BMJ  2007;335 (22 September), doi:10.1136/bmj.39343.610613.47

Editor's Choice

Training our doctors

We have pondered the BMJ's coverage of the UK's crisis in specialist training. Our critics might characterise it as too much too late: too much for readers outside the UK, too late to have influenced decisions being made behind closed doors and to mitigate some of the heartache, upset, and upheaval.

Amid the long list of factors that contributed to the tsunami of MMC and MTAS (well described by Madden and Madden recently: BMJ  2007;335:426-8 doi: 10.1136/bmj.39300.591632.DE) one factor has been studiously avoided in most discussions—medical immigration. Difficult though it is to raise, it cannot be ignored.

We decided a few months ago to commission a head to head debate on whether UK training posts should be reserved for UK graduates. Then a few weeks ago Graham Winyard, a former postgraduate dean, sent us an article on the same question. So this week we devote some space to what Winyard calls "the elephant in the room."

In a few years' time, thanks to the expansion in medical student numbers, the UK will be able to meet its medical workforce needs largely through its own graduates. Given this change, Edward Byrne, who graduated in Australia but trained in the UK, argues that failing to provide training opportunities for the vast majority of UK graduates would be a waste of human potential and a failure of care for young doctors (doi: 10.1136/bmj.39302.639792.94). Edwin Borman, however, says that restricting opportunities for non-UK graduates would be unfair and would damage UK medicine (doi: 10.1136/bmj.39302.403021.94). Graham Winyard says that it makes no sense to expand medical schools if we can't enable the extra graduates to pursue a medical career and contribute to the NHS. He calls for suspension of the skilled migrant programme for doctors and recommends that applications from overseas graduates should be considered only after those from UK graduates (doi: 10.1136/bmj.39330.686840.AD). If this doesn't happen, he warns, things will be even worse next year.

The anger of those caught up in the MMC debacle is eloquently expressed by Parashkev Nachev (doi: 10.1136/bmj.39342.515961.59). He reserves his main ire for the royal colleges, saying that the big issue is not the welfare of junior doctors, monstrous though their loss has been, but the damage to professional standards. I would argue that the welfare of doctors is closely bound up with professional standards and that one of the problems has been that the changes in training brought about by MMC have hit at just the same moment as the European Working Time Directive. The result has been a staggering collapse in continuity of care and mentoring for junior doctors, and the definite risk of a reduction in the quality of training. One royal college president told me that clinical decision making has suffered. No longer do you see in the notes the classic junior's diagnosis "chest pain query cause." Instead you are more likely to see the words "await senior review." We must hope that these broader issues of length and breadth of training, as well as the difficult issue of medical immigration, will be prominent in the independent and government reviews that are due to report over the next weeks and months.

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