A study of the use of log books in the training of psychiatrists

There is an increasing interest in the role of audit in medical practice. Less emphasis has been placed on audit by trainees and it has traditionally involved the use of log books or case books for examination purposes. One type of log book simply lists the diag noses of consecutive cases seen. Such a record is used in the Viva part of the Examination for Membership of the Royal College of General Practitioners. Another form of log book, often referred to as a case book, usually involves a more detailed account of the cases seen by the trainee. Case books form part of the Examination for Membership of the Royal College of Obstetrics and Gynaecology as well as the MRANZCP and Canadian Psychiatric Examination. The working party on the MRCPsych Examin ation (1985) recently considered the use of log books or case books but it eventually rejected the idea. They felt such records were not a substitute for the adequate maintenance of case notes and would not be an effective discriminator in examin ations. The working party did note the value of log books or case books as an aid to training, although the disadvantage of the latter is the extensive dupli cation of material from case notes in a "polished"

There is an increasing interest in the role of audit in medical practice. Less emphasis has been placed on audit by trainees and it has traditionally involved the use of log books or case books for examination purposes. One type of log book simply lists the diag noses of consecutive cases seen. Such a record is used in the Viva part of the Examination for Membership of the Royal College of General Practitioners. Another form of log book, often referred to as a case book, usually involves a more detailed account of the cases seen by the trainee. Case books form part of the Examination for Membership of the Royal College of Obstetrics and Gynaecology as well as the MRANZCP and Canadian Psychiatric Examination.
The working party on the MRCPsych Examin ation (1985) recently considered the use of log books or case books but it eventually rejected the idea. They felt such records were not a substitute for the adequate maintenance of case notes and would not be an effective discriminator in examin ations. The working party did note the value of log books or case books as an aid to training, although the disadvantage of the latter is the extensive dupli cation of material from case notes in a "polished" form.
In 1987, the Residency Review Committee for Psychiatry in the USA promulgated new regulations governing the conduct of residency training pro grammes. These included a requirement that audit of the residents' clinical activity be maintained throughout their training attachments (Stein, 1986). One of the recording systems used was intermediate between a log book, which merely lists diagnoses, and the more extensive case book. This format may prove to be a useful application of audit to training of junior psychiatrists. In this study a two-stage trial of the use of such a log book was carried out by trainees on a teaching hospital psychiatric registrar rotation.

The study
The log book The log book consisted of a pocket-size, loose-leaf binder containing brief instructions for use. This introduction was followed by three main sections: the first listed the trainees' goals for the specific clini cal attachments: the second had tables for recording cases seen; and the third section had summary sheets to keep a running record of clinical experience.

Stage I Aim. To see if log books could be used for open learning and self evaluation.
Six trainees newly appointed to the Newcastle Registrar Rotation agreed to take part in a six-month trial of the ue of the log books. Three of the trainees had psychiatric experience before joining this scheme. Three trainees were merely given the log book and asked to monitor their clinical experience. The remainder were given an individual introduction to the log book, its rationale and use, but were again left to monitor their own work. No further input was given to any trainee on the use of the log books. At six months, trainees were asked to return the log books together with a questionnaire on its usefulness.

Stage II
Aim. To see if log books could be a more effective teaching tool if incorporated into teaching sessions.
Eight junior trainees, all working at the same hos pital, were asked to take part in a six-month trial. At the start of the attachment, the Clinical Tutor gave a detailed introduction to the log book. Information recorded was then used as a basis for monthly regis trar clinical meetings which focused on topics of rel evance to trainees, e.g. the assessment of suicide risk; the management of acute schizophrenia; the classifi cation and management of depression, etc. The topics were agreed in advance and the trainees were asked to extract relevant data from the log books prior to the clinical meeting to allow discussion of the differing problems. The log books were collected at the end of six months and the trainees again completed a brief questionnaire.

Findings Stage I
Three log books were returned, the remainder having become 'lost' at some stage in the project. Of the books returned, one was up to date with 54 cases recorded, one was partially complete with 16 cases recorded and the third had not been used at all.
Five questionnaires were returned. Only two trainees reported having a virtually complete record of their clinical work, and they rated the log book as relatively easy and quick to use. Both had previous psychiatric experience and had been given an intro duction to the log book. The others found it difficult, time-consuming and estimated their records to be less than 50% complete. Most trainees commented that the log book was useful but that a major diffi culty was remembering to use it, especially in a busy job! Various suggestions to improve on the first trial were put forward, including the topic teaching sessions as had already been planned for Stage II.
In summary, there was general agreement that the log book provided a useful framework for reading around clinical topics, but few trainees felt it would help them recognise deficits in their experience or provide a starting point for research.

