Doctors' professional values: results from a cohort study of United Kingdom medical graduates

OBJECTIVES: To examine young doctors' views on a number of professional issues including professional regulation, multidisciplinary teamwork, priority setting, clinical autonomy and private practice. METHOD: Postal survey of 545 doctors who graduated from United Kingdom medical schools in 1995. RESULTS: Questionnaires were returned by 95% of the cohort (515/545). On issues of professional regulation, teamwork and clinical autonomy, the majority of doctors held views consistent with current General Medical Council guidance. The majority supported the right of doctors working in the NHS to engage in private practice. Most respondents thought that public expectations of doctors, medicine and the NHS were too high, and that some form of rationing was inevitable. On many issues there was considerable variation in attitudes on the basis of sex and intended branch of medicine. CONCLUSIONS: The results highlight the heterogeneity of the profession and the influence of specialty and gender on professional values. Doctors' attitudes had also been shaped by broader social changes, especially debates surrounding regulation of the profession, rising public expectations and the need for rationing of NHS care.     

The current status of senior house officer postgraduate education in a single region

OBJECTIVE: To assess postgraduate education (PGE) for paediatric senior house officers (SHOs) in a single region. METHODS: A survey of all paediatric SHOs in the region was undertaken in the form of a questionnaire and telephone contact. The standard set by the Committee of Postgraduate Medical Deans for SHO education formed the basis for the questionnaire; there should be (i) a designated educational supervisor for each SHO, (ii) regular work appraisal and counselling and (iii) 4 h protected teaching per week. Supplementary questions were asked regarding methods of teaching and study leave. RESULTS: There was a 92% response rate from SHOs and 90% of SHOs contacted had a named educational supervisor. The mean time for protected teaching per week was 2.14 h, although this varied widely between centres. There were many different teaching methods used and 82% of SHOs had no difficulty in obtaining study leave. There was a particular problem for those who were working shifts or cross-covering. CONCLUSIONS: Our study has shown that paediatric SHOs in Wales are reasonably satisfied with their postgraduate education, although there is considerable variation between different units. Several areas have been highlighted which need to be improved if we are to provide SHOs with adequate preparation for the specialist registrar training grade.     

Educational supervisors evaluate the preparedness of graduates from a reformed UK curriculum to work as pre-registration house officers (PRHOs): a qualitative study

INTRODUCTION: In 1996 the University of Liverpool introduced an integrated problem-based learning (PBL) medical curriculum incorporating the recommendations of Tomorrow's Doctors. This paper investigates whether the PRHO (pre-registration house officer) educational supervisors who supervise Liverpool graduates believe that the reformed curriculum is producing house officers who have the competencies outlined by the General Medical Council. METHODS: Forty-one interviews were arranged with a sample of educational supervisors in the Mersey Deanery area to ascertain their views on the competencies of Liverpool PRHOs. The interviews were tape-recorded, transcribed and analysed. RESULTS: The supervisors felt that the PRHOs had been well prepared to work as PRHOs, and compared with traditional graduates they were actually better prepared for the job of PRHO. They saw the PRHOs as competent communicators with improved clinical skills, who had good attitudes, were aware of limitations, were team workers, good at history-taking and examination and had different approaches to finding information. There was a very confusing picture regarding basic knowledge, with some consultants expressing concerns, despite saying they had adequate knowledge to work as PRHOs. It emerged that there was little consensus about the knowledge base of the traditional or PBL graduates or what knowledge level was needed at this stage. DISCUSSION: Educational supervisors believe that the reformed curriculum in Liverpool is producing competent PRHOs who have been better prepared for the role of PRHO than previous graduates. It could be that uncertainty over knowledge base may be the price paid for reducing the factual burden and improving preparedness for professional practice.     

