Working Conditions for Burns Resident Doctors—Better Now than Ever?

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Thank you for the opportunity to review this manuscript. The paper is interesting and informative, and indeed evoked some personal memories,  but the scientific merit is low. The article provides a rather blurred description of working conditions in a single (exceptional) UK hospital in the 1970s and attempts a comparison with the present day. Differences in working conditions are stark but probably no more so than in other fields, such as steel foundries and buildong sites. Apart from some basic data on pay and hours of working, a narrow comparison beween these two worlds seems futile. 

The survey itself is poorly described. The population was apparently recruited using a poster, dissminated locally.  What about bias? Numbers do not add up: 66 responders were doctors and the remaining 10 were HCPs. However, 7 HCPs were excluded from analysis. Why does Figure 5 show responses from 7 HCPs? The numbers involved seem very small to allow logistic regression. 

I think the authors' description of Jackson's immense contribution to burn surgery fall short. His ingenious use of alternating homgraft and allograft strips set the course for excision surgery for decades. 

In summary, the manuscript definitely has interest, with particular relevance for burn care in Birmingham, but I am not convinced that the EBJ is the proper journal for this paper. 

 

 

 

 

 

Author Response

We are grateful for your kind comments on how you found the paper interesting, and we are particularly pleased it evoked some personal memories. We hope that this may be the case for many readers should this find an audience. Thank you for taking the time to review our paper. We would like to respond to your insightful suggestions and observations as detailed below:

• Differences in working conditions are stark but probably no more so than in other fields, such as steel foundries and building sites. Apart from some basic data on pay and hours of working, a narrow comparison between these two worlds seems futile. - Thank you for your comment. We completely agree that the field of burn surgery is just one area of significant change over the last 50 years. However, we felt that there was sufficient interest in the differences for members of our speciality to be as interested as we were to hear about some of those changes and reflect on them. When we discovered a link to the past of our own burn centre from 50 years ago it generated interest locally, and when the poster was recently presented at the ISBI in Birmingham it sparked discussion about what we have learnt from the past and how it may affect the current recruitment and retention crisis we are facing in the area of Burns Surgery currently in the United Kingdom.  
• The survey itself is poorly described. The population was apparently recruited using a poster, disseminated locally.  What about bias? Numbers do not add up: 66 responders were doctors and the remaining 10 were HCPs. However, 7 HCPs were excluded from analysis. Why does Figure 5 show responses from 7 HCPs? - There is an issue with clarity in our paper. Thank you for highlighting this. It just so happened that the seven people excluded from data analysis because of incomplete demographics were all HCPs, (i.e. three HCPs were included in the data analysis). Your insightful comment led us to reconsider the value of including HCPs in such low numbers and we have removed them from the analysis in the revised version. Further, we have received an additional two responses from colleagues during the period between paper writing and now. Therefore our data has been amended and now represents to opinions of 68 doctors and no health care professionals. Secondly, we have added further description about the survey dissemination, data collection and exclusion criteria in the “poster dissemination and survey" section, plus a section on bias in the discussion to address this discussing information, response, recall and selection bias. These now read “The key points raised in the interview were assessed for historical accuracy by performing literature search, as detailed below. This data was then summarised in a poster (Figure 2). This was displayed in communal areas in the burns centre, and disseminated to all training and consultant level doctors working in the plastic surgery department via group communications platforms (Email and WhatsApp). The poster was linked to a QR code to access a voluntary brief anonymised questionnaire from a free survey collection tool (Survey Monkey). Demographics were collected, in addition to training grade and career length. The key question posed by the survey was, after considering all the information “Would you rather be an SHO in 1970 or 2023?”. Responses were excluded if duplicated, incomplete of from non-doctors..”
• The numbers involved seem very small to allow logistic regression. – Thank you for raising this important concern. The minimum sample size for binary logistic regression are seemingly widely debated and controversial in statistics. Some texts (Harrell, F.E. regression model strategies – springer  2016) name a few “rules of thumb” (i.e. the commonly quoted 10 cases with least frequent outcome for each variable). Looking specifically at binary logistic regression with low numbers of sample size, it is more unclear as to what is acceptable, with minimum numbers  dependant on odds ratio and overall event proportion. Harrell suggests a number of 96 or greater. Hsieh however (Hsieh FY, sample size tables for logistic regression, Stat in med 8, pp795-802, (1989)) provides flexibility and insight into this low sample size issue. For our revised sample size (n=68), we would have to assume a higher odds ratio and larger event proportion, meaning the overall power of the statistical reliability is much less than a lager sample size . Considering this, and following your insightful comment, we feel it is simply distracting from the main message of the paper to discuss at length a controversial issue in statistics to justify a less reliable test.  Accordingly, we have eliminated reference to binary logistic regression in our abstract and results section, preferring to focus on the simple unpaired t-test (p=0.035).  We have briefly mentioned logistic regression in the limitations section accordingly: Finally, the numbers in this survey are relatively small to perform alternative more powerful statistical tests. Whilst binary logistic regression for age and voting preference was found to be significant (p=0.044), a sample size of 68 requires a larger overall event proportion and odds ratio.

