Pre-registration rotations into general practice: the concerns of pre-registration house officers and the views of hospital consultants

Does responsibility drive learning? Lessons from intern rotations in general practice

BACKGROUND

The intern (or pre-registration) year has been criticised in the past for its emphasis on service delivery at the expense of educational achievement. It is hoped that new approaches to early postgraduate training such as the foundation programmes in the UK, will make clinical education more structured and effective. Intern placements in non-traditional settings such as general practice have been shown in the past to improve the quality of learning. Little is known however about which features of the general practice learning environment contribute most to the perception of improved learning.

AIMS

This aim of this study was to examine the learning environment in general practice from the perspective of interns, (the learners), to determine the factors that contribute most to motivating effective learning in a general practice setting.

METHODS

This study used a qualitative case study approach to explore the effects of two different learning environments, (general practice and hospital) on learner motivation amongst a small group of interns.

RESULTS

We found that the biggest difference between the hospital and general practice learning environments was the increased individual responsibility for patient care experienced by interns in general practice. Greater responsibility was associated with greater motivation for learning.

CONCLUSIONS

Increased intern responsibility for patient care does appear to motivate learning. More work needs to be done on providing interns in hospital posts with greater patient responsibility within an effective supervisory structure.

Practical experience and confidence in managing emergencies among preregistration house officers

OBJECTIVES

To assess the experience gained by pre-registration house officers (PRHOs) at the end of their first post. To assess confidence in managing common emergencies and experience gained in practical procedures. To compare traditional six month posts with four month posts and to compare the experiences of PRHOs posted in teaching hospitals (THs) with those based in district general hospitals (DGHs).

DESIGN

Interview questionnaire.

PARTICIPANTS

152 graduates from Edinburgh University Medical School in 2000 who had completed their first PRHO post by February 2001.

RESULTS

There were few significant differences in confidence in managing emergencies and in numbers of practical procedures attempted between respondents from four and six month posts or between those holding TH and DGH posts. PRHOs had gained little experience in practical procedures: fewer than 15% had performed five or more of a number of procedures including lumbar puncture, pleural aspiration, chest drainage, and insertion of nasogastric tube. A high proportion of PRHOs indicated that they felt confident initiating management of conditions in specialties of which they had little or no experience.

CONCLUSIONS

Rotations of three four month posts do not seem to reduce overall experience in the PRHO year. There is little difference in experience gained between TH and DGH posts. PRHOs perform few practical procedures and some may be overconfident in their own abilities.

Preregistration house officers in general practice: review of evidence

OBJECTIVES

To examine the strengths and weaknesses of the national and local schemes for preregistration house officers to spend four months in general practice, to identify any added value from such placements, and to examine the impact on career choices.

DESIGN

Review of all studies that reported on placements of preregistration house officers in general practice.

SETTING

19 accounts of preregistration house officers' experience in general practice, ranging from single case reports to a national evaluation study, in a variety of locations in Scotland and England.

PARTICIPANTS

Views of 180 preregistration house officers, 45 general practitioner trainers, and 105 consultant trainers.

MAIN OUTCOME MEASURES

Main findings or themes weighted according to number of studies reporting them and weighted for sample size.

RESULTS

The studies were unanimous about the educational benefits of the placements. The additional learning included communication skills, social and psychological factors in illness, patient centred consultations, broadening of knowledge base, and dealing with uncertainty about diagnosis and referral.

CONCLUSIONS

Despite the reported benefits and recommendations of the scheme, it is not expanding. General practitioner trainers reported additional supervision that was unremunerated. The reforms of the senior house officer grade may resolve this problem by offering the placements to senior house officers, who require less supervision.