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Rapid Responses: Rapid Responses published:
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Local preferences are key
- Rudolf N Cardinal (23 June 2007)
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Unfair
- Ram edara (24 June 2007)
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REFERENCE-BASED SPECIALTY CAREER PROGRESSION
- Shelley Vamadevan (24 June 2007)
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Can we learn from other countries?
- Robert A Watson (25 June 2007)
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360° Review - Value In A Changing Workplace
- Ulka U Paralkar (26 June 2007)
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Do not forget Wales
- Liam G McKnight (27 June 2007)
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Sub-specialisation in Surgery: what is the appropriate level?
- Kieran R Gallagher, Humphrey Scott, Shane Barker (14 September 2007)
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Selection for specialist Training- A fair approach
- Vaibhav Tyagi, Deepti Tyagi (1 October 2007)
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Rudolf N Cardinal, SHO in cardiology Addenbrooke's Hospital, Cambridge CB2 2QQ
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Jefferis makes the important point that central matching schemes with local selection can work, and do work in other countries. There are many critical differences between this year's UK Medical Training Application Service (MTAS) process and schemes such as that operating in the USA (which involves an application system, the Electronic Residency Application Service, and a separate matching system, the National Resident Matching Program). One difference is that employers are not constrained in how they establish their preferences - and this is critical. Employers should not be obliged to use a national standard application form, or, worse, a national scoring system, for that is ludicrous. Moreover, it is unnecessary, since it is in every employer's own interest to select those they think will be the best doctors. The purpose and true benefit of a national system is to make a set of interlocking simultaneous choices, and to optimize employers' and applicants' happiness in so doing. Done properly, such a system based on local employer preferences should address other failures of MTAS 2007, such as the failure to address the needs of academic medicine [1]. I develop these and related arguments elsewhere [2]. [1] BMA Medical Academic Staff Committee (June 2007), Clinical academic training: a lost opportunity, at http://www.bma.org.uk/ap.nsf/Content/Clinicalacademictraining [2] Cardinal RN (2007), at http://pobox.com/~rudolf/medicine/Cardinal_Proposals_Tooke_Inquiry_18June2007_public_version.pdf Competing interests: 2007 applicant for ST1 academic psychiatry and ST2 core medical training |
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Ram edara, NonPrincipal GP HD3 4ef
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Dear Editor, I read Tony Jefferis's analysis with great interest as it is vital to have more and more openions about this process in order to produce a fool proof system. I appreciate he must have worked hard to collect all these information. But it looks like he failed to understad one major thing about international doctors(IMGs) when he describes UK DIRECTIONS at the end of the article. He rightly pointed out that in all other countries International Graduates are considered only after the local graduates and the system should be like that. But he failed to regognise that all those countries doesn't encourage IMGs to come to their countries before they are offered a job placement. That was the major mistake the NHS workforce planners done in the recent past, as PLAB allows IMGs to come in to the country before they get a job. In any other country Tony Jefferis analysed, this is not the case. IMGs go there only if they are offered an interview and go back home after the interview and allowed to the country of selection only after he has a job offer in his hand, which is by all means is fair and consequently they work harder and feel more responsible. I realise that Mr.Jefferis is an associate dean to a prestigious Deanery and not aware of this and accuses IMGs for contributing to the competition and failing of MMC/MTAS.This isn't IMGs fault, this is NHS work force planners fault, IMGs does't exist if they weren't asked to come in. Once they are in the country, it's the inviting country's responsibility to provide jobs to them because they came here only because NHS ivited them by widely publisiging in for ex. Indian news papers and other media 6 yrs ago. I am sure you disagree. I am not surprised if you don't publish this letter. Regards Competing interests: None declared |
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Shelley Vamadevan, SpR Anaesthetics and Intensive Care Queen Victoria Hospital NHS Foundation Trust, Holtye Road, East Grinstead RH19 3DZ