• I think the authors' description of Jackson's immense contribution to burn surgery fall short. His ingenious use of alternating homgraft and allograft strips set the course for excision surgery for decades. - Thank you -Mr Jacksons work is certainly undersold here on reflection.  We have significantly added to this section in order to provide context as follows: The model of centralised burns care established here by the centre’s founder Mr Douglas Jackson and colleagues including Mr Jack Cason in the 1960s and 70s has been key to the design of the national burns service in place today. Douglas Jackson was an early advocate of the team approach to modern burns management, and pioneered excision and grafting, beginning in 1954, starting with small burns and gradually increasing up to 30% Total Burn Surface Area (%TBSA). Prior to this the process of expectant management and allowing burns to “slough and separate” had been largely practiced. (3,4). He published several important papers, including describing the zones of burn injury in 1953, which forms the basis for current understanding of the pathphysiology of burn wound progression and the potential to limit or increase harm caused by the initial insult. He describes diagnosing the depth of burn injury using methods including the pinprick test (5,6) . In 1972 he wrote “Tangential excision and grafting of burns - The method, and report of 50 consecutive cases.” (7) The interviewee remembers Mr Jackson travelling to the United States having been invited to present his work to a trans-Atlantic audience, as someone at the forefront of one of the most pivotal changes in the management of burns in the last century.

In summary, the manuscript definitely has interest, with particular relevance for burn care in Birmingham, but I am not convinced that the EBJ is the proper journal for this paper. - We do hope you could reconsider the EBJ as home for this with the revisions described above and with the development of historical context and further development of the discussion as suggested by the co-reviewers. Our initial feeling on meeting someone who remembered personally the days of Mr Douglas Jackson as a colleague was that it is rare we have such a close link with the history of such an influential figure, and we wanted to recall the reflections before they are lost. It is an opportunity to learn from those who have gone before us, in order to inspire future surgeons.

Reviewer 2 Report

Comments and Suggestions for Authors

A very nice and interesting paper on the change of working conditions for junior docs in burns.

No issues regarding the data/material, however, a few on spelling and clarity:

Abstract: "heath care" should probably be health care.

Bleeps? haven't seen that word before but assume it's a pager? maybe clarify?

Table 1
>"Outcomes", 2024 - Modified Baux Score (10; 5; 4) I do not understand what's within the brackets.
>PA maybe be common in English speaking language but could be clarified for non-native English speaking people.
>"Burn aetiology" "Flash fame" should be flash flame?
>Surely % distribution of burn aetiology can be provided for 2024?

Table 2
RPI/CPI - doesn't mean much to non-native english

Page 11, "Workload...", 2nd paragraph "...have bought about.." - brought?

Figure 6 and text - baby boomer, Gen X/Z, Millenials - not really any solid definitions on these expressions, maybe announce how you have defined them?

 

Author Response

 I would like to thank you for taking the time to read our paper and for your kind words in how you found the paper interesting. I’m pleased you could not see any major issues with the content or material. I am also grateful for your constructive comments on formatting. Please see below our responses to these individually:

