Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
MMC: Words speak louder than Actions
- David Owen, Rick Adams (17 March 2007)
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Any ethics (or evidence) applied to MTAS?
- Jane L Gibbins (17 March 2007)
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Learning from Primary Care
- Anne Holmes (17 March 2007)
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The Caldwell Solution to MTAS
- Gordon Caldwell (18 March 2007)
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Pilot project would have been more appropriate
- Mahesh C Thagadur (19 March 2007)
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MTAS is not the first
- Alison Giles (19 March 2007)
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Trust Me I'm a Doctor ? - MTAS - The Problem and a Solution
- Martyn W Neil (19 March 2007)
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Facing our shame and finding our voices again.
- Eileen McGinley (20 March 2007)
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A countdown to confrontation
- Ebaa SS Alozairi (20 March 2007)
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I was on the RemedyUK March
- Annie Y Lau (21 March 2007)
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Many people missing the point.
- Katrina S Davis (21 March 2007)
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A bleak future for Postgraduate Training
- Satyajit Nag (21 March 2007)
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raging against MTAS
- clarissa d fabre (23 March 2007)
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An Orwellian Mess
- Swethajit Biswas (23 March 2007)
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Thank you for your support, but will the government deliver?
- Abhijeeth R Shetty (23 March 2007)
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MTAS. Focus the aetiology not the symptoms
- Anthony E Young (29 March 2007)
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Who is responsible for MTAS?
- Chris M Laing (31 March 2007)
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Critical week for MMC/MTAS: Individual Consultants and Staff-Councils will decide the fate of MTAS
- Morris J Brown, Morris Brown, Ashley Grossman, George Hart, Philip Home, Kay-Tee Khaw, John Monson, Roy Taylor, Nick Wright (2 April 2007)
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Ways of improving
- Jason Y K Chan (3 April 2007)
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Re: Critical week for MMC/MTAS: Individual Consultants and Staff-Councils will decide the fate of MTAS
- Gregory W Taylor (3 April 2007)
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David Owen, SHO ITU St Thomas's, London, Rick Adams
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The MTAS application has a 150 word section entitled “Describe your understanding of the importance of medical research to a trainee doctor” We agree there is no better way to distinguish candidates who are interested in medical research than simply asking them whether they think research is important. We hope to see MTAS continue unchanged with one proviso. Perhaps instead of being asked their qualifications or exam results, candidates should be asked what they think the relevance of qualifications or exam results are to a trainee doctor. We also suggest replacing criminal disclosure forms, with the question - "Describe your understanding of the importance of not committing violent crimes whilst a trainee doctor" Rest assured we will not be mentioning this letter on our MTAS applications. However, we look forward to describing why we think it is important for a trainee doctor to write to the BMJ, and what can be learnt from the experience. MTAS shortlisters: Please do not read the last 27 words of this letter, as we have exceeded the 150 word limit Dr David Owen, Dr Richard Adams Competing interests: David Owen has an interview for London/KSS ST2 General Medicine, and Rick Adams for London/KSS psychiatry ST1 |
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Jane L Gibbins, SpR Palliative Medicine Frenchay Macmillan Unit
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We all welcome change when the aim is to provide better care to our patients. MTAS has been a complete shambles, and many of our profession have felt this for sometime having contacted local MPs to make a change (prior to implementation). What a shame that they failed to listen.(Perhaps they may benefit from a communication skills session?) Our profession makes everyday decisions on the basic four principles of ethics. It is evident that MTAS has not considered any of these. We are also encouraged to apply evidence in our daily care to patients. Does the application process have any evidence base behind it? We look forward to a revision of the process when autonomy, non- maleficance, beneficance and justice have been applied. In that way, we may have more confidence that our patients will get best care in the future. Best wishes, Jane Gibbins Competing interests: None declared |
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Anne Holmes, General Practitioner Tithebarn Medical Centre, Stockton on Tees, TS19 8RH
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General Practice used an application form, similar to the Medical Training Application Service (MTAS) form, in it's recruitment process last year. Some of us involved in shortlisting found the work onerous and it was difficult to grade the middle candidates although extremes often shone. Plagiarism was evident. The challenges of that system led some visionary colleagues to develop the machine marked tool which was piloted on GP Registrars. Despite my initial sceptism, I believe our current system to be a vast improvement and one that works well with large numbers. General Practice also has experience of Deanery wide interviews and selection processes. I am left wondering why none of the hospital based specialties were unable to benefit from our expertise? Competing interests: Anne Holmes is a question writer for the GP shortlisting exam and has previously shortlisted application forms |
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Gordon Caldwell, Consultant Physician and DME bn11 2dh
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MTAS The Caldwell Solution This solution to me appears simple, low cost financially, practical and would be popular. The only agencies or people to lose out seem to be the DoH, MMC and COPMED, the main proponents of the MTAS system and philosophy. The Colleges, NACT and NHS Employers carry some responsibility, but were mainly presented with the chance to offer minor changes to a fait accompli, already moving ahead at top speed with huge momentum. GPVTS selection should continue, because it seems well planned and effective. Recruitment to Radiology and Histopathology can probably also continue. This process would apply to all doctors who on 05/02/2007 had eligibility to work in the UK from August 1st (All UK doctors, EA Doctors with appropriate English language skills, and non EA Doctors with highly skilled migrant status). The solution is based on moving the F2s, who have not gone into GPVTS, on in August to a "General Training Year" including permission to go overseas to work e.g. Australia, New Zealand etc. In the UK the jobs they would move into would be often those marked as FTSTA (i.e. with PMETB approval for training). At the end of the year they would only need to present a "portfolio" of clinical cases seen, procedures