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Testing Times For Junior Doctors

The importance of understanding and acting on the results of laboratory investigations is vital to ensure patients receive the correct treatment and care, but are our new intake of junior doctors up to the task? MedLabNews investigates why it appears to be...

TESTING TIMES FOR JUNIOR DOCTORS

An often quoted statistic from a Health Select Committee report written a few years ago stated that: "Up to 70% of all diagnoses in NHS patients depend on laboratory tests and hence NHS pathology services are critical for the day to day evidence-based care of patients." But according to Dr Danielle Freedman, a spokesperson for the Association for Clinical Biochemistry, the value of these important investigations may be being threatened by the very people who order the investigations in the first place, namely the junior hospital doctors, some of whom who do not understand laboratory tests.

Speaking to MedLabNews recently, Dr Freedman says there is a need for an urgent review of the junior doctor's teaching curriculum. "With no standardisation of the medical curriculum for the teaching of basic sciences, how will junior doctors become competent in requesting and interpreting investigations in laboratory medicine?"

With patient safety now a fundamental priority for the NHS, Dr Freedman has concerns over the long term impact this situation could have on it. "Most acutely ill patients are cared for by the most junior medical staff with the least knowledge and experience. Thanks to the reduction in the amount of teaching of pathology and laboratory medicine, these doctors have little understanding of what tests to order and how they should be interpreted. The elimination of pathology and laboratory medicine from the curriculum in many medical schools and consequent lack of knowledge of basic science among junior doctors therefore is jeopardising patient safety."

From her own experience and that of colleagues around the UK, Dr Freedman concludes that foundation year 1 and 2 doctors appear to have little concept of how laboratory tests should be used and their role in diagnosis. "Many seem unaware that laboratories have staff able to help them, not only with interpretation, but also with advice on appropriate testing. Furthermore a recent study by Stuart Smellie et al found that 25% of all emergency requests were inappropriate."

But how has this situation arisen? Dr Freedman believes it has been the result of a steady decline. "The decline of teaching basic science in the undergraduate curriculum has not only had an impact on the knowledge base for junior doctors but also the lack of exposure to pathology for example has had an impact on the percentage of doctors selecting pathology as their first choice of career. This has been the findings of a survey undertaken in conjunction with Professor P. Domizio and the Royal College of Pathologists who looked at a national survey of medical graduates between 1974 and 2002. The reasons included the low profile or status of pathology, the decimation of academic pathology, negative media portrayal and the impact of integrated curriculae in medical schools".

While there is very little literature to demonstrate the impact of the knowledge of basic sciences by junior doctors and its bearing on patient outcome, there is no shortage of anecdotal and circumstantial evidence as Dr Freedman points out. "For example many of my colleagues in the profession have seen patients who were discharged into the community only to return to hospital having suffered a major myocardial infarction because of a poorly-performed troponin test. Junior doctors are performing this and other tests at the wrong time, and sometimes with little understanding of what to do with the results when they get them back from the laboratory. Even worse, juniors are teaching other juniors and so bad practice is becoming ingrained."

The findings of another survey - Learning needs in clinical biochemistry for doctors in foundation years by Victoria Khromova and Trevor Gray reported in Annals of Clinical Biochemistry - demonstrate the need for additional teaching in clinical biochemistry. In the study, junior doctors felt more confident in their knowledge of when to request tests than their ability to interpret the results. Their study also demonstrates a lot of these aspects particularly the fact that the first and second year doctors were not competent interpreting the results of liver function tests, protein investigations and haematinics assays such as B12 and red cell folate. Very few indeed were competent in interpreting the results obtained from a haemolysed patient sample. More than 70% of the doctors surveyed requested specifically extra teaching in clinical biochemistry. What has also been recognised nationally is that there is no standardisation of undergraduate curriculum and there is enormous variation with regard to the amount of time spent on teaching basic science across all medical schools. For example, Trevor Gray eluded that in his own teaching hospital at Sheffield, medical students only receive 3 hours of clinical biochemistry training in their 5 years as an undergraduate, whereas other medical schools, particularly in the South West, have regular interactive teaching in clinical biochemistry and the other pathology specialties. What was extraordinary was that the survey also revealed that there was little difference between the confidence level of year one and year two doctors suggesting that this is unlikely to improve without further teaching, in other words both groups were of the same standing of knowledge base. It is also worrying as the year two doctors are not aware of their lack of knowledge and they may feel therefore falsely confident."

Although this type of evidence is worrying in itself, clearly there is a serious risk to patient safety if results are not acted on or worse still, misinterpreted, something Dr Freedman readily acknowledges. "There is a huge impact in terms of patient safety and we have many examples in my own laboratory where troponin results for diagnosis of myocardial infarction are requested not following the correct protocol and a mis-diagnosis could therefore be made. Other examples we have seen include junior doctors taking blood samples from a drip arm and thus producing erroneous electrolyte results which again can have potentially serious consequences for the patient if acted incorrectly on.

What is also worrying is that many junior doctors also seem to have little or no awareness of the issues around pre-analytical factors affecting performance of diagnostic testing such as lipaemia and worse still are often unaware of the significance of reference ranges and thus interpretation of the results. Also we have noticed the mismanagement of a very common clinical condition in acutely ill patients, namely hyponatraemia, an area in which I have spent a lot of time teaching our junior doctors to ensure better understanding. My own experience of teaching first and second year doctors basic clinical biochemistry has also has revealed that there is gross variation in the knowledge base depending on where they will have trained. They range from knowing absolutely nothing to being reasonably competent".

Although the Royal College of Pathologists is reviewing the undergraduate curriculum for pathology and laboratory medicine, Dr Freedman believes further urgent action needs to be taken to address this issue "It is essential that the General Medical Council, universities and medical schools take note to protect both patients and junior doctors." The way this situation can be improved is by not only addressing the undergraduate curriculae which the Royal College of Pathologists is attempting to do, but this also has to be done through the universities and medical schools to perhaps some form of standardisation across the UK, but also more group teaching to small cohorts of final year medical students and also Foundation Year 1 and 2 doctors on the wards. I know myself and many of my colleagues around the country are actively involved in teaching them the basics of clinical biochemistry. In addition, on line tutorials could be a useful adjunct. My own experience is that I have had to put on extra sessions for the first and second year doctors and they have really appreciated the value of these".

But although measures like this will undoubtedly help the situation, Dr Freedman and her colleagues fear that unless something is urgently done to improve the knowledge and competence of laboratory testing by junior doctors, then it will be the patients who will inevitably suffer the consequences as well as the junior doctors themselves

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