• Abstract: "heath care" should probably be health care. - Thank you. Reference to all health care in the reference has been deleted secondary to the suggestions of other reviewers.
• Bleeps? haven't seen that word before but assume it's a pager? maybe clarify? - Thank you - indeed this is the common phrase for pagers in the UK. We have changed this for clarity to pagers as you suggest. 
• Table 1 "Outcomes", 2024 - Modified Baux Score (10; 5; 4) I do not understand what's within the brackets.- Thank you this is an error and has been deleted. 
• PA maybe be common in English speaking language but could be clarified for non-native English speaking people. - This means "Per annum". - I have converted this to its full phrase instead of PA for clarity.
• "Burn aetiology" "Flash fame" should be flash flame  - Thank you. This has been amend.
• Surely % distribution of burn aetiology can be provided for 2024- Thank you. This is now provided.
• RPI/CPI - doesn't mean much to non-native English - This is a measure of inflation (Retail price index) - I have now provided an explanation of it in the manuscript. This now reads “Retail price index (“RPI” – a measure of inflation measured by the UK’s office for national statistics) adjusted doctors’ salary in 1970.”
• Page 11, "Workload...", 2nd paragraph "...have bought about.." - brought? - Thank you. This has been amended.
• Figure 6 and text - baby boomer, Gen X/Z, Millenials - not really any solid definitions on these expressions, maybe announce how you have defined them? Thank you. I have reformatted the graph to provide the date of birth ranges for each generation for clarity. These have also been discussed in further details in the discussion section and now reads ad follows: “The wide-ranging differences between generations are discussed at length in the literature. Some of the key domains commonly discussed is the difference in work ethic, life priorities and expectations from employers and in various generations. For example, Baby Boomers (1946-1964) are often seen as valuing hard work, loyalty to their employer and career advancement through traditional means with a strong emphasis on job security. Generation X (1965-1980) tends to prioritise a balance between work and personal life valuing flexibility and independence. Millennials (also known as Generation Y) (1981-1996) are characterised by the desire for meaningful work, the opportunities for continuous learning and stronger preference for work life balance. Generation Z (1997-2010), the youngest group of doctors currently in our workforce, places even more importance on flexibility and social responsibility, expecting employers to offer not only good working conditions, but also to take stances on broader social, political and employment issues.”. We have also provided a reference for the quoted age ranges and above paragraph - Costanza, D.P., Badger, J.M., Fraser, R.L. et al. Generational Differences in Work-Related Attitudes: A Meta-analysis. J Bus Psychol 27, 375–394 (2012)

Reviewer 3 Report

Comments and Suggestions for Authors

This is interesting reading which is more of a snapshot of working conditions, salary, social life of a doctor and burn care practices of the time through the eyes of a junior doctor in 1970 (albeit a recollection).  This is followed by a survey of current doctors and healthcare professionals seeking their preference of which year they would like to be working. It is unclear if the survey had targeted responses based on the collective experience of the working pattern, salary, burn care etc in 1970 versus that of today or indeed each element of the variance.  How did they capture the detailed responses. What exactly was the purpose of this exercise given the conditions/practices were so different.  Furthermore, they have not included the questions asked of the 1970 doctor nor the details of the survey to be able to understand what data was collected. 

What they have not commented on is how does all of this reflect on the doctors knowing their patients or continuity of care provided to the patients.  

I am unsure the relevance of the allied healthcare professionals view on whether they would be SHOs in 1970 or 2024? They are not medics: so what are they commenting on and what is the relevance of their responses?  Burn care practices have evolved over time so what is being compared and what is the relevance?

This manuscript will be a better read if all of the above are addressed.  There are typing/spelling errors which I have not commented on and will need to be addressed.

I have not come across the way the references have been quoted in the body of the manuscript and will need to be corrected to the standard format.

 

Author Response

Thank you for the positive feedback regarding our paper. We are pleased you found the read interesting. Your comments are greatly appreciated. We have improved our paper based on your suggestions in the following way:

