Improving senior house of®cer experience

Considerable attention has been given to reorganizing

higher specialist training1 and more recently to im-

proving the pre-registration year.2,3 We now need to

focus our attention on senior house of®cers (SHOs) so

that those completing an improved pre-registration

training do not become disillusioned, and those pre-

paring for higher training in specialist medicine or

general practice are prepared for their career. The

General Medical Council publication The Early Years 4

gives a clear direction. It highlights the importance of

ensuring that doctors working in SHO posts have ap-

propriate training and support if they are to provide

high quality patient care and learn to be effective

practitioners.

Cooke and Hurlock5 have identi®ed that improve-

ments in SHO training are occurring, but they also note

that the experience varies from excellent to poor. Their

work suggests that where training is good, it is often the

result of individual enthusiastic consultants, rather than

a coherent policy across a Trust or deanery. They have

also identi®ed that some specialities, notably general

practice, psychiatry and paediatrics achieve greater

uniformity in high quality training. Although it is en-

couraging that most SHOs had an identi®ed educa-

tional supervisor, it is disappointing that the process is

not yet suf®ciently robust to ensure regular protected

teaching time and effective workplace learning.

The GMC has made it clear that medical royal col-

leges and postgraduate deans need to work together to

set and monitor standards for SHO posts. One of the

dif®culties that both the colleges and the postgraduate

deans face is that SHOs are not a uniform group. Some

individuals in SHO posts are clearly in basic specialist

training, others are clearly in general practice vocational

training and a third group seem undecided about their

future career. Since the introduction of the single

higher training grade there is now a fourth group of

SHOs ± those who are waiting to enter higher training.

This last group frequently works as part of the middle

grade rota and has very different learning needs from

the other groups. Thus, standards for training posts

need to ensure that there is clarity about the process of

learning, the potential clinical experience of the post

and the level of supervision provided.

Recent NHS policy6 has identi®ed the importance of

life long learning for all health care professionals. The

Review of Continuing Professional Development in

General Practice7 identi®ed a model that could equally

well be applied to SHOs as to the primary health care

team. Paice8 has already identi®ed that one of the key

factors that leads to satisfaction in trainees is effective

educational supervision. Without too much additional

work it should be possible for each trainee to meet their

educational supervisor during their ®rst week, prefera-

bly on the ®rst day, to share what the post will entail;

what learning opportunities it offers and what the

trainee needs to gain from their time in the post to meet

college requirements and their own aspirations. This

meeting should also allow the trainer to make an early

assessment of the trainee's previous experience and

make a judgement about the trainee's con®dence and

competence. This in turn should allow the trainer to

decide what support and senior cover will be necessary

during the early part of the post. It is also a time in

which opportunities for formal training and study leave

might be explored so that appropriate arrangements

can be made. Many specialities are beginning to use

educational agreements, so that there is clarity about

what educational opportunities are available and what

is expected of the trainee in terms of attendance and

preparation.

Effective training posts have four key elements, reg-

ular appraisal with an identi®ed educational supervisor,

workplace learning in which the trainee is guided

through new ways of handling clinical or organizational

problems, formal education and study leave. Achieving

the four elements satisfactorily may be inhibited by lack

of skills in educational supervision and a culture within

the Trust or directorate that does not value the im-

portance of professional development. There will al-

ways be a tension between service and education. Some

specialties have managed to overcome the problem by

engaging staff grades or clinical assistants to cover the

service during protected teaching time. Other Trusts

have managed to change the culture so that the post-

take round is recognized by medical and other health

care professions as an important time for re¯ection and

learning. Traditionally medical education has been

through an apprenticeship model. Formal education

Correspondence: Professor Jacky Hayden, Dean of Postgraduate Med-

ical Studies, Department of Postgraduate Medicine and Dentistry,

The University of Manchester, Gateway House, Piccadilly, Man-

chester M60 7LP, UK

Commentary

402 Ó Blackwell Science Ltd MEDICAL EDUCATION 1999;33:402±403

sessions will never replace the important learning that

occurs around the bedside, in theatre and in outpa-

tients. However, changing work patterns of trainees

have limited the opportunities for apprenticeship

training and consultants may need to learn new ways of

imparting their experience and expertise effectively.

Medical directors, clinical tutors and college tutors may

need to consider how they will ensure that trainees work

with consultants who uphold the values of Good Medical

Practice9 so that the traineesobserveeffective rolemodels.

SHO posts are getting better, but there is still con-

siderable room for improvement. Colleges need to set

explicit standards for the key elements of training posts,

including the preparation that consultants will need

before they can take lead responsibility for doctors in

training. Trusts, particularly medical directors and

clinical tutors, need to develop effective monitoring

systems to ensure that education is being delivered to

the explicit standard. Postgraduate deans and colleges

need to work together to ensure that there are effective

external monitoring systems of Trusts. These moni-

toring systems need to collate and evaluate all the in-

formation that is currently held by the colleges and the

postgraduate dean so that fair judgements can be made.

Where under-performance is detected in a Trust, clear

goals need to be set and agreed by all parties. Senior

house of®cers are our future consultants and general

practitioners and they deserve the best possible expe-

rience in their early years.

Jacky Hayden

Manchester

References

1 Department of Health. Hospital Doctors: Training for the Future.

The Report of the Working Group on Specialist Medical Training.

Health Publications Unit; 1993.

2 General Medical Council. The New Doctor. London: GMC;

1997.

3 General Medical Council. The New Doctor ± Supplement on

general clinical training in general practice. London: GMC; 1998.

4 General Medical Council. The Early Years. London: GMC;

1998.

5 Cooke L, Hurlock S. Education and training in the senior house

of®cer grade: results from a cohort study of United Kingdom

graduates. Med Educ 1999;33:418±423.

6 Department of Health. A First Class Service: Quality in the New

NHS. London: Department of Health; 1998.

7 Calman K. A Review of Continuing Professional Development in

General Practice. London: Department of Health; 1998.

8 Paice E. Is the New Deal compatible with good training? A

survey of senior house of®cers. Hospital Med 1998;59(1):72±4.

9 General Medical Council. Good Medical Practice. London:

GMC; 1998.

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Improving SHO experience · J Hayden 403