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MODERNIZING MEDICAL CAREERS – How the system is changing and how overseas doctor will be affected
GME
in Pakistan GME in
THE UK GME in THE
USA
In August 2002, The Chief
Medical Officer of the
UK
published a paper called "Unfinished Business, Proposals for Reform of the
Senior House Officer grade”. It had been recognized for years that the General
Professional Training administered through the SHO system had many drawbacks.
This paper proposed changes to the SHO grade in order to remove those flaws.
Subsequently, a body was set up, called Modernizing Medical Careers (MMC)
to implement these changes.
The reforms that are being
introduced to replace this system are far from universally approved. Many
doctors in the UK
feel that the reforms suggested by Unfinished Business have as many drawbacks as
the system currently in place. Be that as it may, the reforms are due to start
on a national level in August of 2005 and only time will tell how effective they
will be in improving the current system and (more importantly for us) how
overseas doctors will be affected by them.
The previous section
“Postgraduate Medical Education in the UK” described the structure of the system
in place at the time of writing (January, 2005). This current system will begin
to undergo massive restructuring starting from August 2005 to be completely in
place by August 2007.
Before getting into the details
of the proposed new system, here is a summery of how the present system works -
currently, when a doctor ends his PRHO post, he actively competes for SHO posts
in a variety of specialties which lasts for 6 months each. He does this for a
period of years during which he completes his Membership in one of the Royal
Colleges. After doing so, he competes actively for Type I SpR posts in a certain
subspecialty, or failing that, enters into a staff or trust grade post.
In order to understand the
proposed new system, you need to understand the old one first so you can
correlate the two. To this end, in the text that follows, I have emphasized the
correlation between the current system and the proposed new system in order to
provide a point of reference from which the new system can be better understood.
In the text that follows, my statements of correlation will begin with the words
“Compared to the old system…”
For convenience’s sake, the
present system (that is, the one still in place as of January, 2005 – the time
of this writing) will be referred to from now on as the “old” system and the
system set to be introduced in August, 2005 will be referred to as the “new”
system.
In the new system, after
British medical students graduate, they will enter a 2-year Foundation
Programme.
The first year of this
programme is called Foundation Year 1 or FY1. Starting August
2005, all British medical graduates will automatically enter
an FY1 post. FY1 consists of 3 rotations each lasting 4 months - one in
medicine, the second in surgery and the third in another specialty.
The PRHO post of the old system
will no longer exist as the FY1 will move in to take its place. However,
compared to the old system, in content and availability of posts, FY1 closely
resembles the PRHO post - and as such will represent the same level of
difficulty for overseas doctors to attain.
After completing 12 months in
FY1 the doctors will move on immediately to Foundation Year 2 or
FY2. This will happen in August, 2006 – the date when FY2 will be
introduced nationally.
The FY2 is a completely new
grade, which did not exist previously. Compared to the old system there is no
counterpart for FY2. The FY2 will consist of 3 rotations (in 3 different
specialties) lasting 4 months each. Besides specialty-specific exposure and
training, FY2 doctor will be also be trained in the following “generic” skills:
·
Clinical Skills
·
Effective
relationships with patients
·
High standards in
clinical governance and patient safety
·
Use of evidence
and data
·
Communication,
team working, multi-professional practice etc.
·
Understanding of
the different settings in which medicine is practiced
·
Care of acutely
ill patients
The FY2 was created in order to
train doctors in essential generic skills which will be of use to them
regardless of the specialty they end up pursuing. Besides this, exposing doctors
early on to different specialties will, theoretically, give them a chance to
sample different specialties so they stand a chance of making a more informed
decision of the specialty they wish to pursue later on. Compared to the old
system there was no such post that actively concentrated on these generic
skills. In effect, the FY2 post is seen as a major innovation to the UK
post-graduate medical system.
During their time spent in FY2,
the doctors will be actively assessed by their supervising consultants. In such
assessments, the FY2 doctors will have to practically demonstrate that they are
competent in the generic skills listed above. If they succeed in doing so, the
fact will be formally documented.
In other words, during the
course of the programme, the doctor does not need to give any membership exams
to prove his competency. His documented assessments will be the qualification
needed to move forward after he finishes the programme. This form of assessment
is called “competency based” – i.e., a positive assessment will be
written for him only when he practically demonstrates his competency to his
supervisors - not by passing some exam. Competency-based assessments is a
recurring theme in the MMC reforms, and may have significant consequences for
overseas doctors, as we shall soon see.
Ultimately, the first batch of
“foundationers” will finish the programme in August 2007 and move on to
the next stage.
According to a November 2004
Careers BMJ issue,
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 specialist training to be in place. The Modernizing 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.”
Whatever structure it takes,
the next step after the Foundation programme will be to enter an coherent and
well-structured specialist training programme. In other words, once you enter
the programme that follows the Foundation posts, you should not have to compete
for jobs every 6 months, but continue to remain in the same training programme
for least a number of years. By contrast, compared to the old system, doctors
would have to compete regularly for SHO posts.
