Intended for healthcare professionals


Impact of medical school teaching on preregistration house officers' confidence in assessing and managing common psychological morbidity: three centre study

BMJ 1997; 315 doi: (Published 11 October 1997) Cite this as: BMJ 1997;315:917
  1. Chris Williams (psycjw{at}, senior lecturer in psychiatrya,
  2. John Milton, research fellow in psychiatryb,
  3. Paul Strickland, honorary consultant psychiatristd,
  4. Nick Ardagh-Walter, senior registrar in psychiatryc,
  5. John Knapp, senior registrar in psychiatrye,
  6. Simon Wilson, senior registrar in psychiatrya,
  7. Peter Trigwel, senior registrar in liaison psychiatryf,
  8. Eleanor Feldman, consultant liaison psychiatristg,
  9. A C P Sims, professor of psychiatry
  1. a St James's University Hospital, Leeds LS9 7TF
  2. b Department of Psychiatry, Duncan Macmillan House, Nottingham NG3 6AA
  3. c Nottingham Healthcare NHS Trust, Nottingham NG3 6AA
  4. d Meadowbrook, Department of Psychological Medicine, Salford M6 8HG
  5. e York House, Manchester Royal Infirmary, Manchester M13 9WL
  6. f Leeds General Infirmary, Leeds LS1 3EX
  7. g Department of Psychological Medicine, John Radcliffe Hospital, Oxford OX3 9DU
  1. Correspondence to: Dr Williams
  • Accepted 17 February 1997


The psychiatric problems of inpatients in hospital are associated with distress and increased complexity of care.1 The admission assessment by preregistration house officers provides an important opportunity to detect and treat these disorders.

Subjects, methods, and results

Questionnaires were given to all preregistration house officers during the third month of their first post (October 1994) at the two largest hospitals in three teaching centres. Each centre has a different style of teaching undergraduate psychiatry. In two centres (1 and 2) psychiatry is taught in one block in the fourth year. The third centre (3) offers an integrated course, with lectures in liaison psychiatry during all three clinical years and psychiatry in the fourth year; moreover, liaison psychiatry is part of the final examination. The survey was repeated during the second house job after different training interventions (a compulsory lecture in centre 1 and a voluntary, clinical, problem oriented teaching in centre 3); centre 2 (no intervention) acted as a control. Any differences in score in this assessment could result from the residual effects of medical school teaching, the impact of the training intervention (centres 1 and 3), plus additional effects of maturity, training, exposure to peers or senior staff, and the effects of doing the questionnaire during the first house job.

The questionnaire used a system based, clinical checklist (respiratory, cardiovascular etc) to ask about questions that were routinely asked or considered when a new patient was admitted. In addition, three short clinical scenarios were used: a 50 year old woman who was depressed and weepy was used to assess house officers' confidence in assessing and treating depression; a 20 year old asthmatic patient repeatedly admitted with panic and hyperventilation was used for anxiety; and a 40 year old man with excessive alcohol intake for alcohol misuse.

In all, 135 of 160 questionnaires (84%) were completed, with no differences in completion rates between sites (χ2=0.15, df=2, P=0.93). Questions on physical aspects such as the presence of coughs, angina, ankle swelling, and palpitations were routinely asked by over 90% of house officers, but questions on psychological state were rarely asked or even considered. Preregistration house officers often believed they lacked the skills to assess and treat these three common psychiatric problems (1).

Effects of different teaching interventions on attitudes to clinical assessment and treatment. Values are numbers (percentages)

View this table:

Analysis was based on the reported style of training received by the doctors. Only 22 (16%) had been taught to assess psychosocial factors routinely during their first clinical year, and 49 doctors (36%) were taught additional psychiatry during their final year. These doctors felt most confident in assessing and treating these common psychiatric problems. At the second survey no differences were found between centres so the results were combined and the interventions deemed ineffective.


Tomorrow's Doctors recommends that students learn how to carry out a mental state examination.2 We found that newly qualified doctors rarely assessed or had confidence in treating common psychiatric conditions, and our findings may even underestimate the extent of these problems.3 4 Two different postgraduate teaching interventions failed to improve these results.

When students are taught at an early stage that an awareness of psychological disorder is important in assessing all patients, and when this is reinforced throughout the clinical years, they are likely to be more confident in assessing and treating common psychological problems.

Many medical schools are currently reviewing their undergraduate psychiatry curriculums.5 We believe that an integrated assessment which addresses physical, psychological, and social aspects of illness should be taught and examined in all components of clinical medical training. Such changes may improve the competence of doctors and overall medical care.


Funding: None.

Conflict of interest: None.


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