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Junior doctors are performing fewer emergency assessments – a cause for concern

  • Linda Waddell (a1) and Colin Crawford (a2)
Abstract
Aims and method

Due to concerns regarding the reduced exposure of junior trainees to risk assessment, we have examined emergency assessments carried out in Forth Valley, Scotland, during a 4-month period to ascertain the assessor, time of assessment and outcome.

Results

During the 4 months of the audit, an average of 13 emergency psychiatric assessments were carried out by each trainee. The majority of these assessments occurred overnight (81%).

Clinical implications

Experience of emergency assessments by trainees was limited and tended to occur during on-call periods when there is little chance for teaching. With this limited exposure, trainees are missing out on valuable experience in emergency risk assessment and management planning.

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Copyright
This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Corresponding author
Linda Waddell (linda.waddell@nhs.net)
Footnotes
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Declaration of interest

None.

Footnotes
References
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1 Department of Health. The NHS Plan: A Plan for Investment, a Plan for Reform. Department of Health, 2000.
2 Scottish Executive. Delivering for Mental Health. Scottish Executive, 2006 (http://www.scotland.gov.uk/Resource/Doc/157157/0042281.pdf).
3 Woodall, AA, Roberts, S, Slegg, GP, Menkes, DB. Emergency psychiatric assessments: implications for senior house officer training. Psychiatr Bull 2006; 30: 220–2.
4 Griffin, G, Bisson, JI. Introducing a nurse-led deliberate self-harm assessment service. Psychiatr Bull 2001; 25: 212–4.
5 Royal College of Psychiatrists Psychiatric Trainees Committee. Finding the Balance: The Psychiatric Training Value of Out of Hours Working. Royal College of Psychiatrists, 2008 (http://www.rcpsych.ac.uk/pdf/PTC%20The%20training%20value%20of%20OOH.pdf).
6 Royal College of Psychiatrists. Specialist Training in Psychiatry: A Comprehensive Guide to Training and Assessment in the UK for Trainees and Local Educational Providers (OP69). Royal College of Psychiatrists, 2009.
7 Callaghan, R, Hanna, G, Brown, N, Vassilas, C. On call: valuable training experience for senior house officers? Psychiatr Bull 2005; 29: 5961.
8 Pelosi, AJ, Jackson, GA. Home treatment – enigmas and fantasies. BMJ 2000; 320: 308–9.
9 Glover, G, Arts, G, Babu, KS. Crisis resolution/home treatment teams and psychiatric admission rates in England. Br J Psychiatry 2006; 189: 441–5.
10 Coutts, P, McLaren, G, Crawford, C. Providing alternatives to inpatient care: the intensive home treatment team pilot in Forth Valley. Ment Health Rev J 2006; 11: 3740.
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BJPsych Bulletin
  • ISSN: 1758-3209
  • EISSN: 1758-3217
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Junior doctors are performing fewer emergency assessments – a cause for concern

  • Linda Waddell (a1) and Colin Crawford (a2)
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eLetters

Junior doctors performing fewer emergency assessments

alfia ubaidullah, Core trainee year 3
15 November 2010

The article by Waddell and Crawford clearly depicts the concerns among many junior doctors. They are quite right in saying that the introduction of new specialist teams and nurse led services although reduces waiting time and improves capacity has considerably reduced vital clinical experience for a junior trainee.

As a junior doctor in psychiatry working in a tier 4 service for young persons, my on call duty is to cover varied subspecialties like forensic, addictions, rehabilitation and adolescent units. Due to cover from ‘hospital at night team’ after 17:00 hours everyday, we as trainees do not get enough exposure to emergency assessments. Although there is a positive aspect to this arrangement in that one could be comfortably at rest during on calls, concerns are raised when a trainee is unable to see “atleast 50 individuals with a range of diagnosed conditions and with first line management plans conceived and implemented” by the end of training.Also preparation for the vital MRCPsych CASC examination is affected. Thusa lack of exposure to emergency assessments is a curse rather than a boon in any trainee’s career path.

To ensure achieving necessary clinical skills, what might help is senior clinicians voicing our concerns to the trust authorities to allocate emergency assessments to junior doctors and other physical aspects to nurse led teams. It is quite worrying to accept that in reality, many trainees fill this gap by doing extra locum shifts in various other trusts where there are more opportunities to improve their clinical skills.
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Conflict of interest: None Declared

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A Trainee's Perspective

Zena Bayatti, CT2, Old Age Psychiatry
08 September 2010

As one of the many psychiatry trainees who are affected by this reduction in assessments, I was relieved to see this article published in the The Psychiatrist. It draws much-needed attention to something that has been known for a while now, but this brings home the message that something needs to be done. There were different suggestions highlighted in the article by Waddell and Crawford(1), and a week-long placement with the crisis and assessments teams seems to be a good option, especially forthose trainees who do not have the opportunity to assess any patient in anemergency during their core training years.