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The Jefferis’ analysis (1) of international practice with regards the use of references for entry into specialty training highlights some deficiencies in our current practice. Reference-based assessment of candidates has, in declared policy at least, been out of favour. The process attempts to be fair, the fear being that using verbal recommendations and references would promote bias and favouritism. Hence the widespread policy is for a candidate to be selected on the basis of a brief selection process, and references are only reviewed afterwards to ascertain if there are any objectionable details. Surely, for references to be of any value, it is fundamental that they be evaluated early in the process. The principle of fair assessment of all candidates through a uniform application process free of any other influences is rational. But this requires a selection system that is comprehensive, and designed to recognise and reward those who have demonstrated the required abilities including professional sincerity, while identifying those whose commitment is less than ideal. There is arguably no current process that successfully does that. The changing working practice in the UK amplifies this deficiency further because the opportunities for trainers to consistently assess individual trainees have diminished with the reduction in the number of hours spent in hospital. So while in the past, one’s ‘knowledge, skills and attitudes’ would have been recognised and highlighted by multiple supervisors, it is now very easy to ‘slip under the radar’. I agree with the conclusion that the reference system needs to be more discerning and elaborate. This would then have to be introduced into the selection process as part of the assessment not after selection. The emphasis on elective supervisors’ assessments reportedly used abroad is useful. However, the provision of more detailed forms to individual referees in the UK, I feel would turn it into a tick-box exercise which will probably not be much more effective, because of the implications of working time reduction discussed above. Also referees are named by the applicant, and therefore their opinion might not reflect a trainee’s true performance and attitudes. Trainees are always informally discussed at consultant/ trainer meetings. This process must be formalized in order for a detailed collective assessment and opinion of individual trainees to be crystallized. This would identify the qualities of the trainee within the job quickly and guide any further necessary action. It is this composite reference, from the departmental consultant body as a whole, that should then be used as part of the process of fairly determining suitability for progression within the specialty. 1. Jefferis T. Selection for specialist training: what can we learn from other countries? BMJ. 2007; 334: 1302-1304 Competing interests: My undergraduate and early post graduate training was in South Africa. |
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Robert A Watson, clinical instructor UNC-chapel hill
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I thank the author for his accurate review. I do understand that the article was reporting just in the context of MTAS/selection alone, however I do think that without an appreciation of the differing countries pre/post-graduate medical education algorithms and healthcare delivery models the individual selection measures are difficult to interpret and not exactly translatable. In the US there is a common objective examination taken by everyone prior to postgraduate training, that is the same test for all US graduates and foreign trained US nationals and IMGs.The scores then may or may not be used by program directors in selection. There is no ‘special track’ for international applicants in the US as the article reported and I do not personally believe all US programs explicitly consider domestic graduates before IMGs but rather, just as in the UK, the so called elite programs take there own-just as Oxbridge and the London schools always have even above other domestic graduates). The US has a very large undersupply of US medical school graduates and effectively two tiers of medical school with MD or osteopathic graduates. I can appreciate why the author only visited/reported on the English speaking diaspora due to the relative linguistic ease, however I do believe the forces that have driven change within the UK medical system over the last 20 years, and will continue to, have occurred due to reaction to EU integration (e.g. Calmanization, EWTD, MMC etc) and certainly not thru any leadership- particularly from within our profession. A review looking at selection systems in France, Germany, Poland etc may therefore well have been of more relevance to the future of medicine in the UK. At the end of the day selection should be based on objective criteria i.e. common examination results, the applicants ranking within there own medical school and/or ‘relevant’ past experience/skills/externships and not subjective ‘linguistic dexterity’ or subjective references and/or non- relevant experience, for the majority of programs, i.e. intercalated BSc, PhDs and research carried out for career progression only. The objectivity vs. subjectivity of interview is a little more difficult and open to much debate. I perceive that the main problem of MTAS was the non evolutionary ‘Big Bang’ implementation – how can a SHO (4-6yrs out) be objectively compared to a HO? Ultimately the problem with MMC maybe the career lock-in or lock-out experienced by those who have succeeded