Preregistration house officers in the Thames regions: changes in quality of training after four years.

OBJECTIVE--To measure changes in the training and workload of preregistration house officers over four years. DESIGN--Postal questionnaire. SETTING--The Thames health regions. PARTICIPANTS--1049 preregistration house officers. RESULTS--Response rate was 69% (725 replies). The proportion of house officers officially on duty > 83 hours a week fell from at least 42% to 21%, and the proportion officially on duty < or = 72 hours rose from no more than 9% to 40%. Adequate guidance in breaking bad news increased from 25% to 46% (p < 0.0001; 95% confidence interval for difference, 16.2% to 25.8%) and guidance in pain control increased from 36% to 46% (p < 0.01; 5.0% to 15.0%). The number of house officers attending an induction course increased from 61% to 94% (p < 0.001; 28.9% to 37.1%). There was no change in the proportion unable to attend formal educational sessions because of clinical commitments or in levels of satisfaction with consultants'' educational supervision. The median number of inpatients under house officers'' care fell from 20 to 17, but the numbers of patients clerked in an average week showed little change. House officers were less satisfied with the clinical experience their post provided (proportion dissatisfied rose from 30% to 39%; p < 0.01; 4.2% to 13.8%) and less enthusiastic about recommending their post to a friend (proportion neutral or not recommending rose from 30% to 42%, p < 0.0001; 7.9% to 16.9%). CONCLUSION--Despite progress in reducing hours of duty and providing induction courses, the training that hospitals and consultants provide for house officers is still unsatisfactory and inconsistent with the General Medical Council''s recommendations.     

Preregistration house officers in general practice.

OBJECTIVES--To obtain from house officers who had rotated through general practice in their pre-registration year their views about their experience; and, separately, to compare the overall hours and type of work performed by hospital based and general practice based house officers. DESIGN--Postal questionnaire; and self recording of working hours and duties during four consecutive weeks. SETTING--Inner London teaching hospital and nearby general practice. PARTICIPANTS--28 preregistration house officers in general practice, 1981-91; and 12 preregistration house officers, four each in medicine, surgery, and general practice. RESULTS--26 out of 28 questionnaires were returned (response rate 93%). Twelve respondents were following or thinking of following a career in general practice. Twenty five respondents were satisfied with the clinical and educational aspects of the general practice rotation and would recommend the rotation, and 25 thought four months was about the right length of time in general practice. With regard to hours and type of work performed, hospital based house officers worked on average 55.5 hours a week (excluding on call), with an average of 12.5 hours (22.5%) spent in clinical activities; general practice based house officers worked about 41 hours a week, of which 24 hours (58%) were in clinical activities. House officers in hospital received less than one hour''s specific teaching a week; those in general practice received nearly three hours'' a week. CONCLUSIONS--A preregistration rotation in general practice is a popular alternative to the hospital based rotation. Although this is a limited study, other medical schools should consider introducing general practice options for preregistration house officers.     

Preregistration house officers in the four Thames regions: I. Survey of education and workload.

OBJECTIVE--To assess the education and workload of preregistration house officers in the four Thames regions. DESIGN--Postal questionnaire. SETTING--Teaching and non-teaching hospitals in the four Thames regions. PARTICIPANTS--1064 Preregistration house officers. RESULTS--Response rate was 70% (740 replies). Nine per cent of house officers (66/729) worked a rota of one in two. The average house officer had 20.4 inpatients under his or her care and admitted 23.2 patients per week. Sixty two per cent of house officers (459/740) felt that they spent an excessive amount of time on non-medical tasks of no educational merit; 75% (546/725) had never received adequate guidance on breaking bad news and 64% (467/729) had never received adequate guidance on pain control; 34% (249/731) did not feel confident that they could perform cardiopulmonary resuscitation unsupervised. House officers would tend to recommend their post to a friend. CONCLUSIONS--There are deficiencies in preregistration training in the four Thames regions. The General Medical Council''s requirements are not being heeded.     