learned and involvement with teaching and learning, the same if they have been overseas. If suitable posts are vacant in the F2s current Trust, their contracts could be extended, without interview provided they meet end of F2 "competences" (comptences is an undefined MMC neologism). The opportunity to go overseas would be welcomed by many F2s, and in the past has greatly benefited juniors and the NHS. The problem is to create the vacant posts for the F2s to move into. Many will unfortunately have fallen vacant because non EA doctors without highly skilled immigrant status are having to leave the UK. More vacancies can be created: Trusts could be instructed to recruit Consultants from Calman SPRs early in the new financial year. The posts vacated by the Calman SPRs moving on could be filled by SHOs moving on into a Calman SPR post ( i.e. extend Calman for another year) or into ST3 or ST4 MMC posts. Specialist Training Committees could interview as usual for these posts. SHOs in post now could also be allowed to have an extension on contract for a "General Training Year". They could also go abroad for a year. If they stay in the UK they could be allowed to be flexible with colleagues about the posts they work in over the year e.g. a surgeon wanting to do colo-rectal might choose to do 4 months colo-rectal, 4 months gynaecology and 4 moths urology, in a mini rotation with an O and G, and Urology junior. This "buys" a year to sort things out, and in the future always allow this "gap" year for F2s. My problem with the 16th March MMC MTAS Solution The solution is based on juniors in general getting one interview in round one – this severely limits the geographical options for working. Also the word "eligibility" comes up repeatedly. The terms for eligibility are opaque. I know many juniors who went in circles from MTAS, to MMC, to College websites to try to identify the eligibility for ST2 and ST3, and some "senior" juniors who were willing to go back years to ST1, just to get into their chosen career. Although the process claims to be "competency based" the eligibility was time defined, and related to "national training number" (NTN) posts. Thus a junior with 2 years 1 day experience in an NTN post in Paediatrics has to apply to ST3, whereas a junior with 2 years 1 day experience in Paediatrics, 18 months in NTN posts and 6 months in an identical post without an NTN can apply to ST2, but not ST3? I know of a junior, who's interview time was taken up with 2 Consultants arguing about whether the junior was eligible! However if the 16/03/2007 solution is acceptable to the juniors we seniors must work hard to make it work. If it in not acceptable, we must seriously consider a Gandhi style Boycott of Round One and force a solution out of the DoH, like "the Caldwell solution". Dr Gordon Caldwell FRCP Director of Medical Education 33 Chesswood Road Worthing BN11 2AA Drgordon.caldwell@googlemail.com Competing interests: I submitted a text with the same ideas to the Daily Telegraph on 18/3/2007, but in a different format and proposing a ballot on the MTAS process |
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Mahesh C Thagadur, Staff Grade Psychiatrist Adult Mental Health, Cannon House, 6 Cannon Street, Southampton. SO15 5PQ
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The Department of Health and Postgraduate Medical Education and Training Board have been planning to implement changes to medical training for more than two years. The new online application system should have been piloted in a few deaneries first before introducing it at the national level. The pilot project would have given them beneficial insights and some sort of validation. The have introduced an application process at a national level which will determine the fate of more than 30,000 doctors without any validation or prior experience from a smaller project. Competing interests: Applied for ST4 in psychiatry but not short-listed in round 1. |
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Alison Giles, Paediatrician-consultant Lancashire
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I read Tony Delamothe's article and was concerned to see that he mentioned the UK general practitioners admissions scheme as something to possibly aspire towards. The machine readable test he mentions is an MCQ. The candidates spend a morning in a hall answering this, plus some mock questions for three hours. It does not matter whether you score 89%, as I did, or 64% (The pass mark) as this is taken as only a pass/fail tool to allow progression to the next round. The next round is a mirror of MTAS with five pithy questions such as "Give an example of your team work?" or "When were you last stressed?" Again, a test of creative writing which has caused all the furore in MTAS. Answering "I was last stressed when I had to answer another question like this, because you can't look at my CV or interview me" is not allowed.If a candidate gains enough marks on this, relative to everybody else, you progress not to an interview but an assessment centre. Here you are asked questions about scenarios. In my case these did not once touch upon medical knowledge. Instead, I was asked how I would deal with a patient with cancer asking for an over supply of morphine, and how I would feel if my receptionist came to see me as a patient. I have never felt as demoralised and disillusioned in a process during my medical career.To think that it would be held up as something to emulate is a further blow. At no point did anyone establish that I almost completed a GP scheme previously, worked as a GP abroad, completed my paediatric training and have duel accreditation in neurology, and have MRCP, as well as years of experience in the NHS, and multiple clinical assessments at an easily accessible UK College. Tony Delamothe mentions the white elephant in the room of IMGs and reluctance to talk about this. When I attended for the GP MCQ after March 2006, most of the hundreds of applicants in the room were IMGs.I achieved 39 on the short answers, and the aribitrary cut off for interview was 40. Several doctors on the HSM programme were instead appointed. I have been more than ready to talk about this and asked to see the Director of General Practice. It was he who was unprepared to talk about it in any fair or professional manner, as were the College of GPs who have failed to answer. Tony Delamothe writes about appointments on "merit." The profession seems increasingly confused on the definition of merit in a doctor. Instead of CVs we now submit information on audit and research and waffle.This means that more mediocre "research" is done by non-academics to "enhance" CVs. What happened to good research being done by the right people for the right reason? Clinical ability and experience are taking an increasingly back seat.I have never had a patient ask me about publications, or recent audit. They instead ask if I've seen a similar case, will I get that cannula in first time, and will I explain things to them honestly and clearly? I feel common sense is being sacrificed, as it has been for some time, on the altar of political correctness and my career has certainly suffered because of this. MTAS has simply highlighted the scale of the problem.I personally am tired of apologising for the fact that years of experience in an NHS hospital and training in a British medical school should not be seen as more favourable for a post in British medical practice. Why is the UK doctor always assumed, as Tony Delamothe says, to be "not quite so good?" If the Colleges are so concerned about the calibre of UK medical student training then shouldn't they be answerable to this, and why do so many overseas doctors aspire to join us in our ineptitude? Isn't it the case that we are increasingly tying ourselves in knots about application systems for the sake of overseas doctors?Anything that might advantage a British doctor has been negated or made worthless. That is the white elephant and I'm more than happy to talk about it. It is the Colleges, BMA and Government who are remaining silent. Yours sincerely Dr Alison Giles Competing interests: None declared |