Entry into the programmes
following the Foundation programme would be made on a competitive basis. The
criteria for selecting a candidate will be his competency based assessments,
which were made during his time in the Foundation programme. There is no
parallel to this compared to the old system. That being the case, an overseas
doctor may find it difficult to secure his place in a post-foundation programme
without having gone through the foundation programme himself.
As the issue of what will
happen after the Foundation programme has to be faced in August 2007, the
structure of the post-foundation programme has not yet been formally agreed upon
at the time of writing (i.e., it is “still up in the air”). However, currently
the consensus is that a post-foundation programme will follow one of the
following two formats:
The First Proposal
The first proposal is that FY2
should be followed up a 2-3 year Basic Specialist Training, BST (Keep
in mind that if the BST proposal is adopted, it will start from 2007. Therefore,
currently the term ‘Basic Specialist Training’ is not in widespread use. I am
pointing this out to avoid possible confusion with another BST acronym which
stands for Basic Surgical Training. This is a simply 3-day course offered to
junior doctors in surgical specialties. It should not be confused for the Basic
Specialist Training).
Compared to the old system, the
BST is equivalent to the General Professional Training (GPT) a doctor attains
during his different SHO posts. Therefore, a doctor in a BST program in the new
system would be equivalent to an SHO in the old system.
The BST will be offered in one
of the following 8 specialties:
·
General Medicine,
·
General Surgery,
·
Child Health,
·
General Practice,
·
Obstetrics &
Gynecology,
·
Mental Health,
·
Anesthetics,
·
General Pathology
If a doctor decides to enter a
BST programme in General Medicine, he would be rotated through different
specialties for those 3 years and will have to complete his MRCP(UK)
qualification during that time. Compared to the old system such well-planned
rotations through the different specialties of medicine (or any other specialty)
was very difficult for overseas doctors who were compelled, by the difficult job
situation, to take whatever SHO rotations they could get.
The BST programme will be a
continuous, uninterrupted contract lasting 2-3 years (depending on the
specialty). After the doctor gets the contract, he will not have to compete for
a job until his BST is over. During the BST, he will study for and complete his
membership in the Royal
College
of his specialty. (This is actually very similar to the Residency programmes of
in the US system.)
Compared to the old system, the
attainment a membership in a Royal College was up to the SHO. He could stay in
SHO posts for years and not gain membership. In the new system however, he would
have to finish his membership during his BST training period. Once his BST is
over, the doctor will compete for a place in a Higher Specialist Training (HST)
programme for training in a subspecialty. If for example, after finishing a BST
in General Medicine, a doctor wishes to enter a HST programme in Neurology, he
would have to compete for such programmes using his ‘competency-based’
assessment profiles of the preceding years of his career as well as other
qualifications he has picked up (by “Growing his CV” - which is explained
below). Once he enters the HST programme, he will be given an NTN/VTN and
continue for a number of years, without having to compete for jobs, until his
HST is over. During the course of this HST programme, he will earn his CCST,
Certificate of Completion of Specialist Training and qualify as a consultant.
Compared to the old system, the
HST programmes are not a major innovation. Remember, the MMC reforms are aimed
at improving the training of junior doctors in the SHO grade. Doctors in HST
programmes are not junior, and so this part of the system has not been changed.
Even in the old system, the HST programmes were multiple-year contracts in which
the doctors were allocated VTN/NTN numbers. Therefore, this part of the old
system and new system are the same. The grade of a doctor in an HST programme
will be SpR, just as it was in the old system.
The following diagram
illustrates the new system.
The Second Proposal
The second proposal is to unify
the BST and HST programmes into one seamless programme that lasts 4-8 years
(depending on the specialty). This scheme has been nicknamed the “run-through”
grade – in that the doctor will come straight out of the Foundation programme
and “run-through” a single, unified 4-8 year programme towards a
consultant-ship.
The first few years of this
“run-through” programme would involve training in the generic specialty, and not
the subspecialty. For example, if a doctor entered a “run-through” programme for
Gastroenterology, he would not be exclusively trained in just Gastroenterology
for the whole 8 years, but be exposed in the first few years to all the other
Medical sub-specialties as well.
Compared to the old system, for
the first few years of the “run-through” grade, the doctor would be equivalent
to an SHO of the old system while the latter years, he would be equivalent to a
Type 1 SpR.
Using Both Proposals
It is quite possible that the
different Royal Colleges will adopt different proposals. Currently, it is
thought that the Royal College of Physicians prefers the first proposal while
the Royal College of Surgeons is leaning towards the second. However, in either
case, the doctors will be inducted to the programmes following the FY2 on the
basis of their competency-based assessment profiles during their time as “foundationers”.
