House jobs: separating the facts from the fiction

Alan Woodall gives some sensible advice on how to choose your house jobs

Firstly, let's get one thing clear. I am no expert when it comes to house jobs. I've only just graduated myself, and start my first post in August. So how on earth can what I have to write be of any use to you? Well, while I don't have the on the job knowledge yet, what I do have to share is the personal experience of choosing preregistration house officer (PRHO) jobs and succumbing, to a lesser or greater extent, to the myth mongering that accompanies the application process. I also interrogated some house officers who were coming to the end of their first year, and also those further up the hierarchy. Many professed a feeling that they chose their jobs based on subjective advice and wished that they had spent more time considering all the PRHO options available.

A few years ago Jessica Westall, former student editor of the studentBMJ, wrote an informative article on the nitty-gritty of choosing house jobs in the past,1 so rather than repeat old ground I thought that it would be interesting to look at some of the myths that surround the process of climbing on to the first rung of the medical career ladder.

Myth 1: Choose the consultant, not the house job

Wrong. While it may seem a great idea to work for the dean of medicine, bear in mind that most PRHOs spend relatively little of their time with the consultant and, more importantly, the higher the consultant status, the chances are the less you are likely to see them because of their non-clinical responsibilities. Many people apply for these jobs for the references that they hope to get at the end of the post rather than the teaching given, although undoubtedly some of these posts are excellent. While these may help in getting senior house officer (SHO) positions in some competitive specialties, you should ask yourself if it is the educational content of the post, rather than the reference that attracts you. Six months can be a very long time to spend in a job you hate, and perhaps receive a lukewarm reference as a result. Equally, it is not sensible to choose a post simply because "Consultant Y is really easy going and nice to medical students." This may translate into "lack of interest in training/teaching people properly?" Think carefully about committing yourself to working in a job that you are not really interested in for the sake of working with one person.

The most valuable thing to do first is draw up a list of jobs that you are interested in and chat to the house officers in each post. Do they seem to be getting a good balance between acquiring responsibility and valuable teaching or have they put up with six months of abuse, boredom, or indifference for the sake of a reference or an easy life? Talk to some of the SHOs and nurses on the wards where you would be working. Get as much information from the people you will be working with about the job, not about the consultant. It is better to choose posts which will offer you opportunities to widen your experience of medicine, perhaps gain a taste of a specialty you may consider for a future career, and which fits with your personality and interests. A reference from the professorial unit would undoubtedly be an asset when applying for some SHO jobs, but this does not guarantee future success in obtaining competitive posts, and should not be the sole criterion used to make your final choice.

ULRIKE PREUSS

Myth 2: Teaching hospital posts are the best jobs

Ask yourself this question: "Best for what?" By the end of medical school, you will have begun to appreciate the differences between teaching and district hospitals, and the nature of the PRHO posts in each type. Teaching hospitals are usually more heavily staffed with doctors than district general hospitals (DGH), and that means you may get more teaching from other staff and see more exotic illnesses. However, you may think that you get less opportunity to take responsibility and be lowest in the pecking order of who gets to assist in theatre or learn new practical procedures. Working in a district hospital where you take on more work yourself can give you the confidence to act decisively and acquire practical skills at an earlier stage, which can be a major attraction for future employers. The negative side to DGH posts can include feeling isolated in a small hospital or overstretched when you are still finding your feet. However, these are still generalisations. Again, the reality is that neither teaching nor district hospitals are better. Their working environments are just different. At PRHO stage it is best to get a wide range of experience, so a sensible approach - which many people I spoke to followed - was to do one job in each type of hospital to get the best of both worlds.

Myth 3: GP-PRHO jobs are no use for a future surgeon/pathologist, etc

Treat this myth with the contempt it deserves. These posts are not a soft option for the mediocre. The majority of PRHOs I spoke to who had completed these posts gave enthusiastic feedback and seem highly motivated from their experiences. They got plenty of individual teaching, learnt to appreciate the wider context of the interplay of physical, psychological, and socioeconomic factors that manifest as illness, and had an opportunity to broaden their medical horizons. New options, incorporating four month placements in psychiatry, anaesthetics, paediatrics, or obstetrics in addition to the General Medical Council's requirement for full registration of four month posts in medicine and surgery, are now available. The PRHO year is the start of your career - use it to test drive options that you might not otherwise consider as future career paths. You may be surprised at what you find you like. The experiences and perspective you have when you are a student are not always an accurate reflection. And a word of warning - if a consultant tells you that it limits your experience to spend only four rather than six months in their specialty - take this with a pinch of salt. This is the beginning of your career. Does an extra eight weeks make that much difference in terms of experience at the PRHO stage? Few consultants I spoke to thought that this is of major importance. It is likely that these posts will become the norm rather than the exception in the future, and that must be good for improving the relationship and mutual understanding between different specialties, to the benefit of patients and clinicians alike.

