What happens after foundation programmes?
Any firm answers are still a long way off, as Deborah Cohen finds out
Three years is hardly any time to implement a new framework for doctors, training, and yet 2007 is the date set to roll out the full complement of training reforms for specialists. The Modernising Medical Careers working party responsible for overseeing the changes, openly agrees that there is still a lot to do. According to Derek Gallen, a member of the working party, most of the plans for what happens after exiting foundation programmes are "still up in the air."
Various reasons are touted for these radical changes in doctors' training, but the key reason behind the reforms is to improve service provision. Derek Gallen says: "There's a need to increase consultant numbers and workforce and move towards a consultant led service. To do that, there needs to be a reduction in the length of time in training, whilst increasing the educational content of that training so there's not a reduction in patient care." Despite the looming implementation date, not much is concrete, and structures and processes are still liable to change.
Simon Calvert, deputy chair of the BMA's Junior Doctors Committee, says that the BMA sees this as an opportunity to improve the current situation where high expectations often lead to disappointment: "Doctors may be unrealistic in their expectations and not know that they are unable to get an SpR [specialist registrar] number and spend ages as an SHO [senior house officer] before giving up--this is a waste of their time."
This could work in a number of ways, depending on a doctor's career aspirations
Run through
One method of training proposed by the Junior Doctors Committee and currently gathering general support, is a programme which combines basic and higher specialty training. Dubbed the "run through grade" by some, the Junior Doctors Committee hopes that the new system will reduce the number of non-standard grade posts (trust grade posts and so on), be more flexible if career aspirations change, and also recognise previous experience. Ultimately the SHO grade will become obsolete and doctors will either be on the foundation programme or in specialty training (see figure).
For the certain
Doctors who are confident that they want to do something specific can openly compete for numbered specialist or general practitioner training positions. If successful, there will be no further competition for posts and they will be trained in that position for however many years specialty training takes--until they become a consultant or general practitioner.
However, early entry on to a definite pathway does not mean that doctors would neglect other areas of medicine and be trained in that specialty only. Simon Calvert explains: "For example, if you want to be a gastroenterologist, all your training would be geared towards that. But you would not just spend the six or seven years [of training] just focusing on gastroenterology--you would go through other medical specialties as well, in much the same way as people would at the moment."
For the uncertain
Doctors unsure about their pathway can still apply for specialist training in an area they might like to do. Simon Calvert suggests that opting for a broad based programme, such as acute care, would be best for this group: "That then allows them to narrow it down, but they've had a chance to experience a variety of different fields. They might do some medicine, some intensive care, and some A&E [accident and emergency], which is all relevant to whichever future career path they might do. They would then be able to narrow it down to one specialty."
Credits
These proposals are not necessarily the way the training is going to shape up. What specialty training will actually consist of, and how focused career choices need to be after the foundation programme, is still under discussion (box 1). However, it is anticipated that the first years of specialist training will contain some generic medical, or surgical skills, and the early years will be similar across specialties. This means that everyone will obtain a series of competencies that are comparable across the specialties. Doctors will get credit for the competencies they gain and will be able to take them forward into a new specialty--they won't have to start again from the beginning.
Box 1
Use the same principles as current higher specialist training whereby a doctor applies for:
* Specialty streams
* Surgical specialties
* Medical specialties
* Anaesthetics
* Mental health
* General practice
* Paediatrics
* Obstetrics and gynaecology
* Radiology
* Pathology
* Public health
Broad based entry
* Community medicine leading to general practice, public health, medical specialties, paediatric, psychiatry
* Acute specialties leading to medical specialties, emergency medicine, intensive care medicine, paediatrics, anaesthetics, diagnostic specialties
* Surgical specialties leading to surgical specialties, radiology, obstetrics and gynaecology
* Diagnostic specialties leading to radiology, pathology, microbiology, chemical pathology
* System based medicine leading to neurosciences, skin sciences, thorax, vascular sciences, women's health, child health
Adapted from the BMA's slide presentation given at the Modernising Medical Careers conference in September 2004
Shorter programmes and shorter hours?
One stumbling block in the way of any new training programme, is balancing shorter training programmes with doctors working fewer hours to comply with the European Working Time Directive. How can such programmes still produce consultants with the current level of expertise?
