Background

Although most rotations still follow the traditional route of six months spent each in medicine and surgery, several factors have recently combined specifically to reopen the debate about the value of incorporating general practice into the experience gathered by preregistration house officers on rotations. These factors include changes in under graduate medical education, explicit descriptions of the attributes expected of doctors, and the increasing importance of primary care.²

An amendment to the Medical Act in 1997 made it possible for preregistration house officers to be trained in settings other than publicly owned buildings. This change indicated an intention on the part of the government to encourage the placement of preregistration house officers in primary care settings.

In addition, the GMC has recently added strong support for these rotations, stating that they offer invaluable insights for preregistration house officers considering general practice as a career, as well as those who intend to specialise in hospital medicine. A 1998 publication by the GMC, The New Doctor: supplement of general clinical training in general practice, states that an appointment in general practice, as part of a rotation involving broad experience of hospital medicine, can provide the preregistration house officer with a unique opportunity to learn about patient care within the community setting.³

Of key importance was the decision taken by the NHS Executive to fund a national pilot programme of over 40 new rotations for preregistration house officers, incorporating four months in general practice, which started in August 1998. With the current impetus behind these rotations, it seems important that undergraduates should be aware of some of the issues involved.

Issues to consider

In 1999 we completed a primarily qualitative evaluation of the four pilot rotations in the South Thames region, which focused on the experiences of key stakeholders: preregistration house officers, general practitioners, and consultants.⁴ On the basis of the experiences of the 12 participating preregistration house officers, we set out here some important considerations to help you decide whether this type of rotation is suitable for you, and to enable you to get the most from the experience if you decide to go ahead.

Motives

If you are certain that you want to pursue a career in general practice, a rotation in general practice could provide you with a very useful "taster" of the professional path you have chosen. Conversely, it could be argued that if you are very sure that you want to become a general practitioner, you might wish to maximise your time in a hospital setting. If you are certain that you want to pursue a hospital career or uncertain which direction you wish to take in your future professional life, a rotation in general practice could present a unique opportunity for you to gain experience in general practice.

The order of the rotation There are advantages and disadvantages attached to doing general practice as the first, second, or third job.⁴ Think carefully about the order of rotations that would suit you. In our study a rotation with surgery as the first placement followed by general practice proved particularly difficult, because of the lack of similarity between the two jobs. Think about the jobs you will be applying for as a senior house officer. For example, if you want a medical rotation as senior house officer then you may need a reference from your medical consultant, and it might be preferable to complete your medical job sooner rather than later in your preregistration year. You will need to negotiate any changes to your rotation order with other colleagues on the rotation, the general practice trainer, and the supervising postgraduate dean or clinical tutor.

The general practice experience

Find out about the practice. Are all the practice members committed to the scheme? Who will your trainer be? A good relationship between preregistration house officer and trainer is very important as you will be spending a great deal of time together. Is the trainer prepared to be flexible and tailor the experience to suit you as an individual?

Location is an important consideration. If the practice is some distance from your base hospital, is it located close to any regular public transport? Are there car parking spaces available? Find out how you can claim for the travel expenses that you incur.

The hospital jobs

If the medical and surgical jobs in the rotation are based in one hospital, consider the experience to be gained there. Do you want to spend all of your preregistration year at either a teaching hospital or a district general hospital? If the hospital based teaching programme for preregistration house officers is repeated every six months, you may miss out in terms of teaching. Is your post viewed as an "extra"? This might mean that you will not gain sufficient experience, or that you will be expected to provide holiday cover for other firms. The traditional six month medical or surgical placement is often split between two firms. If you are spending the whole of your four months with one firm, what sort of experience will you gain there?

Personality and maintaining social links

Are you an independent person who can work alone? While working in general practice you will be well supported by your general practice trainer and the primary healthcare team. It is important, however, to be aware of the fact that for most of your working day you will not be in direct contact with your hospital based colleagues. Over half of the preregistration house officers in our study did feel isolated despite the fact they were based in friendly and supportive general practices. You are therefore strongly encouraged to maintain social links after hours. You should also be given ample time to meet your fellow preregistration house officers at the weekly teaching sessions. We noted that preregistration house officers who were based in practices with general practice registrars often found this helpful, as was the opportunity of attending the educational sessions arranged for registrars.

Learning opportunities

One of the great advantages of a general practice placement is the formal time set aside for self directed learning. To gain maximum benefit from this, you need to be someone who enjoys taking responsibility for directing your own learning. Although most preregistration house officers in our study thrived in this situation, a few complained about being bored and found it difficult to fill their time.

Monitoring your experience

Constantly monitor the experience you are gaining throughout the year. For example, make sure you have the opportunity to do enough "first on-calls" in each four month hospital placement. If you lack experience of specific clinical procedures, point this out to your consultant or general practice trainer early on. Let other firms know that you are seeking experience of particular procedures.

Applying for posts as a senior house officer

Discuss with your consultants and general practice trainer how best to "sell" the experience of general practice on your curriculum vitae and during interviews. In our study, we found that in general the 17 hospital consultants interviewed valued specific aspects of the experience to be gained in general practice. These included: the increased breadth of experience; greater intraprofessional understanding; the gaining of specific clinical skills; and a greater understanding of the relationship between primary and secondary care.⁵

Make the most of the experience

The four month placement in general practice proved to be an enjoyable and powerful learning experience for many of the preregistration house officers in our study. For them, general practice offered a unique opportunity to learn and develop, both as doctors and as individuals.

Clare Williams, research fellow
Peter Cantillon assistant postgraduate dean,

Mac Cochrane, postgraduate dean, Department of Postgraduate Medical Education, Guy's King's and St Thomas's Hospitals Medical School, St Thomas's Hospital, London SE1 7EH


studentBMJ 2000;08:131-174 May ISSN 0966-6494

1. General Medical Council. The new doctor. London: GMC;1997.
2. Oswald N. Valuing general practice in the house officer year. BMJ 1998;317 (classified section 26 September):3.
3. General Medical Council. The new doctor: supplement of general clinical training in general practice. London: GMC;1998.
4. Williams C, Cantillon P, Cochrane M. Pre-registration house officers in general practice: an evaluation of the South Thames pilot rotations 1998-1999. London: Department of Postgraduate Medical Education, GKT Hospitals Medical School, 1999.
5. Williams C, Cantillon P. Pre-registration rotations into general practice: the concerns of PRHOs and the views of hospital consultants. Med Educ (in press).