• It is unclear if the survey had targeted responses based on the collective experience of the working pattern, salary, burn care etc in 1970 versus that of today or indeed each element of the variance. How did they capture the detailed responses. - Thank you for raising this - We have clarified this in methods section. Responses were based on collective experiences with no individual variance. This now reads: “The key points raised in the interview were assessed for historical accuracy by performing literature search, as detailed below. This data was then summarised in a poster (Figure 2). This was displayed in communal areas in the burns centre, and disseminated to all training and consultant level doctors working in the plastic surgery department via group communications platforms (Email and WhatsApp). The poster was linked to a QR code to access a voluntary brief anonymised questionnaire from a free survey collection tool (Survey Monkey). . Demographics were collected, in addition to training grade and career length. The key question posed by the survey was, after considering all the information “Would you rather be an SHO in 1970 or 2023?”. Responses were excluded if duplicated, incomplete of from non-doctors..”
• What exactly was the purpose of this exercise given the conditions/practices were so different. - Thank you. The article arose from discovering someone who had personal experience of working with a pioneering burn surgeon, and a desire to record that. Locally this raised significant interest when we produced the poster, and prior to this when we were discussing the interview. We felt that during the current climate or often negative stories about retention of burns surgeons, this would be a light hearted interest piece which would give pause to reflect on the advances made in burn care in the last 50 years. Furthermore, we felt it may help to provoke discussion about the working expectations of today’s doctors, and the changing workforce. We have added an intention to that effect in the discussion: "By exploring the working conditions of the past, and assessing current burns and plastic surgeons’ attitudes to the changing workplace, we aimed to pause and reflect on our history and evolution as a specialty over the last half century. In a climate where recruitment and workforce satisfaction are often negatively represented, we can look with some objectivity to the past and consider if this is justified, or if, as our survey showed, there are many aspects of today’s working practices for a prospective burn surgeon, that may be attractive and better than the past. The living link to a pioneering burns surgeon led to many local discussions about the huge changes that have taken place in burns care in the last half century, and how proud and positive we can be about the future of burns surgery as a career. It also highlighted the changing views of the workforce, and whilst not designed to be a comprehensive social study, again provided useful insights for future planning of jobs within the department."
• Furthermore, they have not included the questions asked of the 1970 doctor nor the details of the survey to be able to understand what data was collected. - Thank you. We did consider a full transcript and if it is felt this would add to the piece can provide one. However, it was an extremely long interview and probably would not keep the readers’ interest. We have provided an additional text box with examples of the key questions asked to give a flavour. We have also added more detail in the methods section about the questions asked in the survey. -
• What they have not commented on is how does all of this reflect on the doctors knowing their patients or continuity of care provided to the patients.  - Thank you, you are correct in noticing this. We have added to the introduction " One view is that in the “good old days” patient care was simply better: better continuity of care and familiarity one’s patients; vastly improved exposure to surgical problems and breadth of practice; a greater feeling of being part of a team, with the “firm” structure, and close bonds of doctors whom often lived on site and frequented the doctors’ mess. Many believe that doctors were more respected (and possibly more respectable) and although you worked hard, you played hard.
• I am unsure the relevance of the allied healthcare professionals view on whether they would be SHOs in 1970 or 2024? They are not medics: so what are they commenting on and what is the relevance of their responses? - Thank you. On reflection and with similar comments from reviewer 1, due to low numbers from allied health professionals, we have removed their answers from the results, statistical analysis and figures. Further, we have had 2 further responses from doctors during the last 2 months. Therefore all amended statistics now represent the views of 68 doctors only.
• Burn care practices have evolved over time so what is being compared and what is the relevance? – We hope that this is a thought-provoking article on how much burn care has evolved over the last 50 years, told through the eyes of junior doctors within the same unit. Many of the changes are causes for celebration within the burns community: The improved survival rates due to pioneers such as Douglas Jackson; the decrease in flame burns and industrial injury through better legislation; the better work-life balance now, meaning a job in burns surgery is a open to more trainees. The living link with a pioneer of burns surgery provides insight that will one day be lost, and as we stand on the shoulders of giants, we should acknowledge how far the speciality has come in the last half century. We think this is relevant when considering where we are going as a profession, at a time when retention of urns surgeons and junior doctors in the NHS is waning.

 

• This manuscript will be a better read if all of the above are addressed.  There are typing/spelling errors which I have not commented on and will need to be addressed. - thank you for highlighting this. They will of course be addressed.
• I have not come across the way the references have been quoted in the body of the manuscript and will need to be corrected to the standard format. - thank you, there seems to have been an error with the referencing system. We have ensured that references are appropriately standardised using the Harvard system.

Reviewer 4 Report

Comments and Suggestions for Authors

This is a well written manuscript and a novel study essentially examining perceptions of changes in lifestyle and working conditions from 1970's and compared to today. The survey was well crafted and allows for a realistic comparison of the two time periods. There are also great photographs and documents from BAH that allows for a solid framework to support the manuscript. Would expand the discussion section and expound on the impact that generation had on results. Also the Covid epidemic had a profound effect on delivery of burn care world-wide, can some of that impact be reflected in this study.

Comments on the Quality of English Language

The English was of good quality. This was a structurally a well-written manuscript.

