Pre-registration House Officer Year Research Articles

Linking appraisal of PRHO professional competence of junior doctors to their education

In the UK, new medical graduates are known as Pre-registration House Officers (PRHOs). Postgraduate Deans are responsible for the PRHO year and for the final certification of PRHOs to allow them to be fully registered by the GMC as medical practitioners. However, as much as appraisal of professional growth is central to PRHO training, they are in need of a robust assessment mechanism to detect, at an early stage, individuals with significant clinical and professional deficiencies. Documented, reliable and valid ongoing information on PRHO performance will provide information for early intervention and will establish ‘hard’ observable evidence, for certification decisions. Thus, an approach that links appraisal/assessment of professionalism and clinical skills to education is the way forward. This paper describes a new approach to appraisal/assessment of PRHOs, which is currently being piloted in a number of regions in Scotland. The conceptual paradigm was developed during the last three years as a proposal for a Scottish national PRHO reform. ‘Grounded’ qualitative studies were employed to explore trainees’ and trainers’ perceptions of the expected competences (outcomes) of PRHO performance for appraisal/assessment purpose. The GMC recommendations are reviewed in light of the study results. An assessment model emerged that links appraisal to education. PRHOs’ cumulative performance is documented over one year of training resulting in diagnostic profiles that provide guidance for evaluation and training of PRHOs. Poor performers are flagged in the early stages of training, thus allowing early intervention. The feasibility and acceptance of the model by educators, the health system and PRHOs has yet to be established.

Exit learning outcomes for the PRHO year: an evidence base for informed decisions.

To evaluate potential learning outcomes for pre-registration house officer (PRHO) training and develop an evidence base for informed decision making. A 2-stage Delphi process was employed to establish the opinions of Scottish stakeholders with regard to learning outcomes for the PRHO year. Doctors involved in the provision of PRHO training, including deans, postgraduate tutors and general practitioners (GPs) with trainees, were invited to participate in the study. Respondents rated a range of outcomes according to which they believed should be included or excluded from the PRHO training year. Learning outcomes identified for PRHOs were grouped under the 12-domain framework of the 3-circle model: 'What the doctor can do', 'How they approach their practice' and 'Their professionalism'. Based on the consensus opinions gained in the Delphi study, the ratings were classified into priority groupings. Priority 1 contained 45 of the original 81 learning outcomes, representing each area of the 3-circle model, with emphasis on the domains of clinical skills, patient investigation/management, communication, appropriate attitudes and personal development. Health promotion and disease prevention was the only domain not represented at priority 1. Priority 2 contained 24 outcomes with emphasis on the understanding of clinical skills, patient management and personal development. Priority 3 contained 12 outcomes indicating a lack of emphasis for some outcomes, particularly the role of the doctor and health promotion. Consensus on the learning outcomes for PRHO training has been achieved, providing an evidence base for curriculum planning. The relative priority assigned to these outcomes can facilitate the use of the evidence. This evidence base should be referred to when reviewing any PRHO training programme.

Modernising medical careers

Modernising medical careers proposes the introduction of Basic Medical Training (BMT) programmes to replace senior house officer (SHO) rotations. The current pre-registration house officer year and a broad-based first SHO year will become Foundation Years 1 and 2. This will be followed by a programme with eight options. To become a physician would entail doing the Medical Programme (as distinct from surgical, general practice, etc), and at the end of this a Certificate of Completion of Training in general internal medicine could be awarded. Specialty training will follow sequentially. Advantages, disadvantages and uncertainties of this proposal are discussed.

Doctors' views of their first year of medical work and postgraduate training in the UK: questionnaire surveys.

The first year of postgraduate work for newly qualified doctors in the UK, the pre-registration year, is spent working intensively in training posts under supervision. Our aim was to report the views of pre-registration doctors on these posts. Questionnaire survey. All medical graduates of 1999 and a 25% sample of graduates of 2000 from all UK medical schools. Doctors' views on the pre-registration house officer (PRHO) year, recorded as ratings in answers to questions and statements about the year. In reply to the question 'How much have you enjoyed the PRHO year overall?', rated on a scale from 0-10 (0 = no enjoyment; 10 = enjoyed it greatly), 44% of respondents (1341/3068) gave scores of 8-10; in all, 83.2% of respondents gave scores in the upper half of the scale (> or =6). However, there were criticisms of specific aspects of working conditions. Only a third agreed that their training during the year had been of a high standard. Posts in medicine were rated more highly than those in surgery for quality of training. Differences in views held by women and men junior doctors were few. However, where differences existed, women were slightly more positive about their work than men. Most graduates enjoyed the pre-registration year but there is still considerable scope for improvement in working conditions and training. Men and women gave similar responses, which suggests that later divergence in their career pathways is not attributable to different views formed about work in their pre-registration year.

Traditional finals and OSCEs in predicting consultant and self-reported clinical skills of PRHOs: a pilot study.

