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General Practice GENERAL PRACTICE Preregistration house officers in general practice Joe Wilton Abstract of medicine, surgery, and general practice. It was Objectives-To obtain from house officers who approved by London University, initially for three had rotated through general practice in their pre- years, and evaluated.6 Although 3056 preregistration registration year their views about their experience; house officers were in post in 1991 in England,7 this is and, separately, to compare the overall hours and still the only established rotation in general practice, type of work performed by hospital based and offering three places a year. The General Medical general practice based house officers. Council places great importance on the preregistration Design-Postal questionnaire; and self recording year, yet several studies have reported poor educational ofworking hours and duties during four consecutive provision, inappropriate duties,l°'l excessive hours," weeks. and discontent among house officers. 13 Setting-Inner London teaching hospital and I obtained from doctors who had rotated through nearby general practice. general practice in their preregistration year their Participants-28 preregistration house officers in views about the rotation and drew conclusions about general practice, 1981-91; and 12 preregistration the value of such a scheme. I also compared the overall house officers, four each in medicine, surgery, and hours and type of work performed by hospital based general practice. and general practice based house officers. Results-26 out of 28 questionnaires were returned (response rate 93%). Twelve respondents were following or thinking of following a career in Method general practice. Twenty five respondents were BACKGROUND satisfied with the clinical and educational aspects of The practice is based in a health centre near St the general practice rotation and would recommend Mary's Hospital in inner London. In 1981 it had about the rotation, and 25 thought four months was about 6000 registered patients and three partners, and in the right length of time in general practice. With 1990 it had about 8000 patients and five partners (two regard to hours and type ofwork performed, hospital part time). There is one practice nurse, a practice based house officers worked on average 55.5 hours a manager, a trainee general practitioner, and attached week (excluding on call), with an average of 12-5 community nurses. Each house officer in the general hours (22'50o) spent in clinical activities; general practice house officer scheme works four months in the practice based house officers worked about 41 hours practice and four months each in medicine and surgery a week, of which 24 hours (58%) were in clinical at St Mary's Hospital. All applicants are interviewed activities. House officers in hospital received less by the relevant hospital consultants and the super- than one hour's specific teaching a week; those in vising partner in the practice. Selection is based on general practice received nearly three hours' a week. merit, and no preference is given to candidates who Conclusions-A preregistration rotation in general favour general practice as a career. practice is a popular alternative to the hospital based The medical house officers work for general medical rotation. Although this is a limited study, other and cardiology firms, each with its own consultant and medical schools should consider introducing general registrar and with patients on several wards through- practice options for preregistration house officers. out the hospital. The surgical house officers work for the academic surgical unit, based mainly on one ward, with a team including the professor of surgery, senior Introduction registrar, registrar, and senior house officers. The preregistration year after graduation from The general practice house officers hold seven medical school has been a legal requirement since the surgeries a week, with an average of eight patients per Medical Act 1950. Traditionally, the preregistration surgery, and have one half day a week for home visits. year takes place in hospital, and the most common There is one half day a week for tutorials and one half rotation is six months of medicine and six months of day for project work. The general practice house surgery. officers work in a similar way to trainee general The Medical Act 1978 made the creation of pre- practitioners, except that they cannot legally sign registration house jobs in general practice a possibility, prescriptions. House officers can investigate, refer, and in 1987 the General Medical Council published and admit to hospital, but they are expected to discuss a booklet on recommendations for general clinical important changes in management with a partner training in which it stated that it wished "to encourage before proceeding. There is an introductory pro- opportunities for acquiring experience in general gramme for new doctors, in which they observe each practice during general medical training."' Several partner in surgery and on visits, spend half a day with Lisson Grove Health review articles have discussed preregistration training each attached nurse, and work on the reception desk. Centre, London NW8 8EG in general practice, 2-4 and the personal experience of The general practice house officers are given a Joe Wilton, general one house officer has been described.' consulting room and a car. Most live in the hospital practitioner In 1981 a preregistration rotation in general practice residence for the general practice rotation, but on call was introduced at St Mary's Hospital Medical School, duties can be from home ifthis is near the practice. The BMJ 1995;310:369-72 allowing house officers to rotate four months each on call duty is one night in two on weekdays and one BMJ VOLUME 310 11 FEBRUARY 1995 weekend in three. House officers often visit patients working in general practice. Other career choices alone, but they are always on call with one of the were anaesthetics (three doctors), medicine (three), partners, who screens the phone calls from patients obstetrics and gynaecology (two), surgery (two), and then delegates if appropriate. House officers industrial medicine (two), and ophthalmology (one); do not visit alone children under one year of age. The one doctor was still undecided. practice sometimes uses a deputising service for visits In response to a question on whether they thought after 11 pm. four months' rotation in general practice was about the right length and, if not, how many months might FIRST PART OF STUDY be better, 25 house officers thought four months For the first part of the study I sent a questionnaire was right; the remaining house officer would have with accompanying letter in August 1993 to all house preferred six months. When asked if they would officers who had rotated through general practice in the recommend the general practice rotation to a colleague first 10 years of the scheme (1981-91) and whose 24 respondents said they would and two were not current address could be traced. To preserve confi- sure. dentiality each questionnaire was identified by code In response to the question, "Do you think having number only. A repeat letter and questionnaire the general practice rotation on your curriculum vitae was sent four weeks later to non-respondents. The had any effect on being selected for subsequent jobs?" questionnaire asked for details about the respondent- 13 of the respondents thought it had helped and 13 such as age, sex, and career intentions-and about either thought that it had had no effect or were not respondents' views of the rotation, with structured and sure. None thought that it had hindered job applica- free text questions. tions. When asked, "Have you ever regretted missing the four months in hospital?" 25 respondents said that SECOND PART OF STUDY they had not. For the second part of the study I asked eight In response to a question asking respondents to hospital based house officers (four in medicine, four in select one of three statements that most closely surgery) and four general practice based house officers reflected their own view of general practice rotation, to complete a time sheet for four consecutive weeks six respondents thought that every house officer should of their work. The periods chosen were "typical" have to rotate through general practice, 20 thought that months-that is, not during peak holiday periods or at house officers should have a choice of some jobs in the beginning or end of a rotation. This part of the the preregistration year that rotate through general study began in February 1991 and was completed by practice, and none thought that general practice should May 1994. not be part ofpreregistration training. Each house officer was given a standardised form, Table I shows the respondents' levels of satisfaction which included definition of terms, and asked to with overall clinical experience and perception of record: relevance to a career in medicine. Table II shows the * Time ofarrival at and from questions and responses in the final part of the departure workplace questionnaire, where respondents could comment in * Time spent in clinical activities-defined as clerking free text form about specific aspects ofthe rotation. or talking to patients (or surgery times for the general Table III shows the findings ofthe second part ofthe practice house officer)-and associated activities, such study, in which house officers were asked about their as writing up case notes and ordering investigations
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