Effect of the undergraduate curriculum on the preparedness of pre‐registration house officers

In 1993, the UK General Medical Council (GMC) document Tomorrow's Doctors1 made wide ranging recommendations about basic medical education in the UK. It specified that the purpose of undergraduate or basic medical education is to ensure that ‘the newly qualified doctor is well prepared for the responsibilities of the pre-registration house officer year’1 and has ‘attitudes to learning that inspire the continuation of the educational process throughout professional life.’1 Medical schools in the UK responded by revising their curricula to varying degrees. Three schools – Glasgow, Liverpool and Manchester – adopted problem-based learning (PBL) curricula. Manchester was the first to start its new PBL curriculum and has since been courageous and prolific in publishing outcomes of the curriculum under the leadership of Paul A O'Neill. This edition of Medical Education includes a further paper in the series by O'Neill and colleagues.2 In it, they compare the experiences of pre-registration house officers (PRHOs) from Manchester's previous traditional curriculum with those of PRHOs from its new curriculum, using qualitative methods to analyse the PRHOs' reports of critical incidents. They found that PRHOs trained by the traditional curriculum experienced more difficulty in weighing up options when dealing with patients with complex medical problems, whereas those trained by the new curriculum seemed more comfortable with consulting senior doctors on decisions about patient management and had more realistic expectations of their own abilities. New curriculum PRHOs were also very clear about asking for, or demanding, help when it was needed, in contrast to those from the traditional curriculum, who often highlighted the difficulties they experienced in obtaining help. The authors speculate that these differences may be understood as an effect of the changing curricula. As a result of the format of PBL used in Manchester in Years 1−4 of the new curriculum, they believe that students become more aware of their personal limits and better at dealing with uncertainty. This extends into Year 5, when students bring their own challenging cases or incidents to the group for discussion. They argue that the differences between the 2 cohorts may be conceptualised as differences in their ability to deal with uncertainty, either in relation to knowing how to manage patients or to knowing when they need support or assistance. A further innovation that coincided with the introduction of the new curriculum in Manchester is a period of PRHO shadowing. The GMC recommends that students should have opportunities to shadow a PRHO in the post that they will take up when they graduate.3 It further recommends that such attachments should normally last at least 1 week and that they should take place as close to the point of employment as possible. In Manchester, students undertake an 8-week period of shadowing at the end of the course. Despite this substantial attachment period, O'Neill and colleagues found that PRHOs in both cohorts highlighted their emotional involvement with patients as being a critical factor in their experience and several suggested that they had felt unprepared for the emotional aspects of caring for patients. The findings suggest that newly qualified doctors still experience emotional distress and that this experience needs to be acknowledged and supported. The PRHOs in this study also reported feeling unprepared for the complex communication issues they were confronted with.2 The new Manchester curriculum includes a communication strand that runs throughout the course.4 Problem-based learning cases are designed to give students a context for communication in health care; from Year 3 onwards the emphasis is on small groups and feedback, utilising videotaped consultations with simulated patients and role plays. This kind of communication skills learning is found in many other UK medical schools and it would be a cause for concern if these courses were not adequately preparing our students for their PRHO responsibilities. Further research is required to answer a number of questions raised by this study. What is the optimum duration of the period of PRHO shadowing and what should it comprise to make the most of the learning experience? Should students have opportunities for discussing their experiences during the period of shadowing? How can we ensure that our communication skills courses are effectively preparing our students for the difficult communication issues they will face as PRHOs? How can we prepare our students for the emotional aspects of caring for patients? Faculty members at Manchester have been courageous in sharing their outcome evaluations with a wider audience, but we need to determine how the findings from the Manchester curriculum compare with outcomes from other curricula in the UK. Is there something about PBL methods that produces PRHOs who are better prepared for some aspects of the job or are other aspects of the revised curricula − not unique to PBL − important? The implementation of this type of research requires a bold experiment in vertical collaboration between university schools of medicine and postgraduate deaneries, as well as horizontal collaboration between medical schools across the UK, so that the outcomes from different curricula can be described.