and those who have ‘failed’ which again is different than in the US due to to short residencies (3yrs gen. medicine!), pre-categorical positions and the multiple fellowship options. I do agree with the authors closing remarks that a golden age of selection did not exist and I personally think the old system was/is opaque and at worst nepotistic. I was an HO/SHO in the UK between 1993-98 and then a surgical resident and fellow in the US up to the present time. Within the context of the postgraduate education system in the UK the training was poor and the application procedures for posts and the moving locations ever 6 months chaotic. On the other side of the argument financially the rewards were very good and the system very flexible for the individual (NB- I earned more 10 yrs ago in the UK than I do now swapped my specialty and vacationed often!!). The high reputation of UK postgraduate training was maintained due to the experience gained over a very, very long unsupervised time (+15yrs) of non consultant delivered service commitment. If I could digress a little -the inconvenient truths for the future of UK doctors (I believe as an outsider) include; i) Doctors in training should be paid for there service commitment NOT there training and thus by shortening there service commitment to increase the training over a shorter period of time should mean lower pay. If the trainees want no service commitment then perhaps physician assistants will be required in the UK! ii) There needs to be consultant delivered healthcare in reality and not in name and talk only, not consultant supervised. (If the generals really were in the trenches this would create real pressure for system changes!!) I predict however that i) juniors will accept the MMC because the wages will remain high (thanks BMA!) and ‘training’ short. A sub- consultant grade will emerge in 7-10yrs to maintain service commitment but still with the title ‘consultant’ (if it hasn’t another name then the colleges can ignore it) and remuneration for all but a new higher tier of consultants will fall (a bit like the rest of Europe?). The profession will still be moving the deckchairs on the titanic by measures like complaining /altering the selection processes (MTAS). In the end its just the economics of supply and demand but within a monopolistic market place (NHS) and poor supply side management (profession) (that is unless you can operate in other markets i.e. plastic/ENT/ortho etc) . I hope I can just continue to observe from afar. Kind Regards Rob Watson FRCS Competing interests: None declared |
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Ulka U Paralkar, SHO Anaesthetics and Intensive Care, William Harvey Hospital, Ashford TN24 0LZ,
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As clinicians our performance at the workplace hinges, over and above our ability, on the way we conduct ourselves with other professionals. This has become particularly vital with the change to shift-based work patterns when we are likely to deal with multiple different people during patient management. Also the increasing emphasis on multidisciplinary care of patients places the onus even further on the ability to manage within a team. Unfortunately such communication and interpersonal management are intangibles that can not be readily defined or taught. Clinical staff are encouraged to undergo training in teamwork and communication but that is not a prerequisite to progressing in their field. This is never really formally assessed. Exams assess one’s knowledge, and consultant workplace assessments supposedly examine one’s skills and attitudes. But one is invariably naturally on one’s best behaviour for the brief episode of work with the supervisor. So the true attitude displayed within the healthcare team is never documented. And it is this interaction that is of utmost importance as it will define how an individual will perform upon achieving levels of seniority. 360° reviews as a concept have the potential to be an assessment tool of this very difficult area. I agree with Jefferis’ analysis of UK direction (1) that “the current 360° summaries on each foundation trainee tend to group at the upper end of the scale”. For reviews to be useful they have to be comprehensive, confidential, and above all distributed to the relevant personnel by someone independent of the person being assessed. Also those selected to provide this review should have been in direct clinical contact with the person concerned, ie, not provide a review on the basis of rumour or heard opinion. Though popularly criticized as a futile exercise, properly designed and conducted 360° reviews will define whether one possesses this vital ingredient of patient management. 1. Jefferis T. Selection for specialist training: what can we learn from other countries? BMJ. 2007; 334: 1302-1304 Competing interests: None declared |
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Liam G McKnight, Consultant radiologist morriston hospital,swansea SA6 6NL
