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Pre and post qualification training and development - we want your views

As yet another shake-up of medical training is under discussion, the BMA wants to hear its members’ views on pre and post qualification medical training and development. 

This consultation is structured around a series of principles that we think must underpin the training and development of doctors. 

If you believe in high quality medical care, medical professionalism and the need to defend it, please read on and give us your views and experiences.  We will use the responses to this consultation to guide the BMA’s future policies and actions in this vital, fast-changing area.

We would like as much feedback as possible, but if you are not able to read the whole document, please go to the principles that most interest you.  

Please note that this consultation is for BMA members only, so you will be need to sign in using your usual website login information before following any of the below links. 

Introduction and questions 1&2 

Read an introduction to the consultation from Ian Wilson, chair of the BMA representative body

Responsive to the population's health requirements

Health needs are changing, and so the way health professionals are training may need to change too. Here we look at how medical training may need to evolve to keep up with the population's changing needs.

A process of continuous lifelong professional development

Medical careers are not static. In this section, we examine how and why doctors should never stop learning. 

Rooted in an ethos of professional excellence

The UK's doctors are professionals, not just employees. In this section, we look at what this means in the context of medicine, and how it can be maintained. 

Fair and inclusive

Medical careers and the training and development systems that support them must reflect the diversity of the medical workforce and the patients it treats. Here we look at how well this is working and what more work there is to do. 

A supportive process for learners and trainees

Doctors shoulder a great deal of responsibility. Here we examine how training and development must help them to help their patients.

Valued and supported, by employers and infrastructure

Without a strong and properly resourced infrastructure, medical training and development will suffer, ultimately to the detriment of patient care. This principle seeks your views on how robust the current structure is in this regard. 

12 replies

  • I am afraid training is at an all time low. Educationalists and the drive to competency has at best resulted in mediocrity and at worst widespread incompetence. Professionalism has been undermined by the nonsense of eportfolio and pointless appraisal. Trainees simply do not have enough factual knowledge and history taking has more or less disappeared to be replaced by "evidence based" care bundles or a cookbook approach to patient care. Unless we return to the basics of listening to the patient and addressing their problems in an honest fashion the future is bleak.
  • It has been obvious to senior consultants that the breadth, depth and competency of specialist trainees has droppe as a result of MMC and EWTD changes. This has had a profound effect on surgical trainees for whom there is no substitute for hours spent getting hands on experience both during 9-5 and out of hours. A small amount of 'guided independent operating' either parallel to a consultant's theatre or remotely supervised using camera/monitor technology encourages a safer degree of trainee decision making.

    As consultants we are constantly faced with trainees holding Trusts to 'ransom' for exceeding legal working hours when it suits then yet happily flouting these laws when offered extra paid sessions. This doesn't provide them with balanced 'firm based' training but simply puts them on full shifts that further reduces the quality of their training .

    We need an urgent review of EWTD exemption across all specialties that maintains training quality and avoids exhaustion and unnecessary calls out if hours.
  • The future of training is a huge issue, hence it needs to be simplified down in order to address the key failings of the Shape of Training and the failings of current training, which Shape completely fails to address in my opinion.

    First, do no harm - Shape has never provided any cogent justification for the major structural changes it proposes, our first intention should be to do no harm and Shape doesn't do this, it proposes major harmful and regressive structural change without a coherent evidence base or argument to justify such changes.

    Secondly what are the future needs of patients? Shape never answered this question or even set about even trying to answer it in a coherent fashion. The false dichotomy between generalism and specialism is totally nonsensical. In the UK many of us train to become generalists with specialist interests. Also the assumption that more patients will need less experienced subconsultant 'generalists' is based in think tank guff and cost cutting, rather than any real thought for quality of care and patients.

    Training time. To deny the importance of time served and experience is madness, and this is what Shape proposes, instead relying on poorly validated competency based assessments as 'outcomes'. Shape proposal to dumb down the consultant grade by effectively branding registrars as 'consultants' is regressive and dangerous, it should be resisted at any cost.

    Moving GMC registration. The problem with this proposal is how on earth will medical school graduates be trained to the level of those who have finished their FY1 year as claimed by Shape? This needs clarification as it appears total unachievable and potentially dangerous.

    Credentialing. There is no proven benefit to formal accreditation of competencies post completion of training, arguably it will simply create an expensive layer of bureaucracy that will cause multiple harms in the form of demotivation and hitting recruitment/retention, much like revalidation. Also the danger of having registrar level 'consultants' who are still training to achieve proper consultant status as we see it today, while being unprotected by training structures as they are not formally trainees and subject to the whim of their employers, should not be ignored. The introduction of credentialing has the potential of causing a lot of unintended harm while providing no clear benefit to anyone, including both doctors are patients.

