Senior house officer training: time for reform

The difficult issue of senior house officer (SHO) education and training in the UK was the theme of a recent ASME meeting. In the UK, each stage of postgraduate medical training is managed by a variety of professional, managerial and educational bodies, making it more difficult to improve clinical education. Issues relating to the pre-registration house officer (PRHO) year are being addressed,1,2 and a new specialist registrar grade (SpR) has been introduced to higher specialist training.3 Between the PRHO year and higher specialist training is the senior house officer grade (SHO) (Fig. 1). Outline of postgraduate training in the UK. Problems relating to SHO training, including, for example, poor supervision, unstructured education, inadequate careers advice, minimal assessment, poor working conditions and difficulty obtaining study leave, have been documented over several years.4,5,6 The Academy of Medical Royal Colleges recommended improvements to the SHO grade7 and the General Medical Council emphasized the need for structured training and supervision.8 Postgraduate deans and trust managers are seeking ways of balancing effective education with service needs. Recent studies show that improvements are being made9,10 although training quality across the UK is patchy and variable. A recent study of UK medical graduates found that almost two thirds of SHOs had discussed their progress with consultants and a quarter rated supervision as ‘excellent’. Disturbingly, almost half of SHOs did not have protected teaching time and almost one sixth were unable to take study leave. Enthusiastic individual consultants rather than trust polices appeared to be responsible for improvements in training.11 Despite a reduction in hours, SHOs are working more often ‘out of hours’ when they are less likely to be supervised.12 Radical reform is difficult to achieve while SHOs are perceived as the ‘workhorse’ grade and they continue to be front-line providers of care. The introduction of the European Working Time Directive for doctors in training in the near future will exacerbate even further the problem of balancing service with high quality educational provision.13 All SHOs should move through defined educational programmes (as opposed to posts created solely to meet service demands) that recognize trainees’ different aspirations, expectations and career needs, and incorporate effective educational approaches as well as meeting service requirements. This is especially relevant for overseas doctors who form a significant proportion of the NHS medical workforce. These doctors are generally satisfied with their training, but non-white doctors are less optimistic about their future career prospects.14 SHOs may benefit from a period of broad generic training of 2–4 years, including a ‘core’ year, to gain broad experience of up to eight specialties, including acute and critical work, and accident and emergency. Whether trainees are in ‘core’ programmes, general professional training, general practice training, in higher specialist training, or on personally constructed programmes, several principles should apply. Standards of clinical performance should be set and performance regularly monitored and appraised. Movement between specialties should be flexible enough to accommodate changes in circumstance, particularly for those who wish to harmonize work and home commitments. Expert and relevant career advice must be available to enable SHOs to make informed career decisions and to identify appropriate career paths. Training programmes must be time-capped, credited and exited only when satisfactory progress has been made. Trainees that fall into none of the above groups for a variety of reasons should be carefully monitored, assessed and helped to find an appropriate career path. No doctor should be left for an indefinite period functioning solely as a service provider. Implementing such a complex model would be extremely difficult to organize and manage. Career SHOs, in surgery for example, may be reluctant to spend extra time in general professional training which may delay their acquisition of specialist skills or may extend the number of years spent gaining their specialist qualification (CCST). Despite demands for flexible and part-time working, opportunities are scant and difficult to arrange. Some doctors have experienced negative attitudes and feel they may be considered less committed to their career or chosen specialty. SHOs believe that the part-time option damages their future career prospects.15 General practice training is an independent issue. Should it be regarded as a specialty or basic professional training? Resolving this question will have an important bearing on the construction of postgraduate training. There is a view that all trainees would benefit from a period in general practice. It provides unique opportunities for learning, including, for example, access to autonomous patients, one-to-one supervision, experience of illness in domestic and community contexts, development of desirable personal and social attitudes and consulting skills. In addition, general practice trainers are selected, trained and accredited, and paid. PRHOs are not averse to a period of general practice training or even extending the PRHO year to two years. Certainly, the reduction in working hours has reduced their exposure to common acute medical and surgical conditions15 and SHOs’ clinical experience may have been similarly reduced. What of clinical competence? How can we be sure that doctors have been adequately prepared and assessed at each stage of their training to ensure fitness for practice? The use of both formative and summative assessments in addition to Royal College examinations would ensure that all aspects of training are assessed. In addition, appraisal portfolios or records of in-service training and assessment that incorporate, for example, topics included in Good Medical Practice,16 could be used as documentary evidence of clinical experience. This idea is not entirely new and it does raise serious questions about ownership, confidentiality and purpose.17 No less important or less possible is the exciting idea that collaborative partnerships between Royal Colleges and postgraduate deans in different geographical areas could introduce a ‘cross-fertilization’ of ideas through joint training programmes, multidisciplinary sessions and perhaps, multidisciplinary assessment. But many cultural and practical difficulties would have to be overcome to achieve these goals. When decisions are made relating to the structure, length, content, explicit clinical standards, educational systems and assessment of SHO training, a uniform, united approach, agreed and managed between Royal Colleges and postgraduate deans, implemented and monitored by trusts, medical directors and clinical tutors, may be an important step towards providing more flexible training opportunities that are educationally sound. This will inevitably mean increased effort at a difficult time when there is a shortage of resources. The promise of more doctors and nurses in the NHS Plan will be a long time coming.18 SHOs are the general practitioners and specialists of the future and deserve the very best possible training that meets both their individual aspirations and personal needs, and equips and motivates them to provide the very best care for their patients.

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