Career Focus

Preregistration house jobs in general practiceValuing general practice in the house officer year

BMJ 1998; 317 doi: (Published 26 September 1998) Cite this as: BMJ 1998;317:S2-7162

Preregistration house jobs in general practice

Six months of surgery and six of medicine is the time honoured split. Julia Thomson casts an admiring glance at a rotation that includes general practice

  1. Julia Thomson
  1. senior house officer in paediatrics
  2. professor in primary care, Universities of Teesside and Newcastle upon Tyne, Primary Care Resource Development Centre, Middlesbrough TS7 OPN

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    There was nothing wrong with my house job. I had a friendly team and a fair boss, and, although busy, I was not unduly bowed under by the pressure of it all. But I never professed to being a budding vascular surgeon, and two months into the job I began to wonder whether the rigid preregistration house year of six months medicine and six months surgery was really the most efficient way to train tomorrow's senior doctors. After a particularly hectic Friday night on call dealing with an intracerebral bleed, the usual run of non-specific abdominal pains, and a man who had inserted a light bulb into his rectum, I went to see a friend of mine who is doing part of her preregistration post in primary care and asked her a few questions about life as a house officer in general practice.

    What are the advantages of your job?

    Many. It's a friendly working environment and I don't have a bleep, so no one disturbs me when I'm dealing with patients. Having a GP supervisor is like having a personal tutor on tap all the time. He is very keen on evidence based medicine and we can look up on the computer the latest information on the management of cases, particularly uncommon ones.

    No bleep&emdash;what bliss! But how do you have the time to look everything up?

    Twenty five minutes are allocated for each patient. I have a protected half day during the week and have time to study during the day between surgeries.

    So do you see fewer patients than hospital preregistration house officers?

    No. I see about 15 patients a day, but 15 different patients every day, so in a week I see many more cases than I ever saw in hospital, where you are seeing the same faces every day. I also see a much wider variety of pathologies. True, I am not exposed to the specialist knowledge that you may be exposed to in hospital, but I had that when I did my hospital house posts, so I don't feel that I've missed out.

    Isn't it mostly psychological problems that you deal with?

    Many patients do have a psychological component to their presentation. They can take a long time to sort out&emdash;you can't just look in their ear and send them away&emdash;but it's quite a challenge to get to the bottom of it and rewarding when you detect a “good going” depression.

    How much autonomy do you have?

    I am better supervised here than I ever was in hospital. I can't sign prescriptions; I write them and the GP signs them for me. I see the patients on my own, but the GP checks what I've done after the consultation. We are developing a list of diagnoses and managements that I have seen enough of and can now handle alone. He still likes to check up on the children and babies I see.

    What about following patients up?

    I sometimes go to hospital with a patient&emdash;for their scan, for example&emdash;and I can cancel a clinic to fit this in if necessary. I always have the option of asking patients to make another appointment in a couple of days if I am unsure of what is going on. Results come back from the hospital daily and make up quite a lot of the paperwork I have to deal with.

    Is there much paperwork?

    Some of the GPs in my practice put everything on the computer; others still write in the notes. I have to fit in with whichever GP is supervising me during that session. Referral letters are time consuming, although less so than at first. I didn't want to write anything foolish. Hospital doctors are sometimes quite scathing about GPs' letters, but when you work in the community you see why GPs send in “dodgy admissions.” It's quite hard to work out what's going on in poorly lit houses with soft squashy beds, no ECG or blood results to help you, and the family dog pushing its nose up your skirt.

    Do you miss the practical procedures you did in hospital?

    You mean putting in cannulas in the middle of the night? Funnily enough, no. I don't get a chance to do central lines in the GP surgery or aspiration of effusions etc, but there is a “minor ops” clinic one afternoon a week, and I stitch, inject joints, take blood, do intramuscular injections, and help out in the baby clinics.

    You have a family to go home to&emdash;would the lifestyle appeal to a newly qualified, single 23 year old?

