and there is NO WAY they could afford to pull out and retrain for
> another 3-4 years in some other specialty, NOT earning the bucks while they
> train, thus unable to pay off the debt AND get on the housing ladder AND
> start a family all at that time. So they stay in EM and the system burns them
> out in 10-15 years. Then they move into "urgent care" (which is the same as
> general practice but WITHOUT getting to know the patients well), or running a
> restaurant or some other business...
>  
> I have shown over 20 American EPs by now through my own ED, giving them the
> grand tour and also demonstrating HOW we work and how our rota runs and how
> we interact with other specialties, etc. Their jaws drop. They cannot believe
> how nice things can be for EM...
>  
> Personally I know I would not enjoy doing night shifts. But I think
> shop-floor consultant night shifts will come in for bigger EDs only and I
> would like to work at such a place and do them AND not like them. There are
> other things I don't like, but I think they are the right thing to do. We all
> have things like that.
>  
> I am already working in a system where we are used to vetting the decisions
> of our juniors for cases without waiting for them to call on us for help. It
> works very well. I cannot see how to do it in a small ED.
>  
> Of course, trainees at my place also see their consultants under work-stress
> sometimes. But then they realise that we still walk in at the start of our
> shifts with a smile, happy to be where we work, which is NOT as common among
> our non-EM colleagues - THEY admit that. Then they realise how "anti-social"
> hours translate into shorter clinical activities and more time away from
> work. 9 out of 10 of them look, panic and opt for another career. We keep the
> rest. Nice!
>  
> I can write a couple of hours more about what's wrong with EM in the USA, but
> I'll spare the List. Happy to reply OFF-list if anyone wants to know. I'll
> summarise instead with a non-show-biz set of characters... Not John Wayne;
> not JFK... Cows instead... All cows know that the grass is greener on the
> other side. A happy cow is that which enjoys the yellow grass. And all of us
> have seen a busy night in the ED and so we know how much more yellow grass
> comes in every day. Do we really want lots of cows to share it with? Or
> should we instead focus on how fewer of us can deal with it more efficiently
> and be rewarded appropriately?