Bridging a training gap: Senior House Officers in ...

Community Medicine © Oxford University Press 1986

Vol. 8, No. 4, pp. 292-294 Printed in Great Britain

Bridging a training gap: Senior House Officers in community medicine in Leicestershire L. J . Donaldson and Michael Clarke

Introduction Although the backgrounds of recruits to training schemes in community medicine are varied, the switch to the specialty is usually accomplished after the trainee has already undertaken posts in hospital or general practice and then decided upon a change of career. If a candidate has a clear intention to train for the specialty at the outset, there is at present little scope for entry to a training scheme directly after the pre-registration year. It is, of course, possible for such a person to choose relevant clinical jobs and then after a period of, say, two years apply for a registrar post in community medicine or one of the MSc courses. This demands a detailed understanding of the system. Moreover, in an era when many training schemes for other specialties as well as for vocational training in general practice are increasingly becoming 'packaged' to allow early career choices to be made, it is easy to see potential recruits to community medicine being lost, at a time when there is a crisis in manpower in the specialty. In Leicestershire, where our undergraduate medical curriculum1 contains such a strong commitment to epidemiology and other disciplines basic to community medicine, we now have regular enquiries from students in their final or pre-registration year about career opportunities in the specialty of community medicine. To meet the needs of this group, we have developed a Senior House Officer (SHO) rotation in collaboration with clinical consultant colleagues and the Regional Postgraduate Adviser in General Practice which provides both relevant post-registration clinical experience and an early introduction to community medicine. We describe the scheme here.

Establishing the scheme In setting up the scheme our main aims were to provide the postholders with: (i) basic post-registration clinical experience; (ii) an introduction to, and early experience of, the range of work undertaken in a health service and in an academic department of community medicine; (iii) an opportunity to carry out project work and investigations Leicestershire Health Authority L. J. DONALDSON, Chairman, Division of Community Medicine Leicester University Medical School MICHAEL CLARKE, Professor of Epidemiology Address correspondence to: Professor Michael Clarke, Department of Community Health, University of Leicester School of Medicine, Clinical Sciences Building, Leicester Royal Infirmary, P.O. Box 65, Leicester LE2 7LX.

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within the clinical services to which they were attached; (iv) an introduction to general practice and the option to take the full trainee year if they so wished. Since all the initial enquiries from graduates were made to the academic department, we undertook much of the initial groundwork to establish the posts. This seemed particularly appropriate. Firstly, one of us (L.J.D.) had held successively, the offices of honorary secretary and chairman of the Division of Community Medicine, a 'cogwheel' committee with full status in that it has a seat on the District Hospitals Medical Staff Committee. Secondly, we already had close working links with groups of clinicians which had been established through undertaking applied research and investigation of clinical services (see for example refs. 2-6). We therefore felt we had the necessary contacts and influence with clinical colleagues to be able to represent the potential attractions of collaborating in a scheme of this sort. The posts are funded from the community medicine budget so that they are supernumerary to the clinical speciality concerned. At the outset there was a need to gain recognition from three main bodies: the Faculty of Community Medicine, the Royal College of General Practitioners and the Royal College associated with the clinical post.