This is a significant point for overseas doctors as we shall see below:
The only difference between the
two proposals is that while in the first, the BST and HST are separated, in the
second, they are unified. Therefore, for the sake of simplicity, in the text
that follows, I will refer to the grade following the Foundation programme as
the BST grade.
The short answer is: no one
really knows for sure. Some people say it will improve matters, while others say
it will make things worse. What is clear however is that most overseas doctors
will enter the programme in FY2, not in FY1 (which will be as scarce as the PRHO
posts of the old system).
We will only really find out
what consequences the Foundation programme will have for overseas doctors after
August 2006 when the FY2 is formally introduced. However, in my opinion, things
will stand to get a lot harder for overseas doctors in 2006. This is why I
believe this to be the case:
One of the fundamental
principles behind the “Unfinished Business” reforms is to guarantee continuity
of training. In other words, the training of junior doctors should progress
seamlessly from one programme to the next, with the next programme building on
the progress made in the first. Therefore, the training programme(s) after
FY2 will be designed in such a way as to build upon the training imparted
during FY2.
Resultantly, the consultants
hiring junior doctors into programmes that follow FY2 will assume that the
doctor applying has all the generic skills demanded for the successful
completion of the FY2. The only way to prove that a doctor has these skills is
to have favorable “competency-based” assessments – and these can only be
attained by going through the FY2.
Therefore, it follows that when
the FY2 is over and doctors start competing for the post-foundation programmes,
the consultants hiring people into these programmes will actively prefer
doctors who have spent a year in FY2. These FY2 doctors will have
competency-based assessment profiles that prove they have the generic skills
needed to enter the post-foundation programmes.
Overseas doctors may very well
have the same generic skills, but coming from a different medical education
system, they may never have been able to formally document them.
Consider again the generic
competencies that an FY2 doctor is supposed to have attained:
·
Clinical Skills
·
Effective
relationships with patients
·
High standards in
clinical governance and patient safety
·
Use of evidence
and data
·
Communication,
team working, multi-professional practice etc.
·
Understanding of
the different settings in which medicine is practiced
·
Care of acutely
ill patients
An overseas doctor may know
precisely how to establish an effective relationship with patients, or how to
work in a team, or understand the different settings in which medicine is
practice – but how will he prove it? While the FY2 doctor will have been
actively assessed by his seniors, the overseas doctor will not have had the
advantage of such documented assessments.
This leads us to the possible
creation of an immense problem: If FY2 doctors are going to be actively
preferred for post-foundation programmes, then every overseas doctor coming to
the UK in the next few years will concentrate on applying for this one grade,
the FY2 because obtaining this post will maximize his chances of getting into a
post-foundation programme. Currently, overseas doctors can apply for SHO posts.
SHO posts don’t have a clearly defined, hierarchical place between the PRHO and
the Staff-grade/Consultant grade post. The SHO posts are currently a set of jobs
that fill the blank needed to get the Membership training experience. With the
advent of the FY programme, this vague gap will be removed. From 2007 onwards,
junior doctors will either be in a Foundation program or in a post-foundation
programme. Since the surest way of obtaining a post-foundation programme is to
come from a Foundation programme, and since the only entry level for overseas
doctors will be an FY2, overseas doctors will descend, in their thousands, on
the limited number of FY2 posts in the year 2006.
Keep in mind that this is
speculation (and my own personal theory at that) and may prove not to be the
case. For example, one could argue that the NHS is actually introducing a new
grade: the FY2. And because of the introduction of a new grade the job situation
may not change appreciably.
The fact that I’m speculating
at all, and not citing references and sources that give precise predictions of
what will happen should in itself communicate the fact that great uncertainty
prevails with regards to this issue amongst the overseas doctors community in
the UK.
Another likely effect of
introducing the Foundation system is a reduction in the “job season” from twice
a year to once a year. Currently, in the SHO system, the jobs are available in
February and August. However, with the Foundation system, since the FY2 (by
definition) is a one year contract, they will only be advertised once a year
(before August)
It is also unclear how easy or
otherwise it will be for overseas doctors to enter the BST programmes even if
they have done the FY2. Will the traditional bias against overseas doctors
hoping for a training post that leads to an CCST prevail and carry over when
they apply for BST programmes? Will overseas doctors be given 1-year (or less)
stand-alone contracts in the BST programmes? And how difficult will it be for
overseas doctors without an FY2 qualification to enter directly into BST?
These are questions to which
those in the Modernizing Medical Careers themselves don’t have confirmed,
guaranteed answers. We will all find out when the times comes, that is 2007 when
the BST programmes are scheduled to start.
This sub-section should convey
to you the uncertain job situation for overseas doctors of the next couple of
years and encourage you to keep abreast of the situation in order to maximize
your readiness when the time for the move to the UK arrives. No doubt, the
situation will become clearer somewhere in 2006 as the Foundation ‘graduates’
enter the next stage. | 
