Medicine has always been a highly competitive career option, attracting some of the brightest and best of each generation. For those who succeed, the rewards go beyond job satisfaction and social standing. Few careers guarantee the same level of income and security of employment. Fewer still offer the same high odds of getting to the top of the professional ladder by becoming a consultant or principal in general practice. After years of good fortune, these benefits are seen by most doctors almost as a right. Other professions must look on with envy.

The fallout from the current reforms of postgraduate medical training, Modernising Medical Careers (MMC), is shaking these expectations to the core. The tacit understanding that some specialty training programmes were more popular than others has now been turned into the hard reality of competition ratios.1 In 2007, there were 53.2 applicants for each post in the third year of specialist training in cardiothoracic surgery, whereas fewer than one person applied per post for a similar number of jobs in clinical immunology. Next year is likely to be even more competitive, …