Preregistration house officers in general practice

BACKGROUND

The practice is based in a health centre near St Mary's Hospital in inner London. In 1981 it had about 6000 registered patients and three partners, and in 1990 it had about 8000 patients and five partners (two part time). There is one practice nurse, a practice manager, a trainee general practitioner, and attached community nurses. Each house officer in the general practice house officer scheme works four months in the practice and four months each in medicine and surgery at St Mary's Hospital. All applicants are interviewed by the relevant hospital consultants and the supervising partner in the practice. Selection is based on merit, and no preference is given to candidates who favour general practice as a career.

The medical house officers work for general medical and cardiology firms, each with its own consultant and registrar and with patients on several wards throughout the hospital. The surgical house officers work for the academic surgical unit, based mainly on one ward, with a team including the professor of surgery, senior registrar, registrar, and senior house officers.

The general practice house officers hold seven surgeries a week, with an average of eight patients per surgery, and have one half day a week for home visits. There is one half day a week for tutorials and one half day for project work. The general practice house officers work in a similar way to trainee general practitioners, except that they cannot legally sign prescriptions. House officers can investigate, refer, and admit to hospital, but they are expected to discuss important changes in management with a partner before proceeding. There is an introductory programme for new doctors, in which they observe each partner in surgery and on visits, spend half a day with each attached nurse, and work on the reception desk.

The general practice house officers are given a consulting room and a car. Most live in the hospital residence for the general practice rotation, but on call duties can be from home if this is near the practice. The on call duty is one night in two on weekdays and one weekend in three. House officers often visit patients alone, but they are always on call with one of the partners, who screens the phone calls from patients and then delegates if appropriate. House officers do not visit alone children under one year of age. The practice sometimes uses a deputising service for visits after 11 pm.

FIRST PART OF STUDY

For the first part of the study I sent a questionnaire with accompanying letter in August 1993 to all house officers who had rotated through general practice in the first 10 years of the scheme (1981–91) and whose current address could be traced. To preserve confidentiality each questionnaire was identified by code number only. A repeat letter and questionnaire was sent four weeks later to non-respondents. The questionnaire asked for details about the respondent—such as age, sex, and career intentions—and about respondents' views of the rotation, with structured and free text questions.

SECOND PART OF STUDY

For the second part of the study I asked eight hospital based house officers (four in medicine, four in surgery) and four general practice based house officers to complete a time sheet for four consecutive weeks of their work. The periods chosen were “typical” months—that is, not during peak holiday periods or at the beginning or end of a rotation. This part of the study began in February 1991 and was completed by May 1994.

Each house officer was given a standardised form, which included definition of terms, and asked to record:

• Time of arrival at and departure from workplace

• Time spent in clinical activities—defined as clerking or talking to patients (or surgery times for the general practice house officer)—and associated activities, such as writing up case notes and ordering investigations

• Time spent on administration—defined as organising discharges and admissions, chasing and filing results, phone calls, recording for audit, and correspondence

• Time spent attending meetings (excluding ward rounds)

• Time spent learning in individual or group teaching sessions specifically intended for preregistration house officers

• Time spent on ward rounds (hospital house officers only)

The number of overall hours per week was taken as the total from the start to the end of the working day. Time taken in miscellaneous activities, such as meal and coffee breaks or travelling between wards or to patients' homes, was not recorded and was included in the overall working day. When a house officer was on call it was assumed that normal duties finished, and on call began, at 7 pm.

EFFECTS OF SCHEME ON PRACTICE

The general practice house officer scheme has operated at Lisson Grove Health Centre since 1981, and by July 1994, 39 newly qualified doctors had passed through the practice. The presence of house officers is seen as a positive contribution to the practice. They are usually fresh, enthusiastic doctors who appreciate reasonable working hours with high levels of clinical contact with patients and more responsibility than in some hospital house jobs.

The rotation, however, adds a considerable strain to the practice. A new, inexperienced doctor arrives every four months. After five or more years of mainly hospital based training the house officers often have an organic rather than a whole person approach to patients. They may overinvestigate and prescribe for patients who have social or psychological problems. However, they usually adapt quickly to their new environment and make a positive contribution to the care of patients.