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Martyn W Neil, Specialist Registrar in Orthopaedics & Trauma Surgery Northern Ireland
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The General Medical Council (GMC) who regulate doctors, in ‘Good Medical Practice’ state that “Patients must be able to trust doctors with their lives and health”. It would appear sensible therefore that any change to the selection of doctors or training should seek to encourage the trust that exists between doctor and patient. The public should have confidence in the selection and training of doctors. How then can the new framework ‘modernising medical careers’ (MMC) and the ‘medical training application service (MTAS)’ do this. To date we have seen a catalogue of errors and problems which do nothing to promote confidence in the selection and training of doctors. The web-based application process has had significant technical difficulties, website crashes and application deadlines having to be extended. Part of the short-listing processes was meant to be a computerised process, this failed in a number of regions resulting in applications having to be dealt with by hand. The Web-based application has included questions such as “Provide a recent example of your experience within a work team that was not functioning optimally. How did you identify this? What steps did you take and how did this affect the team?” It could be suggested that these types of questions are open to ‘creative writing’ and as such how can a selector validate what a candidate has answered. If selectors are interested in identifying aptitudes, personalities, motivations or other skills on an application form only validated methods can be justified as being equitable. There are reports of short-listing not being done in a blinded fashion. This is truly at ‘crisis of confidence’ as the royal colleges have warned. An urgent review has been announced by the government. This is however too late. Despite serious inadequacies and flaws in the MTAS system interviews introduced by MTAS are to continue at present. However, we have already seen one panel of consultants refuse to conduct job interviews on the grounds that they were unfair. Doctors should be selected for interview on the basis of verifiable information only and ‘points’ can be awarded for such information. However, is it justifiable and equitable to award points for information given in an application form which cannot be verified? It could be suggested that no-one should be appointed to run-through training using information which cannot be authenticated or corroborated. Is there a solution to the current problem? There is almost five months left until doctors have to take up new posts. I would suggest it is unlikely that the current MTAS system and the problems already identified can be corrected in order to allow doctors to be appointed using a fair and justifiable process. The General Medical Council indicates in ‘Good Medical Practice’ that “you are personally accountable for your professional practice and must always be prepared to justify your decisions and actions”. The solution as I see it, is suspend the current MTAS system for one year and for each region and deanery to appoint doctors to training jobs as previously they did in a manner which they see to be fit and justifiable. The MTAS system has been criticised for being inadequately piloted, as such we should use the current situation as the largest pilot possible, identify the problems and inadequacies, and determine solutions and remedies for these in consultation with all the stake-holders. Only then can such a new system of selecting and training doctors be introduced in a manner which promotes confidence in doctors and patients and the general public as a whole. Competing interests: None declared |
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Eileen McGinley, Consultant Psychiatrist in Psychotherapy Psychotherapy Unit, Maudsley Hospital, Denmark Hill, London SE5 8AZ
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One aspect I think worth highlighting in Tony Delamothe's helpful editorial was how much the MTAS (Medical Training Application Process)process was shrouded in mystery, so much so that the tutors and trainers were themselves left so much in the dark that we were often unable to answer trainees' questions about their applications in any helpful and containing way. This was despite many hours spent at meetings addressing MMC (Modernising Medical Careers), but where MTAS was barely mentioned. I think this has added to the levels of distress that we have painfully witnessed among so many of our juniors, as their confidence in us to help them deal with the situation they are facing has been badly shaken. For the Consultant body to regain some of its credibility it has lost over the MTAS process, we now have to have honest answers to the questions concerning what is really being required of the medical profession in practical, but also in ethical and moral terms, to implement MMC as it is being proposed. This will include an honest appraisal of the number of training posts for each deanery, how many training posts are being lost, and how the profession intends training hospital doctors based on merit. There also seems to me to be an ethical issue concerning how to stand up for juniors who have already gone through a competetive process in order to get their current training posts and now face losing these hard won training posts in the MTAS process. Like many other Consultant colleagues, I have found it difficult to look my junior doctors in the eye over MTAS and the way in which the interviews have been conducted. However, perhaps if as Consultants and Trainers we can face our shame of having been implicated over the mess the junior doctors are going through, and not feel driven by our guilt into helplessness or hopelessness, or of responding only with outrage, we can begin to address what aspects of the process we think are wrong and those aspects of MMC we are in favour of. Personally, I am in favour of halting the MTAS process and reverting back to the application and interviewing process that was in place, with the improvements that were already enforced to make it a fairer system. The implementation of MMC can then continue to be planned for and implemented, but at a proper pace, and with all parties being more honest and open about the implication of these changes to the face of medical training in the UK. Eileen McGinley Competing interests: None declared |
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Ebaa SS Alozairi, Speacialist Registrar Diabetes and Endocrinology. Fullbright Fellow at Harvard Medical School USA NE1 4LP
