Pre-registration house officer rotations incorporating general practice: does the order of rotation matter?

Junior doctors' learning and development in foundation year 1 posts in palliative medicine

BACKGROUND

The ability to provide good palliative care to patients is increasingly recognised as a core clinical skill that all doctors should possess. Few junior doctors, however, feel competent in breaking bad news, pain relief and the care of dying patients by the time they are fully registered to practice.

AIM

The aim of this study was to explore doctors' experiences in foundation year 1 (F1) palliative medicine posts.

DESIGN

Participants underwent semi-structured interviews and interview transcripts were analysed using Interpretative Phenomenological Analysis.

SETTING/PARTICIPANTS

The study involved a purposive sample of six F1 doctors matched in 2005-2006 to rotations incorporating palliative medicine posts at two acute hospital National Health Service (NHS) Trusts and one NHS hospice in the UK.

RESULTS

F1 doctors were satisfied with the learning opportunities provided by the posts, which achieved the right balance between supported and autonomous working. They described learning through their day-to-day interactions with staff, including specialist nurses, and by practising their skills on the job. Some struggled, however, to make the transition to a more independent learning style in the clinical environment. Trainees felt the post helped them to develop generic skills, such as symptom control, diagnosing dying and breaking bad news. Whilst they found split posts and on-call rotas disrupted their palliative care learning, these offered important opportunities to learn additional F1 skills.

CONCLUSIONS

F1 posts in palliative medicine in the UK have positive influences on perceived generic skills development and practice. These findings might encourage the development of more rotations incorporating palliative medicine in the future.

The development of reasoning skills and expertise in primary care

WHAT IS ALREADY KNOWN IN THIS AREA • The acquisition of clinical reasoning skills from novice to advanced student has been described and compared with experienced clinicians Research from the field of cognitive psychology suggests that development of such skills depends upon organizing packages of information into coherent structures which are quickly accessible from memory. These are called 'instance scripts?. Various strategies are employed in reasoning, starting with step-by-step analysis by novices, moving towards categorisation processes in-advanced practitioners (e.g. pattern recognition). WHAT THIS WORK ADDS • This work suggests a reference framework for reasoning skills and expertise development from novice to experienced practitioner within primary care. It extends ideas from existing Studies using medical students into postgraduate professional development, encompassing various transitions from newly qualified doctor to training registrar, and from new principal towards the experienced practitioner. • Within these transitory stages, reasoning strategies are highlighted, including potential problem areas and appropriate educational implications. The role of follow up mechanisms for GP registrars is suggested to enable validation of illness vectors in the natural history of disease and recovery. Extension of training schemes to provide for expertise development in primary care is proposed as the logical context where such skills can be improved. SUGGESTIONS FOR FUTURE RESEARCH • Current research in medical education in the UK appears to be heavily concentrated upon skills and competency assessment. These are more easily measured than cognitive skills. However, the impact of early clinical contact in UK medical schools upon cognitive skills could be compared with other countries where clinical contact is still delayed. Early patient contact may shift acquisition of some cognitive skills back in the proposed framework. • In addition to this, the impact of the foundation programme upon doctors subsequently entering primary care will provide the biggest stimulus for research, assuming that cognitive attributes, such as decision-making skills, are assessed alongside practical competencies.

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.