How consultants, hospitals, trusts and deaneries affect pre-registration house officer posts: a multilevel model

OBJECTIVE: To examine variation in reported quality and working conditions of pre-registration house officer (PRHO) posts. To use multilevel modelling to determine how much of the variation was due to the effects of consultant firms, hospitals, trusts and deaneries, as well as variation at the level of the individual doctor. DESIGN: Questionnaire survey of national sample of PRHOs at the end of the pre-registration year. Multilevel modelling was carried out using MLwiN. SETTING: PRHOs working in UK approved medical and surgical posts in NHS hospitals from August 1996 to January 1999. PARTICIPANTS: One thousand, four-hundred and thirty-five PRHOs who had previously been part of an extended cohort study of medical student selection and training. They reported on a total of 4926 posts, on 2721 identifiable consultant firms, in 336 hospitals, in 264 trusts and in 17 deaneries. MAIN OUTCOME MEASURES: PRHOs' perceptions of the overall quality of all PRHO posts they had worked in, and working conditions in the current post. RESULTS: Twenty percent of PRHO posts were described as excellent and 34% as very good, through to 6% reported as not very good, poor or bad. The overall rating of the post showed highly significant variation at the level of hospital/trust, and consultant firm. Other aspects of posts, such as working conditions showed variation at the level of deanery, trust, hospital and firms, with different patterns for the different measures. Assessments of stress in PRHOs (GHQ, burnout, response to uncertainty), and a desire to leave medicine, showed no variation at the level of deanery, trust, hospital or firm. CONCLUSION: Some aspects of a PRHO post, in particular overall rated quality, but also many aspects of working conditions, show substantial variation at the level of hospital, trust and consultant firm, suggesting that differences reflect local variation in working practices and treatment of PRHOs, with the possibility of change and improvement. The lack of any variation at the level of deanery, trust, hospital or firm in stress of PRHOs suggests that these responses are idiosyncratic, individual responses by doctors themselves, rather than a general characteristic of posts, hospitals, trusts or deaneries.     

Stability and change in career choices of junior doctors: postal questionnaire surveys of the United Kingdom qualifiers of 1993

OBJECTIVE: To report on stability and change in career choices of doctors, between 1 and 3 years after qualification. DESIGN: Postal questionnaire surveys. SETTING: United Kingdom. SUBJECTS: All doctors who qualified in the United Kingdom in 1993. MAIN OUTCOME MEASURES: Choices of eventual career expressed 1 and 3 years after qualifying. RESULTS: The overall pattern of career choices at year 3 differed a little from that at year 1. For example, choices for general practice increased from 26% to 29%, choices for medical specialties fell from 22% to 18%, and for surgical specialties they fell from 17% to 14%. However, because changes of choice between specialties tended to 'cancel out', the aggregated data masked much larger changes when considered at the level of individual doctors. Overall, 74% of respondents retained their year 1 career choice in year 3 (78% of men, 70% of women). Of doctors who chose a hospital specialty in year 1, 71% chose the same specialty in year 3, 18% had switched choice to another hospital specialty, and 9% had switched choice to general practice. The percentage who changed choice from hospital specialties to general practice between years 1 and 3 was lower in the 1993 cohort than in all previous cohorts. Of those whose year 1 choice of long-term career was general practice, 89% retained that choice in year 3 and 11% switched to other branches of medicine. Even by year 3, less than half of all respondents (and a smaller percentage of women than men) signified that their long-term choice of specialty was definite. In year 3, 78% of all respondents, and 79% of doctors from homes in the United Kingdom, intended definitely or probably to practise medicine in the United Kingdom for the foreseeable future, which represented little change from the figures in year 1. CONCLUSIONS: About a quarter of doctors change their career choice between years 1 and 3 after qualification, and less than half regard their choice in year 3 as definite. Flexibility is therefore needed, well beyond the first post-qualification year, to accommodate changes of choice. Where training opportunities in a hospital specialty are limited, doctors are now inclining, more than in the past, to switch to an alternative hospital specialty rather than to general practice.     

Views of junior doctors about their work: survey of qualifiers of 1993 and 1996 from United Kingdom medical schools

OBJECTIVE: To investigate the views of junior doctors about their work. DESIGN: Postal questionnaire surveys. SETTING: United Kingdom. SUBJECTS: Doctors who graduated from medical schools in the United Kingdom in 1996, surveyed at the end of their preregistration year (2926 respondents), and graduates of 1993 surveyed 3 years after qualification (2541 respondents). RESULTS: Almost 70% of the 1996 qualifiers felt that they worked excessive hours and 80% felt that they undertook too many routine non-clinical duties. Only 24% agreed that their postgraduate training was of a high standard and 22% felt they were being asked to perform clinical tasks with inadequate training. A total of 70% were dissatisfied with arrangements for cover for absent doctors. Senior doctors and nurses were regarded as supportive by most respondents, but hospital management was not. Although 65% were satisfied with their future prospects, only 36% had been able to obtain useful careers advice. Job enjoyment was reasonably high, with two-thirds scoring 6 or more on a scale from 1 (not enjoying at all) to 10 (greatly enjoying), but 70% of respondents felt that they had insufficient time for family and social activities. A briefer questionnaire sent to the 1993 qualifiers in 1996 showed similar results. CONCLUSIONS: More needs to be done to ensure that junior doctors are trained appropriately for the tasks they undertake, to ensure that they regard their training highly, to reduce excessive non-clinical work, and to provide reasonable working hours and cover.     