As we move from standard 'long case' final examinations to new objective structured formats, we need to ensure the new is at least as good as the old. Furthermore, knowledge of which examination format best predicts medical student progression and clinical skills development would be of value. A group of medical students sat both the standard long case examination and the new objective structured clinical examination (OSCE) to introduce this latter examination to our Medical School for final MB. At the end of their pre-registration year, the group and their supervising consultants submitted performance evaluation questionnaires. Thirty medical students sat both examinations and 20 returned evaluation questionnaires. Of the 72 consultants approached, 60 (83%) returned completed questionnaires. No correlation existed between self- and consultant reported performance. The traditional finals examination was inversely associated with consultant assessment. Better performing students were not rated as better doctors. The OSCE (and its components) was more consistent and showed positive associations with consultant ratings across the board. Major discrepancies exist between the 2 examination formats, in data interpretation and practical skills, which are explicitly tested in OSCEs but less so in traditional finals. Standardised marking schemes may reduce examiner variability and discretion and weaken correlations across the 2 examinations. This pilot provides empirical evidence that OSCEs assess different clinical domains than do traditional finals. Additionally, OSCEs improve prediction of clinical performance as assessed by independent consultants. Traditional finals and OSCEs correlate poorly with one another. Objective structured clinical examinations appear to correlate well with consultant assessment at the end of the pre-registration house officer year.

New doctors' perceptions of their educational development during their first year of postgraduate training

The General Medical Council (GMC) in the UK describes a wide range of competences in which the new medical graduate should develop during the first postgraduate year. New graduates are known as pre-registration house officers (PRHOs). In this study, semi-structured open interviews with PRHOs approaching the end of their first postgraduate year were used to explore the trainees' perceptions of their development.After the interview their views on the importance given in their experience to the GMC's competences were explored though a questionnaire. Most noticeable from the interview data was the PRHOs'emphasis in the development of generic skills required of working in the ‘real world’—skills such as communication, team working and the ability to cope with responsibility. In some outcomes, their noticeable progression, e.g. communication, or lack of progression, e.g. health promotion, reflected their views on the importance given.With other outcomes there was a paradox, e.g. practical skills were rated highly but were not noticeably developed; the role of the doctor was noticeably developed but was not highly rated.Overall the PRHOs developed most strongly in the ‘professionalism’ domain with not all the skills in the ‘tasks’ domain being similarly developed. This study helps to define the benefits and opportunities of the PRHO year, as currently perceived by the trainees, and should be of interest to those involved in the planning and delivery of postgraduate training.

Stressful incidents, stress and coping strategies in the pre-registration house officer year.

Previous studies have drawn attention to the stresses experienced by doctors in their first year. To gain a deeper understanding of the causes of stress in newly qualified doctors, how they cope, and what interventions might make the year less traumatic. Postal questionnaire. This study focused on an open question asking about a stressful incident, the coping strategy used to deal with it, stressors in general and current levels of stress using the General Health Questionnaire. 336 hospitals throughout the United Kingdom. A cohort of doctors followed from the time of their application to medical school, studied towards the end of their pre-registration year (n=2456). The response rate to the questionnaire was 58.4%. The incidents were categorised into the major groups Responsibility (33.6%), Interpersonal (29.7%), Overwork (17.0%), Death and disease (13.0%), and Self (6.7%). GHQ revealed psychological morbidity in 31% of respondents. Stress levels were highest in those reporting an incident about Responsibility or Self, lowest in those describing Death or disease. Stressors in general and preferred coping strategies differed between the groups. The incidents suggested the following interventions to reduce stress: better supervision in the first few weeks in post, at night, and for medical problems on surgical wards; more attention to avoiding sleep deprivation; more time for discussion with colleagues at work; more personal time with friends and family. The choice of incident described was influenced by the personal characteristics of the respondent.

Pre-registration house officers and ward-based learning: a 'new apprenticeship' model.

The pre-registration house officer (PRHO) year can be seen as a formal apprenticeship into the profession of medicine, and as central to the identity construction of the doctor. The year characteristically involves rotation between specialties, including attachment to ward-based 'firms', where consultants teach PRHOs. Teaching and learning in ward-based environments is under-researched, and the current literature displays a bias towards a psychological model of pedagogy that focuses upon transmission of knowledge and skills from one individual to another. Such a model offers a necessary, but not sufficient, explanation of how work-based learning occurs. Understanding the PRHO apprenticeship year should include reference to cultural dimensions to learning, especially socialisation into the profession. This constitutes an 'extended' (or 'hidden') curriculum model that may be theorised through contemporary ideas of activity learning within a 'new apprenticeship' framework. The dominant psychological model can lead to an expectation for a uniform method of teaching and learning in ward round contexts that (a) ignores important differences in educational climate between established communities of practice, and (b) orients both teachers and learners to one-to-one transmission and reception, rather than sensitising to how knowledge may be held across members of a working group. The latter shifts emphasis away from reception to issues of active access. PRHOs, as novices, are not relegated to passive learning roles, but may actively co-construct knowledge with experts, offering potential transformation of the practices of ward groups.