Derek Gallen is confident that such programmes will deliver and will be more educationally robust than the current system: "The competency based training that will underpin the new framework, will give us a much better understanding of what these doctors can do at any stage in their training. This is a very open and transparent progression, so that the public and the profession are assured of the skills of the doctors. Doctors will have to have those competencies signed off."
He continues: "We're moving towards a lifelong learning model. So even if you're qualified as a consultant, you carry on training as some of the more in-depth and specialised training may come after someone has been appointed as a consultant." He also believes that a competency based framework will make it easier to work part time or flexibly and also to take time out as there will be specific skills, targets, and measurements to reflect doctors' abilities.
Role of the royal colleges
Royal colleges across the United Kingdom are currently looking at how specialty training can be adapted to meet the challenges of the Modernising Medical Careers agenda (see web extra). Under the reforms, they will determine the competencies and the specialty curriculum. The new Postgraduate Medical Education and Training Board (PMETB) will have to approve the curriculum and decide what is acceptable training and competencies.
Currently, the colleges are at different stages in their planning. Pilots starting in August 2005 include histopathology specialty training; a shortened urology training, focusing on uncomplicated "office based" surgery; and, in Leicestershire, a three to four year course in academic, general, and internal medicine.
Royal College of Surgeons
The Royal College of Surgeons of England recently announced their proposals for surgical training reform, prompting pejorative headlines in the press. Bernard Ribeiro, vice president of the college, is keen to emphasise streamlining training programmes rather than merely shortening them: "What we're trying to do is shorten the length of time SHOs spend milling around the system before they're selected into higher specialist training."
As surgical training moves from a time based mode to a competency based one, some surgical specialties will be shorter than others. Bernard Ribeiro explains: "Training might either be five years after the foundation programme or up to eight years."
The college hopes to have multiple choice question (MCQ) exams--like the MCQ part one of the membership of the Royal College of Surgeons (MRCS) exam--at the end of the foundation programme, and in the first year of specialist training, to select potential surgeons. This will be coupled with a portfolio from medical school listing interests and skills, together with various assessment tools assessing dexterity, aptitude, and innate skills.
The first year after the foundation programme will be called the "specialty defined year of training", and will be in the wider surgical area to allow trainees to try different surgical specialties. During this time, their competencies will be assessed using logbooks and reflective learning. At the end of that year, trainees will have to decide their specialty, which will be tested by an exam--MRCS part 2. If a doctor is successful, he or she will be selected into further specialist training and stay there until becoming a consultant.
The Royal College of Surgeons is currently working on the curriculum and is planning to pilot it in four deaneries early next year. Bernard Ribeiro acknowledges what this will mean for current consultants: "The college fully appreciates the huge burden that we're putting on our consultants, who will have the responsibility of training the new generation. At the moment, we're fairly concerned that there is no remuneration process."
He also thinks a change in surgical practice will help: "An impediment to training is that consultants do emergency work and daytime elective work at the same time. Consultants should be on call and have no elective commitments, or do elective surgery--not both. In this way, training opportunities can be taken up either in an emergency or elective setting. Work patterns need to change."
Royal College of Physicians
Currently, the Royal College of Physicians' official line is that they will continue with foundation year 1 and foundation year 2 and then have two years of specialist training, which they have renamed "basic specialist training." After this, trainees would take the membership exam and then apply for specialist training. This is similar to the current system. However, they may wait to see what happens to the Royal College of Surgeons before they finalise any plans.
Workforce problems
Simon Calvert is cautious: "For the colleges to say we can deliver training within this number of years, is looking at training from a workforce way. It's a quick way to increase the number of consultants by 2008--which is part of the NHS plan. But it doesn't really solve the workforce problem. Suddenly, if all those people who were doing service at a junior level were to disappear, the service would collapse, so there's going to have to be very clear transitional arrangements."
Fitting it all together
There's still uncertainty about how it will all fit together, how it will all be sustained, and what will happen to the service grades traditionally held by staff grade and associate specialists and those in trust grade posts.
Derek Gallen is optimistic: "Modernising Medical Careers would like all hospital posts after the foundation years to be training posts." But the year after foundation programmes is a contentious issue. All trainees will have followed a generic foundation programme so it may be difficult for selectors to determine aptitude and drive for a certain specialty. In this year, some trainees might make unsuitable early career decisions and others might want to gain more experience before they decide. And will their competencies be assessed during this year? Although a year's extra experience might be useful for the selectors, the Junior Doctors Committee is keen to avoid it.
