Saturday, 1 September 2007

"MMC & MTAS 2007 – a post-mortem" or “Lies, bad advice and how I got my job”

Last week, Hospital Phoenix wrote about some nonsensical advice that was given to one of his friends at his trust induction. This got me thinking about MMC once more. There are many things that are horribly wrong about Modernising Medical Careers and the Medical Training Applications System but, as someone who actually had to negotiate this disaster, the single thing that I found most galling, most frustrating and most stressful about it was the utter lack of information about the scheme and how it was intended to run.

In spring 2006, when the changes to the medical training system started to change from vague chatter on the college websites to firm plans, I tried and tried to find out how certain aspects of my training and experience would fit into the new system and what I should be doing to get a job. It was all in vain. I lost count of the number of times that my questions were met with a shrugging “I don’t know.” In December 2006, I was getting more than a little stressed by it all and contacted, in rapid succession, – MMC, the royal college of physicians, the royal college of anaesthetists and PMETB about what I should do when the application process began. Nobody had any idea. Here are a few of the responses I got:

PMETB: “I don’t know, applications are nothing to do with us.”
MMC: “I don’t know, you should just apply to whatever you think and not be too picky about where you want to work.”
RCoA: “I don’t know, you don’t fit into any of our boxes do you – ask MMC”
MMC (the second time): “I don’t know – maybe you should do an FY2 year.”
RCP: “I don’t know, but you have your exam so I think you’ll be OK.”
RCoA: “If you do find an answer, could you come back and tell us because we’d be interested to know too.”

Do you feel my pain? Finding any sort of useful information was like drawing blood from a stone and the information I did manage to extract was either unhelpful or just plain wrong. The consultants at the hospital I where I was working at the time were less than useless and I took gossip about the changes among fellow junior doctors with a pinch of salt. I discounted rumours like “they are going to sacrifice a whole generation of SHOs to make the new system work” and “there are going to be thousands of unemployed junior doctors” and “families will be torn apart by this” as scaremongering by the hospital stress-heads. Surely they wouldn’t do that to us? I thought.

I was wrong. As you probably know, the actual reality was far worse.

Advice from consultants about getting a job through MTAS was appallingly bad. They just trotted out the same stuff that had helped under the old system and I don’t think they realised that the goalposts regarding job applications had fundamentally changed. This is part of the reason why it came as a surprise to many when high quality candidates weren’t even being short-listed in Round 1 (later renamed to Round 1a). At various times during the application process, various consultants told me things like; “It’s very important that you have your [post-graduate] exams, it’ll help you stand out” and “It’s always worthwhile contacting and visiting the department [of the job you’re applying for] before the interview” and “Make sure your CV looks good” etc… etc…
All this advice sounds reasonable, but was absolutely useless when it came to applying for jobs this year. I very much doubt I’m alone in being told these kind of things by my seniors but the facts are that if you paid attention to your bosses and actually followed advice like this, you’re highly likely to be unemployed right now.

The MMC themselves recognise that misinformation and a lack of useful information was one of its (many) major failings this year and, to be fair to my former bosses, they were probably as much in the dark about the changes as we were.

The thing that galls though is that, as the system fell apart and as it became increasingly apparent that you needed to do something different in order to get a job, the old advice still stuck.

I’ve commented before about how I feel let down by Liam Donaldson and the government for instigated and overseeing the MMC fuckup. I also feel let down by the senior doctors, the consultants, during the whole affair. Generally, I felt the majority of them just didn’t care at all, the advice given by them was often a load of bollocks and the way the BMA (led by consultants) behaved when they sided with the government against us juniors was truly disgusting.

I was interviewed four times in Round 1a, including once for the position I was working in at the time (effectively being re-interviewed for the job I was already doing), and didn’t get any job offers.

Round 2 was a total fucking debacle. Jobs were (or weren’t) advertised ad hoc, in random, hard-to find places for stupidly short lengths of time. Some deaneries made life as difficult as possible for applicants and, in places, what MMC said about how things were meant to run bore little or no resemblance to what was actually happening.

Here are some examples of skulduggery by the deaneries in round 2, all of which are DIRECTLY contrary to what was published on the MMC website. The London Deanery advertised and then closed its Round 2 anaesthetics jobs BEFORE round 1 had even finished and then appointed only current London-based trainees to the positions. The Round 2 Core Medical Training jobs for the South Yorkshire South Humber Deanery were PHYSICALLY IMPOSSIBLE to apply for from outside the region because the application form was only made available on the day of the deadline and they insisted on having 10 paper copies. The Leicester, Northampton and Rutland Deanery didn’t even bother publish a deadline for its Round 2 anaesthetics jobs.

These are just examples that directly affected me and I’m sure there are many, many more examples across the nation. By the way, if any of you do know of any more, I’d be interested in hearing about them.

Anyway, after many hours spent filling out endless application forms, I got myself short-listed in Round 2. I was successful at interview and was given one of the much-sort-after ST run-through positions. I was very lucky indeed.

I was on the phone to my old registrar the other day and, apparently, the new junior doctors on the firm are less qualified and less experienced than we were. This begs the question, “how come they got the job and I didn’t?”

