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Student Careers

Senior house officers: the lost tribe?

BMJ 2005; 331 doi: https://doi.org/10.1136/sbmj.0510372 (Published 01 October 2005) Cite this as: BMJ 2005;331:0510372
  1. Kaji Sritharan, clinical research fellow1
  1. 1Imperial College. London

Doing medicine used to mean a job for life, but these days many junior doctors are facing unemployment. Kaji Sritharan investigates reports of a crisis in senior house officer jobs

Recent concerns about doctor shortages have seen the creation of new medical schools, expansion of existing medical schools, and active recruitment of doctors from overseas. It seems a bizarre contradiction junior doctors unable to find jobs? Is there really a problem?

Simple healthy competition?

Is this all down to the same healthy competition for jobs that happens every year? It doesn't seem that simple to the doctors affected. “I've applied for at least 30 jobs and have only been shortlisted for one and this had over 1050 applicants,” says Clare Swaney, a career accident and emergency senior house officer (SHO). “In the end though it came down to experience and I'm in the situation where I'm too experienced for foundation year 2(F2) pilots but not experienced enough for a stand alone SHO post. It's not a problem that is isolated to any one region either-I have friends in London, Newcastle, and Manchester who are in a similar position.“ “There has always been healthy competition and I was lucky in that I did get a job,” says SHO in surgery Pete Holt, “but at least a third of my friends-and these are people who have trained in Oxford, Cambridge, or London don't have a job for this August.”

Ask the BMA

In July 2005, BMA News reported that more than a third of SHOs had no job for August. “I think that the situation is a lot worse than that,” says James Haddow, an SHO in surgery who has recently returned from working in New Zealand. “Six out of 10 of my close friends have been unable to get jobs:” In addition, BMJ Careers has reported a fall of about 28% in the number of training grade jobs advertised in the past three years (although the relation between job adverts and actual posts is complicated).

Ask the Department of Health

The Department of Health has no central figures on the numbers of doctors out of posts. When I asked the Department of Health for comments, they provided the following statement. “The figures being quoted in some press reports are wildly inaccurate. We have spoken to all of the postgraduate deaneries and there are only 122 preregistration house officers who are currently not placed-far from the thousands claimed in some press reports. We also know that there are further vacancies still available, even in London. There is simply no question of hundreds of doctors being `on the dole.' The BMA survey was a very small survey and was not a representative or weighted sample. There are always stories like this at this time of year as junior doctors make the transition into the senior house officer grade.”

Entry into the SHO grade is competitive and just as in many other areas of work-there has always been healthy competition for posts, particularly in popular areas such as London, and in popular specialties such as surgery, but we are working with the NHS to ensure that all our junior doctors find training posts. We want these doctors to progress and develop their careers in the NHS where we see them as our doctors of the future.”

Asmaa Al-Kufaishi, who has just completed her preregistration house officer year is irate. “Of course there's a problem. [The Department of Health] should have predicted the shortfall of 112 posts and made jobs available early. Instead, a lot of doctors have been left dempralised and frustrated.”

Ask hospital trusts

“I've contacted lots of trusts asking when their rotation or training jobs will be advertised,” says Haddow. “The answer is invariably that these posts have been absorbed into the foundation 2 pilots.” This is a suggestion which is refuted by the Modernising Medical Careers (MMC) team. “Some posts both trust grade and training SHO posts-have been incorporated into F2 pilots, but if anything this should increase the total number of training posts available,” said their spokesperson. “The future is uncertain,” suggests Haddow. “Trusts that I've contacted don't know what will happen come 2007; they've said it's likely to be dictated by [the Postgraduate Medical Education and Training Board].”

Doctors leaving the NHS

“Of the 10 people I worked with [in the emergency department] as an SHO, four are leaving medicine because there are no jobs,” says Holt. “I know of two people who are leaving medicine to go into law, one is going to work for the United Nations, and the other is taking a year out to decide what to do. I've applied for between 20 and 30 jobs and had no idea it was going to be this difficult I'm not even getting short listed,” reports Haddow. “I've thought about either leaving medicine or going back to New Zealand-life may be tough out there, but it's not as tough as it is here. I've registered with a locum agency,” he adds, “but I'm worried though-with so many doctors in the same position as me even this work could dry up.”

If there is a genuine shortage of SHO jobs at the moment, what could have caused it?

Poor workforce planning?

“[The BMAs Junior Doctors Committee] for years have predicted that the current problem would occur with any attempt to eliminate the SHO grade... MMC has just expedited it,” says Simon Eccles, chairman of JDC. “The increased need for doctors predicted by the European Working Time Directive (EWTD) also hasn't happened,” he explains. “Initially the easiest thing for trusts to do to plug the gaps created by EWTD was to fill the rota with eight trainees. Now trusts have had time they've reexamined and redesigned rotas with fewer doctors.” “It's a tragic loss of precious staff from the NHS,” adds Swaney. “Many are going overseas… I'm very disappointed in the poor workforce planning.” If the problem is down to poor workforce planning, it wouldn't be the first s time. In cardiothoracic surgery an excess of 80 surgeons have been trained and many post-CCST (certificate of completion of specialist training) are now being advised to re-train as general practitioners.

