Preregistration house officers in general practice: review of evidence

Abstract

Objectives

To examine the strengths and weaknesses of the national and local schemes for preregistration house officers to spend four months in general practice, to identify any added value from such placements, and to examine the impact on career choices.

Design

Review of all studies that reported on placements of preregistration house officers in general practice.

Setting

19 accounts of preregistration house officers' experience in general practice, ranging from single case reports to a national evaluation study, in a variety of locations in Scotland and England.

Participants

Views of 180 preregistration house officers, 45 general practitioner trainers, and 105 consultant trainers.

Main outcome measures

Main findings or themes weighted according to number of studies reporting them and weighted for sample size.

Results

The studies were unanimous about the educational benefits of the placements. The additional learning included communication skills, social and psychological factors in illness, patient centred consultations, broadening of knowledge base, and dealing with uncertainty about diagnosis and referral.

Conclusions

Despite the reported benefits and recommendations of the scheme, it is not expanding. General practitioner trainers reported additional supervision that was unremunerated. The reforms of the senior house officer grade may resolve this problem by offering the placements to senior house officers, who require less supervision.

What is already known on this topic

Pilot schemes across the country have offered preregistration house officers the opportunity to rotate into general practice

Many studies have reported on these rotations, but there has been no review summarising their strengths and weaknesses

What this study adds

Rotations in general practice are unanimously welcome and offer a valuable training opportunity

However, the schemes are not expanding, mainly because of the unremunerated supervisory role of trainers

Proposed reforms to the senior house officer grade may help by offering placements to senior house officers instead, who are able to prescribe and require less supervision

Introduction

In 1998 the government made funding available to support a national scheme for preregistration house officers to spend four months in general practice as part of their preregistration year. Before this, placements in general practice were uncommon, partly due to the wording of the Medical Act 1983, which limited the placements to health centres (amended in 1998), and partly because of the burden of supervision, additional costs, and administration. In contrast, in Denmark all young doctors spend six months in general practice after finishing university.¹ But attitudes in the United Kingdom were changing in the 1990s, and the General Medical Council indicated that general practice should be viewed as an appropriate setting for trainee doctors to learn the duties of a doctor in advance of full registration: “Such a post will offer invaluable insights into the interface between primary and secondary care for the intending hospital specialist as well as enabling PRHOs contemplating a career in general practice to assess the validity of their choices.”² The General Medical Council has identified broad aims for general clinical training in hospital and in general practice.² We reviewed all the studies that reported on placements of preregistration house officers in general practice to determine the strengths and weaknesses of the scheme, to identify any added value from such placements, and to examine the impact on career choice.

Methods

We searched Embase, Medline, ERIC, FirstSearch, PsycINFO, and the search facility of www.timelit.org.uk and www.educationgp.com with the key words “pre-registration,” “house officer,” and “general practice.” We also checked the reference sections of identified articles for any studies not picked up on the databases.

As this is a relatively under-researched area, we aimed to include all studies that reported on the experiences of preregistration house officers in general practice in the United Kingdom, irrespective of sample size. We listed the main findings or themes from each study and compared them with others to determine common themes. These were weighted according to the number of studies reporting the theme and the sample size; studies with larger samples were given a higher weighting.

Results

In 1998, 42 new programmes for preregistration house officers were established and evaluated as part of a national initiative.³ The evaluation of the nationalscheme was conducted by postal questionnaire. The study compared the new rotations of four months in general practice, surgery, and medicine with the conventional rotations of six months in medicine and surgery. Overall, 51% (54 of 96) of preregistration house officers on the new general practice scheme responded, thus we advise caution in generalising from the findings.

