Junior hospital doctors' views on their training in the UK.

To ascertain the views of senior house officers and registrars on the educational and training component of their posts, a questionnaire was sent to all full-time doctors working in training posts in general and/or geriatric medicine at three district general and three teaching hospitals. Completed questionnaires were received from 64 (61%) of 105 doctors who were contacted. Most had a careers counsellor or tutor, although less than two-thirds thought they had benefited from this arrangement. The majority of doctors attended at least two medical tutorials or meetings per week; most wanted to attend more but were unable to because of other work commitments. Supervision by more senior staff on the ward was deemed by most to be satisfactory, but less so in out-patient clinics. Overall, one-third of doctors thought that training was inadequate and three-quarters wanted a greater amount of formal education. The majority of junior doctors'' time was spent on routine work and most considered :training'' constituted less than 10% of their working time. Doctors in training require more sessions designated as educational, with protected time to attend these.     

Practical experience and confidence in managing emergencies among preregistration house officers

Objectives: To assess the experience gained by pre-registration house officers (PRHOs) at the end of their first post. To assess confidence in managing common emergencies and experience gained in practical procedures. To compare traditional six month posts with four month posts and to compare the experiences of PRHOs posted in teaching hospitals (THs) with those based in district general hospitals (DGHs). Design: Interview questionnaire. Participants: 152 graduates from Edinburgh University Medical School in 2000 who had completed their first PRHO post by February 2001. Results: There were few significant differences in confidence in managing emergencies and in numbers of practical procedures attempted between respondents from four and six month posts or between those holding TH and DGH posts. PRHOs had gained little experience in practical procedures: fewer than 15% had performed five or more of a number of procedures including lumbar puncture, pleural aspiration, chest drainage, and insertion of nasogastric tube. A high proportion of PRHOs indicated that they felt confident initiating management of conditions in specialties of which they had little or no experience. Conclusions: Rotations of three four month posts do not seem to reduce overall experience in the PRHO year. There is little difference in experience gained between TH and DGH posts. PRHOs perform few practical procedures and some may be overconfident in their own abilities.     

Do house officers learn from their mistakes?

Mistakes are inevitable in medicine. To learn how medical mistakes relate to subsequent changes in practice, we surveyed 254 internal medicine house officers. One hundred fourteen house officers (45%) completed an anonymous questionnaire describing their most significant mistake and their response to it. Mistakes included errors in diagnosis (33%), prescribing (29%), evaluation (21%), and communication (5%) and procedural complications (11%). Patients had serious adverse outcomes in 90% of the cases, including death in 31% of cases. Only 54% of house officers discussed the mistake with their attending physicians, and only 24% told the patients or families. House officers who accepted responsibility for the mistake and discussed it were more likely to report constructive changes in practice. Residents were less likely to make constructive changes if they attributed the mistake to job overload. They were more likely to report defensive changes if they felt the institution was judgmental. Decreasing the work load and closer supervision may help prevent mistakes. To promote learning, faculty should encourage house officers to accept responsibility and to discuss their mistakes.     

The US residency programme--lessons for pre-registration house officer education in the UK?

The 1994 NACT Wyeth-Ayerst Travelling Fellowship provided the opportunity to compare the education and welfare of pre-registration house officers in the UK with their nearest counterpart in the US residency system. Investment in all aspects of learning was impressive, as was the retention of the central role of the patient in education. Adequate clinical exposure must take into account both the changing pattern of care delivery and the need to limit junior doctors'' hours of work. Service containment is difficult to achieve. The self-educating potential of junior medical staff should be maximised and a post analogous to ''Chief Resident'' in the US could be considered. Explicit educational aims and objectives must be stated so that meaningful assessment can be carried out and feedback provided. Adequate support systems are essential and an earlier start to the working day is encouraged.     

Part-time medical training: 15 years' experience in the Oxford region

Part-time training of doctors with domestic commitments has taken place successfully in the Oxford region since 1966; 249 doctors have now passed through such training schemes and a further 120 are currently training part-time. Two training schemes are now offered for doctors at senior house officer and registrar level: one of six to eight sessions a week for those undertaking recognised training aiming for consultant or principal in general practice posts, the other of one to two sessions a week providing ad hoc training for those unable for personal reasons to follow a recognised training programme. For doctors at senior registrar level, part-time training entails five to eight sessions a week. Of the 115 doctors who have left the schemes and are now in career posts in the United Kingdom, 19% are now consultants, 30% in other hospital posts, 27% in general practice, and 18% are clinical medical officers; overall, 71% of those in career posts are working part-time. This experience shows that part-time training can be successful and that there is a continuing need for part-time career posts.     

