THE REGISTRAR SYSTEM IN NON-TEACHING HOSPITALS

966

Special Articles THE REGISTRAR SYSTEM IN

NON-TEACHING HOSPITALS D. VELLACOTT M.B. Camb., F.R.C.S. A SENIOR REGISTRAR

FOR most provincial non-teaching hospitals the registrar system is a comparatively recent innovation. Senior registrars or their equivalents-first assistants-have for many years been a feature of teaching hospitals, where their position and duties have been fairly clearly defined, with minor variations between different schools. Their duties usually consist of emergency and routine surgery at the discretion of the " chief," certain duties in outpatient clinics, the teaching of students, and responsibility for the documentation and recording of cases. Research is usually voluntary, although sometimes suggested and directed by the chief. Teaching hospitals are to some extent the " shop-window " of medicine and surgery, and as training centres they are justifiably regarded with great respect, credit accruing to the registrars fortunate enough to hold appointments there. In the career of the would-be consultant a registrarship is a crucial stage, for it offers him an opportunity to form, in the light of practical experience, fundamental principles for the future ; to benefit from the experience, direction, and criticism of senior staff engaged in the same problems that he has to face ; and to make good himself. CRITERIA

What are the particular facilities in teaching hospitals which help the would-be consultant Briefly, they seem to be these : (1) Working with, and learning from, men eminent in the profession ; (2) practical experience ; (3) the teaching of students, which forces the registrar to clarify his own ideas ; (4) practical work, during a formative period, in a school ; (5) opportunities for attending lectures and meetings in, or near, the teaching centre, and readily available libraries and museums ; (6) opportunities for research and controlled investigations, with first-class ancillary services ; (7) facilities and accommodation for learning and practising the proper recording of cases ; and (8) contact with the basic medical sciences of anatomy, physiology, and

pathology. If these criteria are accepted, how does the position of registrar in a non-teaching hospital compare with that of his colleague in a teaching hospital ?z? As regards the

a

under whom he works, he may not be at a disadthat his chief may not be interested in, or accustomed to, teaching ; and for practical experience and clinical material, the non-teaching may surpass the teaching hospital. In the remaining six points, however, the registrar at a non-teaching hospital is often at a disadvantage. Furthermore, he is liable to become so involved in practical work, and problems arising from shortage of beds, as to lose sight of the ideal management of a case. He may receive a fine training in life-saving, but his work is necessarily directed to keeping patients out of hospital rather than to selecting patients for admission, and surgery that is economically important is in danger of being neglected. Moreover, outpatient clinics may be so large that history-taking and clinical examination are curtailed, and investigation by ancillary services substituted. Speaking of surgery, one cannot fail to notice that super-specialised units often appear to gain certain advantages over general units. The former seem to catch the sympathetic eye of the public, of committees, and men

vantage, except

members of staffs, obtaining better ancillary services (including their own physiotherapists) and full clerical assistance. The stomach is removed by either a thoracic or a general surgeon ; but the team-work supporting the former is not always as good for the latter. It seems that undue importance may come to be attached to registrar service on a specialised unit, so that a succession of appointments to such units may become necessary to

lay

obtain a recognised general surgical training. General surgery deserves clearer recognition as a basic training for would-be consultants ; and support for general units should equal that for special units. It may, of course, be pointed out that general surgeons often have a

particular system of a

interest in

one

and certainly a does much to ensure

branch ;

rotation of balanced training.

registrars

House-appointments

should

provide

a

general training

for the recently qualified doctor. In this respect the non-teaching hospitals have in the past rivalled the

teaching hospitals, resident obtaining practical experience from large and varied’ clinical material, together with greater responsibility than is usually allowed in teaching hospitals. Does not the adoption of the registrar system endanger the value of these appointmentsf After holding a house-appointment, the decision has to be made whether to go into general practice or to try to become

a

consultant. If the latter

course

is chosen,

a

registrarship should be a definite rung on the ladder, with prospects of advancement, and encouragement to study. The non-teaching hospitals could, and should,. provide training and prospects rivalling those in teaching hospitals ; otherwise registrars working in non-teaching hospitals will find themselves at a disadvantage in the competition for consultant posts. PROPOSALS

