A recent survey has shown that eight in 10 doctors surveyed admitted that the top priority in their training is cardio-pulmonary resuscitation (CPR) and emergency medicine both in and out of the hospital. They realize they need far more training in this crucial sector. The survey, carried out by the National Public Health School’s health economics group, headed by Professor Yiannis Kyriopoulos, and the health and welfare administration department at Athens Technical College, headed by Professor Sotoris Soulis, has indicated a need for professional training for hospital doctors in emergency room techniques and the new medical technology used there. Another 58 percent of doctors say priority in their training should be given to special techniques and treatments, as well as public health. Another priority, they say, should be the treatment of hospital infections, which are becoming a real problem for modern hospitals. Doctors in Greece are not required to undergo continual training. The survey showed that Greek doctors are well informed on scientific developments, mostly in the time-honored way of attendance at seminars and subscriptions to journals. To a lesser degree, they refer to electronic data banks or take long-distance courses via the Internet. There are considerable problems involved in continuing education because of the absence of mechanisms to plan, monitor and evaluate the various activities involved. In recent years there has been some progress, in that a few public hospitals have set up vocational training centers. However, most of the 32 agencies certified to train regional hospital staff are concentrated in the Athens area. ’15 days practice is not enough’ According to experiential research, every three years about 80 percent of information in the human brain becomes redundant. Even if this were not true, knowledge of medicine acquired in 1970 is not enough for 2001. Some is still valid, some is invalid or else amended. The importance of continuing training in the sector of emergency medicine was emphasized by the director of the Aglaia Kyriakou Children’s Hospital, Yiannis Papadatos, in an interview with Kathimerini. I am not surprised doctors feel the need to be trained in various aspects of emergency medicine. Unfortunately, I am well aware not all doctors know how to treat emergency cases. There is a tendency for a task force to be set up in hospitals to take over when a serious case comes in to the outpatients’ clinic, such as after a traffic accident, a serious burn or septicemia, he said. Where there is an intensive care unit in the hospital, then this group usually comprises staff from that unit, otherwise anesthetists put the patient on life-support, he added. Straight talk The emergency response isn’t always enough. I saw it after the earthquake of September 1999. Our hospital was on duty, and a lot of the injured – and the dead – were brought in. When I arrived I saw a lot of people working on a child who was dying, there was no point. We had to help children whose condition was not yet hopeless; what else can you do when 40 injured are brought in? But that is something you have to be trained to do, to distinguish the slightly injured from the moderate and serious cases. Isn’t that taught at university? An attempt is made over 15 days in the fifth year of training as part of intensive care, by Professor Haris Roussos. It is obviously not enough time, despite Dr. Roussos’s considerable efforts. From a study by the National School of Public Health and the Technical Institutes, I see that hospital doctors are making persistent requests for training in cardio-pulmonary resuscitation (CPR), which comprises a series of actions, from A to B and then C, that you need constantly to be reminded of. You can’t learn it in one go. You can’t go from A to C and then B, as unfortunately is often the case. The first part is chest compression and mouth-to-mouth ventilation. Are there doctors who do not know that? Many do not know it in the proper sequence and in the right manner. At foreign universities medical students learn it every year as part of their studies. When they start working in a hospital, they have a refresher course in it every year. Basic CPR is a technique that we should all be acquainted with. Of course. If I myself am at the beach and am faced with a person with cardiac arrest, I wouldn’t have any drugs or equipment with me. I’d have to use my hands and my brain. Patients have to be kept alive until they can be taken to a hospital where advanced resuscitation can be carried out using drugs and life-support equipment. The patient has to be kept stable. That is now done by an intensive care specialist or anesthetist, isn’t it? Not normally, it isn’t necessary. All doctors should know how to do basic and advanced resuscitation. We shouldn’t have to wait for the experts to save the day. In any case, as you yourself said, everyone should know how to do basic CPR, as well as nurses and physiotherapists. Don’t forget that in the USA, 60 million Americans (out of a population of 250 million) have learnt how to do it and often have refresher courses. I repeat; CPR and emergency pre-hospital medicine is something that is missing from the training of Greek doctors. In even a difficult case which is not immediately life-threatening, a doctor has the luxury of searching on the Internet or consulting with specialists. But when a patient’s