    Therefore overall the case for major structural reform has not been made, the evidence base behind Shape is non existent, it relies on dogma and hot air from biased think tanks, not solid high quality evidence. Structural change should be resisted unless there is a clear proven gain to its introduction, as it abundantly not the case with Shape's potentially dangerous ideas (CST/shortening training/GMC registration moving etc).

    Further rambling here:

    http://ferretfancier.blogspot.co.uk/2014/12/the-shape-of-training-key-issues.html
    http://ferretfancier.blogspot.co.uk/2015/02/the-straw-men-of-shape-of-training.html
    http://ferretfancier.blogspot.co.uk/2015/01/credentialing-shifting-more-costs-onto.html

    There are numerous issues which Shape ignores which could easily be improved within today's structures and without the need for major structural changes, these include:

    -regulation is failing (GMC too conflicted, we need genuine independent regulation of LETBs which are too often allowed to mark their own homework)

    -trainees need to be listened to and asked the right questions (poor trainers should not have trainees and there needs to be far far more trainee input into the regulation of training)

    -experience needs to be valued and the current harmful over reliance on competency based methods needs to be rejected as it has failed (tick box assessments need to be moderated as they are potentially harmful in terms of demotivating and encouraging minimum standards - we need a more qualitative less burdensome system which encourages excellence)

    -poor training posts need to be removed quickly and this can only be done if service is less dependent on trainees

    -teams are vital for patient care and learning, work needs to be done on reintroducing structures which support this continuity and team based structure


    Therefore Shape needs rejecting in full, the review has been too conflicted and methodologically flawed to be used in any form. We need a new open and transparent discussion about the future of training which looks at training quality and nothing else, not the needs of self interested short termist employers or self interested politicians.

    Unless training is made the sole priority of a review of training, we shall continue to destroy standards by pursuing the short term needs of career politicians and not our patients.
  • In reply to James Michael Glancy:

    I cannot agree more. The ePortfolio interferes with knowledge gain. I genuinely believe that patients want doctors who know medicine. I am horrified by my juniors' lack of knowledge about standard core medicine, and horrified at the time spend examining their own navel. I have been in this profession for 35 years and never has knowledge been considered such a low priority as now. Please can we ensure that ALL doctors who design teaching curricula are PRACTISING doctors as those teaching alone have lost sight of reality.
  • In reply to Jill Belch:

    Absolutely agree, the current system can be summed up with 3 no words, no team, no role model and no curiosity
  • I used to enjoy teaching, and went to considerable effort to make it interesting for the students and trainees. Then along came Work Based Assessment and the ghastly ePortfolio. I was unable to fully complete my Educational Supervisor form at my last appraisal (at least partly because I didn't understand the titles of every section), and rather than make stuff up in a language that I don't speak it seems easier to simply give up the role.

    How have we let medical education be ruined like this? I'm afraid endless reflection will never reveal the nerve supply of Teres Major, and worse still, a system that justified itself partly on the prevention of unsuitable juniors' progression seems to make it easier for them!

    All that is necessary for the triumph of useless educational reforms is for most of us to do nothing.
  • Medicine is a practical science. There is no substitute to getting hands dirty. Trainees are protected these days like kids and will remain kids if training continues like this. It takes an experienced Clinician only few minutes to assess how good the trainee is. No bits of paper will give that information ever. I have seen trainees with extremely well written pieces of paper but in terms of practical conduct, they are very poor. Pre Calman, training was not structured but far more rigorous. Post Calman, it has slowly descended into organised shell with not much substance. The clinical acumen is fast declining. I am afraid this shape of training doesn't address any of these issues. Solutions are to get rid of EWTD, Training portfolios should be replaced by a brief report by trainer (team leader) annually. Trainees should be part of a team for at least one year in one hospital, following the team's rota including emergencies, looking after the team's patients.
  • In reply to James Michael Glancy:

    I am a GP trainee, and agree entirely with the comment about e-portfolios. I'm not sure if there can be another specialty which requires as much naval-gazing and as little medical knowledge in order to have a successful appraisal. I have just spent the last two hours rating myself on competences such as 'community orientation' and 'communication'. This has done nothing to make me a better, more competent doctor - I have to set aside 'learning' time as a separate entity from 'e-portfolio time' as the two are simply not compatible.
  • Sir(s),

    It is fascinating to see so many negative thoughts on the subject of medical training. I had thought that I was merely being old fashioned and reactionary. And yet, how depressing it is to see that we have allowed ourselves to be pushed into this mess. One would have hoped that a sensible body of intelligent and motivated people would have had more foresight.

