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Pre-registration posts in general practice: the chance of a lifetime?

1989; Wiley; Volume: 23; Issue: 4 Linguagem: Inglês

10.1111/j.1365-2923.1989.tb01555.x

1365-2923

Nigel Oswald,

Global Health Workforce Issues

From the time of the second Medical Act in 1886 until long after the advent of the National Health Service the British law required that qualification in medicine indicated competence to practise. As medical knowledge and technology increased in quantity and complexity the gulf between medical student and independent practitioner could not be bridged any longer simply by passing an examination. The Goodenough Committee (1944), designing the future of medical education in a national health service, proposed one year of compulsory hospital work before registration. This proposal was made in 1944 and the necessary legislation was introduced in the Medical Act of 1950, becoming effective on 1 January 1953. Goodenough stated clearly the conditions appropriate to the pre-registration year. House officers were to be considered to be continuing their education, to have responsibility for a limited number of beds and to have time for thought, personal study and for the ‘personal investigation of the social and environmental conditions of the patients with whom they come into contact’. Posts would only be available in approved hospitals and would be adequately supervised by senior staff. The committee gave its view that the year should be divided into two 6-month appointments, one in medicine and one in surgery, but stated that in future other arrangements, including attachment to general practitioners, might be considered. Following the Committee of Inquiry into the Regulation of the Medical Profession (Merrison 1975) the Medical Act 1978 made it possible for up to 4 months of the pre-registration year to be spent in approved posts in a health centre. The General Medical Council Recommendations on Basic Medical Education, published in 1980 (GMC 1980), acknowledged this. The GMC re-emphasized the educational nature of posts, confirming that the pre-registration year be considered as the conclusion of basic medical education which, by means of a period of increasing clinical experience and responsibility, would prepare new doctors for careers as specialists. There has not been widespread enthusiasm for pre-registration attachments in general practice. Reported experience is scanty (Freeman & Coles 1982; McGuinness 1982; Harris et al. 1985; Harris 1986). St Mary's is the only medical school in the UK currently running a regular rotation, and the published work emphasizes administrative difficulties and the heavy responsibility on the supervising department. However, there are strong arguments for regarding the experience of 4 months as a houseman in general practice as a unique opportunity, especially for doctors who will follow a career in hospital medicine. Medical training for hospital doctors in the UK remains almost entirely hospital-based and rigidly separates experience inside hospitals from that outside. The result is that hospital doctors' experience of medicine and illness in the community is usually limited to their attachment to GP tutors as clinical students. On the other side, vocational trainees preparing for general practice do house officer and senior house officer posts which are full-time resident hospital service appointments, and then switch abruptly to general practice traineeships which carry no hospital responsibility. Carefully designed pre-registration posts in general practice would allow those involved to have simultaneous responsibility in both primary and secondary care. This is an opportunity which the present pattern of basic medical education does not allow at any other time. General practice is the setting in which a number of important lessons can be most effectively learnt. The first is how the decision to refer to secondary care is made, remembering that this is the activity which directly generates the majority of consultant work-load. It should be part of the training of all doctors who will be involved with the treatment of acute admissions in hospital to have been personally responsible, under supervision, for deciding on the need for referral from the community, and to have experienced that combination of influences — diagnostic uncertainty, disadvantageous physical surrounding, family anxiety and patient resistance — which may colour the decision. In general practice housemen can gain experience in making supervised referral decisions and can balance this by managing at home patients in whom referral is thought to be inappropriate. In these patients housemen can monitor subsequent progress, learning skill in the use of time and learning to understand better the natural history of conditions where the initial presentation gave rise to the consideration of serious illness. The second benefit of a pre-registration attachment in general practice is to make real the concept that illness is not a hospital phenomenon but, for the patient, begins outside hospital and continues, often, long after discharge. Few medical students can avoid learning that being ill involves more than the symptoms and signs on which doctors base diagnoses. But their own experience as junior doctors on acute medical and surgical wards inevitably results in a close identification of findings and illness. This is how it comes about that a hemiplegic patient, initially expected to die but now able to walk, can be described as making ‘an excellent recovery’ while the reality of the patient's experience is that he has lost speech, job, potency and independence. Doctors who treat cerebrovascular disease, diabetes, rheumatoid arthritis and dementia will understand much better what these conditions mean to patients and why they vary so much clinically between patients if they have had experience of the illness not only in the hospital but in the patient's own context. It is essential for all doctors to understand that patients are active, not passive, participants in the progress of their illness, and such experience is most easily and effectively given in general practice. Thirdly, it is important to observe the efforts being made in preventive medicine. Experience limited to the hospital clinic and ward gives a simplified view. The doctor advises and the patients, if they know what is good for them, comply. In general practice it is possible to see and understand more clearly the efforts made by patients which nevertheless meet with failure. General practice is the place to learn how much explanation, effort and support are required if the doctor genuinely wishes a patient to lose weight, to give up smoking or abstain from alcohol. Understanding this helps all of us to appreciate the difficulties which our often glib advice may pose for patients and, as the techniques of health education develop, become more effective in helping people to change their habits. Finally there are certain key experiences which remain with young doctors for a lifetime, setting patterns for future behaviour. Many of these are met in hospitals, but others can only be found in general practice. Examples include seeing for oneself the determination of the old and the chronically ill to maintain independence in their own home, the devotion and tenderness of families caring for a dying relative in their own front room, and the effects on a family of a handicapped child living at home. All of these experiences teach, in a way which a lecture never can, how we can be unaware of the extent and the depth of the consequences both of ill health and of the limitations of medical intervention. At the same time the doctors, whose hospital experiences foster the idea that people are passive and ineffectual, realize the extent to which people wish, and are able, to remain in control of their lives and futures. It goes without saying that such experience can only be achieved as a houseman in general practice by careful organization. It will not be achieved by attaching housemen to health centres as junior trainees and letting them see large numbers of unselected patients in routine surgeries. It can be done by giving housemen responsibility for assessing and following up large numbers of patients who believe that they may have a serious illness. A paper in this issue of the journal (Oswald & Kassimatis: ‘A house officer in general practice: a different experience’, pp. 322-27) describes such an attachment and assesses its educational and clinical potential. Its conclusion is that the benefits of the attachment of pre-registration housemen to general practice should be positively reassessed.