How specialist training reform sparked crisis of confidence
From Mmc
BMJ 2007;334:508-509 (10 March), doi:10.1136/bmj.39146.640613.59 Observations
The week in medicine How specialist training reform sparked crisis of confidence
Rebecca Coombes, journalist, London rcoombes@bmjgroup.com
Computer crashes, 8000 angry junior doctors fearing unemployment, and talk of a shambolic and corrupt selection process have dominated recent coverage of Modernising Medical Careers
What's happened?
Last month an estimated 30 000 junior doctors became the guinea pigs for a new and untested system for filling specialist training places within the NHS. Around 20 000 are UK doctors either currently employed as senior house officers or emerging from the foundation stage. The remaining 10 000 who have registered for training places are from the European Union or other overseas candidates. All junior doctors have had their contracts terminated from August and have had to apply for jobs through the online service MTAS (Medical Training Application Services), which by last week had descended into "pandemonium," according to the BMA. Emotions were running high even before the service went live at the end of January. With only 22 000 posts available, and 30 000 eligible candidates, 8000 doctors faced an uncertain future. The BMA's beef is not with the number of posts, which is roughly the same as before, so much as with what it perceives as the unfairness of the new system—it claims the system seems to be a lottery rather than one based on merit. On Monday a panel of consultants in Birmingham refused to conduct job interviews on the grounds that they felt the process was unfair. Andy Garnham, a surgeon in Wolverhampton and a member of the panel, told the Times (6 March) that The consultants were unhappy about the way that a shortlist had been prepared from the original 650 applicants. "The whole system had serious flaws," he was quoted as saying. "No long list had been done and there were people on the shortlist who were ineligible, whose qualifications had not been checked or whose immigration status was in doubt. This is the last selection procedure doctors go through before they are qualified to become consultants, so it is vital to get it right. Professionally, we didn't think it was fair to patients or to the candidates to be part of a faulty system." The MTAS system (www.mtas.nhs.uk) has been blighted with technical problems, further fraying the nerves of applicants. The computer crashes had allegedly resulted in lost applications, although Methods Consulting, which runs the site, denies that any data have been lost. There were complaints of poorly devised forms that gave little space for listing clinical experience and qualifications. The deadline for applications had to be extended twice after the overworked website repeatedly crashed. By last week, many doctors expecting to be notified of an interview were still waiting. Talkboards and newspapers' letters pages were alive with complaints from seemingly overqualified candidates who felt they had been denied a place unfairly. The BMA said the system was "potentially open to corruption" after consultants from some areas were said to have complained that unqualified staff were shortlisting candidates for interview and that shortlisters were able to alter candidates' scores. Shortlisters are supposed to assess answers to each question blind, but, according to a letter to health secretary Patricia Hewitt from the chairman of the Junior Doctors Committee, one consultant complained that his fellow shortlisters' comments were visible. The BMA has now appealed to health secretary Patricia Hewitt to delay the interview process until the government can prove that all shortlisting has been consistent and fair. Meanwhile, junior doctors are fundraising to mount a legal challenge to the system. Remedy UK (Doctors Challenging Prescribed Reform; www.remedyuk.org), which is organising opposition to MTAS, is leading a national demonstration on 17 March and is urging doctors to speak to the press about how "they, their lives, their families, and their patients are being affected."
How are junior doctors reacting?
How do you "work" the new application process in order to score top points and thereby secure a coveted interview, asked candidates. Posting on Doctors.net.uk, Andy Fearnley, one candidate who failed to get an interview in the first round, and who has a first class medical degree from Cambridge University, said: "The majority of marks available in the application process were assigned to how a candidate answered a banal set of poorly worded, verbose questions with limited if any clinical relevance." In a letter to the Guardian, Sarah Spencer, a consultant in emergency medicine, wrote: "The form concentrated on skills deemed important by psychologists (questions about motivation, self-awareness, commitment, vigilance, coping with pressure) and scarcely allowed reference to experience and skills. The highest scoring applicants were those who were best able to blow their own trumpets."
