Choosing a house jobBMJ 1999; 318 doi: https://doi.org/10.1136/bmj.318.7183.2 (Published 27 February 1999) Cite this as: BMJ 1999;318:S2-7183
You don't need to know where you want to be in 10 years time to choose your first post, but planning will give you a head start, says Jessica Westall
For most students, choosing a house job seems like a big step on to a largely unplanned career ladder. Consultants see things differently: I was unequivocally reassured that house jobs were the least important career move I would ever make in terms of defining my future specialty. However, the post you end up in does affect your wellbeing, which is more than a short term consideration. How you feel about your first job as a doctor influences the way you feel about future career plans and will directly affect your reference and curriculum vitae. The year also acts as a foundation for the rest of your career in terms of skills and practical experience. In this article I outline a scheme for assessing the options.
To find out from the current house officer
The intensity of the work - average number of patients, hours' sleep on call, holiday cover, bleep-free periods
Educational aspects - hours and reliability of teaching sessions, supervision and support, routine tasks, how varied the case load is
Environment - quality and availability of the food (especially at night), mess life, staff disposition
Wellbeing - subjective enjoyment and stress levels, regular appraisals, career guidance and counselling
To find out from the consultant
The role of a house officer - what you can get out of the job, teaching sessions and practical procedures
Your evaluation - who you are accountable to, your named supervisor, how you are assessed
His or her special interests
The key to finding a house job you are going to enjoy is to be informed before you apply. Firstly, you need to know what your personal priorities are as they will influence your choice of job. Whether it is more important to you to work with a consultant who shares your personal philosophy or to work near your childcare facilities will give you a framework for assessing jobs. The earlier you start this part of the process the better. Certainly, if you are thinking of going abroad you should approach your postgraduate dean two years in advance of starting house jobs, and you should do so a year in advance if you want to move to a different region in the United Kingdom or want to work part time. However, you should try to visualise how working might change your priorities. A friend who moved to be nearer her family later regretted leaving university friends at a period when she didn't have the time or energy to make new relationships.
Personal aspects that influence job choice
Social situation - such as family commitments
Career plans and ambitions
The importance of your working environment
How you spend your free time
Personality and skills
Special interests - such as working for a doctor enthusiastic about evidence based medicine
As well as geographical location, other personal choices include which specialties you want to work in, for how long, and in what order. You must complete at least four months in a medical post and four months in a surgical post in order to register. You can then spend the other four months in any other post approved for general clinical training. Some regions now offer a spell in general practice,(1)(2) paediatrics, psychiatry, or anaesthetics - your postgraduate dean can advise you of the options in your region.
You will also have preferences about the environment you want to work in. District general hospitals tend to give you more practical experience - they tend to be busier, have fewer senior staff per house officer, and have a more general and representative case mix. Teaching hospitals get the tertiary referrals, which means they might have more “interesting” cases clinically, but the case mix will be more specialised. The fine tuning of patient care often required in a specialist unit can mean that house officers are less involved in decisions about management. There are also more doctors on each firm competing for training. Anecdotal evidence suggests that district general hospitals are friendlier places to work. Of course, none of these stereotypes holds true in every situation - you have to find out about the individual post.
What do you want to get out of the job? Doing some career planning now can help you decide which job will give you the greatest future benefit. It doesn't really matter if you don't know where you see yourself in 10 years' time, it is more a question of assessing your preferences. This is something you can do yourself, according to Sonia Hutton-Taylor, a consultant in career guidance.(3) She advises taking time to evaluate your performance, strengths, and weaknesses. It is really about keeping your options open. For example, if you really enjoyed surgery as a student, you might look for a house job that will encourage you to do some minor operations. A list of procedures you have done will look good on your curriculum vitae if you later decide to apply for surgical training. If being a physician appeals, experience in a busy general medicine job followed by a more relaxing surgical post is a good option. If you opt for three posts of four months each you can afford for a couple to be experiments in specialties that you are interested in. If you do know where you want to train as a senior house officer it is often easier to get a postgraduate job in a hospital where you are known.
Taking your personal priorities into consideration, you can draw up a shortlist of jobs or rotations that you would apply to. You cannot really do this until you know what is available in the region you want to work in. Universities normally send out a list of rotations to final year students 10-12 months before the jobs are due to start. If your medical school runs a matching scheme - an application system that matches students' job preferences to consultants' preferences for candidates - the list won't include consultants who opt out of the scheme. In this case your postgraduate dean can tell you about any “external” jobs. The idea of shortlisting is to create a list of jobs to assess: choose a few more rotations than you can actually apply for - matching schemes often have a limit - but not so many that you run out of steam investigating their pros and cons.
One factor crucial to choosing a job is what the present house officer has to say about it. Telephone and ask if there is a good time to call or meet for a chat. This is about your personal development rather than hoping that they will tell the consultant that you contacted them, so it's not a lot of use doing this the day before your interview.
You will want to know what the working environment is like, which will influence how happy you will be in the job. Some students apply for house jobs simply because of their perceived prestige. But it is the content, not the signature on your reference, that counts. If you are miserable through lack of sleep, a bad tempered boss, little or no middle grade support, and awful food, it's going to be hard to get a glowing reference.
Learning on the job
You should ask about the educational opportunities of the job. The purpose of the preregistration year is general clinical training.(4) It should equip you for further training in any one of over 70 medical specialties. Although house officers provide a service, the year should build on your knowledge and improve your confidence in things like clinical decision making and interacting with patients. The year has been severely criticised in the past, especially for long hours too full of routine tasks to be of educational value.(5) The high levels of dissatisfaction among junior doctors was the impetus behind the BMA's West Yorkshire Junior Doctors Committee's guide to the house jobs in its region. It surveyed house officers about their posts and published the results: this not only provided a useful tool for final year students choosing a job in the region but also put considerable political pressure on hospital trusts to bring poor house jobs up to standard.(6) Despite the educational targets that were set for posts to reach by 1995,(7) jobs vary widely, and you should assess them carefully.
The educational value of a job does partly depend on how much you enjoy it, but more objective measurements include the reported support and supervision from seniors, the time spent on routine tasks, and the amount of dedicated, “bleep-free” teaching received. Choosing a house job where phlebotomists do the routine blood sampling and a ward clerk does the filing means that there is less chance that these tasks will fall to you.
The best way to assess a job is to do it. If you are particularly interested in a post ask the house officer if you can do a locum for him or her. This is also a good way to meet the consultant and other staff you will be working with and looks impressive on your application.
Approach the boss
Some medical schools advise against this, but it is not “canvassing” consultants, it is researching which jobs to apply for. Some consultants will consider your approach as the only polite and proper way to apply for a job; ask the secretary for advice. In the job you will spend more time with nursing staff than with your boss, so your actual rapport with consultants is less important than you might think. However, you do want to assess how they see your role and how they run their team. Although the house officer can give you an idea, it is worth asking the consultant about the training potential of the job.
To see what a hospital is actually like you can arrange a guided tour through the hospital's personnel department, which should also be able to answer your questions on the contractual details of the post. For advice on pay, hours, and what different rotas and contracts mean, contact your local BMA office. The BMA membership guidance booklet First House Job also discusses the application procedures for house jobs.(8)
Going for what you want
Prioritising what is important to you will help you evaluate which jobs are going to suit both you and your long term plans. It should also help you get the job. If you have done your research you will ask informed and intelligent questions in the interview and have a good explanation when you are asked: “So what made you apply for this post?”