heart and respiration are unstable you have no time to waste, you have to act. Hospital doctors and those in outpatients’ departments are often in that position. I imagine that they know what to do. Let me put it this way. They should know more, and 80 percent of those who completed the survey questionnaire admit as much indirectly, by replying I would like to be trained in this specialization. That basically means I don’t know, or I know a little. Those compulsory seminars for doctors in Western Europe, Canada and the USA are beginning to be introduced here. For example, Professor Androulakis of Patras has begun to work in this direction in his treatment of injuries, and other clinics are following suit. The first hour is crucial for life. We say the first hour is golden and the first half-hour platinum, even more crucial. This means that if you have an accident on the island of Sikinos, the doctors at the medical center there have to stabilize you before sending you to Athens. That is why I believe there should be compulsory training for all doctors. After all, if a central authority doesn’t do it, then the university should. How long will we have to keep paying for this failure? I’ll give you an example. With chest compressions, you have to press down on the sternum with a specific amount of force. You shouldn’t use all your strength, nor a very slight pressure, which would be ineffective. If you press down too hard, you could break ribs and that could cause other medical problems. We should do here what they do abroad. After the training course there are examinations. In some countries, if you don’t know how to do it properly, they take away your degree. As doctors we are supposed to do good. Shouldn’t someone be required to check up on what I know? Unfortunately, there are no means of checking or evaluating. If you come from Harvard, the chances are you are very well trained. What about those who received their degrees from Eastern Bloc countries? At regular intervals, there is a way of monitoring and checking as to how many patients have been admitted and the mortality rate. For example, there are major problems at the pediatric clinic at the hospital in Tripolis, but they are still training specialists. Only one or two doctors are actually doing clinical work. How can they possibly train other doctors? Results show that most Greek physicians are highly specialized The survey was carried out among a random sample of doctors in Greek hospitals to discover details of their training and research experience, as well as what they see as their training requirements. About 500 questionnaires were distributed. Generally, it emerged that doctors have a high standard of scientific training, since most (72 percent) have undergone postgraduate specialization, and nearly all (97 percent) know at least one foreign language. They represent nearly all specializations in senior positions with 11 to 20 years’ service and are aged 36-60. The survey showed that they generally keep up with developments in their fields, mostly from scientific journals (82.5 percent) and conferences and seminars (60.2 percent). More men than women participate in conferences and seminars, particularly those with postgraduate degrees, who are therefore generally more involved in research. The specific sector in which they have specialized and their position in the medical hierarchy does not seem to have a bearing on their attendance at conferences or their research activity. What is important is their length of service, as most doctors working in hospitals have six to 10 years of experience. Six in 10 doctors say they have undergone professional training in the past five years, four in 10 through the Health Ministry, and three in 10 through the private sector. Another 18.4 percent followed training programs at a university and 9.2 percent the Interior and Public Administration Ministry’s Continuing Education Institute. Doctors working at hospitals for six to 10 years spend more time at seminars, whereas those with over 20 years’ service spend the least. Seventy percent of doctors believe that the long duration of most of the training programs is a deterrent. Up to two weeks is considered long enough to be away from their work. Half of them believe programs would be more accessible if they were held within working hours. Those who do not attend seminars attribute their absence to the burden of work, although they believe they are necessary. There is no doubt, on the basis of surveys and other scientific evidence, as well as public opinion, that Greece’s doctors have a high standard and a lot of potential, said Kyriopoulos. It is also accepted that the exercise of clinical medicine in Greece is way behind that in other developed countries. However, investment in human resources through training has not been given top priority. Progress made in recent years by means of the vocational guidance centers at regional hospitals, as well as the worthy efforts of medical associations, are a start. What is needed, however, is a more serious approach, with the evaluation and certification of training programs and an obligation on the part of doctors and the organizations that employ them to invest in their human resources, he added. This is the major challenge for the years to come, and a significant prerequisite for improving the quality of medical services and defending patients’ interests.