The nature of the rotation During the six months of community medicine, the SHO spends part of the time attached to the NHS department and part within the academic department. Given the limited time available it would clearly not be feasible or desirable to rotate the SHO around all consultant members of the department as might be done, for example, in a registrar training programme. Instead, tasks are allocated to a pool from the workloads of the consultant members of the Division and SHOs undertake them under the consultant's supervision and also, on a day-to-day level, under the supervision of a senior registrar in a manner analogous to the work of a clinical service. Their programme during this part of the rotation also includes attendance at a range of NHS committees to give them an insight into this sphere and participation, as assistant group leaders, in the undergraduate teaching programme. With our own graduates, this has proved particularly rewarding since they have been consumers of the programme themselves as undergraduates. The six months of community medicine also includes regular attendance at Community Child Health Clinics to maintain the component of direct patient contact. This is important as it preserves a clinical element to the post which is both desirable and necessary for accreditation purposes. The arrangement of the other three jobs in the rotation has varied considerably since we started the scheme. At the outset we tried to allow the SHOs to choose a job which reflected their particular interests. Thus, individuals have undertaken jobs in paediatrics, general medicine, obstetrics and gynaecology, psychiatry, infectious diseases and accident and emergency. This arrangement proved difficult, mainly because it meant that some consultants who had given enthusiastic support initially to the scheme did not necessarily have an SHO continuously in post, and indeed long gaps between incumbents occurred in some specialties. There was an additional disadvantage from not having the posts continually filled in that investigations undertaken by an SHO whilst in a particularly clinical firm could not be continued by another if not finished within the space of six months. Most importantly, the posts which seemed most appropriate were those where there was a natural 'community' perspective to complement the clinical service. Our present arrangement, a fixed rotation with four six-month jobs, with four SHOs permanently in post is as follows: (a) community medicine; (b) infectious diseases; (c) obstetrics and gynaecology; (d) general medicine (with an interest in diabetes mellitus).


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Table 1 . Some of the tasks undertaken by Senior House Officers in community medicine Establishment of a mass cardiopulmonary resuscitation training scheme Production of a video-tape to assist in smoking cessation groups Design of a diabetic case register, including a national review of such schemes Assessment of the psychiatric in-patient populations in the light of the discussions about closure of the large psychiatric hospitals Estimates of prevalence of insulin-using diabetes using U100 notifications An investigation of the reasons for list cancellations and curtailments in operating theatres A study of the validity of estimates of the prevalence of dementia in a local population A survey of the prevalence of eating disorders in the general population An investigation of hepatitis vaccine efficacy

During the clinical post, the SHO participates fully in the work of the firm concerned, including 'on-calF responsibilities but there is an agreed period of time each week allotted to community medicine work and also time set aside to allow an introduction to general practice. Arrangements are made by the Postgraduate Adviser in General Practice for the SHOs to participate in tutorials run by the Vocational Training Scheme, to be attached to a local training practice and to undertake a trainee year at the end of the rotation if they wish to take up this option. Some examples of the tasks undertaken by SHOs to date are shown in Table 1. Conclusions One of the keys to the success of any training scheme is good recruitment and careful selection of entrants. We decided at the outset, however, that it would not be fair to design the scheme in such a way that the trainees had to make a clear and irrevocable decision to pursue a career in community medicine. This would have happened effectively if we had not ensured clinical jobs of an adequate standard to provide basic post-registration experience. Instead, we were prepared to accept that many people on leaving the scheme would enter general practice as is the case with most SHO grade posts. This does have a 'pay off' in increasing the number of general practitioners in possession of some of the skills of the speciality of community medicine and with strong links with the local department of community medicine. It does mean, however, that people should be recruited who are giving very serious consideration to a career in community medicine. It is too early to say what proportion of Leicestershire SHOs will go on to take up a career in community medicine but one, out of our first two graduates of the two-year scheme, is now a registrar in community medicine locally. REFERENCES 1. Clarke M, Clayton DG, Donaldson LJ. Teaching epidemiology to medical undergraduates: the Leicester experience. Int J Epidemiol 1980; 9: 179-185. 2. Clarke M. Perinatal audit: a tried and tested epidemiological method. Community Med 1982; 4: 104-107. 3. Clarke M, McGrother CW. Evaluation of health services. Lancet 1983; 2: 515. 4. Levene LS, Donaldson LJ, Brandon S. How likely is it that a district health authority can close its large mental hospitals? Br J Psychiatry 1985; 147: 150-155. 5. Donaldson LJ, Clarke M, Palmer RL. Institutional care for the elderly: the impact and implications of the ageing population. Health Trends 1983; 3: 15: 58-61. 6. Donaldson LJ, Maratos JI, Richardson RA. Review of an orthopaedic in-patient waiting list. Health Trends 1984; 16: 14-15.
