Editorials In the first of these trials, adults with atopic dermatitis who were initially cleared of lesions by two weeks of daily application of a potent topical corticosteroid, fluticasone 0.005% ointment, were recruited into a double blind, controlled, randomised study to investigate whether continuing application of the same preparation on just two successive days each week would maintain the benefit.4 Patients applied the topical corticosteroid, or placebo, to previously healed and any new lesions. Those who continued using the topical corticosteroid showed only slight deterioration of the atopic dermatitis over the 16 week period of the study—significantly less than those who applied placebo, and their relapse rate was almost three times less. No evidence was found of a significant systemic effect from absorption of the topical corticosteroid, and no evidence of skin atrophy was shown by serial biopsies. The second trial5 was conducted over an 18 week period, during which children with atopic dermatitis either applied a potent corticosteroid preparation (0.1% betamethasone valerate) for three successive days followed by the base ointment alone for the following four days, or a weak preparation (1% hydrocortisone) for seven days. Treatment was applied in bursts of seven days only when required. Both groups showed clinically important improvements in severity of disease and quality of life compared with baseline, and no differences were shown in any outcome measure after 18 weeks. Skin thickness was measured at baseline and 18 weeks using ultrasound and showed some thinning in both groups but not clinically apparent in either. The third trial is very similar in concept to the first of these studies.6 The patient groups were much larger, and included adolescents as well as adults. Patients used either fluticasone 0.05% cream or 0.005% ointment (both classified as potent), or the equivalent base. Patients were then divided into two groups for a 16 week trial of maintenance therapy: both groups applied emollient daily, one group in addition applying the same topical corticosteroid, the other the base alone—twice weekly in each case. The results again showed that twice weekly application of a potent topical corticosteroid was clearly superior, with median time to relapse more than 16 weeks, compared with six weeks for emollient alone. Evidence of skin thinning was sought visually only and was not found in any of the patients. For those involved in the care of patients with atopic dermatitis these are important studies as they show that topical corticosteroids can be used effectively in the medium term as well in as the short term. They
are not as reassuring regarding adverse effects because the treatment periods are still too short for this purpose, nor do they tell us whether similar benefits would persist over longer periods. Nevertheless, they are certainly the most relevant clinical trials to date of topical corticosteroids in atopic dermatitis, because they evaluated ways of using topical corticosteroids that very closely resemble the ways that patients in the real world use them. These trials are not strictly comparable, but the two different types of trials provide valuable insights. The trial by Thomas et al5 shows that, contrary to standard teaching, potent topical corticosteroids probably can be used safely as well as effectively in children. None of the studies addresses the issue of tachyphylaxis directly, but it is relevant that in studies by Van der Meer et al and Berth-Jones et al,4 6 most patients applying a potent topical corticosteroid twice weekly had not relapsed by the end of nearly four months, implying that this intermittent pattern of use may help to prevent or delay the onset of clinically relevant tachyphylaxis. During the past decade, great public concern has developed in relation to topical steroids, which in many individuals comes close to phobia.7 This has meant that many, particularly the parents of children with atopic dermatitis, may refuse to contemplate the use of topical corticosteroids for their child’s disease under any circumstances. These studies provide for the first time some reassurance that topical corticosteroids can in fact be used safely and effectively, if certain guidelines are followed. David J Atherton consultant in paediatric dermatology Great Ormond Street Hospital for Children, London WC1N 3JH (
[email protected])
Competing interests: None declared. 1 2 3 4
5
6
7
Williams H. New treatments for atopic dermatitis. BMJ 2002;324:1533-4. Du Vivier A. Tachyphylaxis to topically applied steroids. Arch Dermatol 1976;112:1245-8. Hoare C, Li Wan Po A, Williams H. Systematic reviews of treatments for atopic eczema. Health Technol Assess 2000;4:1-191. Van Der Meer JB, Glazenburg EJ, Mulder PG, Eggink HF, Coenraads PJ. The management of moderate to severe atopic dermatitis in adults with fluticasone propionate. Br J Dermatol 1999;140:1114-21. Thomas KS, Armstrong S, Avery A, Po AL, O’Neill C, Young S, et al. Randomised controlled trial of short bursts of a potent topical corticosteroid versus prolonged use of a mild preparation for children with mild or moderate atopic eczema. BMJ 2002;324:768-71. Berth-Jones J, Damstra RJ, Golsch S, Livden JK, Van Hooteghem O, Allegra F, et al. Twice weekly fluticasone propionate added to emollient maintenance treatment to reduce risk of relapse in atopic dermatitis: randomised, double blind, parallel group study. BMJ 2003;326:1367. Charman CR. Morris atopic dermatitis. Williams HC. Topical corticosteroid phobia in patients with atopic eczema. Br J Dermatol 2000;142:931-6.