Reforming higher specialist training in the United Kingdom--a step along the continuum of medical education

OBJECTIVES: The requirement to align the arrangements for postgraduate training in the United Kingdom with those elsewhere in the European Community provided the opportunity to review and reform our arrangements for higher specialist training. This paper describes the case for change--the strengths and deficiencies of the traditional pattern of postgraduate medical training, demographic influences in the medical workforce and the need for a more structural or planned approach to training. CONCLUSIONS: Over the past 5 years substantial progress has been made: the introduction of new regulatory arrangements and a new higher specialist training grade; the development of a managed and flexible system for delivering training to standards set by the Royal Colleges and which can accommodate the needs of those pursuing academic and research medicine; and the opportunity for trainees' progress to be measured against published curricula. The significant programme of change has been underpinned by careful workforce planning and the publication of comprehensive guidance. Significant reform of higher specialist training has been achieved. This paper also makes the case for a more strategic approach to planning and developing medical education across the continuum, from entry to medical school until retirement, which can guide medical education and improve patient care into the next millennium.     

Working patterns and the quality of training of medical house officers: evaluating the effect of the `new deal'

The `new deal' on junior doctors' hours of work has led to the widespread introduction of working patterns such as full shifts and partial shifts in the United Kingdom. The impact of these changes on the training of medical staff is unclear. The subjects of the current study were 36 pre-registration medical house officers working shift rotas and on-call rotas at a teaching hospital in the north of England. They were studied over a 12-month period using a self-report questionnaire seeking their views on the quality of their training experience and their satisfaction with the in-service training they received. Nursing staff, consultant and medical student opinion was also sought. Partial-shift and full-shift systems led to reduced hours of work when compared to on-call rotas (mean hours: partial shift 65·0; full shift 59·8; on-call 72·7), but they were associated with significantly lower training experience and training satisfaction scores for the house officers than were on-call systems (P < 0·01). Shift systems were unpopular among consultants and medical students but not nursing staff. Despite reducing excessive hours of work, shifts may be detrimental to the training of medical house officers. The further imposition of shift working should be suspended until such time as the impact of new working patterns on the training of medical staff has been determined.     

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

CONTEXT: Previous studies have drawn attention to the stresses experienced by doctors in their first year. OBJECTIVES: 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. DESIGN: 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. SETTING: 336 hospitals throughout the United Kingdom. SUBJECTS: 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). RESULTS: 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. CONCLUSION: 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.     

A study of pre-registration house officers' clinical skills

BACKGROUND: Little is known about the ability of pre-registration house officers (PRHOs) to perform basic clinical skills just prior to entering the medical register. OBJECTIVES: To find out whether PRHOs have deficiencies in basic clinical skills and to determine if the PRHOs themselves or their consultants are aware of them. METHOD: All 40 PRHOs at the Chelsea and Westminster and Whittington Hospitals were invited to undertake a 17 station OSCE of basic clinical skills. Each station was marked by one examiner completing an overall global score after completing an itemised checklist. An adequate station performance was the acquisition of a pass/borderline pass grade. Prior to the OSCE, a questionnaire was given to each PRHO asking them to rate their own abilities (on a 5-point scale) in the skills tested. A similar questionnaire was sent to the educational supervisors of each PRHO asking them to rate their house officer's ability in each of the same skills. RESULTS: Twenty-two PRHOs participated. Each PRHO failed to perform adequately a mean of 2.4 OSCE stations (SD 1.8, range 1-8). There were no significant correlations between OSCE performance and either self- or educational supervisor ratings. The supervisor felt unable to give an opinion on PRHO abilities in 18% of the skills assessed. DISCUSSION: This study suggests that PRHOs may have deficiencies in basic clinical skills at the time they enter the medical register. Neither the PRHOs themselves nor their consultants identified these deficiencies. A large regional study with sufficient power is required to explore the generalizability of these concerns in more detail.     

