Personal views: The credibility gap
Authors: Cliff Reid
Journal: BMJ (1998)

“No offence,” said the mother of the asthmatic child, “but you’re a casualty doctor; I think my child ought to see a paediatrician.” A few years ago this might have been an understandable request, but times have changed—haven’t they? I was tempted to ask her how she thought a junior doctor in paediatrics would be able to offer more than a specialist registrar in accident and emergency medicine with anaesthetic experience and advanced paediatric life support training. 

Subsequently discovering that mum was a senior registrar in medicine at a neighbouring hospital brought home just how great a credibility problem our specialty still faces. 

The credibility battle is fought every working day. Many doctors seem uncomfortable when a casualty officer wants to discuss the management of a clinical problem, which comes under “their” specialty, failing to acknowledge that emergent presentations happen to be “our” specialty. Other specialists are often quick to criticise accident and emergency management, but it is not unknown for my accident and emergency colleagues to feel that the subsequent inpatient care of patients whom we have managed and often resuscitated has been less than perfect. 

Recent changes in specialist training, the large numbers of trainees, and restrictions in working hours mean that a surgical, medical, or anaesthetic trainee will inevitably be exposed to far fewer emergency cases than their accident and emergency colleagues. For those who do not accept that the sheer volume of experience acquired by a senior doctor in accident and emergency in such emergency cases would inevitably dwarf that of those members of inpatient teams responsible for first line care, I would suggest that accident and emergency doctors can provide a patient with their best chance of an integrated, comprehensive assessment of their problem before admission. How carefully and competently will an orthopaedic team investigate the underlying cause of collapse in their patient with a fractured neck of femur: will they spot the trifascicular block on the electrocardiograph? Who will supervise the maintenance of spinal immobilisation when the anaesthetist takes the trauma patient to the computed tomographic scanner, and then intervene to insist on a laparotomy when the indications emerge in the radiology suite? In ill or injured patients with multiple problems requiring the input of several inpatient teams, who will maintain overall responsibility for prioritising interventions? 

I am concerned that unless we act to improve the image of our specialty, we will fail to attract the best trainees into this rewarding and stimulating branch of medicine. More worryingly, failing to convince our colleagues that we can contribute positively and expertly to the management of critical patients can at worst lead to ownership conflicts and inevitable delays in the process of care. At best it may result in disillusionment and emigration in those of us working in a system that does not always permit us to deliver care to the standard we are capable of. 


We have, however, a long way to go before demanding the credibility we yearn: at the moment, an orthopaedic registrar can act as a locum accident and emergency registrar, with no training in life support skills or an inkling of the contraindications to thrombolysis in acute myocardial infarction. If anaesthetics allowed this it would make the national press, but in accident and emergency it has become historically acceptable for poorly skilled doctors to work alongside the good ones; after all, they can always refer on. We need to ensure that all those working in our departments conform to minimum standards of training. Only then can we shake off the image of signpost waving medically qualified receptionists and begin to universally practise emergency medicine. 


“I look forward to becoming a fellow of a Royal College of Emergency Medicine”



What might the future hold? Perhaps recognition that of all the hospital departments, accident and emergency sees and treats the greatest number of patients—larger than the total number seen in the outpatient department—resulting in acknowledgement of the contribution that can be made to acute care by accident and emergency specialists: not casualty officers but emergency physicians. 

I continue to dream of the day that medical students enthusiastically attend their 10 week attachment in accident and emergency in order that they are best prepared for their compulsory preregistration post in the specialty. I look forward to becoming a fellow of a Royal College of Emergency Medicine, and to welcoming trainee anaesthetists to my department to learn about airway management. In the meantime, my colleagues and I will endeavour to provide the best possible care to our critically ill and injured patients, delivering them to the inpatient teams as comprehensively and competently managed as possible. And should, God forbid, a medical emergency befall me, I know who I would want to assess me in the resuscitation room: an emergency physician. No offence.