Monday, 29 December 2008

Mangling Medical Careers

When I started this blog, I deliberately tried to avoid writing about Modernising Medical Careers (MMC) because the whole debacle pissed me off so much and I’d just get really angry whenever I thought about it.

It’s now two years since specialty training and recruitment came under the MMC umbrella, so I thought I’d revisit the subject to see if the powers that be have managed to iron out the problems the new system had at its inception.

One of the key concepts of MMC, the new post-graduate training system for doctors, was to end the “lost generation” of Senior House Officer (SHO) junior doctors who spend far too long in SHO posts and face far too may barriers to career progression.

A quick look at the MMC website shows how beneficial the changes have been to junior doctors. They’ve got rid of the name “SHO” and given us names like CT1, ST2, FTSTA2, ACCS1 etc… etc… but the jobs that we are doing are essentially the same, so I’ll refer to all these posts as “SHO” in this post to try and avoid confusion. All SHOs would like to progress to being a Specialist Registrar (SpR) with the long term aim to complete our training and become a consultant.

MMC has renamed the SpR posts as “ST3”

Now, lets say that you’re a junior doctor and are coming to the end of your two or three years as an SHO and want to move on to an ST3 (SpR) job next year to progress your training. Oh, and lets say that you want to stay roughly where you live at the moment because that’s where your friends and family are.
For the specialty of anaesthetics, let’s see exactly how many jobs there are to apply for in England & Wales in 2009.

East Anglia and the East of England – 1
East Midlands – 2
Kent, Surrey & Sussex – ZERO
Manchester, Lancashire and the North West – ZERO
Newcastle & the north – ZERO
Oxfordshire – ZERO
Cornwall, Devon & Dorset – ZERO
Bristol and the Severn area - 1
Wessex – 1
West Midlands – ZERO
Yorkshire – ZERO
All of Wales - ZERO

In fact, the only places where are any vaguely sensible numbers of jobs are Liverpool and London. If you happen to live anywhere else, you’re going to have to move. In the whole of the country, there is a sum total of 55 jobs available in 2009. My back-of-an-envelope calculations tell me that there’ll be in the region of 350-450 doctors wanting one of these 55 jobs. What happens to the people who don’t get one of these jobs? Nobody knows, and the impression that I get is that nobody really cares. The situation is even worse for doctors who want to be surgeons, paediatricians or physicians.

Remember that the stated aim was to PREVENT barriers to career progression. How can a system that’s been six years in the making fuck things up so badly?


Nick said...

Have you seen what happens to unsucessful F2 doctors? They now get advice to leave medicine!

"Unsuccessful Foundation doctors will get counselling to
change career and/or be supported for a further year of
training to try again in 2009"

Had to read it twice to believe it

5th Year student

Harry said...

Please correct me if I'm wrong, I'd just like to see if I've understood the whole situation in one very long sentence:

The UK doesn't have enough doctors fullstop, it then doesn't provide any incentive for people to BECOME doctors, nor does it increase the amount of medical places available at universities, but simultaneously brings in magical new rules about how quickly people are supposed to be treated [ie: 4hr rule in A+E], none of which are feasible, while dumbing down the roles played by doctors through the use of codified titles and stupid amounts of hoops to jump through, and to cap it all if you do manage to get through this hellish swamp and become a doctor, within 2 years of working there suddenly arent enough jobs (despite there not being enough doctors in the country fullstop, see above), and you are told to just jack in 7+ years of work?

If that's true surely the clean up plan (MMC, haha) should at least have involved incentivising young people to become a doctor, and making it possible for more people to do so. In my opinion, all this business of not having a job after university, or in your case not having career prospects just 2 years after graduating, ties in heavily with such whacked out schemes as top-up fees, wanting 50% of youth to go to "university", and basically abusing taxpayers' money. I'd give more taxes if I thought they would be spent responsibly.

It's a farce, and no wonder so many young medics are disillusioned with the system / contemplate leaving for work abroad, heavily ironic since the government helped them get where they are yet doesn't seem to look far enough ahead to see they should help RETAIN them, then makes a hoo-hah when the shit hits the fan and the medical situation is worse than before.

In short, I'm not a medic, but hope one day to be, and I feel for you right now. Sadly, I reckon if I take the path to UK medicine I'll face much the same (or, knowing the government, worse), even in six or seven years' time when it will no doubt be painfully obvious that this system is detrimental.

Anonymous said...

Urgh... this is quite worrying. I'm currently working my butt off to complete 2 AS levels in 9 months, while volunteering many hours a week and holding down a full-time job... oh, and bringing up an 18 month old. All because I *really* want to become a doctor.