Simon Calvert thinks than an "extra" year would be a mistake: "You'll get all the same problems that we've got at the moment. It will essentially become the year that everyone sticks in for a couple of years while they're building up their CVs, trying to make up their minds, and it will result in a bottleneck to try to get into specialist training. There must be a place on specialty training for everyone on the foundation programme."
He adds: "If people had spent a few years in between the foundation programme and specialty training, they will be more competitive and it will become an essential unspoken criteria."
What happens now?
For those about to embark on the foundation programme or applying for specialty training, this probably isn't very reassuring.
Simon Calvert thinks that piloting will be difficult: "We're going to need a good period of transition that allows people and the system to modify as it's going along. This hopefully will avoid the people on the old system--the current SHOs--or the people on the new system, being prejudiced."
However, Derek Gallen disagrees: "For those areas where specialty training or the foundation programme hasn't happened, the SHO posts will still be available. Those who have spent more time as an SHO will just find themselves going in at a higher level on to the specialty training. So they will be given credit for the time they've already had--they won't go back to the beginning. For example, if they've had two or three years as an SHO they won't go back to the beginning, they might go into the end of year one or two."
Selection
Despite the Royal College of Surgeons' proposals, it is still not clear how to select the right doctors with the right level of knowledge and competency for specialist training (box 2). One of the ideas in development is a "clearing house" system similar to the UCAS model operated by UK universities.
Box 2
* MniCEX, DOPS, and multisource feedback--A range of tools are currently being trialled in foundation programme pilots. They will combine assessments of the clinical encounter, tests on procedural skills, 360 degree assessments by clinical teams of a trainee's abilities, and direct patient feedback. Using independent judging and electronic recording of data, this new performance framework aims to deliver an accurate picture of knowledge and performance. The relevance and effectiveness of this new assessment programme will be validated as part of the foundation programme pilot phase.
* Sci45: the specialty choice inventory--Already widely used by local deaneries, this paper based and electronic system, developed by Dr Rodney Gale, aims to match the skills, aptitudes, and aspirations of trainees to a range of specialties. The tool can be used to confirm a trainee's choice of career path or provide early career guidance. Currently being used to evaluate the effects of foundation on career choice, it is hoped the tool will reduce the number of trainees opting for specialties for which they do not have the required personal traits or professional competencies.
* Electronic competency based selection--Already used widely in the selection of trainees for general practice, competency based assessment combines a range of test criteria to produce a system that is standardised, fair, defensible, and valid. Using specially designed assessment centres to measure attributes such as communication skills, problem solving, clinical expertise, and professional integrity, this competency based system has proved to be a more accurate test of future suitability than traditional panel interviews.
Adapted from a Modernising Medical Careers document
According to Derek Gallen, current plans would be to recruit a certain number of doctors into each specialty, depending on the needs of the workforce, once a year. Trainees successfully completing the foundation programme would enter a national matching scheme and would rank which specialties they would prefer to do, in the location they want to be. They would then be offered posts depending on their ranking and get an equivalent to a national training number.
Derek Gallen explains: "This system has a lot of merits. It would enable us to place doctors in areas that are 'under doctored' or under specialised, so in workforce terms it's very attractive. But it's possibly less attractive to doctors, who will have to move in order to fulfil their wishes to train in that specialty."
But ranking is another contentious issue and the final details about how it will work in practice, and what elements to score, remain undecided. But whatever happens Derek Gallen emphasises: "The new system will be open and transparent."
The key
For this to happen smoothly, both the Junior Doctors Committee and the Modernising Medical Careers working party stress the need for impartial, accurate careers advice for all doctors to allow them to make the right decisions about their future--something that is
hard to come by in the current system.
Simon Calvert thinks this is a considerable challenge, but necessary for doctors to make informed decisions and sensible applications, and the colleges have a key part to play: "It is important to ensure that the colleges do have shared competencies to allow people to change their mind about their career."
Derek Gallen assures: "This is work still in progress and people have got the opportunity to feed in ideas to the national team and there isn't a lot that's set in stone yet. However, we are working hard to improve the specialty training following the foundation programme."
Proposed specialty training adaptations
Deborah Cohen, student editor, studentBMJ
Email: dcohen@bmj.com
studentBMJ 2005;13:1-44 January ISSN 0966-6494
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