,

The following measures would, it is suggested, improve the value of registrar posts in the non-teaching hospitals, and benefit the hospitals themselves :

House-appointments.- The house-surgeon (or house-physician) should be primarily responsible to the consultant for the management of cases in the wards, taking the chief round and answering questions about the cases, dealing with most of the details of investigation and treatment, and recording history, examination, investigations, operations, and progress of each case. Naturally the registrar should, if required, for cases which he has himself dealt with. The registrar should be concerned more with the management of the ward itself, seeing that the consultant’s particular wishes and methods of management are carried out, that records are properly kept, and that new housemen are helped over the initial period of six weeks or so until they understand the routine of the wards and have mastered such procedures as putting up a transfusion and passing catheters. Facilities for the registrar.-It should be part of the duties of a registrar to summarise and analyse case-notes, not onfy for purposes of recording, but for his own instruction and training ; in this he should be able to work in conjunction with the records department and render considerable assistance. He may be required, by some consultants, to write letters to the patients’ doctors. If this work is to be done efciently, there must be a separate room for registrars, where they will be free from constant interruptions. Clerical assistance is likewise essential. Provision of these two essentials would instantly raise the standard of notes and outpatient records ; ensure a speedier and more efficient contact with general practitioners ; and diminish the number of forgotten patients. But, for the registrars, a separate room and clerical assistance would do much more : it would provide a stimulus to reading and study, and analysis of cases. I have no doubt that registrars themselves would provide medical journals ; and in this local medical societies are already of great assistance. Emergency and routine surgery.-Emergency surgery is good training-for emergency surgery. It would be a pity answer

"

"

967

registrars were employed only in this type of work ; and registrars-or at least senior registrars-might be allotted one operating session a week. Meetings and lectures.-In each hospital one registrar should if

be selected each month to attend a meeting on a subject of his choice, at one of the Royal Colleges, the Royal Society of Medicine, or a teaching hospital, with the obligation to report the proceedings, either verbally or in writing, to his consultants on his return ; and a pool of money should be provided by regional boards to cover expenses where long distances are involved. The granting of opportunities to go on courses, after a certain period of service, might be considered. The recognition of some such system as a privilege of a post in a non-teaching hospital would do much to allay the fears of registrars who consider applying for posts remote from

teaching

centres.

Research.-It is in research that the registrar in the nonteaching hospital finds himself most frustrated. Often masses of clinical material pass before his eyes and stimulate his

interest, but the difficulties already enumerated, and the -involvement pf himself and the ancillary departments in practical work, prevent him from pursuing lines of investigation with proper support. Registrars (if necessary, only the higher grades) should be allowed investigations not vitally essential, and in these the pathological registrar should assist as a part of his duties. Access to post-mortem examinations, opportunities to try operations on the cadaver, and, in interesting cases, the provision of microscopic slides, should be assured. ASSESSING ,

STANDARDS

it is

Finally suggested that the Royal Colleges, or the should take some part in ensuring that boards, regional registrar appointments conform to certain training standards. A system of hospital standardisation, as employed by the American College of Surgeons, has much to commend it. If I may quote 1 : "