Author Response

Thank you for your kind comments on our paper. We please you found the paper well written and novel. It is challenging to portray accurately the differences between two periods in time, and therefore are especially pleased you found the survey well crafted. We hope we have improved our paper based on your feedback, as detailed below:

• Would expand the discussion section and expound on the impact that generation had on results. - Reply: Thank you for highlighting this. We agree and therefore have somewhat reduced some minor details in the interview section to focus more on the generational difference between doctors. In particular, we have looked at work ethic, life priorities and expectations from employers were briefly unpacked. This now reads: A higher proportion of total votes for today’s working conditions were observed. This is interesting when viewed with the current background in the United Kingdom of issues with workforce motivation, pay disputes and working conditions. Motivating factors behind this could be due to reduced or ‘safer’ working hours, rest days and more time to enjoy activities outside of work. Many however would still prefer to work in the conditions of 1970. Perhaps more interesting is the significant generational skew observed for this preference. By exploring motivations to vote for either direction, we may begin to gather insight into the motivating factors for voting preference.
•  
• Intergenerational differences are considered when future-planning by industry. Key domains commonly discussed are the differences in work ethic, life priorities and expectations between generations. Baby Boomers (1946-1964) are described as valuing hard work, loyalty to their employer and traditional career advancement with a strong emphasis on job security. Generation X (1965-1980) tends to prioritise a balance between work and personal life valuing flexibility and independence. Millennials (also known as Generation Y) (1981-1996) are characterised by the desire for meaningful work, the opportunities for continuous learning and stronger preference for work life balance. Generation Z (1997-2010), the youngest group of doctors currently in our workforce, places even more importance on flexibility and social responsibility, expecting employers to offer not only good working conditions, but also to take stances on broader social, political and employment issues.(12) . With a shifting focus to satisfy the priorities of generation Z, employers in 2020 reported a move to better working environment and work-life balance.
•  
• Although not by any means universal, the differences observed between the generations of doctors working preferences in our study therefore is perhaps unsurprising. In addition to this, during the last 5 years of practice, there has been significant tumult in burns care worldwide following on from the COVID-19 pandemic. The working conditions before and after 2020 are within the working memories of doctors of Millennial and older generations, however not of that for generation Z. Most have negative reflections on this period and its ongoing impact on working conditions and the provision of burns care itself, when compared to the period before. This may be a further contributing factor for the generational skew in voting preferences observed.
•  
• There are some limitations with the survey. The recollections are of over half a century ago, and are those of a single junior doctor, working in a single burns centre and thus provide a single snapshot.. The survey was similarly from a self-selecting group of interested parties within the same unit, each with their own varied levels of experience as a burns SHO. .”
• By exploring how burn care has evolved over the last 50 years, told through the eyes of junior doctors within the same unit, and contrasting working conditions then and plastic surgeons’ attitudes to the changing workplace, we aimed to pause and reflect on our history and evolution as a specialty. In a climate where recruitment and workforce satisfaction are often negatively reported, we can look with some objectivity to the past and consider if this is justified, or if, as our survey showed, there are many aspects of today’s working practices for a prospective burn surgeon, that may be attractive and better than before. The living link to a pioneering burns surgeon led to many local discussions about the huge changes that have taken place in burns care in the last half century, and how proud and positive we can be about the future of burns surgery as a career. It also highlighted the changing views of the workforce, and whilst not designed to be a comprehensive social study, again provided useful insights for future planning of jobs within the speciality. Many of the changes are causes for celebration within the burns community: The improved survival rates due to pioneers such as Douglas Jackson; the decrease in flame burns and industrial injury through better legislation; the better work-life balance now, meaning a job in burns surgery is open to more trainees; opportunities in research and enthusiastic teamwork mean that burns surgery is still a career with a bright future.

 

• • Also the Covid epidemic had a profound effect on delivery of burn care world-wide, can some of that impact be reflected in this study. Reply: Thank you for highlighting this. We like the suggestion and therefore have mentioned the major disruptive effect of COVID and its possible influence on the perception of working conditions in the expanded discussion, detailed above.

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

First, I wish to thank the authors for their excellent response to previous comments. The manuscript has been markedly improved. 

While the scientific content is limited, I am pleased that the statistical approach has been simplified.

I think that the paper does have historical interest , although it mainly concerns the development of burn care in the UK and Birmingham in particular. The conditions of junior hospital training decribed are uniquely British , but there is some resonance  with hospital practice throughout Europe. 

I leave the decision to publish with the Editor-in-Chief but I am now happier with the manuscript than I was on first reading.

(As a matter of interest to the authors, Jackson was also invited to lecture at our own burn centre at Beverwijk in the Netherlands (1982?),  which itself has had a major influence on burn care in Europe. His invitation served as a recognition by us of his contribution to burns globally. It was a privilege to meet him.)

 

Reviewer 2 Report

Comments and Suggestions for Authors

Excellently revised.

Certainly warrants publication in EBJ

Reviewer 4 Report

Comments and Suggestions for Authors

No additional comments. This is well written manuscript that gives the reader a historical glimpse into the care of the burn patient.