Skills of medical students and house officers in prescribing narcotic medications

Eighty-eight medical students and house officers were given patient management questions to assess their ability to convert from one narcotic regimen to an approximately equal analgesic dose of a second regimen. Only 8 percent of their answers were within the correct range, even though commonly used reference material was supplied to assist them in answering the questions. There were no significant differences in the responses of house officers from different medical specialties or among all the individuals at different educational levels. Correct answers to the patient management questions markedly increased after instruction on the use of a narcotic equivalency table. More emphasis on the importance of adequate pain control, better teaching of the pharmacology of narcotic analgesic drugs, and additional instruction on the use of narcotic equivalency tables are needed in medical school and house staff training programs.     

Formal education programmes for senior house officers: comparison of experience in three hospital specialties

This study was designed to compare the attendance rate of senior house officers (SHOs) in three specialties at formal educational events, examine experiences of protected time, use of educational objectives, and perceived barriers to attendance and evaluate differences found in the context of variations in training practice within each specialty. A quantitative questionnaire survey was completed by Trent region SHOs in obstetrics and gynaecology, general medicine, and accident and emergency posts. An independent researcher visited a selection of educational programme events over a two month span, recorded attendances, and administered the questionnaire. Attendance rates ranged from 40.8% of those in obstetrics and gynaecology jobs to 55.4% of those in accident and emergency jobs. The questionnaire findings found that service commitments were a major obstacle to attendance for the majority of those in obstetrics and gynaecology and general medicine jobs, while relatively few of the accident and emergency SHOs specified any barriers. SHOs in accident and emergency jobs had significantly more protected time for education and found educational objectives to be more widely used by senior staff. The findings suggest that the planned integration of formal education programmes with appropriate working pattern systems--in this case full shifts within accident and emergency departments--will result in SHOs receiving a better deal in terms of provision and structure of education.     

Knowledge of aspects of acute care in trainee doctors

Deficiencies in trainees' knowledge, skills, and attitudes have the potential to influence the initial assessment, treatment, and outcome of acutely ill ward patients. Knowledge of basic aspects of acute care were assessed among a group of 185 trainee doctors at six hospitals. Many were unaware of the signs of total airway obstruction, confusing them with those of partial obstruction (pre-registration house officers (PRHOs) 11%, senior house officers (SHOs) 14%) or apnoea (PRHOs 47%, SHOs 26%). Knowledge about the use of non-rebreathing oxygen masks was poor; 23% of trainees could not describe the purpose of the reservoir bag or gave answers that were unclear or incorrect. Seven trainees thought that it was involved in humidification, or carbon dioxide collection or removal. Seventeen per cent of trainees could not quote the maximum deliverable inspired oxygen concentration provided by these masks or gave values below the normal range. Thirty one per cent of trainees thought that the lower end of the normal range for pulse oximetry (S(p)O(2)) was below 95%; nine (5%) believed it to be below 90%. There was also poor knowledge of the factors influencing the function of a pulse oximeter. Similar deficits in knowledge and understanding existed in relation to the normal capillary refill time, minimum hourly urine output, the use of the AVPU scale and the role of blood glucose testing in unconscious adults. Only 22% of PRHOs and 21% of SHOs identified the correct percentage hospital survival for patients who suffer an in-hospital cardiac arrest. Knowledge of aspects of consent was unsatisfactory. It is recommended that all medical schools urgently incorporate training about common aspects of "generic" acute care in their curricula.     

Differential diagnosis and the competing-hypotheses heuristic. A practical approach to judgment under uncertainty and Bayesian probability

Evaluating the same diagnostic information across the plausible competing diagnoses is a practical strategy (ie, heuristic) to guide decision making in the face of uncertainty. The prevalence of use of this competing-hypotheses heuristic by 89 first-year house officers was examined in three simulated patient cases. Results indicated that only a minority (24%) of the house officers selected optimal diagnostic information consistent with this Bayesian heuristic across all three cases. Almost all (97%) of the house officers selecting optimal diagnostic information were able to identify the most probable diagnosis specified by Bayes' theorem, while only a chance number (53%) of house officers selecting nonoptimal information were able to identify the most probable diagnosis. The competing-hypotheses heuristic is discussed within the context of diagnostic problem-solving models derived from the literature on medical decision making and clinicopathological conference case records. It is suggested that the heuristic, which does not necessitate any mathematical calculations, may be useful as a complement to clinical judgment.     

The educational component of senior house officer posts: differences in the perceptions of consultants and junior doctors.