Myth 4: It is every student for themselves when it comes to getting that job

Some of your colleagues will be pretty desperate for a particular post and may try various ways to find favour with their prospective consultant. While thankfully the days of students golf caddying or acting as free babysitters for their potential boss have mostly disappeared, others may try to sew up a job before the matching scheme begins or the post is advertised formally. Be careful if you do this. There is a fine line between showing initiative in contacting a consultant to find out more about a job and blatant canvassing for a post. Try to establish that you simply wish to meet the consultants to find out more about the post rather than waving your CV under their nose to impress them at the first opportunity. While some consultants might, unfairly, offer you that prized job ahead of the competition, others could view this as a sign that you are fearful of honest competition and are not one to play fair or work as a team member. Seek advice from the current post holders about how to approach the consultants to get more information. Try to find out what they are looking for in a house officer, and decide if you fit that description, rather than deluding yourself that you can bend your personality to fit what the consultant wants.

What do you want to get out of your house jobs?

No two medical students are alike, and it would be a great limitation on training pathways if all PRHO posts were identical. Choosing a post that fits your personality therefore helps to smooth your entry into the medical career. Do you want a hectic post with lots of pressure and responsibility from the early days of the job, or a post which allows you more time to reflect and develop your confidence during your attachment? It can be difficult to assess what kind of person you are, but it is wise when looking for a particular post to undertake a SWOT analysis - consider your own strengths and weaknesses, and look at the opportunities and threats that the post might offer. Analysing yourself can be a painful experience so ask your trusted friends what they think your best and worst qualities are, and how they would view you in that post. You may find their answers illuminate more about yourself than you know, and help you to rationalise your future career choices.

A question of money

Within the past year there has been a radical shift in the way in which PRHOs are paid for overtime work. The previous system of additional duty hours payments, typically paid at 50% of the basic hourly wage, has been superseded by a complex system of banding posts according to the hours worked and overtime pattern which attract a flat rate payment over and above the basic salary. This has been introduced to force NHS trusts to make their junior doctor posts comply with the new deal targets, first set in 1992, for hours worked and rest requirements. From December 2002 a trust that is still forcing a PRHO to work in a non-compliant (band 3) post will have to pay that person a 100% bonus, doubling the annual basic salary of approximately £18 000.

While this sounds very attractive to a cash starved student, it is not necessarily a good idea to apply for posts attracting these noncompliant payments. Remember, there is more to enjoying your PRHO job than the amount on your monthly pay cheque, important though that is. Trusts which have still not achieved new deal compliant posts by this time have not really addressed with any degree of urgency the fact that their junior doctors are working unsafe practices, and have failed to act after having almost 10 years since the original agreement to achieve a good working pattern for their junior doctors. If trusts have not tackled this problem by now, how likely are they to have addressed other junior doctor concerns that make the difference between a job being pleasant and being a nightmare - namely, decent accommodation, good quality canteen food available while on call, and protected time for PRHO teaching during shifts?

Where possible, try to choose posts that are compliant with new deal targets. This might mean that you have slightly less money at the end of the month, but chances are you will have had a better working experience with a trust that values its employees and recognises the need for clinicians to receive adequate rest. Oh, and if you haven't already done so, join the BMA. It will, in most local offices, provide a contract checking service before you start, have gathered feedback from previous PRHOs on the quality of the post and publish this for their members' information, and will act in the rare few cases where a doctor has a serious grievance with an employer.

Rounding it up

In summary, try not to worry too much about your PRHO jobs; choose those you think you will benefit from educationally and enjoy socially. Contrary to popular rumour, where you do your first house job and with whom you work counts for far less than most people think when trying to ascend the career ladder. Most consultants recognise that this is the first step on the career ladder, and little importance will be attached to where you undertook your PRHO jobs as long as you made the most of the opportunities available and demonstrated an ability to act as a team player on your firm. Just try to get a post which will give you good experience, provide useful learning opportunities, and allows you to make the transition from student to fully fledged doctor as painlessly as possible.

Alan Woodall, preregistration house officer, Yorkshire region
Email: alan.woodall@themutual.net


studentBMJ 2001;09:217-260 July ISSN 0966-6494

1. Westall J. Choosing house jobs. BMJ 1998;318(7183):2. www.bmj.com/cgi/content/full/318/7183/S2-7183