Pre-registration house officer training in psychiatry: the London experience

Abstract

Aims and Method

To evaluate whether new pre-registration house officer posts in psychiatry deliver training leading to increased confidence in target skills, based on General Medical Council requirements, and to evaluate trainees' satisfaction with these posts. A structured questionnaire was filled out by the first nine incumbents of the PRHO posts before and after the placements.

Results

Trainees' confidence improved in all the target skills and the posts were all rated as good or excellent. The posts attracted trainees who were potentially interested in a career in psychiatry or general practice.

Clinical Implications

PRHO posts in psychiatry deliver training that meets General Medical Council objectives, and trainees' confidence with core psychiatric skills improves after undertaking the placements.

The pre-registration house officer (PRHO) year is a crucial bridge between undergraduate training and working as a senior house officer (SHO). At its best, it provides the context within which the new graduate can further develop the clinical skills acquired as a student, and work towards an increasing degree of independent practice and decision making. At the end of the year, he/she should have the necessary competences and confidence to work as an SHO. The General Medical Council (GMC) describes very specifically the characteristics of PRHO posts, and charges the relevant local Postgraduate Dean both to commission and to regularly evaluate PRHO posts. In addition, the GMC defines the PRHO experience that a graduate must satisfactorily complete in order to be eligible, on the recommendation of their medical school, for entry into the GMC register as a fully-registered practitioner. This includes at least 3 months' acute general medicine and 3 months' acute general surgery. Traditionally, most PRHO posts have comprised 6 months' training in medicine and 6 months' surgery. However, GMC regulations allow considerably more latitude than this arrangement suggests and in Sheffield, PRHO posts that include psychiatry have existed for many years (O'Dwyer, 1999). Recently, the London Deanery has commissioned over 30 1-year PRHO rotations that include 4 months' medicine, 4 months' surgery and 4 months in another speciality. The specialities have included critical care/general intensive care units, anaesthetics, women's health, general practice, child health and psychiatry. The criteria used to identify specialities suitable for PRHO training were: (1) that these should be in the same hospital or community as the medical and surgical posts; (2) there was a consultant keen and able to take on the role of a PRHO trainer/supervisor, that his/her team had a good reputation for training, and that his/her team were willing to include a PRHO and understood the need for supervision; (3) that the clinical experience came within GMC guidelines and (4) that the timetable of the PRHO reflected the likely competence of a PRHO and had an element of latitude that took into account variation in acquisition of skills and competencies, included a range of learning opportunities and that the post holder should not simply be required to do tedious administrative work that others do not want to do.

Four consultants in three north London community/mental health trusts were identified as keen to take on a PRHO and in August 1999, three rotations were set up. For these psychiatry posts, F.M. and J.H. drafted proposed educational skills based on requirements outlined in The New Doctor (GMC, 1997) and modified these after discussion with the consultant trainers (Box 1). Two of the posts were based in mental health units and one was based with a liaison psychiatrist in a general hospital. The first of the mental health unit posts offers a two-thirds in-patient/one-third community split. The second mental health unit post offers a two-thirds community/one-third in-patient split. The liaison post offers one-third emergency referral work and two-thirds attendance at specialist clinics. All three posts allow for attendance at the unit academic programme and all offer individual educational supervision by the consultant trainer. This paper reports an initial evaluation of these posts and in particular whether trainees feel more confident in the target skills set, outlined in Box 1.

Box 1. London Deanery target skills for PRHOs in psychiatry

1. To take and analyse a full psychiatric history 2. To carry out detailed mental state examinations 3. To develop competence in basic assessment of cognitive functioning 4. To apply knowledge of the relevant psychological factors on the genesis of psychiatric illness 5. To learn the principles of risk assessment, in particular relation to suicide, violence to others and self neglect 6. To apply relevant physical investigations to the assessment of psychological illness 7. To formulate care plans with other members of the multi professional team which encompass medical, psychological and social aspects of treatment 8. To manage psychological illness in people who are physically ill 9. To monitor progress of people with psychological illness through presentation at an acute hospital through to care in the primary and community settings 10. To become experienced in liasing and working with relevant community agencies 11. To be inintroduced to benefits and use of psychotherapies such as supportive psychotherapy and cognitive—behavioural interventions 12. To become conversant with the applicability and the use of the Mental Health Act 1983 13. To gain insight into the doctor—patient relationship and the effect of that relationship on the practitioner. To learn to self-reflect in relation to caring for patients

Method

We drew up a questionnaire to find out how confident trainees were in the skills outlined in Box 1. Each was asked to rate their confidence on a five-point scale. The stems were ‘I feel confident about’ or ‘I feel anxious about’ and each related to the educational skills outlined in Box 1. The five possible responses for each item were; strongly disagree (0), mildly disagree (1), no opinion (2), mildly agree (3) and strongly agree (4). The questionnaires were sent by post to nine trainees within the first month of their placements and within 2 months following the end of their placements.

