Modernizing medical careers: an open letter to Royal College Presidents

Abstract

I write to persuade you that the Royal Colleges' current policy of cooperating with the government and the postgraduate medical education and training board in implementing post-foundation medical training is not in the best long-term interests of either patients, future consultants, general practitioners or the Royal Colleges; all of whom will rely on a cadre of well-trained GPs and specialists to be the backbone of a service buffeted by incessant reform. Led by the Royal Colleges, our current system of postgraduate training has evolved over centuries. Educational enthusiasts from every branch of British medicine developed a system of training and examination regarded by our overseas peers as an example to aspire to. Doctors came from all over the world to take college examinations and developed links with this country that persist to this day. As a result of its evolutionary nature, there were inconsistencies between the training and assessment methods of different specialities and colleges. Nevertheless, standards of education and training have steadily improved to produce GPs and specialists whose abilities were respected world wide. Intercollegiate examinations and modern methods of formative and summative assessment were also making good progress in ironing out inconsistencies. So why have we been seduced by government into embarking on wholesale chaotic change that is causing our most talented graduates to consider emigration and senior colleagues to worry about the standard of care they will receive in old age? A number of influences have changed our training environment. Harmonization of training with Europe (Calmanization)1 appeared feasible, however the juggernaut of the European working time directive,2 applied with regulatory zeal by NHS human resources departments, has destabilized the traditional apprenticeship model of training. The Royal Colleges' ability to reduce the productivity of the NHS in the interests of training has always been viewed as an irritant by government. The creation of PMETB, under the control of the Secretary of State3 was deliberately designed to allow politicians to change the training of doctors at will. At a stroke the fox had entered the hen coop. Where has this led us? Initially the Chief Medical Officer proposed a reform of the post qualification pre-registration year.4 The drudgery of house jobs was to be replaced with an enlightened curriculum providing a broad training whilst acquiring core competencies. This 2-year programme has been welcomed by the profession, but the upheaval of this alone will keep everyone fully occupied in the new training and assessment tasks necessary for its success. The mischief really started when, under the Modernizing Medical Careers agenda, the Government produced a proposal to abolish senior house officers and create `seamless' specialist training,5 churning out narrowly trained `specialists' at the end of a further 4-5 years. Despite considerable misgivings, the colleges agreed to help to implement this, relinquishing their inspection and regulatory role to the Secretary of State assisted by postgraduate medical education and training board. Sweeping cuts to deanery budgets immediately followed. What has gone wrong? It may be helpful to look at this in terms of: The selection process with its manpower implications The quality of the training itself The likely output at completion of training.