    My own story is not very interesting except as an opportunity to view "then" and "now" from the same perspective.

    I am a 60 year old doctor who had the misfortune to be misdiagnosed with Alzheimer's disease when in his 40's. Naturally, I left medicine and had my name voluntarily removed from the GMC register. However, once my Thyroid problem and associated depression was sorted, the Alzheimer's disease was cured. I only mention this story here as my absence from medicine made it prudent to return to medicine as an FY1, what we, in the old days, would have referred to as a Junior House Officer. I have therefore had the unique experience of seeing medical training in the 1980's and in 2010.

    In the old days, the JHO / FY1 was put to work in a ward working between 72 and 120 hours a week. We had our twenty or so patients and we saw them from the time we clerked them in to the time they were discharged. We were well supported as art of a team. If we were in difficulty, we had the Senior House Officer to call and the SHO could call upon the Registrar and he, in turn, could call upon the Consultant. The Consultant used to do a daily ward round and took time to teach. The JHO would present all the cases and if he/she forgot any significant points, the SHO could always be relied upon to know the serum rhubarb. The Consultant would note any features of interest and invite you to listen to that heart murmur you missed at 3.00 in the morning.

    The Consultant saw you each day, including the week ends when your team was on duty, and so formed an insight into your stregnths and weaknesses. No need for e-portfolis back then, (we were blessed by a complete absence of computers!). The person responsible for your advancement knew you.

    I compare then and now. I returned as an FY1 in 2010 as I thought it would be safer to work under supervision. Some things had changed. You used ß blockers in heart failure which took some getting used to! But, more importantly, the link between the Junior FY1 and the Consultant was weakened. The Consultant seemed to be under greater pressure of work and might only visit the ward fleetingly to see any problem patients. The teaching element of the job seemed much reduced. Even on a cardiology unit, the invite to listen to that interesting heart murmur was absent. Matters were not helped by the EWTD which means that there is no continuity of care. The FY1, unlike his predecessor, the JHO, no longer follows through the patients' progress from admission to discharge. Worse still, in the unlikely event that the FY1 gets to clerk-in a patient, he isn't present to present the case to the Consultant and learn what has been missed, overlooked or misinterpreted. Thus the FY1 is left in the precarious position of getting no feedback.

    On the Acute Medical Admitting Unit, the situation is even worse. There is just NO training element to the job. The FY1 scuttles between the ward round and the computer entering requests for tests or looking up results of tests for patients he has never seen. In previous years, the appropriate Royal College would have deemed that the job was not suitable for training purposes. Now we rely on e-portfolios.

    We also rely upon "Clinical Audits" to progress careers. If we do a lot of Clinical Audits, these earn us "brownie points" on the computer system which will enhance our chances of getting the right job. The danger of this process was bought home to me by my observations on the Cardiology Wards at an unnamed hospital. A really decent, likeable junior doctor there wanted to be a Cardio Thoracic Surgeon. He was brilliantly clever and did lots of audits to further his career. The only problem was that he had two left thumbs. He had no manual dexterity what so ever. In the old days, his Consultant would have noted this and guided him into a career in Psychiatry or some area of medicine where his difficulties would not have put either himself or his patients at risk. The Computer is not able to make this determination and so time and expense will be wasted on training this chap to nobodies' advantage.

    I noticed that the rotation on a ward has been reduced from six months to only four. This coupled with the EWTD has reduced a Junior Doctor's exposure to the ward environment by a third resulting in the emergence of the ECG Lady and the Phlebotomist. The result is that Juniors are becoming deskilled. My wife was admitted to the Acute Medical Unit one night in November. I had to show the junior how to do an ECG, help him read it and then do the bloods as he couldn't access the vein. And yet he was the one with all the competency boxes ticked.

    Juniors' training has been harmed in more subtle ways also. In the old days, an SHO would choose his next six month rotation with care. He would telephone the current incumbent in the job and ask what it was like. He might be told that there was little training or that it was a busy job but the training was fantastic. Based on these informal references, the SHO would then apply for the job that best suited his career and training. Thus, good Consultants attracted the best SHO's. Similarly, the Consultants got to choose who would work for them. They had references from the SHO's previous jobs and an opportunity to interview the candidate to see if they would fit in with their team. Now choice has gone. A computer decides who goes where and bad jobs are lumped in with good ones so now nobody has an incentive to offer the best training.

