Why the UK's Medical Training Application Service failed
BMJ 2007; 334 doi: https://doi.org/10.1136/bmj.39154.476956.BE (Published 15 March 2007) Cite this as: BMJ 2007;334:543All rapid responses
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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
Competing interests: No competing interests
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
Ashley Grossman, Consultant Physician and Professor of Endocrinology,
Queen Mary, University of London
George Hart, Consultant Physician and Professor of Medicine, University of
Liverpool
Philip Home, Consultant Physician and Professor of Diabetic Endocrinology,
University of Newcastle
Kay-Tee Khaw, Consultant Physician and Professor of Clinical Gerontology,
University of Cambridge
John Monson, Consultant Surgeon and Professor of Surgery, University of
Hull
Roy Taylor, Consultant Physician and Professsor of Medicine &
Metabolism, University of Newcastle
Nick Wright, Warden, Queen Mary College, London
'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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Honorary Secretary,
Medical Women’s Federation
Tavistock House North,
Tavistock Square,
London
WC1H 9HX
admin.mwf@btconnect.com
www.medicalwomensfederation.org.uk
1. Why the UK’s Medical Training Application Service failed BMJ
2007; 334: 543.(17 March)
Competing interests:
None declared
Competing interests: No competing interests
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 £575 per PLAB exam and £290 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
Competing interests: No competing interests
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.
Competing interests: No competing interests
Re: Critical week for MMC/MTAS: Individual Consultants and Staff-Councils will decide the fate of MTAS
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
Competing interests: No competing interests