Local schemes, usually offering placements at only one or two practices and involving a smaller number of doctors, were also reported. Sample size ranged from single cases to 34 cases (table).^4–21

Response rates for the local studies were higher, but sample sizes were smaller. Several studies used qualitative methods, reporting main themes rather than responses to questions.^4–6,⁹,¹⁰,¹² We report on the views of 180 preregistration house officers, 45 general practitioner trainers, and 105 consultant trainers (table).³,⁴,⁶,²²,²⁵

Generally the schemes have been run by enthusiasts; none the less they have been self critical.³,⁷,⁸,¹² Not all the preregistration house officers were considering a career in general practice, but generally they approved of the scheme.³,⁵,⁷,⁹,¹¹,¹²

Strengths of scheme

Views of preregistration house officers and trainers

The preregistration house officers interviewed in the local studies reported the experience as beneficial and enjoyable and they would recommend it.^4–12 General practitioner trainers were generally positive about the experience,³,⁶,⁹,¹³,¹⁴,²⁵ with several commenting on the benefits for hospital doctors.³,⁵,⁹

Length and order of placements

Although there were variations in the length of the schemes,⁴,⁸,¹⁵,¹⁶ most studies involved rotations of four months in general practice, medicine, and surgery, and this was viewed as about right.³,^6–8,¹¹ Concern had been expressed that spending the first four months in general practice might disadvantage house officers,⁸,²³ but this did not always seem to be the case,³,⁹,²³ although there may be greater isolation from peers.¹² However, those in general practice later in the rotation were reported to have more confidence and to require less supervision.³,¹²,²³

Meeting the aims of the General Medical Council

The aims of the General Medical Council could be met in general practice placements.²,⁵,^7–10 The national evaluation reported that the house officers in general practice had similar learning experiences to those on traditional rotations, including communication skills with colleagues and patients, consultation skills, awareness of illness presentation, and the ability to investigate illness appropriately.³

Added value

The national evaluation reported that a wider variety of learning was experienced by house officers in general practice rotations than those on traditional rotations and, in 26 of the 51 areas measured, the house officers in general practice were judged to be more competent than the reference group. House officers in general practice gained more experience in several areas (box B1). The local studies had similar findings (box B2).

Box 1.

Experiences gained by preregistration house officers in general practice rotations

• Social and psychological factors in illness
• Patients' expectations, and sharing information and decisions with patients
• Specific disease management and prevention
• Incidence and prevalence of disease in the community
• Management of common and chronic illness in the community
• Assessment of patients at home
• Referral
• Skills in information technology
• Ethical and legal aspects of practice³

Box 2.

Main themes emerging as new areas of learning in general practice

• How social and psychological factors impinge on physical health⁴,⁷–¹¹,¹⁴,¹⁶,²⁵
• Broadening of knowledge base, including learning about common illness⁴,⁶,⁷,¹⁰,¹⁶,²⁵
• Learning a different doctor-patient relationship, involving patients in decisions⁶,⁹,¹⁰,¹²
• Improving communication and consultation skills⁴,⁵,⁹,¹⁰—for example, sharing information with patients (more likely in general practice than in hospital)²³,²⁴
• Having greater responsibility for the management of patients⁴,⁹–¹¹,²⁵
• Learning about diagnostic uncertainty in the community and hospital referral⁴,⁷,⁹–¹¹,¹⁴,¹⁶,¹⁹,²⁰
• Gaining experience of areas not usually encountered, such as psychiatry, paediatrics, and obstetrics and gynaecology⁴,¹⁰,¹⁵,¹⁷,²⁰

The national evaluation found that communication skills with patients improved for the house officers regardless of placement. In the qualitative studies, however, the house officers cited communication skills as not only improved but better in general practice,⁴,⁵,^10–12 and that communication with general practitioners had improved subsequently.¹⁰

Uncertainty about diagnoses in the community without the benefits of continuous observation or nursing care and easy access to tests and other professional opinion was an important learning experience and changed attitudes towards hospital referrals.^4–7,^9–11,¹⁴,¹⁶,¹⁹,²⁰ The house officers also reported acquiring a range of generic skills, including teamwork, preventive care, informatics, and organisational skills.⁵,¹⁰