Results

Do trainees gain confidence in psychiatric skills in the PRHO year?

All nine trainees filled out the pre-placement questionnaire (100%) but only five (67%) filled out the post-placement questionnaire. Despite these low numbers, we thought it would be interesting to see whether there were any statistically significant differences between trainees' confidence levels in the target skills before and after the placements. A comparison of pre- and post-placement ratings of confidence was calculated using the non-parametric Wilcoxon signed-rank test. We also asked trainees to rate their overall satisfaction with the posts on a 5-point scale (very poor, poor, satisfactory, good or excellent). Additional information was available on overall satisfaction with posts from four additional trainees who were seen at subsequent Deanery inspection visits to the posts, in which trainees fill out a similar 5-point rating scale. Trainees were also asked to indicate whether they were considering a career in psychiatry or general practice on the pre- and post-job questionnaires.

The item (see Box 1) with the greatest number of pre-placement responses indicating lack of confidence was item 7, relating to the skill of formulating care plans, for which 8 (89%) PRHOs indicated worries. Items 1, 2, 9 and 13, which related to history taking, mental state examination, monitoring progress and understanding the doctor—patient relationship respectively, each elicited six (67%) responses demonstrating lack of confidence. Items 4, 8 and 11, relating to understanding aetiology, managing psychiatric illness in physically ill patients and understanding the benefits of psychotherapy respectively, each elicited five (56%) responses indicating lack of confidence in the skills. Therefore, all of the above mentioned items were seen as problem areas by over half of the trainees before placements started.

The following items were seen as problematic by less than half of the trainees before their placements: items 3, 5, 6 and 12, relating to cognitive state, risk assessment, physical investigations and the Mental Health Act each had four (44%) PRHOs indicating lack of confidence in these skills. Item 10 on liaison with community agencies elicited the fewest responses, three (33%), indicating lack of confidence in the skill.

After completion of the psychiatric placement, an increased percentage of trainees expressed confidence in all of the 13 skills studied. These increased confidence ratings were statistically significant (P<0.05) for items 2 (mental state), 6 (applying results of physical investigations), 7 (formulating care plans), 10 (liasing with community agencies) and 11 (understanding benefits of psychotherapies).

Overall assessment of the posts

Three of the five trainees who completed the post feedback questionnaire rated the placement as excellent and two trainees as good. A further four trainees have completed this question as part of the Dean's evaluation of the post. Of the nine trainees who have provided overall evaluation, five (56%) have rated the placements as excellent and four (44%) as good.

Possible career intentions

All nine of the trainees in this cohort were considering a career in either psychiatry or general practice before the placement, and none of the five who responded to the second questionnaire had changed their minds.

Discussion

The PRHO posts in psychiatry seem largely to meet their targets, in that there is a clear improvement in trainees' self-rating of relevant skills, and the posts seem to be rated highly by trainees who have undertaken them. Our initial impression is that these placements are successful in equipping PRHOs with improved psychiatric skills. While these skills are clearly important for psychiatrists, they also have clear relevance to work in other settings, such as hospital medicine or general practice. It has been found that medical students experience particular stress and Firth (1986) highlighted the stress that they experience in talking to psychiatric patients. These placements clearly increase confidence in all aspects of psychiatric clerking.

The findings also suggest that newly-qualified doctors who opt to undertake a PRHO post in psychiatry tend to do so because they are considering a career either in general practice or psychiatry. The experience tends to confirm these career expectations. J.H. subsequently interviewed two psychiatry PRHOs (but not those surveyed in this study) who had applied for psychiatry posts, with a clear preference for a surgical career, on the basis that this would be their only opportunity to gain experience in mental health skills. However, it seems that most trainees who undertake these placements are at least considering a community-based speciality. Psychiatry is one of many innovative hospital and community options now available to trainees as part of their PRHO experience and it is hoped that these initial promising findings will encourage other colleagues to set up house officer posts of this kind.