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Deskilling of junior doctors

  • Rameez Zafar (a1) and Khurram T. Sadiq (a2)
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Beale, C. (2006) Changing role of the junior psychiatrist – implications for training. Psychiatric Bulletin, 30, 395.
Woodall, A. A., Roberts, S., Slegg, G. P., et al (2006) Emergency psychiatric assessments: implications for senior house officer training. Psychiatric Bulletin, 30, 220222.
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BJPsych Bulletin
  • ISSN: 0955-6036
  • EISSN: 1472-1473
  • URL: /core/journals/bjpsych-bulletin
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Deskilling of junior doctors

  • Rameez Zafar (a1) and Khurram T. Sadiq (a2)
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Re: Training opportunities still exist

Khurram T Sadiq, Educational Staff Grade, CRHT
18 December 2007

Dr A J Shah has raised some very interesting points about the Crisis teamand risk assessment performed by Junior doctors. I would like to disagree withmy colleague about the role of the Crisis team. It is understood that the Crisis team was introduced as a part of the NHS plan 2000 to appropriately use beds for service users and to assess their suitability for hospital admission or home based treatment. I believe the importance of the self harm assessment

cannot be undermined as it is part of the holistic risk assessment which ascertains the risks attached to current mental state and social circumstances, detrimental either to self or others and therefore cannot be ignored.

The study under question is a small study ( Rameez Zafar & Khurram Sadiq 2007) and,although the results cannot be generalised still it gives an idea about the modern working of a junior trainee in Mental Health Services. I agree that the practice of psychiatry is variable across NHS trusts. The difficulty now faced by Junior doctors is a gradual reduction of exposure to psychiatric emergencies. Having worked in different areas and after speaking to various trainees at different levels, it is very much evident that junior trainee psychiatrists are attending to less of A & E referrals. The introduction of EWTD compliant rotas means that the emergency workload which was earlier seen by junior doctors is now shared by CRHT, Liaison and Self harm nurses.

My colleague would agree that trainees need appropriate exposure to improve skills and confidence which are essential for assessing and managing risks in psychiatric emergencies. Lesser exposure would result in substandard assessments and poor outcomes. I would disagree with the comments made by my colleague, about enthusiasm of the trainees as I fail to see any enthusiastic trainee opting to outshine the CRHT in assessing a

crisis. The advent of work based place assessments alone may not be enough for developing the required skills as the practicality of learning in crisis cannot be substituted.

I presently am working with a Crisis team in Leeds. I feel that dealing with matters proactively is the right approach. Reduced exposure to Crisis isa growing issue and the sooner it is realised the better.

Declaration of Interest - None
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Conflict of interest: None Declared

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Training opportunities still exist

Aadil Jan Shah, Speciality Registrar
11 December 2007

I disagree with the view that junior doctors in psychiatry have been deskilled because of the presence of Crisis Teams. The outcomes of the study done by R Zafar and K Sadiq may be true for Lincolnshire Partnership and perhaps for a few other trusts across the country. However, most Trusts provide good opportunities for the trainees to become involved in psychiatric emergencies or self harm assessments. I feel that the overall training opportunities for junior doctors have increased and junior doctors are more confident and skilled than before in dealing with self harm and other psychiatric emergencies.

The above study gives a wrong impression of Crisis Teams. These were introduced to provide home assessment and treatment as an alternative to hospital admission for people experiencing a severe mental health crisis, which necessarily does not include most or all the urgent or self harm assessments. The aim of the service is to ensure that people experiencing severe mental health difficulties are treated in the least restrictive environment and with the minimum disruption to their lives. Those engaging in self harm could be initially assessed by junior doctors and if appropriate referred to crisis teams for follow up.

There is a huge variation in the training opportunities throughout the country. In some trusts junior doctors do joint self harm assessments withthe crisis teams and in some trusts there are regular DSH rota's which include junior doctors, CPN`s and other members of team. Then there are trusts where no crisis teams are available over the weekends and junior doctors tend to do all the urgent assessments in Emergency Departments or deal with referrals from GP`s, many of which include self harm assessments.

I feel it depends on the enthusiasm of the junior doctor. If one is really interested one can find opportunities for such assessments. With the advent of Work Place Based Assessments (WPBAs), trainees now have the requirement to develop skills that will be tested before the examinations and if there are deficiencies in these to correct them while consultants have the responsibility to supervise these and ensure that opportunities are provided to a trainee to improve on these skills.

I am presently working at an inpatient child psychiatry unit and was not carrying out any urgent/self harm assessments at the start of my posting but I discussed my training needs with my consultant and highlighted this need. My consultant has ensured that I am a part of regular DSH rota and has arranged appropriate supervision for this.
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Conflict of interest: None Declared

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Deskilling of Junior Doctor: Back to the Basics

Adeniyi S. Adetoki, SHO Psychiatry
11 December 2007

The article in the recent edition of the Psychiatric Bulletin on the deskilling of Junior Doctors made very interesting reading for me as a doctor with a background in an acute specialty now working in Psychiatry. The significant fall in the number of trainees who carried out risk assessments on patients in crisis following the introduction of Crisis Teams is further proof that the issue of maximizing the efficiency of the training process requires further evaluation and adjustment to sustain quality.

History taking and physical examination are more generic skills that very often inform risk assessment of psychiatric patients. However, there are several articles published on the quality of these assessments carriedout when patients are admitted in hospital. For instance, an article on assessment of the quality and completeness of admission bookings publishedin a previous edition of this Journal showed wide variability ranging from13% to 97% for items recorded in the patients' history (Dinnis et al, 2006).

In an article on the recording of physical examination by trainees inPsychiatry, studies have shown this to be ‘uniformly poor’ or inadequate’.Issues relating to the attitudes of the psychiatrist to physical examination and progressive isolation from acute health services have beenadduced for this, as well as the structure of the training being increasingly focused on specialty (Garden, 2005).

In as much as it is important to address those issues relating to thedeskilling of trainees in Psychiatry with regard to specialty-specific aspects such as risk assessments, it is probably more important to addressthe issue using a bottom-to-top approach.

As an opinion, it might be helpful for trainees to spend some part oftheir time during training in the medical and surgical specialties in order to keep up to speed to an extent with skills previously acquired in those fields. Indeed, it is probable that there are more than just a few psychiatric trainees who really long for an opportunity to effectively deal with real or perceived inadequacies in dealing with issues of patients’ physical health, and consequently be equipped to deliver holistic care to their patients.

Declaration of interest: none.


DINNIS, S., DAWE, J., COOPER, M. (2006) Psychiatric admission booking: an audit of the impact of a standardised admission form. Psychiatric Bulletin, 30, 334-336.

GARDEN, G. (2005) Physical examination in psychiatric practice. Advances in Psychiatric Treatment, 11:142-149.
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Conflict of interest: None Declared

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Psychiatry is a big subject!

Michael C F Smith, Psychiatrist
03 December 2007

Decleration of interest : Nil

I read with interest the article which raised concerns regarding junior doctors exposure to self harm assessments.

It is clear that trainee's require experience of this area, but I feel that the article over-emphasises the relative importance of this whencompared to other training oppourtunities.

The authors figures suggest a large fall in self harm assessments following the introduction of the crisis team. I would be keen to know what the junior doctors were doing with all this extra time.

From my own personal experience, I find that a large number of self harm assessments involve repetition and often do not add to my overall understanding of the speciality.

The amount of information that each trainee must digest and organise is daunting and so the junior doctors timetable must be constructed to ensure it delivers 100% training efficiency.
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