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EDITOR- The politicians have a growing disregard and contempt towards the medical community, aiding plagiarism and lottery. This ridicules all effort, originality and hard work that the junior doctors have put in. The politicians have made serious lapse in judgments in the perception of who the doctors of tomorrow should be. The message concerns the MTAS process of Modernizing Medical Careers, a process which seems set to cause very great damage to our trainees in medicine. Modernisation has done wonders, though not for Medical Careers! The medical field is somewhat grumpy right now - seriously disillusioned with politicians and unimpressed by the public services. Change in the NHS usually makes people uncomfortable, and add a grain of plagiarism and luck of the lottery and you really do have a disastrous recipe. Changes made to the NHS should be well thought out and implemented, not about meeting impossible deadlines and half-baked targets that politicians have set. They should be like custard, fine grained and not lumpy. Abolishing interviews which are appropriate points to scan personality and surveying grades do not match the new assessment tools objective. Medical practice requires intellect and application. MTAS as the name suggests aims to provide a service and this clearly can not fulfill our obligation to society to assure physicians trained meet the higher state of knowledge, competence and professionalism. No solution is perfect and we are against ever tougher competition as modernisation rolls on. This issue should no longer be ignored. Junior doctors are rising up in rampage and marching through the streets of london determined to be heard. Can anything deter their action? Competing interests: None declared |
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Annie Y Lau, Consultant Psychiatrist Child and Family Consultation Service, Shernhall Street, Walthamstow, London E11 3A
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This turned out to be a completely overwhelming experience. For the first time in many years, 12,000 people, mainly Juniors but also Consultants, parents and relatives including children in pushchairs, and even a grandmother in a wheelchair, came out to take part in the RemedyUK March. Many of us were in white coats and scrubs. The placards and posters varied from printed copies supplied by RemedyUK and the BMA, and imaginative home made ones using broom handles, cardboard and poster paint. “My Training, Your Healthcare, Their Mistake”; “Training 4 Junior Doctors”; “Protect our Training , Protect your NHS”; and the home made ones included, “Jobless Doctor”, “I’m Dr --, do you want fries with that?” and “On my way to JP Morgan”. I had only decided to join the March relatively recently. As an Educational Supervisor I had spent many hours with a number of juniors who wanted to tell me how upset and distressed many of them were, either at the MTAS process, or the lack of shortlisting, or failure to secure a London interview when their partners or spouses were already in settled jobs here. They all felt dispirited, and let down by the system; and I felt helpless. Some time ago I had to support my own junior doctor who was very concerned following the High Court ruling to abolish Permit free training, and I urged our Postgraduate Tutor to organise a meeting so we can attempt to support our non EU junior doctors in the Trust who were affected. As time passed it turned out to be a much bigger issue, affecting all of our Juniors, not just the ones from a non EU background. I am happy to say we finally managed to create space for a meeting in our Trust later this week. The day of the event, 17 March, was bright and sunny. I was asked to help with directing people to the College of Physicians from the turning into Regents Park off Euston Road. The trickle of young doctors in scrubs and white coats from 10 am, disgorging from Great Portland Street tube station, became groups of 30 or more from 10.30 am on. Many had travelled in groups from outside London; they said they came from Birmingham, Norfolk, Glasgow, Manchester. Any concerns this event might turn out to be a damp squib were quickly dispelled. The procession moved out punctually at 11 am with a police van in front, and the organisers of RemedyUK leading behind a banner, WWW.REMEDYUK.ORG. We filled the road, and stopped a few times for people to catch up. By the time we reached Euston Station, the police escort told me their estimates were that there were 12,000 participants, and the March stretched all the way back to the College of Physicians at St Andrew’s Place where people were still joining the back of the March. The numbers far exceeded anything we had all expected. People had been signing up to the March, and on the night before, 800 had registered to attend. The organisers had expected between 5000 to 10000, but 12,000 was amazing. All along the way, members of the public hooted their support from their cars. The atmosphere was jubilant, a bit noisy with the odd chant. There were a lot of whistles, and by far the most effective rhythmic accompaniment was from an old metal sink someone had brought along. We noticed Andrew Langsley, the Shadow Health Secretary join us towards the front of the March. The March took a route that passed BMA House, the London Deanery, the Royal College of Anaesthetists, and ended up at Lincoln Inn Fields, where the Royal College of Surgeons was located. I gathered that the initial idea was to have everyone congregate inside Lincoln Inn Fields, but obviously the crowd was too big to accommodate everyone. So most of us went inside, but a large number were outside the park. Then the speeches started. The speeches were all warmly received. A representative from the Birmingham Surgeons who walked out of the MTAS interviews said they did not feel able to collude with a flawed process, and they were very aware they started the ball rolling, with the Anaesthetists taking a determined stand in the following week, followed by the Academy of Royal Colleges asking for the Govt for a Review, which we have now got. David Cameron said the MTAS changes were “an utter shambles”, and promised a Conservative government would treat doctors “like human beings”. He pressed the right buttons; he said, “There’s a simple truth at the heart of this; you came into the NHS not because you wanted to get rich or famous, but because you have a vocation about curing the ill, about serving your community”. Matt Shaw from Remedy UK talked about how the organisation had initially been started in December 2006 by two junior doctors who felt the Colleges and BMA had not done enough to raise public awareness, and that juniors felt betrayed. This has now “exposed the Emperor’s new clothes for what they are”. The government really does have to listen to the voices of the junior doctors, now united as never before. I left, feeling proud I had taken part in an event in which Doctors from all disciplines, specialties, and grades, and their families, had come together, irrespective of the various issues that have often in the past divided us. Juniors and seniors, GPs and Consultants, Primary and Secondary Care. We were all there. We all knew someone whose life had been touched in some way by the MTAS process. And we had all been concerned about what all of this would mean to patient care and Patient Safety, when the caregivers did not feel looked after, and the people who were crying were the doctors on the front line. I also congratulate RemedyUK for their persistence, commitment and determination in continuing their campaign despite the lack of institutional support. These are four young junior doctors without a budget, who have beavered away with their email links and mobiles, showing a sense of professionalism in the best traditions of medicine. The whole profession should be proud of them. Like many others, I, for one, am awaiting the results of the Douglas Review with a great deal of interest. I cannot see however, how sorting all of this out is going to be a cost neutral exercise, when the estimates are that between 6000 to 8000 young doctors are likely to be displaced, even though issues of equity and transparency might be sorted out with the second round of interviews. In the meantime, I sincerely wish Professor Douglas and his team the very best of luck. I believe all of us now need to work closely with our Colleges to get things right. Our credibility as Seniors is at stake, and I do not think we will get a second chance. Annie Lau, MD, FRCPsych Consultant in Child and Family Psychiatry annie.lau@djpconsulting.co.uk 19 March 2007 Competing interests: None declared |
