Should UK training programmes base doctors on one site for two years?
BMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j5235 (Published 14 November 2017) Cite this as: BMJ 2017;359:j5235
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I am excited to hear how the UK training programmes can be improved, but concerned about the comparison drawn between the British and North American systems.<1> The North American “residents” (equivalent to junior doctors) do not complete their training in one hospital only. They do rotate because each hospital has its limitations on clinical exposure. During on-call hours, some speciality seniors may even cover city-wide hospitals. However, their placements tend to be within reasonable traveling distance from one another.
The North Americans have shorter but wider variety of placements, each usually lasting 4 weeks. The residents complete many off-service rotations (i.e. outside their own specialities), especially in the first two years of training. This setup helps residents to understand the work process of other teams. For instance, obstetrics residents need to complete ICU and general surgery placements, so they learn how to make reasonable referrals to these teams in the future.
In contrast, a UK programme placement tends to last four to six months. It does not necessarily mean trainees becoming more familiar with the hospital, because they are restricted to only one area of medicine for months. Some of my Canadian GP colleagues cannot believe that the British GPs can finish their training without having completed one paediatrics or obstetrics and gynaecology placement.
I encountered one NHS teaching hospital which has no inpatient neurology, nephrology, vascular surgery service and thus limit trainees’ exposure in these areas. In North America, this kind of smaller hospital would be considered community hospitals, which are mainly run by attendings but not suitable for residents. It is important to note that the North American residents complete their training in one geographical location, mainly due to having run-through specialty training programmes for 5 consecutive years, and the luxury of writing their board exams near the end of their training. In contrast, the British trainees must apply to higher training every two to three years that could result in relocation. Failure at the Royal College exams in the middle of the training may be another reason for relocation.
Moreover, I question whether longer training in one hospital can lead to better incentives for quality improvement projects. If that were true, we should have seen superior projects among the foundation year doctors, most of which spend two years at the same site.<2> Audit and research projects are popular among the North Americans because these projects give applicants an edge in their residency and fellowship applications. The hospital academic leadership groups also strongly support these projects. In comparison, the UK GP application no longer evaluates applicants’ portfolios and quality improvement projects. Foundation year programmes select applicants mainly based on scores in exams and situational judgement tests. There are now talks on removing the Quality and Outcomes Framework incentives.<4> It is hard to blame some UK doctors for calling audits a ‘mundane tick-box exercise.’<3>
I also question whether longer training in one hospital can lead to better work coverage. The North Americans fully utilise their residents to ensure safe coverage in workplace. For example, GP trainees, who know the local systems well, are scheduled to fill the on-call rota in various teaching hospitals. This setup is very different from many NHS hospitals, which have trainees in unbanded posts, but rather pay expensive fees to external locum agencies to fill the rota. In fairness, I have British colleagues who rather earn less money than being paged back and forth to insert IV cannulas during a locum shift, which does not always have much learning value. If a NHS hospital has only limited number of local trainees available, I fear it will eventually threaten its trainees with GMC referrals for refusing to do extra locum work.<5>
If the British are to adapt the American residency system, we should first critically analyse why our own system fails, and evaluate how other systems succeed.
References
1. Baddeley R. Should UK training programmes base doctors on one site for two years? BMJ. 2017;359:j5235.
2. Cai A, Greenall J, Cai, Dau Col Dau Ding Andrew, Ding DCD. UK Junior Doctors’ Experience of Clinical Audit in the Foundation Programme. BJMP. 2009;2(3):42-45.
3. Glew S, Sornalingam S, Crossman T. Audit: time to review the cycle. Br J Gen Pract. 2014;64(629):606-607.
4. Spence D. QOF’s post-mortem. Br J Gen Pract. 2016;66(648):371.
5. Rimmer A. Junior doctors are threatened with GMC referral for refusing locum work. BMJ. 2017;358:j4037.
Competing interests: No competing interests
Baddeley puts forward a compelling case for the use of residency programmes in UK junior doctor training.
If piloted and implemented well, such programmes could be used to address many factors that are barriers to recruitment in acute specialities and contribute to low morale and burnout.
Countless doctors in training report lack of control over location of placements and late availability of oncall rotas as factors that impair work-life balance and contribute to low morale. In addition short placement durations, breakdowns in the traditional firm structure and rota gaps are challenges to continuity of both patient care and educational experience for doctors. Residency would enable planning for juniors in terms of life, housing, annual leave, childcare etc. In addition such continuity may enable juniors to make meaningful contributions to quality, teaching and research.
If we invest in our doctors in training and we will reap rewards as teams, departments, specialties and trusts.
Competing interests: No competing interests
Although I agree with Robin Baddeley (BMJ 2017;359:j5235) that there are many upsides to a ‘residency’ model and that the proposal “warrants a debate,” I feel you have significantly oversimplified things as there are far more than the two arguments (of being stuck in a ‘failing’ hospital, and a potentially limited array of specialty experience) you give against long placements.
There are significant benefits to trainees in experiencing differing ways of addressing specific clinical presentations with there often being cultural differences between institutions as much as there are between individual practitioners with some placing more emphasis on communication, others on statistics and others on previous experience, for example. The best way for a trainee to work out for themselves how they want to practise is by experiencing and trying these, and other, approaches for themselves and clearly frequent movement benefits this.
We are increasingly expecting our doctors to develop leadership skills and an understanding of how the NHS works, and indeed these are elements of almost all medical curricula, and again this is something that can be better addressed by allowing a trainee to see a wider variety of different models rather than significantly limiting this. Even if one trust is particularly good at engaging trainees in this area and offering good experiences, what about a trust that is below average, with a trainee not moving any time soon to experience better?
One can even question whether working in a ‘failing’ hospital is bad for trainees especially in the light of David Oliver’s recent article on supervision and clinical autonomy for junior doctors (BMJ 2017;359:j4659) as, from personal experience, it’s often these hospitals that give trainees the greatest freedoms to learn experientially.
You generally ignore the viewpoint of an employer or region that may be struggling to recruit. Working, as I do, in the North of England where we have significant recruitment issues in almost all specialties at every level this may well leave some of our hospitals that are already struggling (often due to geographical issues more than anything else) with an even greater issue as trainees will select other sites (or worse, regions) in preference thus creating a vicious circle.
Finally, despite agreeing that working in one setting for a prolonged period can have benefits with development of bonds between doctors there is always the possibility (as much in ‘exceptional’ as well as ‘failing’ hospitals) that a trainee may simply find working with certain individuals difficult and this forces the relationship, which although professional may never be comfortable, on both parties for far longer.
I wonder if the solution is more in considering extending rotations (for example from four to six months which would give many of your proposed advantages) than it is in extending time at any given site.
Fundamentally, however, I wonder if allowing individual regions to find a pattern that suits them rather than a national diktat is the way to go as is well addressed in the proposed new Internal Medicine Curriculum (https://www.jrcptb.org.uk/new-internal-medicine-curriculum) stating that “the exact pattern of individual rotations will remain a matter for TPDs as long as all the curricular objectives are fulfilled.”
Competing interests: No competing interests
Let's reinvent the wheel
Baddeley in Personal View November 18 and Oliver in Acute Perspective on the same page both comment on how the changes of the last few years have affected the training of juniors, and they are not the first to make such and similar comments. The answer is to reinvent the wheel - and bring back the old firm system. Today juniors have no sense of belonging to a hospital or department but are merely travelling through a series of jobs and rotas. Relationships between staff at all levels would be improved as would morale. To say things have progressed too far now and it's now impossible to bring back the old firm system is not satisfactory - a way must be found based on this .
Competing interests: No competing interests