The pre-registration house officer (PRHO) year is a crucial bridge between undergraduate training and working as a senior house officer (SHO). At its best, it provides the context within which the new graduate can further develop the clinical skills acquired as a student, and work towards an increasing degree of independent practice and decision making. At the end of the year, he/she should have the necessary competences and confidence to work as an SHO. The General Medical Council (GMC) describes very specifically the characteristics of PRHO posts, and charges the relevant local Postgraduate Dean both to commission and to regularly evaluate PRHO posts. In addition, the GMC defines the PRHO experience that a graduate must satisfactorily complete in order to be eligible, on the recommendation of their medical school, for entry into the GMC register as a fully-registered practitioner. This includes at least 3 months' acute general medicine and 3 months' acute general surgery. Traditionally, most PRHO posts have comprised 6 months' training in medicine and 6 months' surgery. However, GMC regulations allow considerably more latitude than this arrangement suggests and in Sheffield, PRHO posts that include psychiatry have existed for many years (Reference O'DWyerO'Dwyer, 1999). Recently, the London Deanery has commissioned over 30 1-year PRHO rotations that include 4 months' medicine, 4 months' surgery and 4 months in another speciality. The specialities have included critical care/general intensive care units, anaesthetics, women's health, general practice, child health and psychiatry. The criteria used to identify specialities suitable for PRHO training were: (1) that these should be in the same hospital or community as the medical and surgical posts; (2) there was a consultant keen and able to take on the role of a PRHO trainer/supervisor, that his/her team had a good reputation for training, and that his/her team were willing to include a PRHO and understood the need for supervision; (3) that the clinical experience came within GMC guidelines and (4) that the timetable of the PRHO reflected the likely competence of a PRHO and had an element of latitude that took into account variation in acquisition of skills and competencies, included a range of learning opportunities and that the post holder should not simply be required to do tedious administrative work that others do not want to do.

Four consultants in three north London community/mental health trusts were identified as keen to take on a PRHO and in August 1999, three rotations were set up. For these psychiatry posts, F.M. and J.H. drafted proposed educational skills based on requirements outlined in The New Doctor (GMC, 1997) and modified these after discussion with the consultant trainers (Box 1). Two of the posts were based in mental health units and one was based with a liaison psychiatrist in a general hospital. The first of the mental health unit posts offers a two-thirds in-patient/one-third community split. The second mental health unit post offers a two-thirds community/one-third in-patient split. The liaison post offers one-third emergency referral work and two-thirds attendance at specialist clinics. All three posts allow for attendance at the unit academic programme and all offer individual educational supervision by the consultant trainer. This paper reports an initial evaluation of these posts and in particular whether trainees feel more confident in the target skills set, outlined in Box 1.

Box 1. London Deanery target skills for PRHOs in psychiatry

1. To take and analyse a full psychiatric history 2. To carry out detailed mental state examinations 3. To develop competence in basic assessment of cognitive functioning 4. To apply knowledge of the relevant psychological factors on the genesis of psychiatric illness 5. To learn the principles of risk assessment, in particular relation to suicide, violence to others and self neglect 6. To apply relevant physical investigations to the assessment of psychological illness 7. To formulate care plans with other members of the multi professional team which encompass medical, psychological and social aspects of treatment 8. To manage psychological illness in people who are physically ill 9. To monitor progress of people with psychological illness through presentation at an acute hospital through to care in the primary and community settings 10. To become experienced in liasing and working with relevant community agencies 11. To be inintroduced to benefits and use of psychotherapies such as supportive psychotherapy and cognitive—behavioural interventions 12. To become conversant with the applicability and the use of the Mental Health Act 1983 13. To gain insight into the doctor—patient relationship and the effect of that relationship on the practitioner. To learn to self-reflect in relation to caring for patients

Method

We drew up a questionnaire to find out how confident trainees were in the skills outlined in Box 1. Each was asked to rate their confidence on a five-point scale. The stems were ‘I feel confident about’ or ‘I feel anxious about’ and each related to the educational skills outlined in Box 1. The five possible responses for each item were; strongly disagree (0), mildly disagree (1), no opinion (2), mildly agree (3) and strongly agree (4). The questionnaires were sent by post to nine trainees within the first month of their placements and within 2 months following the end of their placements.

Results

Discussion

The PRHO posts in psychiatry seem largely to meet their targets, in that there is a clear improvement in trainees' self-rating of relevant skills, and the posts seem to be rated highly by trainees who have undertaken them. Our initial impression is that these placements are successful in equipping PRHOs with improved psychiatric skills. While these skills are clearly important for psychiatrists, they also have clear relevance to work in other settings, such as hospital medicine or general practice. It has been found that medical students experience particular stress and Firth (Reference Firth1986) highlighted the stress that they experience in talking to psychiatric patients. These placements clearly increase confidence in all aspects of psychiatric clerking.

The findings also suggest that newly-qualified doctors who opt to undertake a PRHO post in psychiatry tend to do so because they are considering a career either in general practice or psychiatry. The experience tends to confirm these career expectations. J.H. subsequently interviewed two psychiatry PRHOs (but not those surveyed in this study) who had applied for psychiatry posts, with a clear preference for a surgical career, on the basis that this would be their only opportunity to gain experience in mental health skills. However, it seems that most trainees who undertake these placements are at least considering a community-based speciality. Psychiatry is one of many innovative hospital and community options now available to trainees as part of their PRHO experience and it is hoped that these initial promising findings will encourage other colleagues to set up house officer posts of this kind.