    As a profession, we need to be much less compliant and stand robustly for what is right. Somebody has built their little empire on this training fiasco. We recognise that it isn't working. We knew it wouldn't work and yet we did nothing and continue to do nothing to correct the situation. Armies of administrators now govern our post graduate training. Where has that money come from? Or more importantly, what front line services have been hit to pay for this bureaucracy?

    The wastage of both money and personnel is horrendous. We have just been through a general election and nobody can be left in any doubt about the state of the NHS finances and the shortage of doctors. And yet the haemorrhage of money and talent continues unabated.

    The European Union, in addition to giving us the EWTD, also gave us Directive 2005/36/EC on the recognition of professional qualifications which has lead to the GMC's GP and Specialist list. I mention this latter as it has excluded some 250 doctors from being GP's.

    I fully completed my training in General Practice in 1987- 1991 but went to work for the Home Office as a GP firstly in the Immigration Detention Centres and then in HM Prisons. I ended up as the Senior Medical Officer in a local prison with a 25 bedded hospital wing. Unfortunately, it was at this time my Thyroid started playing up and I was diagnosed with Alzheimer's Disease. When I returned to medicine, the rules regarding training had all changed and I was no longer allowed to be a GP. The GMC said that they would be delighted to place me on their GMC's GP List just as soon as I retrained. Health Education England said it would be delighted to retrain me, but first I had to be on the GMC's GP List!!!! What a waste of time and effort. The GMC informed me that there were 250 odd doctors in my position.

    What is worse is that General Practice was much richer for the steady flow of doctors from hospital practice who, for personal or professional reasons, decided to make a career in General Practice. The two GP's who helped me through medical school and postgraduate training had come from a hospital background. The one had been a surgeon and the other a pathologist. That flow has ceased with the introduction of the GMC's lists and the new training directives. The result is that we are chronically short of GP's. Instead of addressing the root cause of these difficulties we are debased into a routine of calling for more money.

    As a profession, we need to be accountable not only to our patients who trust us to do our best, but also to the tax payer who funds this NHS. I would argue that, just as it would be unethical not to do our best for our patients, so it is just as unethical of us to allow this waste of money, recourses and training to go unchallenged. We need to take charge of our own profession and refuse to comply with administrative burdens that harm patient care.

    Dr. Steven R. Hopkins
  • In reply to Steven Hopkins:

    Very well said. As someone who also trained in the 1980s, has two children who have recently gone through the debacle we now call FY1 and 2, then into GP ePortfolio nonsense, and as someone who is now one of those consultants who can see 7 different FY doctors in one day and never get their names, I could not agree more with your synopsis.
  • I think the one line for me that stuck out for me when reading up on shape and submissions was one from the RCOA with regards to a question on how to ensure doctors got the right breadth and quality of training. Part of the answer was that " The current model of shoe-horning training around service delivery is unsatisfactory and there will be a need to separate service from training at least for some sections of the training pathway."

    To truly improve training we need to fundamentally change the way we train people, and it starts with recognising trainers. Trainers being given the adequate time and resources to look after their trainees, trainers picked for the fact that they have been taught to do so and not just been on the half day course and taught to give feedback.

    I spoke to a consultant anaesthetist who worked in America for a time. While I generally detest North American comparisons, he said that their method of training involved trainees being placed in a specific hospital with a specific list of objectives and things they must see and experience and learn. If placed on a neurosurgery module they would fill in their logbooks weekly online and their training programme director would oversee those logbooks on a weekly basis and if found to be missing particular parts of their objective - the head of that department would be called to find out what was wrong and why wasn't that trainee getting that experience and they had better sort it out or the TPD would be forced to fail that trainee. In the UK my logbook gets a cursory look at once or twice a placement - The TPDs look at in once a year at ARCP with all the attendant bits of assessment I have generally asked my consultants to sing while I filled in most of the detail. My point is for that TPD to have that much of an eye on their trainees requires that they get more than one PA (or even half a PA) of time to do that and training needs to be recognised as an additional duty as much as being the clinical lead or the medical director.

    If we can develop proper trainers and proper assessments that actually reflect the knowledge gained with less of a focus on service provision and more towards training then I can see no reason why most training programmes wouldn't not be able to shorten their training programmes by about a year. Crucially this does also require more consultants so that the bulk of service provision moves to consultants, or at least a consultant presence so even on calls have a focused training element to them.