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Katrina S Davis, SHO in Psychiatry South London and Maudsley
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The problem was not the application system, but the way it was used. THE PROBLEM WAS THAT 20,000 SHOs WERE MADE REDUNDENT, and many told, by people who had never seen their work, that they were not good enough to do the job they were already doing... It makes me fuming mad..! It does appear that MTAS is rather flawed, but what has caused the chaos and dismay, is that it was used for a purpose it was not designed for. MTAS was meant to judge applicants at the entry point to specialist training. Therefore, it asks general questions to assess suitability, and puts scant emphasis on experience, because most young doctors have very similar CVs. This year, it was not used for the purpose of sorting those wishing to enter into specialist training, but also used to decide who could continue training. These doctors have three, four or more years' post- registration experience, and have shown their suitability for the specialism by (i) being chosen at interview previously, (ii) still being on a course, and presumably (iii) having satisfactory enthusiasm and attainment that they have been progressing. Take my situation, where after two years of moving every six months to take posts where-ever I could get one, I finally get offered a three- year rotation in psychiatry. I had researched the specialty, found the rotation that seemed to suit me, made a really strong application to the specifications they needed, and got in!!! The bliss... Not having to move. Being able to put down roots, make friends, take up an active role in hospital politics, etc. Only to be told on my first day that, no, while I was offered (and accepted) a three-year post, everyone was giong to have to reapply in a year. But everyone told us "It's OK. It's just a formality. You'll all be fine... You're the best of the best!" WE COULD HAVE TOLD THEM! We are more lost than the original lost tribe. We are the poisoned guinea-pigs from the 'National Curriculum' ('90 - '94), the new 'integrated' medical curriculums ('97 - '04), the hospital mergers (ongoing), foundation pilot schemes ('03 - '06) and the rest. I was not offered an interview in London, so will almost inevitably have to move again. I have an interview in the West Midlands, but even if I get a job, there are five seperate rotations, with no information available to choose between them. Nor will they be able to choose me. Gone are the days when individual rotations could decide what they wanted in a doctor and choose accordingly. They will get a doctor allocated to them, virtually at random, by criteria decided at a national level to select a generic 'good doctor'. Something has gone wrong, but it's nothing to do with IT, nothing to do with 150-word answers, it's to do with plain humanity. We are not allowed to be who we are anymore. Competing interests: Applicant for ST2 Psychiatry, shortlisted by one UoA. |
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Satyajit Nag, Consultant,Endocrinology & Acute Medicine Diabetes Care Centre,James Cook University Hospital,Middlesbrough TS43BW
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The predictable and spectacular collapse of confidence in the Medical Training Application Service(MTAS) first round selection procedure has finally jolted professional bodies into action. Nevertheless, the MMC juggernaut thunders along and has just about passed the point of no return despite the multitude of ever emerging chinks in its core structure. These fault lines span the selection, training and competence of our future junior doctors. A number of us will have wrung our hands in despair and felt rather impotent against this turning tide of modernisation that was thrust on the medical fraternity by Whitehall. A lot of us will have queried whether such a radical change to the existing system of medical education was required at all. Surely competency based assessments could have been incorporated into existing models of training. Unfortunately, modernisation became synonymous with ‘reflective practise’ and ‘run through grades’. MTAS, technical glitches notwithstanding, is the least of problems facing postgraduate medical education in the UK. As a vehicle of delivery for MMC, it will be fixed in due course. Training delivered through MMC however is going to be a different matter altogether. The current state of postgraduate training borders on abysmal. MMC, from its very inception appears to have received complete and tacit approval by the Royal Colleges and the current furore surrounding the selection process appears to be no more than a predictable knee jerk reaction. Sadly, the frustration felt by junior doctors has inevitably led to mudslinging between UK graduates and International Medical graduates. Again, this reflects chaotic workforce planning and a complete lack of communication between the Department of Health and the General Medical Council(GMC) which runs the Professional and Linguistics Assessment Board (PLAB) exam for overseas doctors. The GMC started offering the PLAB exam in overseas centres throughout the world and the deluge of doctors from non EU countries was hardly surprising. The GMC’s disclaimer that workforce planning was not its problem is hardly a responsible stand but at nearly Ł575 per PLAB exam and Ł290 for Registration, one can understand why the GMC is so glib about it. To compound matters, immigration rules were changed overnight and the despair felt by overseas graduates who have invested vast sums of money is clearly understandable. Delamothe quite rightly draws attention to this lost tribe of overseas medical graduates as the ‘elephant in the room, which no one except the international medical graduates themselves seem ready to talk about’(1) MMC is here to stay whether we like it or not. There are too many egos and personal fiefdoms at stake here for MMC to be revoked altogether What we can and should influence is the integrity of the selection process and the robustness of training that is provided to our junior doctors. This has to be fair and equitable. Patient safety is paramount and can only be safeguarded by excellent clinical training which should not be replaced by a ‘tick-box’ exercise. 1. Delamothe T. Why the UK's Medical Training Application Service failed. BMJ 2007;334(7593):543-544. Competing interests: None declared |
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clarissa d fabre, honorary secretary medical women's federation london WC1 9HX