As it is so variable between different units across the country as towhether the trainees get the opportunity to perform emergency assessments,maybe it should be a decision by the local Trust to find a way of getting this valuable training opportunity to its trainees. Whether it is decidedthat a week-long placement is adequate, a half-day session once a month, or even a training post set up for psychiatric trainees to be part of the crisis teams, it is definitely a matter that needs to be addressed, otherwise trainees coming up to advanced psychiatric training posts will not have the important and essential skills to be able to manage safely and efficiently any emergency assessment that come their way.

(1) Waddell, L., Crawford, C. Junior doctors are performing fewer emergency assessments - a cause for concern The Psychiatrist (2010) 34: 268-270.
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What constitutes an emergency assessment

Dr Sunil Kumar, ST4, General Adult Psychiatry
23 August 2010

I read the article with great interest. Though the results appear fairly conclusive the article is somewhat unclear about what constitutes an 'Emergency assessment'?

Emergency assessments often tend to be subject to a number of factorsranging from the availability of staff and resources to geography and local work practice.

Given the higher number of admissions by the junior doctors¹ ( 95 against 21, by or in the presence of IHTT Staff), it would call in the question of the presentations of the patients during the emergency assessment. It would be

curious to know the details of the emergency assessments e.g. how many of the patients admitted during the night were known to the services or how manyof them were brought under Sec. 136?

1. Waddell, L., Crawford, C. Junior doctors are performing fewer emergency assessments - a cause for concern The Psychiatrist (2010) 34: 268-270.
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Conflict of interest: None Declared

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Inconsistencies in Section 136 Assessments

Khurram Sadiq, Locum Consultant Psychiatrist
18 August 2010

Liz Tate rightfully mentioned that there are junior trainees attending to the Section 136 assessments, despite clear guidance in the Code of Practice ofit being done by Section 12(2) approved doctors. Further to that, The Code of

Practice states that a reason should be documented for divulging from the aforementioned practice. In most places this practice of assessments by non Section 12(2) approved doctor is a protocol and a norm.

Every directorate and Trust have their own, local policies, keeping the Code of Practice as standard. For the formulation of a local policy, representatives from multiple agencies like Police, A & E, Ambulance services, Social Services and Mental Health services formulate guidelines for the fluidity of the process of section 136 assessments. Time scales are set for the completion of these assessments and are regularly reviewed.

There are provisions for middle tier or consultant cover to facilitate the Section 136 assessments. Despite these arrangements, there are units where

the attendance of non-section 12(2) approved doctors is the first port-of-call for Section 136 assessments; after a detailed history has been taken from the patient, the Section 12(2) approved doctor is contacted and the assessment completed. Furthermore, it is known that there are places where

patients are discharged by non-section 12(2) doctors after having discussions over the telephone with a Section 12 (2) approved doctor. It has also been

found that there are times when patients are admitted to in-patient beds under Section 136 for more than 48 hours, for example, because the concerned Section 12(2) approved doctor is reluctant to come out to complete the Section 136 assessments out-of-hours. There are few places where the Code of Practice is scrupulously followed, and Section 12(2) approved doctors are the first port of contact.

It makes you wonder that despite of being a part of legal system, Section 136 is very poorly managed as compared to the other sections of the mental health act. There is no unitary form for Section 136 assessment documentation and no accountability for the assessments and detention of persons on Section 136 of the Mental Health act. The time is right to make

amends for this varied practice and measures taken to get it right.
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Conflict of interest: None Declared

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Junior doctors are performing fewer emergency assessments

Martin S Humphreys, Senior Lecturer in Forensic Psychiatry
26 July 2010

Waddell and Crawford(1) have demonstrated very clearly that trainees are becoming more and more limited in their experience of emergency psychiatry. This is, to use their own words, a very real cause for concern. The same may, however, also apply to their experience in day to day psychiatric practice. With so called functionalisation, clinical teamsand their members may be dealing with an increasingly narrow range, if anyat all, of patients, most of who might have the same diagnosis. This is not to deny the need and requirement for individual care pathways and treatment plans, but it may severely limit learning opportunities. Of no less concern, and possibly even more so as it may eventually effect early interest in and recruitment to our speciality, is the influence that thesechanges in service organisation have had on undergraduate medical students' experience of psychiatry.

The development of functional teams, the separation of in patient care from community care, and the increasing specialisation within psychiatry mean that the clinical experience offered in undergraduate placements may not be providing either the depth or breadth of experience required to assure that students see common conditions, follow through thecourse of a single episode from inception to recovery, and understand the range of abnormal phenomena in psychiatry and the treatment options that are available. Most medical schools offer six weeks of placement in psychiatry within the five year course. This exposure is likely to be the only formal training in psychiatry for most doctors training in the UK.

The problems in specialist training highlighted by Waddell and Crawford(1) extend beyond mere reduction in the number and frequency of assessments to experience of presentation and management of anxiety-related disorders, obsessive compulsive disorder and eating disorders, andwill soon include assessment of memory disorders, most of which have been ceded to nurses or psychologists. These trends and changes will ultimatelyaffect the clinical skills of future psychiatrists and recruitment to psychiatry from among UK medical graduates.

1 Waddell l, Crawford C. Junior doctors are performing fewere emergency assessments - a cause for concern. Psychiatrist;34:268-70
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