I have many moments when I think I'm completely crazy and should just stick to my very well paid (if a little meaningless) office job... posts like this make me think I'm even more insane.

I'm sitting here wanting to think - oh, it can't possibly be true and/or - hopefully it'll all have worked out by the time I graduate... but I fear this may be wishful thinking on my part.

Jo said...

Oh {hugs} What a nightmare to be in. No wonder so many trained doctors are leaving the UK for countries where they will be welcomed :-(

Anonymous said...

your stats arnet 100 percent acuurate. Technically anaesthesia doesnt have any "ST3/SpR" posts; you apply for a 7 year guaranteed contract that sees you all the way from an SHO right the way until you are ready to be a consultant.

So really you need to quote the total number of ST1 Anaesthesia places available!

Anna said...

That is no longer true Anonymous. Majority of specialities uncoupled this year. and no longer offer run through training. Instead you need to apply again for ST3 posts after completion of 2 years long 'core training'. Anaesthesia was actualy one of the first specialities to uncouple so I think even the applicants from 2007 and 2008 rounds are not elligible for run through training.

Anonymous said...

2 things

1. Anaesthetics has uncoupled-that means that, with the exception of those appointed to run-through posts in 2007, all will now apply for SHO level posts, and then for SpR level posts. Please lets not go off on a tangent about this confusing aside, because its detracting from the wider issues.

2. workforce planning is a mess. Earlier, it was stated that there were not enough medics. This is utter rubbish-the UK is training more specialists than it can afford to employ as consultants. To aspiring medics, that may sound implausible, please believe me, embarking on a medical course will leave you with huge debts and only an outside chance at even having a medical career-yet alone the one you want in your desired speciality & prefered region. Medical unemployment is already a reality, with growing numbers of completed trained ophthalmologists, orthopaedic surgeons and anaesthetists who cannot find jobs. As more come off the conveyor belt, without any funding for consultant jobs, the problem will get far worse. I'm sorry to disappoint people, but this catastrophe will not be magically resolved in a few years

I speak as a younger consultant

Dr Michael Anderson said...

Nick - not so long ago, if you even considered leaving the NHS, you were regarded as some sort of pariah that had thrown away £250 000 of government money. Now, they're payng for us to go away. It's unbelievable.

Harry - I think that you have summed up this whole sorry mess quite well. There are worrying times ahead.

sesaworuban - It's pretty unbelievable that with so many clever and powerful people involved, that they all got it so badly wrong. Personally, I had hoped that what happened in 2007 would be a bit of a watershed and that things would change, but I'm afraid to say that this doesn't seem to be the case at all.

Jo - I think the fact that people are preferring to take up non-training jobs abroad rather than working in the NHS shows just how bad things have come.

Anon 1 - as other posters have said, anaesthetics has uncoupled. One of the other things that MMC brought in was that SHO training should be "time-capped" meaning that you CANNOT apply for a ST1 job if you've done more than 12 months work in the specialty. Those coming to the end of 2 years HAVE to apply for a ST3 job, and as I wrote, there are hardly any ST3 jobs. The situation is ridiculous.

Anon 2 - You seem to think the fact that the current anaesthetic SHOs have to fight for only 55 reg jobs NATIONWIDE and, at the same time, are PREVENTED from taking further SHO training jobs as a "minor distraction from wider issues."

This was the attitude of many consultants through 2006 and 2007 (with a few notable exceptions) and this attitude and apathy by the consultants was largely why these "reforms" were able to be forced through. Lots of juniors feels they've been sold up the river and left to flounder by the consultants and attitudes like this show that perhaps, they are right.

Your points about workforce planning are worrying for most in the profession. Isn't there a plan for consultant expansion over the next few years to deliver the "consultant delivered NHS service" that the government(s) seem to desire so greatly?

DrJDR said...

It has always seemed to me that the current situation in one way represents quite good workforce planning. Medical student numbers have increasing astronomically. When I started training in Birmingham in 1995 there were 170 in our year - now there are over 400 per year plus a fair number more of graduate entry people. This has been replicated elsewhere and we also have new medical schools opening up.

The result is that the employment market is saturated with doctors who are all desperate for work, and as such will probaly settle for any job. The old concept of picking your specialty is going out, so you will end up doing what there are gaps for you to do. As an employer, this is great - loads of potential candidates, lack of competition (so cheap), ability to pick out the best and leave the rest behind. From the perspective of the individual doctors, of course, this is very bad news.

One of the few good things arising from it all is that I am hoping people will begin to consider what were traditionally unpopular specialities. Psychiatry (my own area) has had enormous problems with recruitment, and we have often ended up with poor quality trainees.

