Wednesday, 3 September 2008

Having a stab at it

When I was training, procedural skills were taught at the bedside by someone a touch more experienced (an SHO or Reg or SR) who would talk you through something like cannulation or siting a chest drain or lumbar puncture or whatever. You just had to crack on and do these things, they're practical tasks, you can't just read up on them. A skill you aquire through doing it, we got better at intubation at cardiac arrests and suprapubic aspiration of urine in kids and siting central lines through doing more and more of them.

As one SR quipped, placing a needle at the ready, "You just need to have a stab at it!"

The benefits of this system were that you got really immersed in the clinical work, your competence (and confidence) got better from aquisition of skills, it was you who were working intimately with patients so developed consultation/therapeutic skills and there was someone who knew what they were doing standing right next to you so if care wasn't right then they would do it (so there was no practising and playing, patients got the right care).

Nowadays, practical tasks can't be learnt "on the fly" like this.

No no no.

Our Deanery organises regular teaching on training, the current vogue for practical skills is of explanation, then showing someone the task talking it through for them, then you doing it silently, then showing them the task with them talking it through to you, then them doing it. Surely life's too short for this.

Worse, once a trainee has done something, it needs documenting. Not just documenting in clinical records what's been done, no, it needs documenting in the trainees logbook or portfolio that they've done whatever.

Worse still, it can't simply be a comment that the procedure was successfully undertaken and any positive/negative feedback noted, it has to also be documented online as a DoPS. DoPS, you don't know? It's unclear to you what a DoPS is?

Fear not, you're in good company.

The DoPS is undertaken on the Royal College of Psychiatrists own web site, entered online (since, of course, electronic information systems, especially online ones, are the safest and most robust methods of storing sensitive information on trainees successes and failures). The Royal College site describes DoPS as "DoPS Direct Observation of Procedural Procedures" one one page but then as "DOPS Directly Observed Procedural Skills" on another.

So, after a trainee successfully administered a depot antipsychotic injection under the auspices of a band 7 nurse, which was the work of moments, we then have to spend an age documenting it all for the trainee.

Is this better than when a nurse could toss the syringe over and say, "Have a stab at it!"


Socrates said...

If what I've read is true about a consultant's training being reduced from 40,000 to 10,000 hours, then I suppose you need to make quite sure they've had a stab at everything at least once. However if 50% of those 10,000 hours are spent at a computer filling in forms...

Tainted_Halo said...

Nursing went the same way.
There are some serious issues that clinicians are 'completing' training without actually doing all the basic requirements.
I never cannulated nor set up an IV drip - but then I haven't done it in 15 years MH nursing either so perhaps no loss. Which makes you wonder why MH trained nurses have to complete it now.
I don't think the training needs to be so structured to be honest. Most clinicians truly learn once they're let loose. Tho it would be interesting to see if there is a massive reduction in errors for which this convoluted evidential training process can take credit.

cellar_door said...

We have a set of mandatory competencies we have to meet - ranging from basic physical obs through to being able to talk to a patient without calling them a wanker - but some of the other skills are optional. These are things like catheterisation; we get taught them in the classroom but are not required to demonstrate competence in practice. I don't know if it's different for adult nurses.

ditzydoctor said...

i agree! we don't have the same system where i come from, but really, the amount of time i spend trying to document proof of my presence and having done certain skills is just amazingly wasted. it stinks :(

Oliver Smith said...

It would appear to me that the changes in medical training will mean that the Consultants of the future have less experience and knowledge than most of those in the post.

I agree that 100 hour weeks are not ideal, but now instead of 10 or 12 years at 100 hours a week, it's 6 or 7 years at 48 hours a week...that's a massive difference. The move to class room teaching is also concerning, considering the fact that many aspects of medicine are practical and hands on!

Will patient care suffer i the future as a result? The answer is probably, but we won’t know until the future is the present and the past!

frontierpsychiatist said...

My experience from physical medicine is that nurses have this the worst - doctors can still learn things like cannulation relatively speedily, whereas nurses seem to have to do about 50 of them observed and the training is much more regimented.

This has its pros and cons, but I fear in medicine this current assessment culture has lead to a lot of grading sheets being signed off without a great deal of time being put into them. I can think of at least one doctor who was waved through assessments whilst still having poor clinical skills...