Medical Education, 1984, 18, 187-190

REPORT

The pre-registration year: report of a conference

K. M. P A R R Y

Scottish Council for Postgraduate Medical Education, Edinburgh

Introduction

Continuity in medical education was the subject of an ASME conference in June 1982 (Medical Educa- tion, 1982). One proposal considered was to attempt to achieve continuity by ‘serial‘ education, with the objectives of each stage clearly defined. Although this idea was attractive it was thought that there was an inherent risk in defining objectives in the relatively simple terms of practical mastery without giving due weight to the less readily characterized intellectual qualities that should accompany it. There was a danger that this might reinforce the tendency to regard medical practice as a technology rather than as the professional task which its historical tradition suggests it should be. Nevertheless the proposal was thought worth pursuing by way of a reappraisal of the pre-registration year, which is the bridge between theoretical teaching and its practical application.

Despite common assertions to the contrary, for many students pre-registration training falls far short of its objectives. They feel unprepared for the responsibilities of their first medical job, confused by the duties they are expected to perform, and unsure who they should turn to for guidance. Sceptics who resist the various attempts at reform, with scathing comments about ‘spoon feeding’, underestimate the long-term effects of stress and uncertainty at this crucial stage of a doctor’s education. A careful and detailed study is needed of the interface between medical graduates’ defined degree of preparedness for their first clinical responsibilities and what they are then expected to do. In the same way the objectives of pre-registration training should be

Correspondence: Dr K. M. Parry, Scottish Council for Postgradu- ate Medical Education, 8 Queen Street, Edinburgh EH2 IJE, U.K.

clearly defined, and related to the more specialized tasks they will be expected to assume as senior house officers.

Criteria for the approval of pre-registration posts introduced by the General Medical Council (GMC) in 1967 (GMC, 1967) sought to ensure adequate supervision by consultants and junior medical staff, a limited workload for the house officers, and ‘at least 6 hours weekly for educational purposes, apart from his free time’ so that the house officer could take part in a planned educational programme. In a review of the effects of these criteria in 1972 (GMC, 1972), the pre-registration year was criticized for lack of super- vision, excessive workload, inadequate time for study, and failure to evaluate the educational benefits of the training. New criteria were then introduced by the GMC as a ‘code of good practice’ (GMC, 1974), and this included similar criteria to those of 1967 but excluded the requirement for any formal educational programme; ‘teaching by in-service clinical training should be the primary objective rather than by a more formal educational programme’.

The aims of training were again reviewed when the GMC held a further conference on the pre-registra- tion year in 1978 (GMC, 1978). The ‘code of good practice’ was thought to have improved training, and much of the conference was devoted to examining ways of increasing the number of training posts to accommodate the expansion of the medical schools in the United Kingdom. Criticism, however, still continues (Christie, 1980), particularly of the degree of consultant supervision and teaching. It appears that efforts to improve the circumstances under which training takes place are not enough. There have also been complaints that the basic medical skills of history-taking and physical examination

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have not been adequately acquired by candidates for the MRCP(UK) (GMC, 1982). In its most recent statement the GMC declares that ‘the principal purpose of (the pre-registration year) is to afford the graduate balanced clinical experience with increasing responsibility for the care of patients. The experience should be acquired under the supervision of consult- ants and other senior medical staff who accept the educational nature of the posts held by the graduate’.

The conference

The educational purposes of pre-registration training were reviewed at a conference convened by the Association for the Study of Medical Education on 6 June 1983. Discussion was based on prepared papers (available from the Association as an occasional booklet) and there were two presentations on the training provided by the British army for its officers and by British Airways for its pilots. These differed from the training arrangements in medicine by the precision with which training objectives were defined and the rigour with which criteria were applied.

