Do textbooks of clinical examination contain information regarding the assessment of critically ill patients?
Introduction
It is apparent that the management of many critically ill patients can be improved with the result that some cardiac arrests, deaths and unnecessary intensive care admissions might be avoided [1], [2], [3], [4]. Suboptimal care has multifactorial origins, but the education of doctors and their preparation for practice may be particularly important [5], [6], [7]. Recent publications have shown significant deficiencies in the knowledge of junior doctors with respect to the assessment and management of critically ill patients [8], [9], [10], [11], [12]. This may result from lack of appreciation of its importance, inadequate training in acute care at medical school, insufficient clinical experience [5], [6], [13], [14], failure of medical school to prepare trainees for future work [15], the absence of a true apprenticeship or, perhaps, a lack of information about the recognition and assessment of critical illness in textbooks. A recent publication has demonstrated deficiencies in information for medical students on musculoskeletal examination skills in commonly used textbooks of clinical examination [16]. We conducted a similar study to assess the amount and accuracy of information regarding critical illness in textbooks of clinical examination and assessment commonly used by medical students or pre-registration house officers.
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Materials and methods
Prior to the commencement of the study, the authors agreed a checklist of clinical signs and measured variables, important in the understanding, detection and investigation of critical illness (Table 1). These followed the standard ABCDE (airway, breathing, circulation, disability, exposure) system of assessment taught on the advanced life support (ALS) [17], advanced trauma life support (ATLS) [18], care of the critically ill surgical patient (CCriSP) [19], immediate life support (ILS) [20]
Results
Thirty books, with publication dates between 1982 and 2002, were studied (see Appendix A). Twenty-two of the 30 texts (73%) studied had been published between 1996 and 2002, with eight (27%) having a publication date since 2000. In four cases, the latest edition of the chosen book was unavailable and, hence, the previous edition was evaluated. The results of comparing the books with the predetermined contents list are summarised in Table 3, Table 4.
Discussion
Irrespective of the diagnosis, clinical deterioration is always accompanied by abnormalities of airway patency, breathing, circulation and consciousness. The ability to prevent deterioration, and subsequent cardiac arrest, requires that these abnormalities be recognised early. Despite the UK General Medical Council’s stipulation that medical graduates must know how to recognise and manage acute illness [23], few UK medical students or trainee doctors have the opportunity to receive formal
Conclusions
Current textbooks of clinical assessment and examination available to medical students and junior doctors do not provide sufficient information regarding the assessment of critically ill patients. We recommend that the authors of these texts consider the inclusion of information regarding the generic signs of acute illness.
Acknowledgements
The authors wish to thank the librarians of the Portsmouth Hospital libraries, the Wessex Region inter-hospital library loan service and the British Medical Association library for their help in locating the texts evaluated in this study.
Conflicts of interest: Gary Smith is a co-designer of the ALERT™ course.
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