There were stories of applications being rushed through without proper consideration. The consultants responsible for shortlisting candidates were poorly briefed and often too rushed and overworked to mark hundreds of applications. "Has every application form been read and scored fairly? Where is the evidence?" asked one second year senior house officer in psychiatry on Doctors.net.uk. D S Jackson, a consultant who emailed the Daily Telegraph, said: "As a consultant, I have had to score e[lectronic] job applications in a system that is banal and inefficient. I feel for this generation of juniors that have been let down by the sheer pig headed incompetence of politicians." One candidate applying for a post at ST4 level in psychiatry, and who has a MSc with distinction, wrote on doctors.net.uk that his career was "in the dustbin." The candidate said, "I worked hard on my application form and suffered the dreadfully tedious PC questions. The site repeatedly crashed or took minutes to load each page. It took me four hours to submit my completed form. I read with disbelief government claims that the site worked well. This is not ‘spin,' it is a lie."
There was a growing suspicion that MTAS was a "sneaky" way of enforcing mass redundancy, according to "KB" on Doctors.net.uk: "We never needed training reform. Our training was fine. MMC is a sneaky way of cost cutting by reducing the overall growth of consultants by attempting to design a path for subconsultant grade consultants whom they can pay less."
What the papers say
The Daily Telegraph was inundated with letters and emails from despairing doctors and their parents. More than 250 emails were posted in response to its coverage of the story, overwhelmingly from distressed junior doctors or their families. "Better trying your hand at the slot machines," "a lottery," and "half-baked, deeply flawed" were a few selected comments. On MTAS, candidates can apply for up to four jobs. These can be training posts in four different specialties in one geographical area; or the same specialty, such as psychiatry, in four different areas; orr a combination of areas and specialties, but only up to four choices. Consequently, those passionate about sticking to their chosen specialty must be prepared to work anywhere in the UK—a logistic minefield for medical couples. K Augustine, in the Telegraph, wrote: "I should be grateful. I have interviews. Unfortunately my husband doesn't so my family with our 16 month old son may be split up—or one of us will have to sacrifice our career as there is no longer much chance of getting back in. There is no flexibility in this inhuman system." Dr NG added: "With over £40 000 of medical school debt, what options are there? Despite public perception being that all doctors are overpaid, golf-playing, Audi TT driving yuppies, clearly we're not. When a large bus narrowly missed taking out my car last night, the thought of ‘what's the point' did flicker across my mind." In a Telegraph feature, Dr Max Pemberton wrote that Modernising Medical Careers should be rebranded "Massive Medical Cull." "On the wards this week there have been scenes never witnessed before—scores of people bursting into tears, inconsolable and scared. They aren't patients though. They are doctors."
Scott Oliver provided a lone voice of support for MTAS. Dr Oliver, a foundation doctor in Glasgow, is also a member of the DoH Modernising Medical Careers team. In a podcast on Doctors.net.uk, he said: "This was not set up as a ploy to put doctors out of a job or to funnel us into careers that weren't of any interest. "I guess the thing to focus on is that come August 1st [when contracts come to an end] our hospitals will still need the same number of doctors to do the same number of jobs that exist just now and, if anything, they are really crying out for highly trained doctors to provide patient care." The DoH said there was no question of halting the system: "It would create greater uncertainty for thousands of junior doctors if the interviews were cancelled. It would also leave trusts in an impossible situation as they would be left without a system of recruiting doctors into posts in August 2007." The government denied that it was planning to employ fewer doctors as a result of Modernising Medical Careers.
How the new training system works Highest ranked candidates are invited for a first round of interviews for posts. Rejected candidates must wait for a second round of applications that decide the remaining jobs. There will still be jobs termed Fixed Term Specialist Training Appointments (FTSTA).