Discussion centred on whether a more precise definition of training objectives in medicine would restrict individual enterprise. It was generally agreed that reliance on the ‘good sense’ of medical graduates to find their own way through the many tasks of the pre-registration house officer and to set their own standards for good clinical practice was inappropri- ate. Supervision depended too much on the goodwill of senior colleagues who, busy with their own clinical tasks, needed a much clearer definition of their educational responsibilities to the young graduates. The main problem was not so much lack of knowledge as its uncertain application; as the house officers assumed increasing responsibility for patients there was a need to assess the quality of the house officers’ decisions rather than their ability to perform technical tasks. It was thought that most house officers did reasonably well, but there was no means of providing remedial teaching for those who did less well-indeed there was not even any satisfactory system for identifying them.

The duration of pre-registration training was discussed; one year had been selected on arbitrary grounds, and made no allowance for individual rates of learning. A longer period would give universities an opportunity to extend their control over the formative years of the young clinician, but this extension would inevitably entail additional re-

sources which would be justified only if better methods of educational supervision could be intro- duced. Too little was known about the educational processes of apprenticeship training. Clinical re- search understandably had first call on most doctors’ interests. But this should not be an excuse for ignoring the need for research into education. Much more needed to be known about the nature of medical apprenticeship, and it was hoped that the conference would act as a catalyst here.

Commentary

Despite the obvious differences between the practice of medicine on the one hand, and flying a plane or commanding troops on the other, there are invalu- able comparisons to be made between medical training and the systems adopted by British Airways and the army; continuity and clearly stated objectives are prominent features of both. The fear in medicine that the definition of precise objectives would be unduly restrictive on the individual enterprise of a doctor (of whose work practical skills are only part) gives insufficient credit to the army’s claim that the training of officers is individualized. Each officer in training is closely observed, and his attainment is subject to constructive criticism. This is applied at every level of authority, and the tactical, technical and leadership aspects of each individual’s responsi- bilities are studied in peer review. Learning is regarded as the process of discovering how errors or poor results could have been avoided and how better outcomes could be achieved.

The nature of doctors’ responsibility was at the root of the conference’s resistance to close compari- son with other types of training. It was pointed out that what doctors’ should do in a particular set of circumstances could not always be taught; it was essential that they discovered how to learn for themselves and the importance of adopting a critical approach to their own work. The cause of poor individual practice was not lack of knowledge but its inappropriate application in the decisions being taken. Yet pre-registration house officers frequently complain that the knowledge they acquired in the undergraduate course is difficult to apply in the ‘real world’ of the hospital ward. They are not always sure to whom they should turn for help, and their work is not subject to formal assessment. Evidence from the MRCP and FRCS examiners suggests that remedial teaching of the basic medical skills of history-taking

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and clinical examination is needed by some house- men. There is no real appreciation of individual variations in the acquisition of basic skills, and the wide variety of training and supervision provided makes it all the more difficult to discover how these skills are acquired. Simple repetition of tasks is not enough; indeed it can reinforce, as well as remedy, poor performance.

The army and British Airways both use simulation exercises extensively. This is not simply because of lack of opportunity for field experience but because they have confidence in this form of training, in which they invest heavily. The techniques used are sophisticated and provide the means of assessing decision-taking abilities as well as manual skills. It was interesting to learn that the recent Falklands war showed how quickly soldiers, well prepared by simulation exercises, responded and adapted to battle conditions. In medicine the assumption that the ready availability of in vivo teaching obviates the need for in vitro learning should be challenged; general practice has shown the value of patient management problems and of video recording in teaching the many facets of the consultation process without breaching the confidentiality of the consult- ing room. The weakness of the ward round as a teaching method is the natural temptation to put the clinical care of patients before the learning needs of the trainees, and although the trainees may learn a great deal as members of the clinical team their attainment needs to be validated. The merit of simulation is that objectives can be clearly stated and their attainment measured. It may well be that only a small minority of house officers fail to reach a reasonable basic level of clinical skill and to demon- strate acceptable qualities of decision-taking, but those few need to be identified and helped the fault may not be theirs. The army is as critical of the training it provides as of those who receive it, and there is no reason why medicine should be more complacent about the training it offers.