The rise of trust doctors Stop exploiting them and start rewarding their input See special issue of Career Focus and Papers p 961
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on standard grade doctors—more commonly called trust doctors—are a relatively new phenomenon in the United Kingdom. They have several different titles, but essentially they have arisen as a means by which hospital trusts can employ additional junior doctors, despite the Department of Health’s ceiling on training grade numbers, which exists 25 OCTOBER 2003
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to prevent a bottleneck at specialist level. Trust doctors are employed by trusts (local hospitals) for service and are therefore not regulated by the royal colleges or the deaneries (departments of postgraduate medical education). There were few posts for trust doctors in the United Kingdom until the introduction of stricter regulations of hours for junior doctors. Trusts most 943
Editorials commonly state that they employ trust doctors as a direct result of these changes. However, the big picture regarding trust doctors is only just emerging 1 2—they are employed mainly in the acute specialties, a significant number work at specialist registrar level, and their numbers are growing fast. Most want to be consultants in the United Kingdom and are in post as a temporary measure. Their work is often indistinguishable from that of the training grades yet few trust doctors have regular appraisals, and trusts report no organisational strategy for their education and supervision. No one has any idea how many trust doctors there are in the United Kingdom because the annual census from the Department of Health includes them as the equivalent training grade. Both the Yorkshire deanery survey1 and the study by Dosani et al2 in this week’s issue, confirm the dramatic rise in the numbers of trust doctors. The medical establishment has so far adopted an uncoordinated approach to the problems this situation poses. Whereas the BMA junior doctors’ committee is opposed to the advertisement of trust doctor posts, in our experience, some colleges encourage them to be incorporated as part of a rotation, so that trusts can increase numbers, and doctors still get the time in the training posts they need. The General Medical Council recently relaxed its rules so that doctors with limited registration can apply for non-training posts. This has made mixed rotations easier, and whereas before trust doctor posts were hard to fill, many trusts now find they can easily fill these posts with overseas graduates if they simply state that the trust doctor post is akin to a training post (http://www.gmc-uk.org/register/). There is a workforce paradox in the United Kingdom. On the one hand we face a shortage of general practitioners and specialists, yet there are already more junior doctors than posts to progress to. There is no doubt that we need more doctors because of demographic changes and the European Working Time Directive. Many consultant posts go unfilled when advertised.3 The Royal College of Physicians estimates that several hundred extra consultants would be needed to implement the European Working Time Directive just to maintain the current level of service.4 The United Kingdom already has fewer doctors per head of population compared with most European countries. The number of emergency admissions is rising each year5 and junior doctors perform most of the out of hours work in many specialties. For this we depend on overseas graduates with one third of senior house officers having trained abroad.6 We have increased medical school output by 2000 per year, which will be delivered in 2008, but this is nowhere near providing the numbers of medical staff needed to implement the European Working Time Directive. Yet despite not having enough junior doctors to implement acceptable shift patterns in many areas,7 the Royal College of Surgeons reports that its specialty still has too many senior house officers for specialist registrar posts,8 which are centrally regulated. At the root of all this is a historical lack of adequate workforce planning, with the resulting two tier system we have today. The current situation poses many questions and few easy answers. If it is in the interest of all doctors to engage in continuing professional development, regular appraisal, and study leave, what is the point of 944
having training and non-training grades? At a junior level, this is an anomaly and should be abolished. While trusts may state that a trust doctor post is akin to a training post, there is no formal assessment of competence and one could argue that this makes a mockery of the idea of limited registration. Acute care is increasingly being delivered by junior doctors who are educationally unsupervised, and this has implications for patient care and for the doctors themselves. Should we simply accept that many junior doctors would not be able to progress in their chosen hospital career? Should we create a renamed, revamped, and destigmatised staff grade type role for such doctors? Or perhaps more imaginative thinking is required in terms of skill mix. Much has been made of recent initiatives (physician’s assistants, extended nurse training, hospital at night schemes), but most of these have only just been set up and will not mature until well after the European Working Time Directive deadline, which requires near universal shiftworking for junior doctors. Finally, we seem to be creating an underclass of doctors at the same time as we are making attempts to correct the injustices which have been inflicted on another group of mainly overseas doctors—the non-consultant career grades. There is a huge moral question mark over employing large numbers of doctors, mainly from the Indian subcontinent, in posts where their identical service is not recognised for training or examinations, the very reason they come to the United Kingdom. It is time to tackle the issue of trust doctors, and a good start would be to have centrally collected data, one recognised title (for example, trust senior house officer or trust registrar), and for the relevant parties to sit down together and formulate a coordinated way forward. Nicola Cooper specialist registrar in general internal medicine and care of the elderly 3 Teale Court, Mansion Gate, Chapel Allerton, Leeds LS7 4AY (
[email protected])
William Burr dean for postgraduate medical education, Yorkshire Department of Care of the Elderly, Leeds Teaching Hospitals NHS Trust, St James’s University Hospital, Leeds LS9 7TF
Competing interests: NC worked formerly as a trust doctor in anaesthesia and intensive care medicine. 1
2 3 4 5
6
7
8
Department for NHS Postgraduate Medical and Dental Education (Yorkshire). A survey of non-training grade doctors in Yorkshire, August 2002. http://www.yorkshiredeanery.com/NTGDSurvey/ NTGDSurvey.asp?mainSection = Survey+Of+Non-Training+Grade+ Doctors+in+Yorkshire (accessed 16 October 03). Dosani S, Schroter S, MacDonald R, Connor J. Factors contributing to non-standard grade recruitment: a survey. BMJ 2003;327:961-4. General Medicine. Hospital Doctor 2003;12 Jun:51. Royal College of Physicians. Medical Workforce Unit. www. rcplondon.ac.uk/college/mwu (accessed 13 Oct 2003). Royal College of Physicians. Skillmix and the hospital doctor. http://www.rcplondon.ac.uk/college/mwu/mwu_01_home.htm (accessed 13 Oct 2003). Department of Health. Postgraduate medical education and training—the medical education standards board (MESB) Consultation Paper. London: DoH, 2002. Department for NHS Postgraduate Medical and Dental Education (Yorkshire). Report from the Improving Junior Doctors’ Working Lives Regional Action Team. Junior doctors’ hours: the new deal. Department for NHS Postgraduate Medical and Dental Education (Yorkshire), University of Leeds, April 2002. Royal College of Surgeons Edinburgh. Position paper on the SHO grade and its relationship to surgical training. rcsed.ac.uk/content/careers/ Educat/traininf/2111200294847.aspx (accessed 13 Oct 2003).
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