In medicine we like to create divisions. Medicine versus surgery, primary care versus secondary care, orthopaedics versus all that is good, gentle, and decent. With the relentless march towards ever further subspecialisation these divisions have become more numerous and more entrenched. With more doctors working in increasingly narrow fields patient pathways have become convoluted and nonsensical, particularly as our population becomes increasingly polymorbid.
The growing recognition of the need for a return to a generalist approach in order to rationalise our patients’ treatments led to the Shape of Training review to be undertaken by Professor Greenaway.1
As a rabid fanatic of generalism I initially felt that this report was filled with many wonderful ideas, even if it was light on how any of it would be achieved. It talked of broadening training for junior doctors, of facilitating transfer between training programmes, and of breaking down the barriers between primary and secondary care.1
This all seems logical. It makes sense to aid the flow of both patients and doctors around the healthcare system and it seems obvious that doctors capable of looking after more than one organ will provide better patient care. Why then was it roundly rejected in a joint statement from 15 organisations representing doctors in training?2
In part it was probably the glaringly obvious fact that shortening training programmes, while also broadening them, is unlikely to improve the quality of the end product. Regardless of how wonderful broad-based training will be, we will still need some specialists and the proposed scheme looks likely only to produce second-rate generalists.
It is perhaps the timescale, a mere 5 years, in which it is proposed that these unproven and unevidenced plans will be rolled out. There is also the suspicion that ‘broad-based training’ may be interpreted as ‘plugging the gaps in the A&E rota’ by many trusts.
More than this is the feeling that trainee doctors were not adequately consulted on how their training should be conducted. It is after all only 10 short years since the Modernising Medical Careers (MMC) reforms created the rigid and narrow training schemes that the Shape of Training review is trying to overhaul.
After 10 years it is only now that people have worked out how to unshackle themselves from the constraints of the ST1–7 gulag. The system was designed to take junior doctors in at one end and spit out consultants at the other end at a predictable rate. It does not.
A major problem with the current system is that it forces people to choose their specialty training programmes a mere few months after finishing their house jobs. This creates such follies as doctors committing themselves to an 8-year training programme in paediatrics having never done a paediatric job. Instead of generating consultants at a predictable rate it has produced a cohort of disheartened trainees who have spent years slipping up and down the training ladder as they try to find the right career.
Many have found that this structured 7-year programme, particularly when combined with the constraints of the European Working Time Directive, has made it very difficult to balance service provision with educational needs, and the quality of training has suffered.3 For these reasons people have become ingenious in making their training work for them, whether it is by escaping to Australia for a year, taking time out to do a masters, or undertaking years of fellowship to acquire skills their basic training has failed to provide.
There is also the new phenomenon of the voluntary ‘foundation year 3’ in which people take locum SHO jobs in order to gain extra time and experience to decide which career will best suit them. In short, people have found ways to make their training more like it was before MMC.
Small wonder then that there is resistance to a fresh overhaul of training, a new system to grapple with, and the latest example of the relentless meddling from without that the medical profession is subject to.
Footnotes
You can read more by Adam Staten at the BJGP blog: http://bjgpblog.com
- © British Journal of General Practice 2015