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Your recent editorial ‘Why the UK’s Medical Training Application Service failed’ (1) did not address one very important aspect of the problem. From the point of view of doctors with families (male or female), the inflexibility of the MTAS system is unacceptable. No longer can doctors apply for individual training posts: what they are offered is a post in a region. The actual job could be anywhere in a huge geographical area. Currently, once doctors have accepted a position in the area, they are not allowed to decline the actual job without being penalised. This can lead to major family problems. For example, we know of a junior doctor whose family is in Cambridge. She was not shortlisted for Cambridge, but has an interview for a ‘London rotation’. Were she to receive a job offer in Bognor Regis or Brighton for example, which form part of the 'London rotation', she would be forced to decline the offer. She would also have to decline an offer from Oxford and Severn, the other two regions for which she was shortlisted. This is an appalling aspect of the system. We must have a process where doctors can apply for jobs at particular hospitals. This has to be the fundamental principle from which any acceptable system will develop. Doctors have become anonymous cogs in a giant machine – they don’t know for whom they are going to work, and the people administering the system appear not to care in the slightest. All they are concerned about is fitting all the cogs (the junior doctors) into this impersonal machine (the current NHS). As a partial solution to the current debacle, doctors must not be penalised for declining offers, and must be eligible to enter round 2, if they so wish. Clarissa Fabre
1. Why the UK’s Medical Training Application Service failed BMJ 2007; 334: 543.(17 March) Competing interests: None declared |
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Swethajit Biswas, Specialist Registrar/CR UK Clinical Research Fellow John Radcliffe Hospital, Oxford, OX3 9DU
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It is clear that MTAS was introduced both hurriedly and with little forethought. Although the Royal Colleges were involved in Department Of Health (DOH) negotiations about MTAS, the DOH pushed its preferred scheme through, operating on the premise that selecting professionals for jobs could be managed by a computer and the assumption that the royal colleges have no experience of operational management anyway. Since consultants relie on competent junior staff, particular at night, to maintain appropriate patient care, it was in the interest of the consultant body in many NHS trusts to come-out against the MTAS selection scheme, as MTAS in my view, does not enable the discrimination of suitable from unsuitable doctors for a given post. In the climate of clinical governance for patient care, this is nonsensical, as professional governance (the appointment of suitably qualified candidates for a job) may have very serious consequences for appropriate clinical care provision. The current BBC2 documentary series called 'The Trap' by Adam Curtis, lays out beautifully the concepts of people and organizations being denuded of operational freedom by top-down government bureaucracy, and ask yourself whether the MTAS debacle is one manifestation of an Orwellian foreground music that pervades much of public service life in the United Kingdom today. Competing interests: None declared |
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Abhijeeth R Shetty, SHO, North Trent Rotational Training in Psychiatry Wathwood Hospital RSU, Gipsy Green Lane, Rotherham, S63 7TQ
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Having been an SHO(Senior House Officer) for 2.5 years and working with few of the best consultants in psychiatry, receiving good appraisals from them and my peers, it turns out that further progress in my career is based on my creative writing skills! Not that I particularly lack an imagination but I honestly answered all the questions in the MTAS(Medical Training Application Service) application using my genuine experiences during my training. Turns out it was not good enough as I was not short listed anywhere. It was a severe blow to my self confidence. It is very gratifying to read Tony Delamothe’s article and the rapid responses to it. I am pleased to know that I am not alone. I am pleased to know that I am a good doctor which the system has failed to recognise like hundreds of others like me. I am pleased to know that the consultant body has opposed this process of selection which is not validated, including trainers in my rotational scheme. And I am pleased the government has acknowledged this and wasted no time to review the whole process. I am optimistic that all is not lost. The independent review panel has guaranteed an interview to all ST3 and ST4 applicants in their first or second choice deaneries. However it remains to be seen how this will be implemented. Information from the review panel it seems is being fed to us in tiny morsels on a weekly basis. But, as an optimist I am looking forward to prove my ‘competencies’ in front of an interview panel. I sincerely hope that the government will not disappoint me and my kindred souls again. Competing interests: I have applied for ST3 in Psychiatry and not recieved any shortlistings |
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Anthony E Young, Retired Surgeon London SE3 9EN
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Tony Delamothe's Editorial and the bulk of the letters in which distressed trainees rage against MTAS are perhaps too focussed on the symptoms rather than the aetiology of this unpleasant but avoidable disease. Bodies that have had to deal on a regular basis with the gospel according to MMC and its bastard offspring MTAS and PMETB know only too well that the real problem is the culture underlying the day to day dictats and deliberations of these bodies. Too often they appear to harbour basic assumption that their own pronouncements are sacrosanct and that the challenges from Royal Colleges, working clinicians, specialist committees, deans...in fact anyone with hands on experience.. can always be set aside in favour of the novel but uninformed views of office functionaries, educationalists, and politicians. Until MTAS, PMETB, MMC and their cosy advisers are prepared to put their hands up and accept that their culture is wrong and that evolution and experience can usefully guide change, the MTAS fiasco, the Article 14 fiasco and all the others will simply be replaced with new ones. Competing interests: Member of the SAC in Surgery |
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Chris M Laing, Specialist Registrar in Nephrology and Intensive Care Medicine Guy's and St Thomas's NHS Trust
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I am surprised at the lack of accountability regarding MTAS. My local Labour MP recently sent me the full transcript of Patricia Hewitt's statement to the House of Commons on March 19th. She stated.... " ... the scoring system and the whole process for applications was developed by the postgraduate deans, working with the department and other partners." In his resignation letter Professor Alan Crockard writes... "MTAS was developed and procured by DH outside my influence. An email (12 October 2005) to our team made it abundantly clear that "Debbie (Mellor) has been tasked with delivering a recruitment system to recruit junior doctor posts specifically FP's and ST's .......I am not clear how far you should (or want) to be involved in this. We don't want to tread on any toes, but equally we need to be clear about what level of autonomy this Programme has". Is it just me or is that last paragraph less than clear? So who did design MTAS - the postgraduate deans as Patricia Hewitt states, or the DH outside of MMC influence? Both these statements cannot be true. I suspect this whole debacle will end in a public enquiry but it would clearly be beneficial to have a bit more transparency and accountability. Competing interests: None declared |
