Association of use of a log book and experience as a preregistration house officer: interview survey
BMJ 1997; 314 doi: https://doi.org/10.1136/bmj.314.7075.213 (Published 18 January 1997) Cite this as: BMJ 1997;314:213
- Elisabeth Paice, dean directora,
- Fiona Moss, associate deana,
- Georgina West, assistant to the dean directora,
- Janet Grant, professor of educationb
- a North Thames Department of Postgraduate Medical and Dental Education London WC1N 3EJ
- b Joint Centre for Education in Medicine London WC1N 3EJ
- Correspondence to: Dr Paice
- Accepted 21 November 1996
Abstract
Objective: To determine whether use of a log book improved the experiences of preregistration house officers.
Design: Confidential questionnaire and interview survey of preregistration house officers carried out as part of University of London inspection process.
Measures: Preregistration house officers were asked to rate educational and pastoral elements of their posts and about the use made of previously distributed log books.
Subjects and setting: Preregistration house officers in North Thames.
Results: The incumbents of 535 of 560 (95%) preregistration house officer posts in the region were surveyed between June 1994 and July 1995, 490 by questionnaire and interview, 45 by questionnaire alone. House officers who had discussed the log book with their consultant expressed more satisfaction with their induction, consultant supervision and feedback, and formal and informal education and were more likely to recommend their job to a friend.
Conclusion: Preregistration house officers who had discussed the log book with their consultant expressed more satisfaction with the educational elements of their jobs. The structured discussion with their consultant about the job and their performance seemed to make the difference.
Introduction
Preregistration house officers have expressed dissatisfaction with the level of supervision, teaching, and feedback they receive from their consultant supervisors, and widespread anxieties exist about the educational value of this year.1 2 3 A survey of Yorkshire consultants revealed that few assessed the effectiveness of their teaching, and feedback offered to house officers was rudimentary.4 Dowling and Barrett found an absence of educational planning, supervision, and coordination.5 They found consultants unaware of the General Medical Council's recommendations about the responsibilities of educational supervisors6 and reluctant to appraise their house officers. Much has been written about the problems but much less about those factors that improve the experience.7 One attempt to improve the experience has been the introduction of log books in the Thames regions. We set out to determine whether use of the log books was associated with preregistration house officers' satisfaction with their posts.
Methods
The log books
In an attempt to provide an educational framework for the preregistration house officer year, a log book was developed by the postgraduate dean of South East Thames, together with the Open University and the Joint Centre for Education in Medicine.8 The aim was to encourage an effective dialogue between consultant and house officer for setting objectives and assessing progress. The log book was small enough to fit in a white coat pocket and contained checklists for self assessment of practical procedures performed, emergencies managed, and educational topics covered. It also contained advice for the consultant about how to set objectives at the beginning of the post and offer structured feedback at intervals thereafter.9
After a trial in South East Thames the log book was introduced in all the Thames regions in 1991. Copies for all preregistration house officers and their educational supervisors were sent to postgraduate centres. Clinical tutors were asked to explain and promote its use among consultant supervisors. Reactions from both consultants and house officers were mixed, and compliance was patchy. The length and content of the checklists were criticised, as was the whole concept of performance appraisal.
None the less, the postgraduate deans continued to supply the log book and promote its use. Guidelines for inspection visits included the sentence “While the use of the log book is in no way compulsory, the postgraduate dean wishes to see regular, recorded, formal assessment of house officers by the consultant supervisor as an integral part of the training relationship.”
Evaluation
On behalf of the University of London the Thames postgraduate deans regularly inspect all hospitals with preregistration house officers. House officers are interviewed, alone or in pairs, by a team consisting of the postgraduate dean or associate, a consultant from another hospital, and an assistant. Visits are arranged to avoid the six weeks after house officers start their new jobs and the popular holiday periods. The inspection visits are taken seriously, and the turnout is good. For the purpose of this study, a questionnaire was developed from questions routinely asked at these inspections and from a similar questionnaire in use for senior house officers in North Thames.10 It covered workload, induction, supervision (consultant and middle grade), formal and informal education, feedback, catering, and accommodation. Finally, house officers were asked how they would recommend the post to a friend who was thinking of applying. For most questions a five point scale of responses was offered where 1=very poor and 5=excellent. Four yes/no questions about the log book were included asking the doctors whether they had been given a log book, whether they had used it, whether they had discussed it with their consultant, and whether they had found it useful. The questionnaires were completed shortly before the interview. Additional questionnaires were distributed to house officers unavailable on the day, for return directly to the dean's office.