Overzealous overseas recruitment?

“I know of a doctor from Cameroon who has applied for over 1500 posts over a five and a half month period whilst working in a fast food restaurant to support himself,” says Swaney. “He was trained to the level of a medical registrar in Cameroon but not accredited here. It must have been soul destroying for him, especially since he was given the expectation that jobs were readily available here,” she adds.

“The perception that training posts are abundant in the UK is high,” agrees Sanoj Chacko, a senior medical SHO who trained in India. “The PLAB (Professional and Linguistic Assessments Board) exam is now being conducted in multiple centres and you naturally assume that once you pass the exam you'll get the job. A general problem for overseas doctors is that you need to do an unpaid clinical attachment to get a UK referee, without which you can't even start to apply for jobs. We should be told that there is a wait or no jobs here beforehand so at least then we can plan,” he adds. The SHO bulgeset to grow?

“If MMC gets this right it will be 2+6 years of training and people won't be hanging around and there won't be bottlenecks and people won't be forced into doing pointless research that is of dubious value to their career and to society as a whole,” says Eccles. “But unless you do two things MMC is destined to fail,” he warns. “(1) End the hospital's reliance on the SHO grade to provide service, and (2) end the reliance on SHOs to prop up the night rota. There are currently 25 000 SHO or SHO equivalents hanging around providing service and if this doesn't stop you will inevitably end up recreating a new grade of doctor after MMC.”

It may, however, be too late. Already there is an anecdotal increase in the number of trust grade posts to fill a service gap left by an alleged decrease in SHO training posts. Furthermore, the promised consultant expansion has yet to materialise.

In August 2007 the first wave of foundation 2 doctors will come through the system and the question running through many SHOs minds is what will happen to them?

Speculation and rumour

“My impression is that the foundation year, when they come through in August 2007, will be given priority for specialist training posts and those who are currently SHOs will be left in limbo,” says Holt. “There is also a real fear that you may even get put back years or, even worse, not be able to train in your specialty of choice.” “It seems that implementation of MMC hasn't been adequately thought out,” says Swaney. “MMC is supposed to remove the bottleneck-to eliminate the lost tribe-but at the moment it feels as if the lost tribe has just got bigger.” More worryingly, should the current trend in securing jobs continue, how many more doctors will become trapped within the SHO bracket? Eccles believes that elimination of the current “lost tribe” of SHOs is possible and estimates the bulge to be approximately 15 000. However, this cannot be achieved overnight, and he predicts the transition period to be between five and eight years, during which the reliance on trust grade and SHOs to deliver service can be progressively reduced and specialist training numbers increased.

Careers advice

“What is needed now is good careers advice,” says Eccles. However, what careers advice there is seems to vary from useful to useless or contradictory. “I've been advised by the Royal College of Surgeons that I fall between two stools,” says Haddow. “I'm not in the old system and I risk being overtaken by the foundation years. But even they don't know what is going to happen in August 2007. The interface between the transition between the old and new system I think is bound to be messy. In retrospect, perhaps I shouldn't have spent a year abroad, but then again I never would have gained the experience that I did had I stayed. I've been advised to go abroad to Australia or New Zealand, to persevere here, to apply for every job, not to apply for trust grade jobs, and also to apply for trust grade jobs,” says Swaney. “Consultants have no idea what will happen.” “There is precious little information,” says Clare Hooper, a medical SHO. “Careers advice is never objective and what we desperately need is something official.” “What would also be really useful is feedback as to why we're not getting shortlisted for jobs,” adds Chacko.

Trainees want honest answers

The paucity of information could almost be excused if it were solely the result of inadequate communication. The truth, however, is that there are no answers to many questions, such as: do we have a problem currently, how will the transition between the new and old system be managed, how will selection into specialty training with MMC work, and how is the future medical workforce shaping up? The only information which has been confirmed is that existing national training number (NTN) holders will be permitted to continue to progress through the existing system. The current cohort of SHOs, therefore, have until August 2007 to obtain an NTN, and with it some hope of career certainty. However, for many this is not an option or is a path not without sacrifice. “Although my rotation finishes in August 2007,” says Holt, “ordinarily I would have liked to have gone on to do research or spend some time abroad. Instead, I feel pressurised into applying for a registrar post that I'm not sure I'll be ready for.”

Conclusion

It appears that the current crisis at SHO level cannot be attributed entirely to MMC. However, with the imminent changes to training there has been much unhealthy speculation, rumour, and uncertainty. The UK Strategy Group met in early September 2005 and answers many of the questions raised in this article. Notes from the meeting are on the website (www.mmc.nhs.uk/pages/spe-cialties) and although areas of concern have been broadly discussed the detail is still severely lacking. Workforce planning remains key to the success of MMC and the management of the transition period. However, unless the Department of Health accepts that unemployment in doctors is a real issue, it also stands to be the Achilles' heel of MMC.

Notes

Originally published as: Student BMJ 2005;13:372

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