The aims of this study were to elicit general practitioner (GP) trainee''s perceptions of the educational structure of their hospital posts, to compare them with those of consultants who had GP trainees as senior house officers (SHOs) in their departments and to examine the use of educational objectives in the hospital component of vocational training for general practice. A confidential postal questionnaire was sent to all the GP trainees (165 doctors) in the hospital component of their vocational training schemes (VTS) for general practice in Trent Region and all the consultants (161 doctors) in Trent who had GP trainees in their SHO posts on that date. Responses were received from 136 trainees (82%) and 134 consultants (83%). Educational objectives were stated as existing in the SHO post by 31 trainees (23%) and by 62 consultants (46%). Of those doctors who said that objectives existed, 19 of the trainees (61%) and 40 of the consultants (65%) said that the objectives were useful. Only nine (29%) of the trainees who stated that educational objectives existed felt that they were being put into practice by senior staff, compared with 41 (66%) of consultants who had made that statement. Of all respondents, 113 trainees (87%) and 100 consultants (77%) agreed or strongly agreed that the use of educational objectives would be beneficial to the trainees. Only 10 (7%) of trainees said that they received no teaching in their current posts. Forty trainees (32%) and 88 consultants (67%) said that teaching took place in protected time. Both groups cited consultants as the member of staff giving the most teaching. Ninety-six consultants (73%) replied that it was possible for GP trainees to obtain study leave, but 102 trainees (75%) either had experienced difficulties in obtaining study leave or had not attempted to obtain study leave. Trainees and consultants differed appreciably in their perceptions of the amount of assessment and feedback which was provided for GP trainees. The use of educational objectives in the hospital component of vocational training was felt to be beneficial by both consultants and GP trainees. Consultants were more likely than trainees to report the use of educational objectives, protected teaching time, GP-orientated teaching, ability of trainees to attend VTS half-day release and the provision of assessment and feedback to trainees.     

Teaching medical gerontology: utilization of a psychiatry consultation program.

This is a report of a pilot project designed to explore the feasibility of using the clinical Adult Service Psychiatry Consultation-Liaison Program at the University of Michigan as the locus for teaching medical gerontology to psychiatric and medical/surgical house officers and medical students. The goals, general techniques, educational content, and implementation procedures are described. Evidence was obtained that teaching medical gerontology through the program is both feasible and effective. Since a nonphysician gerontologist implemented the clinically based teaching program, the project is an example of the possibilities inherent in a multidisciplinary clinical teaching program.     

Self-evaluation by house officers in a primary care training program

Expertise in ambulatory care requires a broad range of knowledge and skills. A modified Delphi survey technique was used to delineate diagnoses, management techniques, and procedural skills in seven subspecialty areas necessary for house officers in a primary care internal medicine training program. Self-evaluation instruments were developed, and residents were asked to rate their abilities in the seven areas. At entry, the house officers generally had more confidence in their diagnostic abilities than in their management techniques and procedural skills. Progression through the training program was accompanied by increases in confidence in all areas except the behavioral sciences. The self-evaluation approach provided a longitudinal assessment of changes in the confidence of house officers throughout their training and an indication of the effectiveness of the educational program.     

Internal medicine house officers' performance as assessed by experts and standardized patients

Three chronically ill patients were trained to evaluate the performance of 31 second-year internal medicine house officers based upon: a checklist for the medical data elicited during the medical interview; the process of the interview (that is, the house officer's interviewing style); and the physical examination technique. Four standardized rating scales were completed by the patients for the evaluations. Expert evaluations of the same house officers were conducted by a trained evaluator who reviewed videotapes of the interview and a faculty member who reviewed the adequacy of the medical history write-ups. Results of the study indicate a high correlation between the patients' and the experts' evaluations of the adequacy of the medical history data collected; less agreement was found in evaluations of the adequacy of the psychosocial data collected. These findings suggest that, if carefully selected and trained, patients with chronic medical conditions can provide reliable and standardized evaluations of house officers' performance at a level consistent with but less expensive than faculty members' evaluations.     

Handbooks, learning contracts, and senior house officers: a collaborative enterprise.

Efforts to bring about improvements in hospital-based education and training for senior house officers over the last few years have raised issues which are gradually being addressed. One of these is the lack of understanding by many clinical teachers of educational principles and their application to senior house officer training. This study describes how volunteer consultants in five specialties in a North West District General Hospital worked together to develop an educational structure for senior house officers. An audit of education and training was carried out across the hospital to help identify problem areas. An education specialist worked with consultants to develop, implement and evaluate a handbook based on adult learning principles. The handbook incorporated a learning contract, formal review process and a curriculum of learning objectives for each specialty. In parallel, consultants created in-house videos which were used to raise awareness of clinical teachers in the hospital about these educational issues. Preliminary evaluation showed positive responses by both senior house officers and consultants to both the study and its outcomes.     

