Residency (medicine) - United Kingdom

United Kingdom

In the United Kingdom, house officer posts used to be optional for those going into general practice, but almost essential for progress in hospital medicine. The Medical Act of 1956 made satisfactory completion of one year as house officer necessary to progress from provisional to full registration as a medical practitioner. These pre-registration house officer posts lasted six months, and it was necessary to complete one surgical and one medical post. Obstetrics could be substituted for either. In principle, general practice in a "Health Centre" was also allowed, but this was almost unheard of. The posts did not have to be in general medicine: some teaching hospitals had very specialised posts at this level, so it was possible for a new graduate to do neurology or orthopaedics, for a year before having to go onto more broadly based work. The pre-registration posts were nominally supervised by the General Medical Council, which in practice delegated the task to the medical schools, who left it to the consultant medical staff. The educational value of these posts varied enormously.

On call work in the early days was full-time, with frequent night shifts and weekends on call. One night in two was common, and later one night in three. This meant weekends on call started at 9 am on Friday and ended at 5 pm on Monday (80 hours). The European Union's Working Time Directive conflicted with this: at first the UK negotiated an opt-out for some years, but working hours needed reform. On call time was unpaid until 1975 (the year of the interns' one-day strike), and for a year or two depended on certification by the consultant in charge - a number of them refused to sign. On call time was at first paid at 30% of the standard rate. Before paid on call was introduced, there would be several house officers "in the house" at any one time and the "second on call" house officer could go out, provided they kept the hospital informed of their telephone number at all times.

A "pre-registration house officer" would go on to work as a "senior house officer" for at least one year before seeking a registrar post. SHO posts could last six months to a year, and junior doctors often had to travel around the country to attend interviews and move house every six months while constructing their own training scheme for general practice or hospital specialisation. Organised schemes were a later development, and do-it-yourself rotations became rare in the 1990s. Outpatients were not usually a junior house officer's responsibility, but such clinics formed a large part of the workload of more senior trainees, often with little real supervision.

Registrar posts lasted one or six years, and sometimes much longer outside an academic setting. It was common to move from one registrar post to another. Fields such as psychiatry and radiology used to be entered at the registrar stage, but the other registrars would usually have passed part one of a higher qualification, such as a Royal College membership or fellowship. Part two was necessary to obtain a senior registrar post, usually linked to a medical school, but many left hospital practice at this stage rather than wait years for promotion.

Most British clinical diplomas (requiring one or two years' experience) and membership or fellowship exams are not tied to particular training grades, though the length of training and nature of experience may be specified. Participation in an approved training scheme is required by some of the Royal Colleges. The sub-specialty exams in surgery, for Fellowship of the Royal College of Surgeons, were originally limited to senior registrars. These rules prevent many of those in non-training grades from qualifying to progress.

Once a Senior Registrar, depending on specialty, it could take anything from one to six years to go onto a permanent consultant and/or senior lecturer appointment. It might be necessary to obtain an MD or ChM degree and to have substantial published research. Transfer to general practice or a less favoured specialty could be made at any stage along this pathway: Lord Moran famously referred to general practitioners as those who had "fallen off the ladder."

There are also permanent non-training posts at sub-consultant level: previously Senior Hospital Medical Officer and Medical Assistant (both obsolete)and now Staff Grade and Associate Specialist. The regulations do not call for much experience or any higher qualifications, but in practice both are common, and these grades have high proportions of overseas graduates, ethnic minorities and women.

Research fellows and PhD candidates are often clinical assistants, but a few were senior or specialist registrars. A large number of "Trust Grade" posts have been created by the new NHS Trusts for the sake of the routine work, and many juniors have to spend time in these posts before moving between the new training grades, although no educational or training credit is given for them. Holders of these posts may work at various levels, sharing duties with a junior or middle grade practitioner or with a consultant.

British medical training is constantly being reorganised. House officers and senior house officers have been replaced by two years of Foundation Year training (FY1 and FY2). Registrar and Senior Registrar grades were merged in 1995/6 as the Specialist Registrar (SpR) grade (entered after a longer period as a senior house officer, after obtaining a higher qualification, and lasting up to six years), with regular local assessments panels playing a major role, and these posts have in turn been replaced in 2007 by Specialty Registrars, who may be in post up to eight years, depending on the field.

Recent changes in postgraduate medical training, collectively organised under the Modernising Medical Careers (MMC), have created new labels for equivalent training grades. Foundation Year 1 is equivalent to the (junior) house officer grade; Foundation Year 2 is equivalent to the senior house officer grade. ST1/ST2 (short for specialty trainee) are also part of the senior house officer grade if the trainee is in Internal Medicine (undergoing the so called core medical training) or Surgery (undergoing core surgical training). It is customary for trainees to sit their Membership examinations (either for the Royal College of Physicians (MRCP) or Royal College of Surgeons) in order to progress and compete for designated sub-specialty training programmes that attract a national training number as Specialty Training year 3 (ST3) and beyond - up to ST 9 depending on the particular training specialty.

After ST2 grade, if in Medicine or Surgery, doctors undergo a compulsory subspecialty training (whilst maintaining service provision in the main specialty), and starting at ST3 grade, are called registrars. For non-medical/non-surgical specialties (ie, radiology, dermatology, etc.) they are called registrars from ST1 level.

The UK grade equivalent of a US fellow in medical/surgical subspecialties is the specialty registrar (ST3 - ST9) grade of sub-specialty training, but note that while US fellowship programmes are generally 2-3 years in duration after completing the residency, UK trainees spend 4-7 years. This generally includes service provision in the main specialty; this discrepancy lies in the competing demands of NHS service provision and UK postgraduate training stipulating that even specialist registrars must be able to accommodate the general acute medical take—almost equivalent to what dedicated attending internists perform in the United States (they still remain minimally supervised for these duties).