Learning in practice

Preregistration house officers in general practice: review of evidence

Jan Illing, Association for the Study of Medical Education research fellow ^a, Tim van Zwanenberg, professor of postgraduate general practice ^a, William F Cunningham, general practitioner ^b, George Taylor, director of postgraduate general practice ^c, Cath O'Halloran, curriculum development coordinator ^d, Richard Prescott, consultant physician ^e. 

^a University of Newcastle upon Tyne, Postgraduate Institute for Medicine and Dentistry, Newcastle upon Tyne NE4 2AB, ^b Corbridge Health Centre, Northumberland NE45 5JW, ^c Department for NHS Postgraduate Medical and Dental Education (Yorkshire), University of Leeds, Leeds LS2 9JT, ^d New Generation Project, South Block, Southampton General Hospital, Southampton SO16 6YD, ^e South Durham Health Care NHS Trust, Bishop Auckland General Hospital, Bishop Auckland, County Durham DL14 6AD

Correspondence to: J Illing

(see also p 1011)

	Abstract

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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

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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

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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

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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 1). The local studies had similar findings (box 2).

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

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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.

	Acknowledgments

Contributors: JI collected and analysed the data and wrote the article; she will act as guarantor for the paper. TvZ read the papers, helped analyse them, and wrote the article. WFC and GT read the papers and helped write the article. CO'H read selected papers and helped write the article. RP contributed to writing.

	Footnotes

Funding: The Association for the Study of Medical Education funded the review through a fellowship for JI.

Competing interests: None declared.

	References

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(Accepted 20 November 2002)