''Shadowing'' a manager: an exercise in senior registrar management training

A senior registrar 'shadowed' a district general manager and a unit general manager for one week each as a management training exercise. The three principal participants describe the exercise from their different perspectives. Consequent issues and the value of such 'shadowing' as a mode of training are discussed.     

The teaching of communication skills in United Kingdom medical schools

A survey was carried out of the teaching of communication skills in medical schools in the United Kingdom during the academic year 1989/90. Comparison with previous surveys shows a considerable development over the last 10 years. Departments of psychiatry and general practice continue to play a major part in such teaching. There was wide variation in educational objectives and in the curricular time available. Concern is expressed about the methods of assessment and the degree of integration between departments. Future plans and the perceived barriers are reported and the implications discussed.     

Primary care consultation skills training: implementing a new training programme for senior house officers in an accident and emergency department

Senior house officers (SHOs) in Accident and Emergency (A&E) departments see many patients who present with primary care problems. Until now, most SHOs have lacked postgraduate training in primary care skills to enable them to meet these patients' needs effectively. This paper describes an innovative training programme that has been developing at King's College Hospital, London. It identifies a new opportunity for general practitioners to contribute to the postgraduate medical education of hospital junior medical staff. The training programme was designed to give A&E SHOs protected time in which to reflect on strengths and weaknesses in relation to primary care consultations and learn from their experiences. Its aim was to improve the assessment and management of patients, and to encourage a problem solving approach within the A&E setting. The programme, established in 1992, was developed through collaboration between the departments of A&E Medicine and General Practice and Primary Care. Evaluation has been a central theme in its development, and has been used to ensure that the training meets the needs of each individual set of SHOs and of the department. It has been used in establishing agreement about the training's value and benefits. The authors discuss some of the methodological difficulties encountered in evaluating this type of educational initiative.     

Career choices of United Kingdom medical graduates of 2002: questionnaire survey

OBJECTIVES: To report the specialty choices of UK medical graduates of 2002, and to compare their choices with those of qualifiers in previous years and with the profile of career grade doctors in different specialties in England. METHODS: We carried out a postal questionnaire survey in the UK and drew comparisons with official data for numbers of specialists. RESULTS: The response rate was 65.3% (2778/4257). A total of 22.7% of the medical graduates of 2002 (28.1% of women, 14.5% of men) expressed a preference for a longterm career in general practice, compared with 25.3% of 1999 and 2000 graduates combined. A total of 31.1% of men and 11.9% of women chose surgical specialties; 0.7% of men and 3.4% of women chose obstetrics and gynaecology; 3.4% of men and 7.9% of women chose paediatrics. There was a large mismatch between the percentage choosing each specialty group and the percentage of senior National Health Service doctors working in the same specialty group. In all, 71% of graduates regarded their career choice as definite or probable and 80% definitely or probably intended to pursue a longterm career in medicine in the UK, compared with 75% of qualifiers in 1999 and 2000. CONCLUSIONS: Career choices for general practice remain low: only 1 in 4 women and 1 in 7 men now choose general practice at this career stage. Very few men choose obstetrics and gynaecology, despite a recent increase in training opportunities. There is no evidence of an increase, compared with recent previous cohorts, in the percentage of junior doctors who do not want a longterm career in British medicine.     

Formal instruction in United Kingdom medical schools about death and dying

The paper reports the findings of a short questionnaire survey of medical schools conducted in June 1983. All U.K. schools replied. Only four schools do not provide formal instruction about death and dying for all their students.     

Promoting effective teaching and learning: hospital consultants identify their needs

OBJECTIVES: The aim of this study was to help hospital consultants identify their needs in relation to teaching skills, leading to the development of a teacher training programme. DESIGN: The study was directed at all 869 consultants in the region and initially involved a postal questionnaire which had a 60.5% response rate. SETTING: Hospitals throughout Northern Ireland. SUBJECTS: Hospital consultants. RESULTS: Results from this questionnaire indicated that while the majority of respondents were interested teachers, only 34% had received any teacher training. The questionnaire was followed by a focus group study involving three groups of consultants drawn randomly from those who had responded to the questionnaire. Participants in these groups identified the following key areas of hospital education: qualities of hospital teachers; selection procedures; problems of teaching in hospitals; the need for teacher training and how it should be provided. CONCLUSION: The study highlighted that hospital teachers need to acquire and update their teaching skills through attending courses that should include basic teaching and assessment/appraisal skills. These courses should last 1 or 2 days and be provided at a regional or subregional level. As a result of this study, teacher training courses have been developed in this region.     