My hope is that the undoubtedly high quality doctors looking for work will consider it more seriously and see the definite benefits (such as lifestyle). Many people not intending to be psychiatrists are surprised when they work in it (eg as GP trainees) and often change their minds. I suspect similar things apply to other little-considered areas of medicine including things like pathology, public health, occupational health etc.

In the long run this is good news for patients too - there is a desperate need for high quality doctors in these areas and all too often this is lacking. It may not be much comfort for the doctors seeking work, but I would encourage them to think very broadly about what jobs they could do.

Anonymous said...

Michael I do think you are again somewhat misrepresenting the situation. In your analysis you ONLY consider the training grades but forget that MMC has created another parralel pathway of training along the Staff Grade/Associate Specialist line.

It seems to me with medical school expansion in the past most UK graduates would make it to consultant and overseas doctors fill in the non training posts. Now, whilst the number of consultant places will still rise, a higher % of UK graduates will have to fill the Non-training posts (ie. a smaller proportion can be consultants).

DrJDR said...

If I may reply to Anonymous above.

There will be a big increase in the number of people doing non-training and staff posts. There remains the possibility of gaining entry onto the specialist register by following the Article 14 route, although it remains unclear how well this will work.

I suppose the problem at present is that UK entrants feel that they have a right to become consultants, as that is what as school leavers and undergraduates we are told - "when you become a consultant...".

Perhaps from now on we need to be more honest with people from an early stage, with becoming a consultant an aspiration that many will not achieve. This might run the risk of putting people off, however - but perhaps that is a good thing!

Anonymous said...

Der DrJDR,

Thanks for your response to my post.

I have often wondered whether perhaps we load too much of the rewards into obtaining a consultant post; in many cases it is almost "consultant or bust". Often this leads to exploitation of juniors in the hope that "one day" it will all be worth it. If the Cons post is no longer guaranteed perhaps its time to properly reform the working conditions patient:doctor ratios taht can make being a junior doctor so horrendous

Dr Michael Anderson said...

Anonymous, DrJDR, thank you both for your comments.

Anon. I'm not misrepresenting the situation at all, the facts are there in black and white on the MMC website. The facts say that if you were an SHO in 2007 and didn't get onto a training program then, the number of CT2 (81) and ST3 (55)jobs available is pitifully small. You cannot apply for CT1, so what can you do? You're stuck in a trust grade job, propping up the SHO rota forevermore.

My post was not meant to encapsulate the entirity of MMC, but to highlight its effects on junior doctors.

Interesting you mention the article 14 route to consultancy. Do you honestly believe this is a serious alternative? Do you honestly believe that people who got their CCT this way will be seen equally to those from the traditional path? Maybe it is a viable, alternative, but I'm not convinced and I certainly wouldn't want to spend years down that path to be told "all CCTs are equal, but some are more equal than others" at the end of it. We only have one life.

Of course, I may be totally wrong about this, and I hope that I am, but I remain to be convinced and there are loads of juniors (and consultants) who share my doubts.

DrJDR and anon
Your points about non-consultant careers grades are good and maybe this should be the way forward. Aphra Behn wrote about this in her MTAS/MMC synopsis in 2007 and maybe it really is the way forward. Time will tell

Anonymous said...

With respect Michael


1. You are correct that there are only a few ST3-level entry slots. I'm not saying this is an aside-there was confusion about RTT & UNCOUPLING IN ANAESTHETICS & CLARIFYING THAT IS AN ASIDE.

2. I've supported my trainees & I consider support to include giving people honest career advice, however much they dont want to hear that advice.

3. You ask whether there are plans for consultant expansion. No. There was a lot of aspirational PR spin about a consultant-delivered service, but it would have been too expensive & trusts could not afford to appoint expensive consultants. Trusts like mine are not planning on recruiting further consultant anaesthetists. I'm very sorry if you dont want to hear or accept that. There will not be consultant jobs for trainees currently in the system.

I agree that trainees are being led up the garden path-you are being cynically exploited to do the out of hours work, with very little chance of employment-yet alone consultant jobs-at the end of SpR training. A mate, who is a college tutor, told me that tutors have been informed that its unlikely there will be post-CCT posts for all current ST3s in anaesthetics. I think thats a disgrace, but please dont blame me because I'm not responsible for that. Deaneries should not have recruited so many to training programes, when theres such little prospect of post-training employment. You appear to be asking for extra ST3 training posts, expecting the government to magic up jobs for you at the end. Given the economic climate, I would suggest that you are being unrealistic.

Anonymous said...

Oh you just exude bright shining hope, man.. thanks! The future is so bleak here.

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