On average a house officer conducts unobserved about 750 consultations in four months, of which 7% are home visits. Despite over 20000 consultations by the 30 house officers who rotated through the practice in the first 10 years of the scheme, only one patient complained to the family health services authority, and the complaint was resolved informally.

VIEWS ON ROTATION

Half of the respondents thought that having the general practice house officer rotation on their curriculum vitae had helped with getting subsequent jobs. If it did indeed help then this may be because the scheme is novel and interviewers were interested to hear about the scheme first hand.

Most respondents welcomed the insight the scheme gave them into how general practice and community services work together. One respondent replied, “Back in hospital, I am now more sympathetic to referrals and writing discharge letters back to general practitioners.” They also liked the high degree of clinical responsibility and independence.

The difference in working environment and culture between hospitals and general practice can make the transition between jobs difficult. House officers coming to general practice as their first job were particularly anxious about returning to hospital for the next part of the rotation, mainly because they believed themselves to be behind their peers in basic hospital house officer skills such as putting up drips, taking blood, and interpreting x ray films. In contrast, house officers coming to general practice after a hospital job described their difficulty in adapting to a different pace of working. One doctor described the frustration of becoming confident in the hospital culture and of “having to start again in general practice knowing nothing.”

The comments made about the most disliked part of the general practice rotation—for example, nights on call and feeling out of one's depth—would probably be made about any house job anywhere. The house officers' specific dislike was not being able to sign prescriptions, a restriction laid down in General Medical Council's guidelines on prescribing. Although house officers may write their own prescriptions, these have to be signed by a partner.

HOURS AND WORKLOAD

Subdividing a working day into different activities, as I have done in this study, may be subjective and not accurate. Activities such as clinical and administrative duties will blur into each other while activities such as the beginning and end of a ward round or a teaching session can be clearly defined. The time sheets were completed by the house officers, not by independent observers.

Ward rounds, surgeries, meetings, and teaching sessions are regular weekly events for house officers, and the times quoted for these on the time sheets were checked for accuracy by referring to the weekly timetable for each house officer. These points have to be remembered when comparing the number of hours worked in a week (excluding on call) by house officers based in hospitals and the number worked by house officers based in general practice (55.5 v 41 respectively) and the type of work performed in those hours (clinical work, 22.5% v 58% respectively).

Regarding educational content, the general practice house officers received nearly three hours' teaching a week. This consisted of a tutorial with the supervising partner and a group tutorial with another partner and the general practitioner trainee. The hospital based house officers in this survey, however, reported little individual or group teaching. Although an average of 14 hours a week was spent on ward rounds, which is the traditional place for teaching in hospital, ward rounds are not specifically intended for instruction for preregistration house officers.

An advantage of individual teaching is the opportunity for pastoral care and career guidance. Preregistration house officers have a demanding, responsible job, usually for the first time in their lives. They are exposed to sick or dying patients and to angry or bereaved relatives, and, when overworked, may make mistakes. During this year they also start applying for senior house officer rotations, which means making career choices. Junior doctors have higher rates of stress and depression than the general population.14 15 The extent of pastoral care and career guidance was not surveyed, but evidence exists that house officers receive little career guidance in the hospital setting.16

CONCLUSION

The findings of the survey of the 26 doctors who had rotated through general practice in their preregistration year suggest that such a rotation is a popular and useful alternative to a hospital house job. The results of the second part of this study suggest that general practice house officers do more clinical work, work fewer hours a week, and receive more individual teaching specifically designed for the preregistration year than hospital based house officers.

The study was based on the only established preregistration rotation in general practice in Britain and on one hospital and one general practice, and conclusions must therefore be guarded. But the scheme at St Mary's Hospital Medical School is considered a success, and other medical schools and their local practices may wish to consider offering similar rotations.

I thank my partners, Professor Brian Jarman, Drs Andrew Elder, Sally Taylor, and Neville Purssell; Dr Lesley Morrison; Anne Fleissig; and Dr John Watson.

For administrative reasons Lisson Grove Health Centre is soon to withdraw from the rotation scheme, but another practice in the area will soon join the scheme with St Mary's Hospital. The medical school is exploring the possibility of expanding the scheme to include more places for house officers.