Preregistration house officers in the four Thames regions: II. Comparison of education and workload in teaching and non-teaching hospitals.

OBJECTIVE--To detect differences in the education and workload of preregistration house officers working in teaching and non-teaching hospitals. DESIGN--A postal questionnaire. SETTING--Teaching and non-teaching hospitals in the four Thames regions. PARTICIPANTS--1064 Preregistration house officers. RESULTS--Response rate was 61% for teaching hospitals and 73% for non-teaching hospitals. House officers in teaching hospitals had significantly fewer inpatients under their care (house physicians 16.9 v 22.9, house surgeons 17.9 v 20.3) and admitted fewer emergency patients per week (house physicians 7.7 v 12.7, house surgeons 6.5 v 9.8). More house officers in teaching hospitals reported that they had too few patients to provide adequate clinical experience. More of their time was consumed by administrative activities devoid of educational value. CONCLUSION--Preregistration house officer posts at teaching hospitals provide less clinical activity and are perceived as less educationally satisfactory by their holders than those elsewhere.     

Senior house officers in medicine: postal survey of training and work experience.

OBJECTIVES: To describe working conditions for senior house officers in medicine in Scotland and to relate these to the quality of clinical training they receive. DESIGN: Postal questionnaire survey. SUBJECTS: All senior house officers in medicine and related specialties in post in Scotland in October 1995 (n = 437); 252 (58%) respondents. MAIN OUTCOME MEASURES: Questionnaires covered hours, working patterns, measures of workload, an attitudes to work scale, and experience of education and training. RESULTS: In the week before the questionnaire, doctors on rotas had worked a mean of 7.4 (95% confidence interval 5.8 to 9.0) hours in excess of their contracts, compared with 3.7 (2.0 to 5.5) hours for those on partial shifts. The most common reason for this was "the needs of the patients or the service." Those on partial shifts reported significantly less continuity of care with patients than those on rotas (Mann-Whitney U test, z = -4.2, P < 0.0001) or full shifts (z = -2.08, P = 0.03). Doctors in general medicine reported significantly higher measures of workload (number of acute admissions, number of times called out, and fewest hours'' uninterrupted sleep) than those in subspecialties. Consultants'' clinical teaching and style of conducting a ward round were significantly related to factors extracted from the attitudes to work scale. CONCLUSIONS: The quality of senior house officers'' training is detrimentally affected by a variety of conditions, especially the need for closer support and supervision, the need for greater feedback, and the lack of time that consultants have to dedicate to clinical training. Efforts should be made to improve these conditions and to reinforce a close working relationship between trainee and supervising consultant.     

Education and training of preregistration house officers: the consultants' viewpoint.

OBJECTIVE--To determine the opinions, attitudes, and requirements of consultants responsible for preregistration house officers in the light of the General Medical Council''s Recommendations on General Clinical Training. DESIGN--A questionnaire was piloted asking 28 questions under the headings professional details, present training arrangements, effectiveness of current training, and perceived help required for implementing the recommendations. SETTING--Two teaching hospitals and nine district general hospitals in the Yorkshire region. SUBJECTS--33 consultants (19 physicians, 14 surgeons) responded to an hour long interview. RESULTS--The traditional teaching ward round, with clinical meetings, was the main educational provision for house officers. Under a quarter of respondents provided specific teaching, which rarely exceeded 30 minutes weekly. Many delegated teaching to other junior or non-medical staff. Few consultants assessed the effectiveness of teaching, and feedback to juniors was rudimentary. There was strong support for the apprenticeship system and concern that it should not be downgraded. Appointing educational supervisors and introducing a structured educational programme were approved theoretically. Pressure on consultants to work faster, participate in audit and management, and accept financial responsibility for their clinical work, coupled with the reduction in junior doctors'' hours, were considered to militate against educational developments. Many respondents felt frustrated and powerless. They would welcome an increased educational role but considered there must be conceptual, contractual, and financial changes. CONCLUSIONS--Fundamental changes are required by both consultants and management before the preregistration year can have proper educational value. Training in educational methods for consultants and a structured curriculum and formative assessment for trainees require recognition and financial support.     