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Morris J Brown, Professor of Clinical Pharmacology University of Cambridge, CB2 2QQ, Morris Brown, Ashley Grossman, George Hart, Philip Home, Kay-Tee Khaw, John Monson, Roy Taylor, Nick Wright
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Alan Crockard’s resignation, and Parthian resignation letter, appear to hole his edifice beneath the water-line, and make this a critical week in deciding the denouement of MTAS. We are beginning to circulate versions of the letter below in response to Deanery requests to take part in the continuation of MTAS. We hope Consultants in other regions will pick this up, and copy to colleagues. Rapid balloting by Staff Councils of Consultant opinion, and grass-roots rejection of further participation in interviews, now appears the only way to stop MTAS and enable a return to Deanery-specific appointments in time for August. This has been the wish of more than 80% of doctors, senior and junior, in every poll conducted to date. A suggested circular for use by Staff-Councils is appended below the letter. Morris Brown, Consultant Physician and Professor of Clinical
Pharmacology, University of Cambridge
Roy Taylor, Consultant Physician and Professsor of Medicine &
Metabolism, University of Newcastle
'From my point of view, this project has lacked clear leadership from the top for a very long time.' So says Alan Crockard in his resignation letter (March 30th). For Consultants to continue 'following orders' to turn up for interviews seems not just a betrayal of our juniors disadvantaged by the system, but no longer even logical. Whose orders? Who is accountable? Medical training, it seems, is run by the recently appointed Director of the NHS Workforce, whose experience till last year was as personnel director at Tesco’s. On Thursday, senior members of the Association of Physicians were addressed by Elizabeth Paice, chair of post-graduate deans, on the background to MMC/MTAS. Not only did it seem that she now recognised the shambles of MTAS, and lack of validity of the selection process - 'I think it is not random' - but her account of the whole rationale for MMC appeared to many underwhelming, flawed and smacking of the evangelical ideology that typifies non-democratic attempts by the few to preach change to the many. Her audience voted overwhelmingly for an immediate return to the previous selection system while both MMC and MTAS are radically revised. The 'lost tribe' of SHO's who were supposed to be rescued by MMC are the ones now suffering (unless in discredited ends-justify-the-means fashion, it is OK to sacrifice one generation for the benefit of the next). The problem to be solved by MMC was the lengthening time from qualification to specialisation. But this was aggravated by EU directives that led to the invention of Trust doctors as an ad hoc extension of the SHO grade. Do the Medical Directors know who is going to make up rotas when we have only the ST1 and ST2 years? Then, from the juniors' point of view, one of the most pernicious aspects of MMC is that they have no idea when they apply for a specialty in a 'location', where or for whom within a large number of possibilities, they will be allocated for the next six years. As for MTAS, it is very hard to understand why the not-so-independent Review body is trying with its weekly announcements to shore up a process which several ballots now show at least 80% of all doctors, at all levels, to want aborted now. None of its recommendations does anything for the 8000 doctors who will end the process jobless. The frequent observation by Consultants that the process cannot be too bad, because excellent candidates are being seen at interview, is a mirage - unlike previously, some top candidates turn up at four interviews, instead of stopping at the first, whilst many others in the random process have not been seen at any. The review body's latest announcement requires that all applicants, without short-listing, receive one interview, but one interview only, before June, with any 2nd-4th choice interviews already held being discounted. Even supposing there can be a level playing field for pre- and post-review style interviews, this will be an extraordinary workload that seems unlikely to be achieved without disrupting clinics, ward-rounds and operating lists. The plan, it seems, is not to ask Medical Directors or Chief Executives whether this can be achieved, but simply to tell them that it must be. Yet at the end of the process, many doctors turning up for their single interview are doomed to remain jobless. It is highly unlikely that this restriction on job applications will be deemed legal when the juniors mount their challenge. While the more sensible Deans may be opposed to the continuing carnage, they feel their hands are tied by being employees of those giving the orders. This is why it upto you now to make a stand. If individual Consultants decline invitation to participate in further interviews, the process will be halted. Some hospitals may be pressured by SHA's to provide fodder for the interviews, even if patient care is compromised. Hopefully their medical directors will resist. Foundation Trusts are in a stronger position, having no need to 'follow orders'. It is difficult for individuals to rebel. Doctors are among the most conformist - it is hard to imagine any other group being so meekly sat upon by faceless civil servants. Much better and easier if we can see each other acting. Some Consultant Staff Councils are already conducting ballots to show the strength of feeling against continued participation in interviewing. We hope such ballots can spread rapidly and strengthen both individual Consultants' and medical directors' resistance to continuation of MTAS. Time is very pressing. The review body has its final meeting this Wednesday. If you can let the Deanery know before then whether you are available for interview, they have a chance of informing the Review body whether their recommendations will fall on ears as deaf as their own; maybe at the 11th hour the majority view will be heard and acted upon. The Deaneries still have time before August to put into place a contingency plan for Deanery-specific appointments to ST3 and Trust appointments to ST1, probably with some extension of existing posts. Of course the present system is imperfect. But let it be changed bottom-up by those who have opted to stay in hospital medicine, not handed down by those for whom both junior doctors and patients are either distant memories or statistics in department of health pamphlets. 