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Tony Jefferis asks what can we learn from other countries about the UK Medical Training Application Service(MTAS) chaos. We can certainly learn from Wales. The Welsh deanery recognised that trainees and trainers had lost confidence in the process.The decision was made to offer all applicants an interview after the initial interviews had been held. A second round of interviews was then held with a similar process. We can therefore use this data to validate the shortlisting process followed by MTAS.All candidates were interviewed and the results of the initial shortlisting did not play a part in the final ranking.It should be straight forward to analyse this data to see how good the initial shortlisting was. I followed the process from the beginning with training,followed by shortlisting and the initial interviews. I also attended 2 of the extra 3 days of subsequent interviews. In Radiology I felt that many if not most of the better candidates had not been correctly shortlisted.If we had not interviewed all candidates then many outstanding doctors would not have had the opportunity to start Radiology training in wales this year. I could not attend all 3 days of the second round of interviews and so it seems to me essential that this data is analysed to inform the Tooke enquiry into the MTAS service.If other specialities in Wales ,Scotland or Northern Ireland have similar experiences then we can say that the initial process was deeply flawed and the process is not validated.It should not then be used again.If however other specialities found that all or at least the majority of the best candidates were correctly shortlisted then we can argue the process has been validated. One final note of caution-do not rely on the data of the final acceptance of offers as a substitute for the rankings.The whole process was delayed because of the extra interviews and so some of the best candidates will have had multiple offers and declined a place in the Celtic Nations because England was able to get their offers out much earlier. It took a huge amount of effort by the deanery staff,the speciality training office and the consultants involved but hopefully we can analyse this data to establish the validity of the MTAS shortlisting criteria.Deming, the father of the continuos quality improvement process is widely quoted as saying" In God we trust but the rest of you give me data"-we have the data can someone please analyse it? Competing interests: None declared |
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Kieran R Gallagher, FTSTA ST2 General Surgery St. Peter's Hospital, Chertsey, Surrey, KT16 0PZ, Humphrey Scott, Shane Barker
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Dear Editor, There have been recent papers(1,2) regarding speciality selection, particularly methods of selection and gender-bias in choice. We asked 66 doctors, of all levels, their opinion regarding the amount of postgraduate experience required for entry to surgical specialties and whether training should be competitive or seamless. 15% of respondents felt that the final year of medical school or foundation year 1 was the level to sub-specialise in surgery. 45% of Consultant responders felt that this was the appropriate time to specialise. Almost 35% of those questioned, the largest group, felt that specialties should be decided on after a period of generic surgical training at ST2, broadly similar to the level at which traditional SHO’s would have specialised. This was also the most frequent response of those who are currently undergoing surgical training. The result of the question regarding whether training should be competitive or seamless was more clear cut with 73% answering that it should be competitive although there were differing opinions as to which years of training this should occur. We have demonstrated that there is a lack of consensus among surgeons regarding sub-specialisation. Seamless training does not appear to be uniformly supported. Mr Kieran Gallagher, FTSTA ST2 General Surgery, St. Peter’s Hospital, Chertsey Mr Humphrey Scott, Consultant General Surgeon, St. Peter’s Hospital, Chertsey Dr Shane Barker, FY1 General Surgery, St. Peter’s Hospital, Chertsey References: 1.) Selection for specialist training: what can we learn from other counties? Tony Jefferis BMJ 2007;334;1302-1304 2.) Has Modernising Medical Careers lost its way? George B P Madden, Anthony Madden BMJ 2007;335; 426-428 Competing interests: None declared |
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Vaibhav Tyagi, Physician Trainee John Hunter hospital lookout Rd New lambton 2305 NSW Australia, Deepti Tyagi
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It has been a long time since subjective evaluation and non objective parameters were followed in selection process of specialist training all over the World. I believe the need of the hour is now to adopt a fair transparent system where nationality,domestic or overseas status would not affect the selection criteria. Instead of relying too heavily on referee reports as is usual in many countries, it would be appropriate to have a MCQ examination with or without a clinical examination in different specialities. The exam would be an objective way to assess a candidate in all aspects rather than a CV , referee reports,or mere 10 minute interview. I believe this would be an objective approach and would translate lip service about fair and transparent selection into action. Competing interests: International medical graduate -Basic Physician Trainee in Australia |
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