Intended for healthcare professionals

Editorials

Postgraduate medical education and training in the UK

BMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f7604 (Published 23 December 2013) Cite this as: BMJ 2013;347:f7604
  1. John Tooke, vice provost (health)
  1. 1University College London, London W1T 7NF, UK
  1. j.tooke{at}ucl.ac.uk

Time for action

As David Greenaway’s report on the future shape of postgraduate medical education and training makes clear,1 this is the sixth report in the United Kingdom in as many years in the wake of the failings in Modernising Medical Careers.2 All reports start from the premise that changes to the current system will be necessary to meet evolving healthcare needs. Our reluctance to adopt changes that have a broad consensus reflects at worst vested self interest in the status quo and at best an innate professional conservatism and a desire to sustain those attributes of a doctor that have served medicine well in the past.

However, reluctance to change also reflects the inherent uncertainty in predicting the future and the length of time before the outcome of profound change is evident. The fundamental problem is how we can provide rigorous, quality assured education that equips doctors with the desired range of capabilities to meet current healthcare needs without having to redesign the system every few years. The report makes it clear that “broad based beginnings” and flexibility are key to avoiding the snakes and ladders of returning to basic training if technological advances or other developments limit the value of a doctor’s hard earned specialist expertise.

Given the rapid shifts in our society’s demography and the likelihood of greater expectations of healthcare among older people in the future, most programmes should have an increased focus on elderly care medicine and the complexity of comorbidity, as suggested. The proposed move from CCT (certificate of completion of training) to CST (certificate of specialty training) is key in that it emphasises that education and training are never “complete.” The proposal to introduce credentialing to define adjunctive specialist capability in specific areas of clinical practice after obtaining the CST provides a practical way to adapt skills to prevailing needs. It also provides a means for clinician scientists to balance clinical, educational, and research demands while still enabling them to exhibit specialist expertise, albeit within a narrower scope of practice.

Whereas the impact of demographic shifts looms large in the report’s analysis, less emphasis is placed on technological developments that also drive change. For example, genomics with its potential to herald a new era of “precision medicine,”3 and the democratisation of medical knowledge, self care, and self referral supported by digital means that will transform the transactional relationship between doctor and patient.

The recommended structural reforms also attempt to tackle another concern about the current system—that, compared with many other developed healthcare systems, the time taken to achieve independent specialist status is too long. Advancement based on evidence of competency rather than on time served may help in this regard. So too may the proposal for doctors to become fully registered as soon as they graduate from medical school, if such a move could be achieved without falling foul of European regulations on programme length. Further shortening could be achieved if the foundation programme was reduced to one year, the second foundation year being incorporated into the first year of general specialist practice.

Such developments would encourage medical schools to focus on preparedness for practice and ensure that final preparations are not put at risk by displacement to another deanery as can happen now.

Full registration at graduation also provides the opportunity to lift the cap on overseas medical student numbers because overseas graduates could then return to their country of origin with a fully registered qualification without having undergone foundation training. In the likely event that there are too few UK/European Union graduates to meet demand in the future, a ready supply of UK trained graduates—familiar with the culture and practice of the NHS—will be available. This would be a more ethical solution than recruiting from overseas graduates who have had no training in the UK.

Many problems remain to be resolved if the proposed system is to work. In addition to the inherent tensions between service and training, the training environment needs attention. Shorter lengths of stay in hospital, limited outpatient follow-up, and shift working with inconsistent teams threaten “on the job” learning. As the report rightly asserts, only clinical environments that provide high quality education and training should be approved for postgraduate medical training. Broader based doctors, better equipped for community and intermediary care roles, can play such a part only if other NHS policies and structures are aligned with this intent. For example, the hospital trust system is currently incentivised to keep patients coming to hospital, rather than encouraging the stated policy of more community based care. The report contains an unfortunate reference to doctors who are “out of training.” Whether on—or not on—a path to CCT, no doctor should be regarded as out of training if he or she is to pursue reflective practice and keep up to date. The review rightly argues for care with the process of transition to the new arrangements, if adopted. The expectations of those entering or considering entering the profession will need to be managed. Proposals to introduce adjunctive training in—for example, management, leadership, and education—during general specialist training could help inculcate a culture of adaptability. This could help doctors accommodate future changes that reflect evolving patient need, particularly if combined with opportunities in service improvement, informatics, and public health. Care in transition however should not be interpreted as an excuse for resistance to change. The broad principles espoused are the right ones, and, as the review makes clear, we should rapidly move to defining which organisations are best placed to implement the changes. The Greenaway report deserves support before a seventh report concludes broadly the same.

Notes

Cite this as: BMJ 2013;347:[ELOCATOR]

Footnotes

  • Competing interests: I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: None.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

References

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