Stage II
Four of the eight log books were returned. Of these, one was up to date with 44 cases recorded, one had been started with four cases recorded and the remaining two had not been used.
Six questionnaires were returned. The trainee who had an almost complete record of clinical work rated the log book as quick to use and of considerable benefit. (This trainee had previous psychiatric experi ence but perhaps most importantly an interest in audit-based research.) The remaining five trainees differed over whether the book was easy or difficult to use (they had widely differing amounts of previous psychiatric experience) but were agreed that it was of little benefit. Nevertheless, one of these trainees was spurred by the log book into keeping copies of dis charge summaries and outpatient letters as a means of personal audit.
In summary, the addition of topic teaching based on personal audit using the log books did not seem to improve their perceived usefulness to the majority of trainees.

Comment
Log books are, of course, not intended to replace the individual teaching for trainees but are a means of using audit as an aid to learning. Their usefulness was tested in the realistic but less than ideal circumstances of a busy university-based psychiatric registrar rotation.
In Stage I, the simple distribution of log books without explanation seemed of little use to trainees. If the books were distributed with some simple instructions they were a more effective aid but per haps only for registrars with previous psychiatric experience. Additional explanation and support from the Clinical Tutor in Stage II appeared to have little impact on the use or usefulness of log books. Nevertheless, four out of 14trainees over both stages were sufficiently motivated (or obsessional) to under take significant personal audit either using or suggested by the log book. They found the exercise both interesting and of help in directing their reading or consolidating learning from the cases they saw.
A third stage of the study might have been to ask supervising consultants to use the log books as a basis for individual tutorials with trainees. However, the considerable variation in the amount of face to face teaching with consultants, together with differ ences in consultant enthusiasm for the log books, would have made this exercise of questionable value.
This study used only one type of log book but it may be that the design could be improved to enhance usefulness to trainees. This is a difficult area as the log book needs to be comprehensive enough to give meaningful information, but at the same time must also be 'user friendly'. Despite this problem there were few criticisms of the design of the log book and it was our impression that trainees quite simply vary in their interest in audit and therefore their desire to use these records.
It would seem that the majority of trainees would agree with the Examinations' Working Party that log books are not an ideal way of evaluating trainees or their training experiences. Given the increased emphasis on audit both in medical and governmental thinking, this should perhaps be a cause for concern. Are there methods of making audit of more interest to junior trainees or should experience of audit be postponed until senior training when preparation for consultant responsibilities is likely to motivate them to take a more active role? For example, the file of copy discharge and out-patient summaries used by one of the registrars in our study provided an excellent record for personal audit, teaching and development of formulation style. (However, issues of data protection must be considered.) A different approach would be to include trainees directly in the evolving arrangements for clinical audit. Individual trainees or their consultant supervisors might wish to experiment with these or alternative methods of audit as an aid to training.

A cknowledgements
We would like to thank the members of the Newcastle Registrar Rotation who took part in the study, together with Mr Alan Warren and Janssen Ltd for provision of log books. Among other things, good medical practice demands continuation of training at every level of professional life. Post-membership psychiatrists who have started their senior registrar (SR) jobs may face a lack of formal training. In many subspecialities of psy chiatry this has been extensively remedied by various training courses and programmes. North West Thames Regional Health Authority (N WTRH A) has six SRs training in the psychiatry of mental handicap distributed to three large mental handicap hospitals. Part of myjob as a senior lecturer at Charing Cross and Westminster Medical School has been to start a formal training course for SRs in the psychiatry of mental handicap in the region. Formal training had not taken place in this subspeciality previously although there had been several informal attempts in the region.

Postgraduate training course in the psychiatry of mental handicap
The first step was contacting the clinical tutors and the SRs to find out about their needs, wishes, plans and expectations of the course. Their responses clearly identified the great deal of enthusiasm and support which was to follow.
The detailed programme for the course was pre pared much before the beginning of each term and needs and expectations of the group were taken into account; the final form was distributed to all consult ants in the psychiatry of mental handicap at NWTRH A for comments and contributions.

The course
The course consisted of one session per week for 12 sessions per term. A total of 36 sessions in three terms have been held at Charing Cross and Westminster Medical School from September 1989 to July 1990. Course participants have been the SRs and other post-membership psychiatrists individually inter ested in the subjects. The sessions started with short announcements of congresses, conferences, forth coming events, and news from different journals on subjects pertinent to mental handicap. It continued with a formal lecture or seminar on the scheduled subject lasting for 40 to 60 minutes which was fol lowed by the journal club. The journal club consisted of recent reviews or original research papers on the same subject. The SRs were given the original papers a week in advance and each was expected to read all the papers and to prepare a presentation of one or two papers for 15-20 minutes. The sessions ended with a 30-minute discussion on the subject.
Informal research supervision has been included in the sessions on a monthly basis. The SRs summarised their work at whichever stage it happened to be. There was usually a lively discussion, ranging from the choice of subjects to the problems in the publication of the presented work. All participants were given the chance of presenting on at least one occasion.