Original reportSelection Matters—A Regional Survey of UK Consultant Opinion on Selection into Postgraduate Surgical and Medical Training
Introduction
To understand the focus of this article, it is necessary to consider the iterations of British postgraduate medical training over the past 2 decades.
After completion of medical school, trainees were provisionally registered with the General Medical Council and were required to complete 12 months of supervised training (generally spending 6 months in internal medicine and 6 months in general surgery) as pre-registration house officers (PRHO; broadly equivalent to the intern grade in the American health care system) before becoming fully registered. PRHO positions were closely matched to the number of graduating medical students in the United Kingdom such that unemployment at this level was essentially unheard of, whereas the appointments procedure was controlled at a regional level by each medical school. Although now theoretically free to practice independently, most doctors would now apply for training posts in hospitals known as senior house officer posts (SHO; broadly equivalent to a junior resident). Application to SHO posts from the PRHO grade was in open competition and included applications from international medical graduates (IMGs). The number of available SHO posts was in excess of PRHO posts such that employment at this level was generally assured for both United Kingdom graduates and IMGs. After working in SHO posts for up to 2 years, applicants would again apply in open competition for registrar (broadly equivalent to a senior resident) posts. In surgery, most registrar positions were 2-year-long rotations after which applicants then encountered a major bottleneck in terms of career progression to the next grade—senior registrar (SR; broadly equivalent to fellow). Appointment to the SR grade was by a locally convened interview panel and was particularly arduous. All applicants were required, for example, to have completed a period of formal research and to have obtained a higher degree by thesis simply to be eligible for shortlisting. It was at this level that many graduates failed to progress. However, once appointed, SR rotations lasted for 4 years and candidates were virtually guaranteed a consultant (equivalent to attending physician) post in due course.1
In 1993, the Chief Medical Officer Sir Kenneth Calman published a report that initiated changes to the training of middle-grade (registrar) staff to ensure that the procedure for specialist registration in the United Kingdom complied with European legislation.2 Key aspects of the Calman report were the creation of a unified registrar training grade (specialist registrar [SpR]) with strict controls on numbers of posts by workforce planning bodies; defined curricula and curriculum-based examinations for entry to each specialty and before completion of training; a designated period of structured training with formal, recorded yearly assessments of progress; and the award of a certificate of completion of training (CCT) at the end of the training pathway allowing appointment to a substantive consultant post in the National Health Service (NHS). Although the Calman reforms succeeded in unifying the registrar grade, postgraduate training was split into 2 tiers—basic and higher specialist training (ST)—corresponding to the SHO and SpR grades, respectively. Predictably, competition for entry to the SpR grade was fierce, and a new bottleneck appeared between the SHO and SpR grades. Thus, for example, in England in 2001, there were 3685 PRHO posts, 15,384 SHO posts, and only 12,648 SpR posts in total (all specialties).3 This situation was exacerbated by a concurrent expansion in so-called “non-training” posts at both SHO and middle-grade level (posts that were filled largely by IMGs) to cope with the limitations on junior doctor working hours mandated by new European Union health and safety legislation (the “European Working Time Directive”).4 Several sources identified problems with training and career progression within the SHO grade stating, for example, the conflict between service provision and training, prioritization of training opportunities for SpRs over SHOs, the lack of structured training, assessment or appraisal, the lack of a definable end point in training (with many candidates spending several years in SHO positions while attempting to enter the SpR grade), and the absence of workforce planning at SHO level.5 Indeed, SHOs famously came to be referred to as the “lost tribes.”6
In 2007, postgraduate medical training in the United Kingdom underwent the biggest change since the Calman reforms of the early 1990s. The publication of the Chief Medical Officer Liam Donaldson's reportUnfinished Business in 2002 highlighted deficiencies in the structure of training and weak selection and appointment procedures within the SHO grade.3 The report proposed 5 principles as the basis for reform of basic ST—that “training should be program-based, be broadly-based to begin with for all trainees, provide individually-tailored programs to meet specific needs, be time-capped and support movement of doctors into and out of training and between training programs.” Of the 19 proposals made, the 3 most radical were as follows:
- 1
The creation of an “integrated, planned 2-year foundation program of general training” equating to the current PRHO year and a generic first year of current SHO training. The successful completion of this program would depend on demonstrating competency in a range of skills, knowledge, and attitudes.
