Introduction

Senior doctors working within emergency medicine (EM) in the UK are aware of the significant changes that the speciality has undergone in recent years. Postgraduate training and service provision are two areas in particular that have attracted a lot of attention.1

Recognising the need for improved medical training, EM has been active in the development and implementation of the Foundation and Specialty Training programmes, providing focused and modernised postgraduate training which aims to produce competent doctors and improves patient care.2 To facilitate this, junior EM doctors spend increased time away from the “shop floor”, attending tutorials and completing assessments, thereby restricting the availability of both trainees and trainers for clinical duties. Combined with shortened EM attachments from 6 to 4 months, this reduces clinical exposure, adversely affecting trainees' experience and potentially impacting on their work place productivity.3 As well as the predictable organisational issues such as more frequent induction programmes and staff turnover, this further increases pressure on senior EM clinicians responsible for ensuring a prompt delivery of service to patients and a smooth departmental or hospital journey.

It has been suggested that junior doctors see fewer patients than their predecessors with the burden of clinical work being transferred to senior clinicians,4–6 thus representing a fundamental shift in service delivery and a move away from predicted work patterns suggested by the College of Emergency Medicine in the “Way Ahead” document.7 Our aim was to chart the trend in work rate among junior doctors and the proportion of work performed by senior doctors over a 3-year period.

Methods

Ninewells Hospital in Dundee is a university teaching hospital with a busy emergency department (ED) providing care for the Tayside region. A smaller affiliated department operates at Perth Royal Infirmary 25 miles away. Together the departments see approximately 75 000 new attendances annually with a typical case mix (66% minors, 22% majors, 11% resuscitation, 18% paediatrics and 22% admitted). Junior doctors staff both departments 24 h per day. Ninewells Hospital benefits from 24-h specialist registrar cover and consultant presence within the department between 0800 h and 0000 h weekdays and 0800 h to 1800 h at weekends. Ordinarily, a specialist registrar and consultant will be present at Perth Royal Infirmary from 0900 h until 1700 h Monday to Friday. Outside these hours, a consultant is on call for both departments and senior specialist trainees at Ninewells Hospital provide telephone and telemedicine support to the departmental staff at Perth Royal Infirmary. NHS Tayside operates an Emergency Nurse Practitioner (ENP) service at both sites. The Perth Royal Infirmary service is operational 7 days a week, with a single ENP working between 0800 h and 2000 h. At Ninewells Hospital the service is limited to a Tuesday, Thursday, Saturday and Sunday, again with a single ENP working between 0800 h and 2000 h. ENP staffing numbers and service provision has remained constant since 2003.

Before August 2006 junior doctors worked as senior house officers (SHOs) in either department for their 6-month EM attachment. Staff expansion in August 2006 and a development in the junior roster provided Perth Royal Infirmary with an additional junior doctor shift daily, allowing doctors to rotate between both departments thus increasing their clinical exposure and maximising learning opportunities. This coincided with the introduction of the Foundation Programme and the reduced duration of EM attachments. From 2 August 2006, 20 trainees (eight SHOs on 6-month attachments, 12 Foundation Year 2 (FY) trainees on 4-month attachments) worked on the junior roster, maintaining a constant ratio of SHO and FY doctors at both sites.

Between 2 August 2006 and 31 July 2007, a prospective observational study was performed in both departments with the number of patients seen by junior doctors (SHO and FY) recorded monthly. Simultaneously, a retrospective analysis of the number of patients seen each month by junior doctors in both departments was performed for the period from 4 August 2004 to 1 August 2006 (SHO doctors). All information was obtained from a computerised patient record and management system (Symphony version 2.21.1.5, Footman-Walker). Investigators were blinded to the performance of individual doctors and, to prevent a performance bias, current trainees were unaware of the study. Productivity was established as the total number of patients seen annually and the mean number of patients seen per hour. The average number of junior trainee shop floor hours was calculated as follows:Average shop floor hours per week=((A×B)−(C+D))/Bwhere A = the number of hours per week, B = the number of weeks spent in the ED, C = the number of hours spent on annual or study leave and D = the number of additional hours away from the shop floor (eg, protected teaching, rest breaks, assessments, etc).

The same period of shop floor absence was applied to pre-2006 trainees as for the current SHOs. Results were analysed using SPSS for Windows and Microsoft Excel 2007, and comparison was made using unpaired t tests.

Neither ethical approval nor consent was required for this study.