Senior house officers and their training. II. Perceptions of service and training.

Aspects of teaching and learning at senior house officer level in South East Thames region were investigated by analysis of the responses of consultants, senior registrars, registrars, and senior house officers to a postal questionnaire. Responses to sections about who teaches senior house officers, how senior house officers learn, and the relation between the service and training elements of these posts varied significantly, according to the status of the respondents; certain grades commonly overestimated their own contribution when compared with the estimates of the other grades. Although the replies of senior house officers showed that they were taught by various grades, 47% of this group did not regard the consultant as their main teacher. Senior registrars and registrars rather than consultants were regarded by senior house officers as best at teaching (63% v 48% respectively). Consultants and registrars were considered to require more commitment to training, personal educational training, and to be more approachable. Inquiry about teaching methods used most by senior house officers showed absence of a systematic approach to training. Only about half of senior house officers cited ward rounds with consultants. Views on the relation between training and service were significantly different among grades, but there was general dissatisfaction. Overall, the findings disclosed the ineffectiveness of senior house officer training posts. This arises from lack of a clear distinction between training and service elements, of educational training for teachers, of a clear contractual obligation to teach im the consultant grade, and of allotted time for training and study for the teachers and senior house officers respectively. Reversal of these current trends is needed for senior house officer posts to fulfil their main training function.     

Senior house officers: the lost tribes.

There are more senior house officers than doctors in any other training grade in Britain but nobody knows what they do in hospitals or has a clear idea what skills they should be learning. Nobody is responsible for them and they suffer from having a poor career structure and inadequate training. Now that there are government initiatives to reduce the hours that junior doctors work and to limit the time it takes to train to become a specialist, the problems that senior house officers face can no longer be ignored. A conference for senior house officers held last week talked about the problems that they face and tried to find some solutions.     

Emotional distress in junior house officers.

In a study of 170 junior house officers who were followed up from their fourth year in medical school mean levels of stress were higher than in other reported occupational groups, and the estimated prevalence of emotional disturbance was 50%, with 28% of the subjects showing evidence of depression. Nearly a fifth of the subjects reported occasional or frequent bouts of heavy drinking, a quarter took drugs for physical illness, and a few took drugs for recreation. Those who were emotionally distressed at the initial study and the follow up were more empathetic and more self critical than those who had low levels of stress on both occasions. Overwork was the most stressful aspect of their jobs, though the number of hours worked was not related to stress levels, unlike diet and sleep. The more stressed they were the more unfavourably they viewed aspects of their jobs. The incidence of distress is unacceptably high in junior house officers, and both they and the hospitals need to deal with the causes of the distress.     

Source of stress in women junior house officers.

OBJECTIVE--To determine the causes of stress in women doctors and relate these to levels of depression. DESIGN--Questionnaire study. SUBJECTS--Of 92 women doctors who had graduated from the universities of Leeds, Manchester, and Sheffield in 1986 and had been working as junior house officers for eight months 70 (76%) returned completed questionnaires. MAIN RESULTS--Mean score on the general health questionnaire was 13.79 (SD 5.20) and on the symptom checklist for depression was 1.43 (0.83). The scores of 32 subjects (46%) were above the criterion for clinical depression. Overwork was perceived as creating the most strain, followed by effects on personal life, serious failures of treatment, and talking to distressed relatives. Both stress and depression were related to effects on personal life, overwork, relations with consultants, and making decisions. Sex related sources of stress were conflicts between career and personal life, sexual harassment at work, a lack of female role models, and prejudice from patients. In addition to these, discrimination by senior doctors was related to depression. CONCLUSION--Changes are needed in the career paths of women doctors, and could be implemented.