Steps in the right direction—changes to the UK foundation programme are welcome

Dear Editor,

With changes to the application process for the two-year foundation programme in the United Kingdom, it is only fitting that we critically examine and evaluate the upcoming changes. Building upon the insights provided by Han et al. in this recent BMJ article, we wanted to shed light on the benefits and potential pitfalls of the revised system (1). While the reform addresses significant concerns, such as reducing stress and anxiety for applicants, it is crucial to carefully consider the impact on academic motivation and the principles that have traditionally guided medical school entry and specialty training.

Under the previous system, allocation to foundation training programmes relied on an amalgamation of the educational performance measure (EPM) and situational judgement test (SJT). However, the new preferred informed allocation system replaces this approach with a computer algorithm that randomly assigns applicants based on their preferred deaneries, increasing students matched to their preferred deanery by 5.6%.

Undoubtedly, one of the notable advantages of the revised system lies in the elimination of the highly stressful situational judgement test (SJT) exam. As attested by a survey, a staggering 85% of medical students reported experiencing significant stress due to this examination (2). Furthermore, the fear of not securing their desired location and potentially losing their social network played a significant role in students' preferences for certain deaneries (3). By removing these stress-inducing elements, the revised system strives to create a more positive experience for applicants and alleviate anxiety.

While reduced stress levels are undoubtedly beneficial, we must not overlook the potential drawbacks of completely abandoning the educational performance measure (EPM)-SJT allocation method. This change may inadvertently lead to a decrease in academic motivation and performance among students. Numerous studies have highlighted the direct correlation between academic mindset, performance, and junior doctor competency (4)(5). The revised system's competency-based approach with a binary outcome raises concerns about the abandonment of meritocratic principles that have long governed medical school admissions and specialty training. It risks undervaluing the accomplishments of high-achieving students who have diligently pursued academic excellence.

Although the elimination of the SJT exam is a positive step, it is worth considering the practices of other global training programmes that distribute stress more evenly. Multiple exams required by these programmes ensure that the burden is shared among candidates, preventing undue pressure on a single assessment (6). Furthermore, the removal of the EPM component may inadvertently trigger a surge in applicants competing for deaneries in London, potentially reducing the number of individuals matched to their preferred locations. Predictions of a 5.6% increase in preferred deanery allocation may not adequately account for prospective changes in student preferences (2).

Advocacy by students for acknowledgement of medically related degrees and extracurricular activities warrants serious consideration. While these activities enrich medical students' training, the former and new systems fail to consider them. However, implementing such systems must be approached with caution, as they could potentially discriminate against disadvantaged students. Balancing the pursuit of equality in opportunity with a holistic approach should be a priority across all medical schools. The current reform, emphasising equality in outcome, may inadvertently compromise the broader objectives of inclusivity and support for students from diverse backgrounds.

We propose a balanced allocation method that incorporates standardised medical exams and extracurricular portfolio assessment. The UKMLA would constitute 80% of the application, while the remaining 20% evaluates extracurricular activities. Optional mock assessments by medical schools would aid student preparation.

In conclusion, we believe the upcoming changes to the application for the two-year foundation programme require careful evaluation of their advantages and disadvantages. Any changes should take into consideration student wellbeing, inclusivity, motivation, and achievement.

References

1. Han O, Lee R. Steps in the right direction-changes to the UK foundation programme are welcome Changes to the allocation system for foundation training may help to reduce the academic pressures on medical students, argue Oscar Han and Reagan Lee. [cited 2023 Jun 27]; Available from: http://dx.doi.org/10.1136/bmj.p1372
2. Major Change To Foundation Programme Allocation Process For 2024 Recruitment | Health Education England [Internet]. [cited 2023 Jun 27]. Available from: https://www.hee.nhs.uk/news-blogs-events/news/major-change-foundation-pr...
3. Miah S, Pang KH, Rebello W, Rubakumar Z, Fung V, Venugopal S, et al. What factors influence UK medical students’ choice of foundation school? Adv Med Educ Pract [Internet]. 2017 [cited 2023 Jun 27];8:293. Available from: /pmc/articles/PMC5404492/
4. Carr SE, Celenza A, Puddey IB, Lake F. Relationships between academic performance of medical students and their workplace performance as junior doctors. BMC Med Educ [Internet]. 2014 Jul 30 [cited 2023 Jun 27];14(1):1–7. Available from: https://bmcmededuc.biomedcentral.com/articles/10.1186/1472-6920-14-157
5. Wilkinson TJ, Frampton CM. Comprehensive undergraduate medical assessments improve prediction of clinical performance. Med Educ [Internet]. 2004 Oct [cited 2023 Jun 27];38(10):1111–6. Available from: https://pubmed.ncbi.nlm.nih.gov/15461657/
6. AMC examinations (Standard Pathway) [Internet]. [cited 2023 Jun 27]. Available from: https://www.amc.org.au/assessment/amc-examinations-standard-pathway/