Results

Between 4 August 2004 and 31 July 2007, 220 114 new patients attended both Tayside EDs (144 994 Ninewells, 75 120 Perth); 143 609 were seen by junior medical staff (65.24%), the remaining 34.76% being seen by senior medical staff (specialist registrars, consultants and associate specialists) and ENPs. Table 1 provides a detailed comparison of annual attendance figures, the number of patients seen by junior trainees, the predicted number of patients to be seen as recommended by the College of Emergency Medicine and the “Way Ahead”,7 and the changing trend in the percentage of patients seen by senior clinicians.

Over the study period the number of patients seen by junior doctors in the ED fell by 4% despite an 11% increase in trainee numbers in August 2006 (18–20), and was disproportionate to an overall fall of 0.7% in total attendances for the same period. The calculated mean number of patients seen per hour annually by junior trainees was 1.45 in 2004/5, 1.30 in 2005/6 and 1.21 in 2006/7.

Figure 1 compares the mean number of patients seen per hour each month by junior doctors in both departments, with trend lines showing the overall changes in performance.

• Download figure
• Open in new tab
• Download powerpoint

Figure 1

Reducing performance in the number of patients seen per hour by junior staff in both emergency departments. Trend lines show the overall changing performance between August 2004 and July 2007.

Discussion

Apprehension about service provision within the ED has increased over recent years. Shorter ED attachments, increased staff turnover and reduced junior trainee work hours has adversely affected their clinical exposure.8 Despite this, in a pilot of the foundation programme, Kilroy and Southworth9 found no reduction in trainees' clinical competency associated with a 4-month rotation, although Kilroy has recently acknowledged that we do not really know what competency actually is or means.10 This study has, however, shown reduced efficiency and patient turnover with a statistically significant 16.6% fall in the mean number of patients seen per hour by junior doctors between 2004 and 2007 (p=0.033, reduction in OR 0.24 patients per hour; 95% CI for reduction in OR 0.082 to 0.213). This decline in workplace productivity is equivalent to each junior trainee seeing 186 fewer patients annually. This has been partially offset by an increase in the number of junior trainees but, overall, senior medical staff also have to fill this deficit.

Within junior trainee ranks there does not appear to be a difference in productivity. A study recently published by this author compared the ED productivity of SHOs on 6-month attachments with Foundation Trainees on 4-month secondments. It demonstrated greater inefficiency as a result of shorter clinical attachments, but there was no statistically significant difference in the number of patients seen per hour by either group over a full year.11 These findings were supported in part by Eager and Banks12 who found that the introduction of the Foundation Programme did not affect the number of patients seen by trainees in their department.

During this study the number of patients seen purely by senior clinicians and ENPs increased to over 35%, presumably due to a reduction in junior productivity. In addition, senior doctors reviewed the majority of patients seen by junior trainees. There is little variation in the work rate by junior trainees at Ninewells Hospital ED where experienced registrars operate a full shift roster, providing round-the-clock supervision. This is in comparison with the falling work rate at Perth Royal Infirmary where immediate senior cover is only available between 0900 h and 1700 h. These findings, supported by those of Jayne et al,13 suggest the importance and effectiveness of having experienced medical staff available 24 h a day in maintaining ED work rate. As well as being an easily accessible source of advice for junior staff, they assist with decision making and patient management.

In the “Way Ahead”7 the UK College of Emergency Medicine suggest that junior trainees should attend to 3000 new patients annually with a work rate of 1.5 patients per hour. This study shows that the number of patients seen has fallen from 91.7% to 78.7% of this target over 3 years. Manpower planning for future emergency departments will have to take this into account. Junior trainees should no longer be seen as the main workforce for EM. Apart from matters of productivity, it is probable that the presence of experienced clinicians on the shop floor reduces unnecessary investigations, referrals and admissions and reduces delays associated with trainees from other specialities reviewing patients in the ED. This hypothesis needs to be tested but, if true, would provide further validation to the suggestion that EDs need to be staffed by experienced trained clinicians.14

Conclusion

Modernised training programmes improve supervision and teaching but reduce the availability of trainees for clinical duties and should not detract from the experience gained through actual patient contact. Junior doctors in EM see fewer patients than their predecessors. This is the result of reduced productivity and is perhaps exacerbated by shorter ED attachments. Senior clinician workload has increased, representing a move away from the traditional model of service provision. Recent increases in the number of EM specialist trainees has helped to absorb the shortfall, but it is likely that the number of trainees will fall in the short to medium term so this is not a sustainable solution.

The 24-h presence and availability of experienced clinicians on the shop floor can guide patient management and the flow of patients through the department. Part of their role should also be to try and maximise the work rate of junior trainees, but it appears they are filling a gap caused by reduced productivity. We suggest an increase in the number and proportion of trained clinicians within EM to continue to deliver effective training, supervision and ensure a safe, efficient and good quality service to patients.