    I think the plan is for GP preregistration house officers to live in the nearest hospital alongside their hospital preregistration colleagues, so evenings will be spent with peers. I also see my hospital counterparts when I attend the weekly teaching session for preregistration house officers at the local hospital. I do miss the team spirit you get in hospital and the huge ward rounds with coffee afterwards, but our practice has a GP registrar who is in a similar position to me and who I get on quite well with. You could feel quite isolated in a practice in which you were the only doctor in training. However, I think that whatever your age, you can't help but get absorbed in the job&emdash;it's all so new and you need to get to grips with it all.

    So where's the catch?

    It's exhausting! GPs seem to work longer hours than senior hospital doctors. Although it is officially a 9 to 5 day, I am rarely home before 7.15 pm, and home visits tend to complicate the time off that I am supposed to have in the middle of the day to make up for the late finish. The timetable is quite rigid, and I can't organise my own time as much as I could in hospital. I am also slightly concerned about going back to hospital in August as a senior house officer now that I'm used to a less hectic way of life.

    So you'd recommend a house job in the community?

    Yes, definitely&emdash;but in combination with hospital jobs, not instead of them.

    So I left my friend's house feeling hard done by. I would have loved to have done part of my preregistration year with a GP. Think how much I could have learnt in all those afternoons I have spent gaining specialist knowledge in ankle brachial pressure index measurement. I console myself, however, that I might not have witnessed the removal of that light bulb had I not been chosen to work in a hospital during my preregistration year….

    Valuing general practice in the house officer year

    Experience in primary care represents a return to the values that inspired the preregistration pioneers, argues Nigel Oswald

    1. Nigel Oswald
    1. senior house officer in paediatrics
    2. professor in primary care, Universities of Teesside and Newcastle upon Tyne, Primary Care Resource Development Centre, Middlesbrough TS7 OPN

      The preregistration year has been intended to be the last year of basic medical education since it was proposed by the Goodenough Committee in 1944.1 This has been re-emphasised by the General Medical Council (GMC) in its guidance on general clinical training2 and on preregistration house officers in general practice.3 The 1978 Medical Act allowed up to four months of the preregistration year to be spent in general practice although its detailed provisions were restrictive. For practical reasons&emdash;including the implications of four month rotations, restrictions on prescribing by preregistration house officers, and the absence of a training and remuneration structure for the practices involved&emdash;the option has been little used. Only two medical schools set up rotations. Southampton's lasted 19 months, and was reported a qualified success.4 St Mary's rotation has flourished since 1981, and remains the only established scheme.5 6

      Changes in the emphasis in medical education7 and explicit descriptions of the attributes expected of the qualified doctor in Good Medical Practice,8 together with easing of the legal restrictions incorporated into the NHS (Primary Care) Act 1997, have reopened the debate about the value of spending part of the preregistration year in the community.9 10

      The aims of the preregistration year are the same whatever the setting for training,2 and many can be achieved in both hospital and primary care. However, given the intense pressures within the hospital environment and the well known difficulties in protecting educational time for preregistration house officers,11, 12, 13 some of the aims seem to be most appropriately met in primary care. These include understanding the natural course of disease, rehabilitation, the relation between primary and secondary care, and health promotion. “The centrality of the consultation,” effective communication, and high level interpersonal skills are also emphasised. These can be very well learned in hospital settings, but the published work on preregistration general practice emphasises the opportunity for reflection offered by a less frantic lifestyle and the benefits of getting to know patients well.14, 15, 16 Part of Goodenough's original vision for the year was that the house officer “needs adequate time for thought, for further study and for the personal investigation of the social and environmental conditions of the patients with whom he comes in contact.” Protecting time for thought and education will be a key element in the success of doctors spending part of their preregistration year in general practice.

      Two other aspects are worth mentioning. With young doctors competing very early for specialist registrar rotations, immersion in the environment of general practice may help some to recognise it as an attractive career option, particularly for those undecided on their career. And those who pursue a hospital based career will understand at least a little more about where their work comes from, and to where their patients return.


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