Students sitting medical finals--ready to be house officers?

An initial survey of students approaching qualification and the preregistration house officer year revealed anxiety about competence in several important clinical skills. A questionnaire study was then undertaken to assess, first, the extent to which students had attained the skills required for the preregistration year and, second, the amount of training in these skills provided during the preregistration year. 122 medical students taking their final examinations were asked about training and practice in eight core clinical skills, and 84 graduates from the same school, approaching the end of their preregistration year, were asked about postgraduate training in these skills. The response rate of each group was 100%. Of the eight skills studied, most had been performed few times by the students at qualification. Less than half the current preregistration house officers could recall training being given in any of the skills studied. There were no significant differences in house-officer training between teaching hospitals and district general hospitals. Regarding needlestick injuries, nearly two-thirds of preregistration house officers were unable to recall any training at either undergraduate or postgraduate level. These results suggest that training in clinical skills can be improved. Training is already changing with use of clinical skills laboratories and logbooks. We also recommend mandatory needlestick training both in undergraduate programmes and in induction courses for preregistration house officers.

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

In relation to pre-registration house officer (PRHO) rotations incorporating general practice, previous research has recommended that where possible, no PRHO should undertake general practice as the first placement, because of the difficulties encountered. It was recognized that logistically, this could make such schemes almost unworkable. Within the context of a larger qualitative evaluation comparing how 24 PRHOs learned in hospital and general practice settings, the issue of rotation order was explored. In-depth semistructured interviews were conducted with the 12 PRHOs who were involved in general practice rotations. They were interviewed at the beginning and end of the PRHO year, and following their return to hospital work after the general practice placement. Each rotation order had both advantages and disadvantages, with no particular rotation order being obviously better or worse for the PRHOs involved. This small qualitative evaluation has highlighted a number of advantages and disadvantages specific to each rotation order, and makes some practical recommendations to help alleviate the problems encountered. It is important that future evaluations of similar schemes consider this issue, as there are conflicting reports about the significance of the rotation order.

Specialty choice, stress and personality: their relationships over time

A longitudinal questionnaire study of 314 medical students followed up as preregistration house officers (PRHOs) and again 7 years later showed laboratory-based doctors were the least happy with their choice of career and were the most stressed now, while surgeons were the most happy with their choice and the least stressed. These differences were apparent 10 years earlier. The study also describes perceived influences on specialty choice and explores how earlier factors, such as personality as students and stress in the PRHO year, may also have influenced specialty choice.

Anaesthetic pre-registration house officers: a survey of doctors and medical students opinions.

The GMC has accepted a proposal from the Royal College of Anaesthetists for a four-month module in anaesthesia, pain management and intensive care for pre-registration house officers. All 135 final year medical students at Aberdeen University and all GPs and hospital doctors (608 doctors) in the highland region of Scotland were sent a postal questionnaire asking their opinions on this module. Sixty-four per cent of medical students, 39% of hospital doctors and 22% of GPs replied. Eighty-three per cent of medical students would apply for the module if available. Eighty-eight per cent of doctors would have found the module useful in their careers. Sixty-seven per cent of doctors would recommend the module to trainees in their current speciality. This survey demonstrates a high level of support and interest in the module. This has considerable implications for the organisation of the pre-registration house officer year.

How do clinicians learn to request permission for autopsies?

A postal survey of 434 clinicians at four local hospitals was undertaken in order to identify the methods by which clinicians learn how to request permission for hospital autopsies and to assess the preferred techniques and timing of relevant communication skills training. The majority of 128 responding clinicians had learnt through personal experience with some assistance from senior colleagues and peers. Few clinicians appeared to have learnt through formal training. The preferred methods for the provision of communication skills training were training in small groups (such as seminars or tutorials) and observation of clinicians at work. The most desirable time for the provision of this training was considered to be between the beginning of the final undergraduate year and the end of the pre-registration house officer year. The communication skills training provided within medical education is in need of improvement. More emphasis should be given to clinical-task- or situation-specific applications such as requesting permission for autopsies.

The pre-registration house officer year: a critical incident study

To define the major problems faced by pre-registration house officers, 328 critical incidents from 200 house officers and related staff were collected. Each incident was analysed and key words representing the main features were abstracted. These were then aggregated into eight broad categories; personal aspects, clinical skills, communication and relationships, problem-related, organization skills, education, dying patients, and administration. Further analysis of the incidents suggested a series of conclusions which include the need for effective supervision of the house officer with feedback on performance. An induction/orientation period is necessary; there is evidence that a proportion of house officers need additional experience of practical procedures; house officers often have difficulty in setting priorities and they have little experience, prior to qualification, of organizational skills; during the year they are very busy with little time off. Facilities and accommodation may be less than adequate. They perceive a lack of support from senior staff to help with personal problems and career guidance; they are conscious that communication skills are of great importance and would like additional help with this; there is little time for formal education during the year. The range of clinical material presented is enormous, however, and the challenge for medical education is to ensure that the opportunities for learning are not missed.