'All that is necessary for the triumph of evil is that good men do nothing.' MMC/MTAS is not evil, it was well-meaning. But the consequences, both immediate and long-term, are catastrophic. This is the week for doctors to wrest the future of hospital Medicine back into the hands of those that care. Suggested questionnaire to Consultant Staff Councils, with covering paragraph: The MTAS review body has recommended that all eligible candidates are interviewed, without shortlisting, for their first-choice job. It is unclear whether this may include re-interviewing candidates previously interviewed, or whether previous interview offers for 2nd – 4th choice jobs will be withdrawn. Colleges have asked that Employers cancel ‘non- urgent’ clinical activities to permit the increased workload which widespread interviewing will entail. Have you participated, or agreed to participate, in MTAS short- listing or interviews? YES/NO Do you feel you have experienced or heard enough about the recent debate to have an informed view on whether MTAS should continue this year in a revised form, or be suspended? YES/NO Do you agree with the recommendation that all eligible candidates are interviewed without short-listing? YES/NO Are you agreeable to participating yourself in interviews, however long this takes? YES/NO Are you willing to cancel clinics, ward-rounds or operating lists in order to participate in interviews? YES/NO Are you willing to cancel other activities in order to participate? YES/NO Would you like the Medical Director to support or object to cancellation of clinical activities in order to permit Consultants to participate: SUPPORT/OBJECT If it is possible for the previous system of Deanery-specific and Trust appointments to be restored in time for posts starting in August, would you prefer to see this happen? YES/NO If Deanery-specific and Trust appointments are not possible in this time frame, would you recommend extension of existing FY2 and SHO posts until Deanery-specific appointments or a revised MTAS process can be arranged? YES/NO Competing interests: None declared |
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Jason Y K Chan, F2 Medway Maritime Hospital
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Can we look elsewhere in how to improve the MTAS application system? If we look at the banking industry, particularly investment banks, their application forms are similar. For example the requirement to demonstrate team work and how you are the ideal candidate for the job, all within 100 words. But in addition you also provide an attached copy of your curriculum vitae, participiate in standardised verbal and mathematical tests. All this information is gathered and weighed up by the human resources department as to interview or not. Importantly the process typically starts in September with application forms opening up and a deadline two months down the line. Thus giving ample time to prepare and submit your application, and also enough time for a thorough review of the application. What if we look across the Atlantic to the US application system? This year they had 27,944 applicants competing for 21,845 first year posts, similar to ST1 in the UK. With 93% of US graduates getting into a program of their choice. If we first look at the time line of the application in the US we will see a significant difference with that of the UK. The process begins in July, allowing two months to prepare a curriculum vitae on line, submit references, complete a personal statement and submit scores from standardized exams. You then choose the institutions that you wish to apply to, with the number limited by the amount of money you are willing to spend. Subsequently in September the institutions that you have applied to can download your application form and decide whether or not to interview you prior to February the subsequent year. This provides ample time to prepare and evaluate applications. If we look at the substance of the applications the most important elements in the application are the standardized test scores and references, with the curriculum vitae playing a supporting role. We are attempting it in our GP entrance exams, however only a pass/fail mark is given, therefore not providing a scale or score to rank candidates. I acknowledge that standardized MCQ tests are not necessarily the best measure of a candidates ability but we do need to have some system of ranking candidates rather than 150 word answers that someone with a creative writing background would score well, and not necessarily a competent doctor. Maybe there should be a national medical exit exam following medical school, similar to the United States Medical Licensing Exam if MMC wishes to continue with the MTAS application, and to properly evaluate candidates. In conclusion there is much that can be done to enhance the MTAS application which is here to stay. With the timescale being of paramount importance at this stage to allow for proper review of applications. In the future hopefully an introduction of some form of standardized test will provide a more objective way of ranking candidates. We should look across the atlantic or into other industries for inspiration. Sincerely Jason Chan Competing interests: None declared |
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Gregory W Taylor, Surgical Research Fellow St James University Hospital, Leeds LS6 2QT
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Sirs, Firstly, as one of the hopeful thousands thankyou so much for providing a voice of reason and common sense amid the clouds of confusuion and contradiction surrounding the MMC/MTAS debacle. One of the great challenges of being a good doctor is recognising when a desperate situation has become unsalvagable, and the sooner that occurs the less pain and heartache there is for all concerned. The national director of MMC and the MMC comittees for Scotland, Wales and Northern Ireland have finally made this recognition, but at the time of writing it seems that MTAS in England continues to be flogged. I would agree that it is the Consultants and only the Consultants who are able to sort this mess out. We (or 80% of us) as juniors have screamed for MTAS to be stopped, yet it continues and the only option left to us is to support a legal challenge. Being previously so apolitical as a profession this is not a road we are eager to go down, but many of us feel there is no alternative. (I belive that most would agree that strike action is unethical, unfeasible and probably illegal). I would also add that there has already been a significant Consultant opposition to the process. The legal challenge has been supported by the Hospital Consultants and Specialists Associtation, and large numbers of Consultants (e.g. from St Georges, Norfolk and Birmingham as well as the authors of the previous article) have voiced their concerns with the continuation of MTAS or indeed MMC in their current guises. The more I read and hear from juniors and Consultants the more it becomes apparent that no-one is actually convinced that there was too much wrong with the traditional process of individual applications to deaneries. A return to this system, at least while a new system with demonstratable improvements can be established, would be welcomed by the majority. The only way this will happen is if the Consultants and Deaneries decide that's what they want. The argument made several times by MMC, the DoH and the Secretary of State that there has always been fierce competetion in medicine simply does not apply to this situation. Never before have applications to training posts been restricted (initially to four, incredibly now only one). Never before has there not been the opportunity to go away, improve clinical skills and CV and try again next time as a better doctor. It is really this 'one shot or your out - forever' maxim, that is driving us applicants to despair and selecting a random cohort of average doctors to become consultants in 4-6 years time. Competing interests: Junior doctor and MTAS applicant |
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