The answer, I think, goes back to what I was talking about at the start of this post – bad advice. If I could go back to December 2006 and give myself one piece of advice it would be to sort out my portfolio and this is the advice that I give to anyone still negotiating the system.

I thought I interviewed very well in Round 1 and was actually quietly confident about getting a job. I was wrong. The computer said “No.” I thought I interviewed very well in Round 2 and was quietly confident about getting the job. I was right, I dodged the dole office with about a fortnight to spare and am now really enjoying my work (though I’m lamenting the fact that I’ve had to move hundreds of miles from my friends and family).

The difference between Dr Michael Anderson in Round 1 and Dr Michael Anderson in Round 2 was that, by the time Round 2 came, I had buffed my portfolio to the max.

I’d gone round and asked my medical students to sign something to say I’d taught them how cannulate and read ECGs, I asked the senior sister to write a letter saying I was nice to patients and staff, I’d got a consultant to write a letter saying that I can ably cover CCU and HDU, the list goes on. I have to say at this point that this wasn’t EXTRA stuff I was doing after failing in Round 1. I was doing all this stuff when I had my Round 1 interviews - it just wasn’t in my portfolio at that time.

Whether you think that I was incredibly shrewd and learned from Round 1 and “sold myself in the best possible light” or you think I “shamelessly played a flawed system to get a job” will depend on your standpoint.

The fact is that in MTAS 2007, this sort of portfolio stuff is considered more important than previous experience, publications, post-grad degrees etc… and this is a fundamental change that my seniors and the majority of my junior doctor colleagues just failed to realise. Whether or not this is the way it SHOULD be is a matter for another debate. Personally, I’m praying that MTAS 2008 will be drastically different to MTAS 2007, but I have my doubts.

You see, as we enter September 2007 and contemplate the applications for next year, I don’t see that a great deal has changed. As was the case in September 2006, it seems nobody has a clue about how the system is going to run next year and everyone is still “waiting to find out.” I’m willing to bet that a junior doctor seeking advice about how to apply next year will find getting any useful information virtually impossible – just like I did last year. To quote a great woman “It’s all a bit of history repeating.”

I hope I’m wrong. Time will tell.

Choose life?

From medical school to retirement, doctors are told and reminded to respect patient’s autonomy. This means that we must respect the decisions they make about their own health, even if that decision seems nonsensical to us. This theme comes up again and again throughout our careers. Our attitudes to patient’s autonomy is tested in exams and vivas, the lawyers remind us about it during the Trust inductions, it’s a common theme in our job interviews, it comes up at conferences, in the media and, most importantly in our daily interactions with patients.

The vast majority of the time, patient autonomy is not a conflict issue. This is because the doctor and the patient are working together, in harmony, to try and achieve a common goal. Patients come to us because they want to get better, we doctors suggest something that we think will make them better and patients usually agree to it and then they usually get better. Their autonomy is driving them in the same direction as our medical advice.

Sometimes, the patient will have a different agenda to the doctor and sometimes, their agendas and beliefs drive them to make decisions that fly in the face of our advice. Sometimes, we can understand where they are coming from and sometimes we can’t. Nevertheless, respecting patient autonomy is one of the core duties of being a doctor.

Anil, one of the new junior medical doctors and fellow MTAS refugee, was telling me about Helen, a 43 year old woman whom he had seen on the Medical Assessment Unit the day before.

Helen came to hospital because she was very unwell. History and clinical examination showed that she was bleeding internally, possibly from an ulcer, and had lost a lot of blood. (For you medics reading, her Hb was 4.9 g/dl). She was critically ill and urgently needed a blood transfusion to keep her alive until the bleeding can be stopped either by endoscopy or by surgery.

The thing is, Helen is a Jehovah’s witness and Jehovah’s witnesses do not accept blood transfusions. Moreover, Helen is a recent convert to the religion and, as such, is much more hard-line about sticking to her beliefs, even in extreme situations.

Those adverts about giving blood really do speak the truth, you know. Blood transfusions do literally save lives. Helen is highly likely to die without a blood transfusion, leaving behind a grieving family, but Helen flatly refused to have one.

This is exactly the scenario that is frequently used to illustrate autonomy in medical school, in junior doctor’s teaching sessions etc… etc… so it’s interesting to hear about this scenario actually unfolding in real life.

The thing about autonomy is that if a patient is lucid and has capacity to make their own decisions, then we have to respect the decisions that they make about their own lives. As doctors, it’s our job to make the patient fully aware of the likely outcome of their decision and to treat them the best we can whilst respecting their beliefs, no matter how bizarre they may seem to us. It is wrong to force our will onto our patients, it is wrong to lie to our patients about what might happen to them.

Anil told Helen that without the blood transfusion, she is likely to die, aged 43. Helen said she understood this but would rather die than have the transfusion. This is her decision.

When Anil finished his shift, Helen was still alive, but was teetering on a knife-edge. She was having intravenous fluids and the medical team were preparing to take her down for an endoscopy to hopefully stop the bleeding. I just hope that the prayers of Helen and her family are answered and she makes it through.