The data from the questionnaires were entered on to a Microsoft Excel 5 spreadsheet and calculations were performed using the statistics package of this program.
Results and discussion
Altogether 535 of 560 (95%) preregistration house officers in North Thames were surveyed, 490 (92%) by questionnaire and interview and 45 (8%) by questionnaire alone. All hospitals received and distributed the log books, but 67 (12%) house officers from 18 hospitals said they had not received one; 186 (35%) had received one, but neither used it nor discussed it with a consultant; 105 (20%) had used the log book but had not discussed it with a consultant; and 177 (33%) had discussed it with a consultant.
House officers who did not receive a log book gave a lower rating to their induction, but otherwise house officers who received a log book but did not use or discuss it did not differ in their responses from those who never received one. Those who said they used the log book but had not discussed it with their consultant were more likely to consider the log book useful, but otherwise did not differ from those not using or not receiving it.
Log book discussers-The house officers who reported discussing the log book with their consultant (log book discussers) did not differ from the others in their rating of the workload or the quality of middle grade supervision, food, or accommodation. They did, however, give significantly higher ratings to their induction, consultant supervision and feedback, and formal and informal education, and were more likely to recommend their post (table 1). It made no difference whether they had used the log book (11% had not), or whether they considered the log book useful (34% did not). From the interviews we learnt that the log book was often filled in the night before the discussion took place.
Comparison of log book discussers (n=177) with other house officers (n=358). Values are scores* unless stated otherwise
Feedback-Offering feedback was not restricted to those consultants who used the log book: 144 (40%) house officers who had not discussed the log book none the less reported having sat down with their consultant to talk about their progress (table 2). These house officers rated their consultant supervision and informal education just as highly as the log book discussers, but the latter gave a higher rating to their induction, attended more formal education, and were more likely to recommend the post (table 3). From the interviews it appeared that consultants who discussed the log book with their house officers spent more time at the beginning of the job making it clear what was expected of them, including attendance at educational activities.
Responses to the question “Have you sat down with your consultant to discuss your progress?” Results are percentages (and numbers) making each response, with 95% confidence intervals of percentages
Comparison of log book discussers (n=177) with others who had received feedback on progress (n=144). Values are scores* unless stated otherwise
Conscientious consultants-Discussing the log book may simply have been a mark of a conscientious consultant who ensured a good educational environment. However, many consultants whose supervision was praised by their house officers had not discussed the log book. We analysed the responses of all those house officers who described their consultant supervision as good or excellent and within this group compared log book discussers with the rest. Induction and formal education were rated higher by log book discussers, and they were more likely to recommend the post (table 4).
Those who rated consultant supervision good to excellent: comparison of log book discussers (n=124) with others (n=196). Values are scores* unless stated otherwise
Conscientious house officers-House officers who were ready to discuss their log books might have been more naturally compliant than their colleagues. However, they did not differ in their rating of the workload, the catering, or the accommodation. More importantly, they did not differ in their rating of middle grade supervision, which was the single factor that correlated most strongly with recommending the post. Also it was clear from the interviews that it was more likely to be the consultant who decided whether the log book was discussed. Several house officers made remarks like this: “I discussed the log book in my last job, and I thought it was useful, but when I mentioned it to my present consultant he asked if I didn't think it was a load of rubbish, so I let it go.”
Objective setting and performance appraisal-The log books have not been greeted with universal favour. Most consultant supervisors did not use them despite continued pressure by postgraduate deans. Objective setting and performance appraisal, almost universally recognised as good employment practice outside the medical profession, are still very foreign to our culture. This survey suggests that time spent by consultants in planned, well structured discussions with their house officers about their problems and their performance may be an important factor in enhancing the educational value of the preregistration house officer year. The log book appeared to be a useful tool for adding structure and focus to such discussions.
Acknowledgments
Funding: The log book was developed with funding from the Wellcome Foundation and the Thames postgraduate deans.
Conflict of interest: None.