The effects of the collapse of the United Kingdom's electronic recruitment and selection system for junior doctors, the Medical Training Applications Service (MTAS), have shaken British medicine.1 Anxiety has been raised about the careers of thousands of young doctors along with questions about the fitness for purpose of some of medicine's key institutions.2 The government has ordered an independent review not only of the recruitment system but of the whole of the new pattern of postgraduate education, Modernising Medical Careers,3 and it is understandable that the system is being blamed for all current difficulties.

The reality, in respect of medical unemployment, is more complicated and more worrying. Even if MTAS had worked perfectly, we would have still faced major problems with medical unemployment because of the government's muddled approach to managing medical immigration. This has created a large surplus of applicants over available training places, making disappointment for thousands inevitable. The policy confusion has compounded a long standing failure to address the implications of the major expansion in UK medical school output for postgraduate education and career structures. These are vitally important issues for the future of medicine in this country. But because immigration is such a sensitive matter, they remain little discussed – the “elephant in the room.”