Supervision

Tutorials and supervision occurred more often in general practice than in hospital and was reported enthusiastically by the house officers.³,⁴,^9–11 Views about supervision in hospital were more guarded.⁴,⁶,¹⁸ The consultant trainers were supportive.³,⁶,²² The national evaluation gained views from 29 consultants involved in the scheme and reported that 93% wanted to continue with it.³

Weaknesses of scheme

Views of house officers

Some house officers felt isolated from their peers, and most placements required a car.³,⁶,^9–12,²³ The inability of house officers to sign a prescription was reported by some as a problem,⁶,¹¹ whereas others reported that this created opportunities for education.⁴,¹⁰,²⁵

Views of trainers

Some general practitioner trainers highlighted the additional supervision needed for the house officers compared with registrars.³,⁴,⁵,⁷,²⁵ The trainers reported a 10% increase in their working week to supervise house officers and requested additional funding.³,⁴,⁷,⁹,²⁵

Influence on career

Around 5% of house officer rotations are in general practice. Studies that examined the impact of such rotations on job interviews found that they helped rather than hindered careers.⁷,¹¹,¹² This experience was likely to increase consideration of a career in general practice.³,¹¹,¹² As most doctors make career choices towards the end of their preregistration year, placements in general practice may boost recruitment to this setting.²⁶

Discussion

The studies we reviewed favoured placements of preregistration house officers in general practice. Such schemes represent a valuable training opportunity and an important means by which trainee doctors gain experience of general practice. This experience is an essential accompaniment to training in hospital, enabling the development of a range of competencies. Despite this, schemes are not expanding but continue, owing to the efforts of committed enthusiasts, alongside concerns that the financial support available does not reflect the degree of supervision provided. Such concerns were also reported in a New Zealand study.²⁷ The recent proposals for the reform of the senior house officer grade offer a potential solution.²⁸ The preregistration year is to be combined with a generic first post-registration year to form a foundation programme lasting two years, which all doctors would undertake. It recommends that all doctors could experience general practice as part of their foundation programme. The question then is not whether experience in general practice should be included as part of postgraduate medical education regardless of intended career, but whether this experience should be before or after registration. Postponing general practice placements to the second year of the foundation programme would overcome many of the difficulties with supervision while maintaining the benefits of both medical education and recruitment to general practice. The capacity for training in general practice would need to be enhanced to cope with the increased numbers.

Table.

Results of literature search for preregistration house officer placements in general practice

Study	No of preregistration house officers	No of general practitioners	No of consultants	Methods	Location
Grant and Southgate (2000)3	54	25	84	Postal survey	National
Illing et al (1999)4	3	1	—	Interviews (qualitative study)	North east
Rowan-Robinson and Challis (2000)5	5	5	—	Interviews (qualitative study)	Mid-Trent
Hewitt et al (2001)6	6	4	4	Interviews (qualitative study)	Edinburgh
Harris et al (1985)7	9	—	—	Self completion questionnaire	London
Freeman and Coles (1982)8	10	—	—	Postal questionnaire	Southampton
Parsons et al (1998)9	12	—	—	Interviews (qualitative study)	London
Williams et al (2001)10 (2000)22 (2001)23	12	9	17	Interviews (qualitative study)	London
Wilton (1995)11	26	—	—	Postal questionnaire	London
Page (2001)12	34	—	—	Postal questionnaire (qualitative)	Manchester
McGuiness (1982)13	1	1	—	Single case report	Liverpool
Taylor and Thomas (1997)14	1	1	—	Single case report	North east
Oswald and Kassimatis (1989)15	1	—	—	Single case report	Cambridge
Illingworth (1994)16	1	—	—	Single case report	Not stated
Greenwood (2001)17	1	—	—	Single case report	Norfolk
Moore (2000)18	1	—	—	Single case report	Not stated
Oswald (1998)19	1	—	—	Single case report	Not stated
Cohen (1998)20	1	—	—	Single case report	London
Blackamore (2002)21	1	—	—	Single case report	Leeds