Electrocardiogram and rhythm strip interpretation by final year medical students.

The pre-registration house officers (PRHO) is often called upon to interpret electrocardiograms ECG. We invited final-year medical students who had successfully completed their written final examinations, to interpret three rhythm-strip tracings, and three 12-lead ECG tracings. The rhythm-strips were of ventricular fibrillation (VF), ventricular tachycardia (VT), and complete heart block. Of the three 12-lead ECG tracings, one was an inferior myocardial infarction (MI), one was atrial fibrillation (AF), and one showed no abnormality. Forty-six medical students attended. Of these, 50% had received no formal training in ECG interpretation, although 89% had tried to learn ECG interpretation from books. Only 9% felt confident in their interpretation of ECG tracings. Of the rhythm-strips, 100% correctly identified VF, 96% recognised VT, and 67% identified complete heart block. Of the 12-lead ECG tracings, 61 % recognised the MI, 54% recognised AF, and only 46% successfully identified the normal ECG as such. The group were significantly worse at 12-lead ECG interpretation compared to rhythm-strips (p<0.01). The members of the group who had received formal training in ECG interpretation were significantly better at interpreting both rhythm-strips and 12-lead ECG tracings (p<0.05). It would appear that formal ECG training as an undergraduate improves PRHO interpretation of ECG tracings, and the PRHO should not interpret 12-lead ECG tracings without consulting more senior medical staff.     

Fifth pathway in New Jersey. House officer preparatory course for US foreign medical graduates.

The Fifth Channel in New Jersey is a Fifth Pathway program for US foreign medical graduates. In its third year, 83 percent of its 81 graduates are house officers at 18 US medical school-affiliated hospitals. Performance as house officers is characterized as competitive with peers, including US graduates. Positive attitudes toward work load, fellow workers, and patients compared with those of fellow house staff are noted. Quality of performance as house officers correlates most strongly with the change in mean scores of two batteries of clinical National Board examinations taken during the Fifth Pathway and less strongly with mean scores of single batteries of National Boards, Intelligence quotient, Educational Council for Foreign Medical Graduates (ECFMG) examination, ang age. Recommendations concerning the implementing of similar programs in other states are presented.     

The views of medical students and junior doctors on pre-graduate clinical teaching.

A total of 277 third and fourth year medical students and 304 house officers and senior house officers were asked to prioritise the content and methods of clinical teaching. Response rates were poor, but similar to that in market surveys. Bedside teaching and medical clerking were considered the most valuable methods of teaching and training in practical procedures such as venepunctures and urinary catheterisation was seen as valuable. The design of new curricula in medical education will need to accommodate the views of its clients.     

Sleep deprivation and junior doctors' performance and confidence

Purpose of study: To determine whether sleep deprivation affects not only junior doctors'' performance in answering medical questions but whether their ability to judge their own performance is also affected by lack of sleep. Methods: A questionnaire based follow up study in two district general hospitals of the Carmarthenshire NHS Trust. Eleven house officers and 15 senior house officers (SHOs) within the medical directorate participating in the on-call rota were recruited between July 1999 and May 2000. Results: SHOs answered significantly more questions correctly (p=0.04) and were more confident than house officers when they were either correct or incorrect (p<0.001). Length of unbroken or continuous sleep is associated with more correct answers (p=0.03) and higher energy (p=0.09) and confidence (p=0.07) scores self rated by the profile of mood states. Length of continuous sleep was not related to the appropriateness of confidence, as measured by the "within-subject confidence-accuracy correlation" (p=0.919). Conclusions: SHOs performed better than house officers even allowing for sleep loss. Sleep deprivation had adverse effects on mood and performance but junior doctors can still monitor their performance and retain insight into their own ability when sleep deprived.     

Junior medical posts in the NHSSB: what the doctors think.

This survey of house officers in the Northern Health and Social Services Board in Northern Ireland demonstrated that they have complaints not just about the number of hours they work. Thirty-nine per cent noted poor standards of food and/or accommodation. Many complained about doing routine "non-medical" work and thought that their working conditions would be improved by nurses having more responsibility for managing intravenous medication and the employment of phlebotomists. Doctors expressed concerns about a lack of career counselling and availability of training in research methods in their posts.