Medical records departments play an essential partindeed they must do if the hospital concerned is to gain the approval of the American College of Surgeons-a standard of merit which all hospitals in the U.S.A. covet and endeavour to obtain. It is termed Hospital Standardization, and it is possible to score 1000 marks. The scoring sheet is divided into eight essential divisions, total score 655 marks, and ten adjunct and service divisions, total score 345. It is significant that the medical record department is allocated to the essential divisions, with the second highest possible score of 150 points, 250 out of the 655 points being allocated to the medical staff organisation. Clinical laboratory comes third in that division with 95 as

points." Some such system would also give candidates for registrar posts some idea of the value of appointments before they actually took them up, and would stimulate competition and rivalry between hospitals. I would ask senior consultants to compare the prospects which consultant practice offers today with those they faced some years ago-prospects, not conditions. It is doubtful whether prospect of financial gain will ever again be the same spur to greater effort. In medicine and surgery we have a profession where opportunities for healthy unselfish enterprise abound. It seems obvious that gratification and fulfilment will have to be derived from the very nature of the work. If standards in medicine and surgery are not to fall, senior members of hospital staffs will have to do all in their power to arouse enthusiasm and encourage capacity for criticism. been formed Obviously, the views expressed here as a result of experience in a particular hospital ; but they may have a wider application. They are frankly expressed because the almost universal adoption of the registrar system calls for a recognised standard of training facilities, and presents a challenge which all non-teaching hospitals should recognise.

have

1.

Royle, E.

Med. Rec. 1950, 1, 28.

EMERGENCY BED SERVICE LAST autumn branch offices of the King Edward’s Hospital Fund Emergency Bed Service were opened at Ealing, Leytonstone, Woolwich, and Wimbledon to carry part of the load which had previously been borne entirely by the head office at Old Jewry. The branch offices now deal with 42% of the applications received. The committee’s report on last year’s working of the service relates how, through this decentralisation, the speed of admission and the proportion of admissions have both been increased though the total number of applications has risen steeply. ,

Since the introduction of the National Health Service the E.B.S. has been working for the four Metropolitan regional hospital boards for an experimental period of two years. The experiment has proved useful, and a new agreement has been reached whereby the E.B.S. is to carry on for a further two years and thereafter indefinitely, subject to six months’ notice by either party. The King’s Fund will continue to pay the first .&6500, which was the cost of the E.B.S. in 1947, and the four boards share any expenses in excess of that sum. THE

YEAR’S

WORKING IN LONDON

The total number of applications received year ended March 31, 1950, was as follows : General acute cases Infectious cases...... Chronic sick cases...... Total number of

cases..

during

the

42,732 14,506 3411

60,649

Of the 42,732 general cases offered, 34,575 were admitted, and 2488 withdrawn by the applicant. For the remaining 5669 no beds could be found, and they were referred back to the applicant. In 1070 of these cases the applicant was a hospital, and the patient was in the casualty department, but could not be admitted to the wards owing to their lack of beds. Comparison of the winter results for 1948-49 and 1949-50 shows that the number of cases admitted, shown as a percentage of cases offered, was 73-5% and 78-5% respectively. The.worst months in each winter were 75% in January and February, 1950, and 60% in

February, 1949. During last winter there was once again difficulty in admitting patients over 60 years of age, although the situation has improved since the first winter of the N.H.S. Nearly all age-groups show improvement over last year, the greatest being in the age-group 51-60 where the percentage admitted increased by 8.1. The exception is in the age-group 0-21 which shows a reduction of 0-4%, largely owing to the number of cases of bronchopneumonia in children which it proved impossible to admit during January. In the winter of 1948-49 the average time taken to admit a case was 56 minutes. Last winter it was reduced to 42 minutes ; to find a bed an average of 3-36 hospitals was approached in each case compared with 3-64 in the winter of 1948-49. During that winter, when the E.B.S. failed to find a bed for a patient, 5-15 hospitals were tried. This year an average of 7-05 hospitals were approached before failure was admitted. The system of dealing with applications for inclusion on chronic sick - waiting-lists was revised in November, 1949, when the records of these cases were transferred to the four branch offices which became responsible for the allocation of cases to the waiting-list of the appropriate hospital management committee. This work is done under the direct supervision of the regional medical admissions officers, who check that the case is suitable for a waitinglist, and take steps to obtain a report on the social circumstances where necessary. The new machinery is working satisfactorily, but it is obvious that the hospital