The training file kept throughout the career of army officers and pilots is not exclusive to these services, and indeed is usual in many professions. There is of course a natural fear of the misuse of personal files held by a monopolistic employer such as the National Health Service; health authorities inevitably accumulate information about their em- ployees, and although it is generally regarded as confidential, the right of access to it is not always clearly defined. A detailed record of individuals’

training experiences, attainments and difficulties could be invaluable both to them and to their educational advisers. The information should be revealed in full to the people concerned, and this could be done by putting the file in their charge. The record should be made available not only to potential employing authorities but also to postgraduate deans and specialty advisers, from whom doctors in train- ing seek educational guidance. Admittedly, senior doctors may feel uneasy about their views on junior colleagues being openly recorded; it is nevertheless important to exclude personal bias from an objective assessment of the attainments of educational goals.

The designation of tutors or teachers in postgradu- ate medical education is commonly opposed on the grounds that all consultants have teaching responsi- bilities in respect of their junior staff. This does not apply in general practice, where less than 10% of principals have training responsibilities. Trainers in general practice are not only specifically remunerated for their teaching responsibilities but are selected on specific criteria and are required to attend teachers’ courses regularly. All consultants have teaching opportunities (some for undergraduate as well as for postgraduate students) but there are few courses for them to attend. Their teaching styles are thus very variable, and it is curious that little attempt has been made to establish good practice and provide clear guidelines for newly appointed consultants. In the face of initial resistance the merit of providing management courses for young consultants has now become we11 established; it is surely time that basic teaching skills are given similar priority, despite the natural wish of consultants to devote their prime learning time to clinical medicine.

The lessons from training schemes outside medi- cine are several:

(1) ‘serial’ education, with the clear definition of objectives at each stage, is worthy of closer scrutiny, particularly with the assurance that objectives can be stated in terms which go beyond the mastery of practical skills and include intellectual qualities appropriate to a self-regulating profession;

(2) some consultants will be better natural teach- ers than others, but if they are all expected to teach, basic skills should not be left to chance;

(3) the extensive use elsewhere of simulation exercises, with their advantage of built-in assessment, warrants their wider application in medical training;

(4) the assumption that ‘doctors learn best by doing’, so that in effect they learn mainly in the

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course of paid employment, has obscured the fact that there is a very small financial investment in postgraduate medical education, particularly when compared with the expense of training in other professions; and

( 5 ) continuity of training needs more than lip service: a written record ensures that objectives are expressed in real terms, and that shortfalls in attainment are not left to the uncertainties of memory.

References PARRY, K.M. (1982) Continuity in medical education. Medical

Education, 16, 367.

Professor Phillip Rhodes, who was responsible for organizing this excellent conference, has prepared an Occasional Publication describing the proceedings which has been published by ASME.

CHRISTIE, R.A.S. (1980) The pre-registration house appointment. A survey in Manchester. Medical Education, 14, 2 10.

GENERAL MEDICAL COUNCIL (1967) Recommendations as to Basic Medical Education. General Medical Council, London. Pp. 20-21.

GENERAL MEDICAL COUNCIL (1972) Conference on the Pre-Registra- tion Year. General Medical Council, London.

GENERAL MEDICAL COUNCIL (1973) Code of Good Proctice in Relation to the Pre-Registration Year. General Medical Council, London.

GENERAL MEDICAL COUNCIL (1978) Conference on the Pre-Registra- lion Year. General Medical Council, London.

GENERAL MEDICAL COUNCIL (1980) Recommendations on Basic Medical Education. General Medical Council, London.

GENERAL MEDICAI. COUNCIL (1982) Minutes for the year 1981 [V.CXVlll/ t..dircatron Committee, 4th November 1983, General Medical Council, London. Paragraph 7, pp. 108-9.