Implementing workplace-based assessment across the medical specialties in the United Kingdom

Objectives  To evaluate the reliability and feasibility of assessing the performance of medical specialist registrars (SpRs) using three methods: the mini-clinical evaluation exercise (mini-CEX), directly observed procedural skills (DOPS) and multi-source feedback (MSF) to help inform annual decisions about the outcome of SpR training.
Methods  We conducted a feasibility study and generalisability analysis based on the application of these assessment methods and the resulting data. A total of 230 SpRs (from 17 specialties) in 58 UK hospitals took part from 2003 to 2004. Main outcome measures included: time taken for each assessment, and variance component analysis of mean scores and derivation of 95% confidence intervals for individual doctors' scores based on the standard error of measurement. Responses to direct questions on questionnaires were analysed, as were the themes emerging from open-comment responses.
Results  The methods can provide reliable scores with appropriate sampling. In our sample, all trainees who completed the number of assessments recommended by the Royal Colleges of Physicians had scores that were 95% certain to be better than unsatisfactory. The mean time taken to complete the mini-CEX (including feedback) was 25 minutes. The DOPS required the duration of the procedure being assessed plus an additional third of this time for feedback. The mean time required for each rater to complete his or her MSF form was 6 minutes.
Conclusions  This is the first attempt to evaluate the use of comprehensive workplace assessment across the medical specialties in the UK. The methods are feasible to conduct and can make reliable distinctions between doctors' performances. With adaptation, they may be appropriate for assessing the workplace performance of other grades and specialties of doctor. This may be helpful in informing foundation assessment.     

Perceptions of how well graduates are prepared for the role of pre-registration house officer: a comparison of outcomes from a traditional and an integrated PBL curriculum

INTRODUCTION: Most medical schools in the UK have been engaged in major curriculum reform based on their premises of what might improve undergraduate medical education. In 1994 the course at the medical school of the University of Manchester changed to an integrated course using problem-based learning throughout and with increased emphasis on community-based medical education. This study explores whether the new curriculum has produced any differences in perceptions of how well graduates are prepared for the role of pre-registration house officer. METHODS: A postal questionnaire was used to survey 1998 Manchester graduates (traditional course) and 1999 Manchester graduates (new course), three months into their first pre-registration house officer placement. A similar questionnaire was sent to the educational supervisors who were supervising the graduates. The questionnaire was designed to measure perceptions of levels of preparedness for the role of pre-registration house officer, using a list of broad areas of competence and specific skills listed in the General Medical Council's 'The New Doctor'. RESULTS: Graduates rated the new course significantly more effective for 12 of the 19 broad competences and eight of the 13 specific skills that were listed. The 'new' graduates rated their understanding of disease processes lower than the 'traditional' graduates, but there was no difference in the ratings given by the educational supervisors for this. Overall the educational supervisors rated the new course as better preparing graduates in five of the competences. CONCLUSIONS: Overall, the evaluation shows that a major change in curriculum approach has changed the profile of the perceived preparedness of graduates for entering professional practice.     

A qualitative study of pre-registration house officers in general practice

OBJECTIVES: To evaluate a unique pre-registration house officer (PRHO) rotation involving half a week in general practice over a 4-month period. House officers' and supervisors' views were sought on the value of this type of rotation. DESIGN: Qualitative study using semi-structured interviews. SETTING: A four-partner postgraduate training practice in a deprived urban part of North-east England. SUBJECTS: Pre-registration house officers and supervisors. RESULTS: House officers gained in educational and clinical terms from their period in general practice. They had a high level of individual supervision and teaching and encountered a wider spectrum of illness than in hospital. They found certain aspects of general practice stressful. The supervision required was greater than that needed for a registrar. The supervision of house officers requires support and possibly further education for the supervisor. CONCLUSIONS: General practice can provide valuable supervised experience at this stage of a doctor's career.