General Practice

What do Wessex general practitioners think about the structure of hospital vocational training?

BMJ 1994; 308 doi: (Published 21 May 1994) Cite this as: BMJ 1994;308:1337
  1. P Littlea
  1. a Nightingale Surgery, Romsey, Hampshire Department of Primary Suegery, Care, University of Southampton, Aldermoor Health Centre, Southampton SO 16 5ST
  1. Correspondence to: Dr
  • Accepted 28 March 1994


Objectives: To assess the views of general practitioners about the structure and content of hospital vocational training and its relation to the training year.

Design: Postal questionnaire.

Setting: Wessex, England.

Subjects: General practitioner trainees undertaking practice training year (n=144), courseorganisers (n=22), and a random sample of two thirds of trainers (n=135).

Results: Questionnaires were returned from 86% (260): 84% of trainees (121), 92% of trainers (124), and 68% of course organisers (15). Most respondents in all groups (84.3%, 95% confidence interval 79.7% to 88.8%) wanted more jobs lasting two and three months to allow a greater range of hospital specialities to be experienced and some of the training year to be carried out before hospital jobs (66.3%, 60.4% to 72.1%). Most hospital specialties were rated at least 6 out of 10 as “useful” for general practice training. A substantial minority of training posts did not have regular weekly teaching (166/541;30.7%, 26.8% to 34.6%) and had no half day (224/541; 41.4%, 37.3% to 45.6%), and over half gave no study leave (293/541; 54.2%, 50.0% to 58.4%).

Conclusions: The structure of hospital training should be reviewed as it does not reflect the views of most trainees, course organisers, or trainers. Individual posts need closer supervision to ensure the availability of basic training requirements. More trainees should be allowed to spend a short time in the general practice before hospital rotations and to choose a greater range of shorter jobs.

Practice implications

  • Practice implications

  • Training schemes for general practitioners usually entail four hospital posts lasting six months each

  • Little is known about general practitioners' preferences for the structure of schemes

  • This study found that most trainees, trainers, and course organisers would prefer to have more hospital shorter posts and some training in general practice before hospital posts

  • Training within hospital posts is sometimes poor in terms of weekly teaching and study leave

  • Hospital training should be reviewed, and closer supervision is needed for trainees in hospital posts


Evidence is accumulating that general practitioner trainees in hospital vocational training schemes and their course organisers are dissatisfied with the hospital component of training for general practice.*RF 1-8* The usual structure of the vocational training schemes in England includes four hospital posts for six months each.9 It is not clear why schemes are structured like this, other than for administrative or service reasons. Furthermore, there is no information on the preferred duration for each post or on general practitioners' preference for some of the training year to be held before hospital jobs. There is also no information from a national survey published in 1990 about the number of trainees who are not getting regular weekly teaching, a regular half day, or study leave.9

I examined the views of general practitioner trainees, trainers, and course organisers on the structure of hospital training in Wessex by questionnaire.


Questionnaire - In addition to closed questions - for example, on preference for jobs lasting two to three months - the questionnaire had an open section for comments.

Power calculation - From the pilot study (in 50 trainees) I estimated that 80 subjects were needed to give 95% confidence intervals of plus or minus 10% for the percentage preferring more short jobs.

Reliability - Fifteen trainees answered both pilot and final questionnaires. Preference for more short jobs and for introductory time in practice were identical between questionnaires.

Mailing - To guarantee a sample of 80 trainees and 80 trainers, with an assumed response rate of 50-60%, all trainees in Wessex (of 144 training in August 1993), all course organisers (n=22), and a 60% random sample (n=135) of the trainers in Wessex were sent the questionnaire. A second questionnaire was sent after six weeks to non-responders.

Analysis - I have used median values with interquartile ranges rather than means and confidence intervals to avoid assumptions of normality for artificial scales (such as “usefulness”). Unless stated numbers and percentages refer to individual people who responded to a question.


The response rate was 86% (260/301): 84% for trainees (121/144), 68% for course organisers (15/22), and 92% for trainers (124/135).

Tables I-III summarise the answers to the questions. Most of the respondents in each of the three groups would have liked to have had more posts lasting two to three months and to have had some of the training year before hospital jobs. Only a minority of the trainees (36/119; 30%), however, had a split training year, and very few trainees had had posts in the minor specialties - for example, less than a quarter had had a post in otorhinolaryngology and less than 15% in dermatology and ophthalmology. In all specialties there were higher “usefulness” ratings (median 1, except accident and emergency, which was 2) if the respondent had had a job in that specialty, which was significant (at P<0.05) for all specialties except dermatology and rheumatology. The preferred median job duration was six months for medicine, paediatrics, and obstetrics and gynaecology; nothing for general surgery; and three months for all the other specialties.


Details of respondents' answers to questionnaire on hospital training posts for general practitioners. Figures are numbers(percentages; 95% confidence intervals) unless stated otherwise

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Most general practitioners in Wessex involved in vocational training want some general practitioner training before hospital posts and more shorter hospital posts to allow a greater range of specialties. This contrasts with the minority in the present study and in a national survey who underwent any of their training year before hospital posts9 and a minority who had done posts in minor specialties. How feasible is it to restructure hospital training to allow more shorter jobs? Locally - for example, the posts lasting two to three months in the Portsmouth scheme or elective (outpatient) attendance at different specialties for six months in the Winchester - and internationally - for example, New Zealand - short posts can be feasible without apparently sacrificing service commitments.

How much time is required to achieve appropriate clinical competence in a subject? Competence for a specialist career will have different priorities than competence for general practice; competency profiles need to be defined and assessed more clearly for each individual postholder. It has been suggested that two months are required to learn the basic physical diagnostic and therapeutic decisions in a post.10,11 Furthermore, given that in some posts the teaching input is poor, it might not be difficult to provide more teaching and thus achieve more overall competence in a well structured attachment of two to three months than currently occurs in a longer post.


Median ratings (interquartile ranges) of respondents for perceived usefulness of hospital posts (1=useless to 10=very useful) for general practice.(dagger) Also shown are median usefulness ratings by respondents who had done post in that specialty

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Numbers (percentages) of trainees who had done a post in given specialty and detailes of training

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The issue of competence across the broad range of specialties that generalists require raises the issue of the length of vocational training. Currently vocational training for general practice is shorter than training for consultant posts. It does not follow, however, that much more time should be spent in junior hospital posts.6 The comments in the open sections of the questionnaires support previous work*RF 1-3,5-9,12-13* that there needs to be more linking between general practice and hospital vocational training and that teaching needs to more relevant and preferably more outpatient based. Hospital vocational training still seems far away from the simple proposition that for each part of the scheme there should be an agreement of the “knowledge to be gained, skills to be acquired, and attitudes to be developed.”6 A broader, more relevant training could be achieved if the practice partof training was extended - for example, by an extra year - and included more intensive integrated outpatient teaching acrtoss a broad range of specialties.

In conclusion, hospital vocational training for general practitioners should be reviewed as thestructure does not reflect the views of most trainees, course organisers, or trainers. Training should allow more shorter jobs and some of the practice year before hospital jobs and provide teaching more relevant for general practitioners' needs. The figures on low teaching, half days, and study leave highlight the need for closer supervision of individual posts; the assessment and review process needs to be more effective, with rapid feedback from postholders. To complement this we need more research to study how best to achieve competencies appropriate to general practitioners ina wider range of shorter attachments.

I thank Dr John Pitts for encouragement and help at all stages of the study; Dr Ian Williamson,Professor AnnLouise Kinmonth, and Professor David Mant for the many helpful comments on the manuscript; and Dr David Percy for encouragement and financial help.


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