- 2
The creation of a unified training grade such that after completion of the foundation program, doctors would enter a “broad-based, time-capped basic ST program” and, subject to satisfactory progress, would move seamlessly into higher ST.
- 3
Review of the role and purpose of postgraduate examinations (eg, Membership of the Royal College of Surgeons [MRCS], Membership of the Royal College of Physicians [MRCP]) with a greater emphasis on “competency-based” assessment throughout training in the workplace.
Whereas applications to and selection into regional postgraduate training programs had previously occurred asynchronously and was controlled by independent regional employment organizations (known as “Deaneries”), MMC sought to synchronize and centralize the selection process at a national level—a decision that would come to be heavily criticized.9 In January 2007, an online computerized application system (the Medical Training Application Service [MTAS]) was activated, which allowed all junior doctors from the SHO grade, middle-grade doctors, and foundation trainees to apply for postgraduate training programs in different specialties and geographic locations. MTAS application forms were developed in conjunction with the Work Psychology Partnership using generic free-text white-box questions with additional specialty-specific questions as needed and assurances made that recruitment and selection would be “fair, open and legally robust.”10, 11
MTAS proved to be one of the biggest disasters associated with MMC.12 In addition to several technical failures, serious concerns were raised in relation to the content of the application forms and transparency of the application process. There were accusations that precedence had been given to “free text answers about competency over evidence of clinical experience” with insufficient weighting for academic achievement.10, 13 Some questioned whether the forms asked about “the sorts of things we consider relevant” and whether they covered “all aspects we want to measure.”12 After the closure of the MTAS application portal, subsequent selection reverted to traditional local Deanery based processes using “tried and tested” application forms and CV-based interviews.10 Although proponents of the latter have cited the largely meritocratic nature of the old system and its ability to select and produce good doctors, others have pointed out that, for all of its faults, some aspects of the MTAS application form did attempt to address deficiencies in conventional CV.11, 14
Given these seemingly opposed viewpoints and their potential to act as a source of ongoing confusion for new junior doctors wishing to optimize their applications, a questionnaire survey was carried out to ascertain consultant opinions regarding selection criteria for entry into ST.
Section snippets
Methods
A questionnaire was sent by e-mail to all 755 consultants listed on the NHS web sites for the following hospitals:
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Barnet and Chase Farm Hospital
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The Whittington Hospital
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University College London Hospital (UCLH)
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Royal Free Hospital (RFH)
Demographics
In all, 98 of 755 e-mail addresses were invalid (ie, returned undeliverable). Of the remaining 657 e-mails delivered successfully, 212 (32%) were returned. Specialty breakdown is presented in Fig. 1—thus, surgical and medical specialties made up 27% (58/212) and 73% (154/212) of the group, respectively. Tertiary and secondary center responders comprised 57% (120/212) and 43% (92/212) of the total, respectively.
Quantitative Results
The results indicate 3 tiers when considering the relative importance of selection
Discussion
The recent attempt to introduce changes to the selection process for postgraduate medical training in the United Kingdom was almost universally rejected by both senior doctors and trainees.14, 17 Given that the aim of the new system was to centralize applications and process them in a “fair, open, and robust” manner, the outcry caused by the change might seem surprising to those outside the United Kingdom. The results of our study provide some insight into the reasons for the reactions of
Limitations
It is accepted that there are limitations of this study. The questionnaire used has not been externally validated, and therefore the validity of using a rank scoring system is unknown. Given that no questionnaires on this subject exist, the authors were compelled to design a new questionnaire without external validation. The use of a ranking approach makes interpretation of the results relative to the 8 selection criteria (ie, all 8 could be viewed as extremely important with the relative
Conclusions
Consultants place significant emphasis on specialty-specific experience and additional research degrees when considering selection for ST 1, which brings into question the “generic” nature of foundation training. Consultants preferred to maintain some subjective controls over purely objective markers in the selection process. There is a need to build on these preliminary findings by conducting further investigations before changes to selection methodology are implemented.
Acknowledgments
We thank all consultants who participated in this study.
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