Intended for healthcare professionals


Integrated specialty training

BMJ 2009; 338 doi: (Published 24 January 2009) Cite this as: BMJ 2009;338:b29
  1. Richard Seah, specialty registrar in sports and exercise medicine,
  2. Cheong Hung Lee, specialty registrar in neurosurgery
  1. 1Royal London Hospital, London
  1. richard.seah{at}


Modernising Medical Careers introduced the concept of run-through training in Britain. Richard Seah and Cheong Hung Lee describe their experiences of entering the programme at ST3 level

One of the key aims of Modernising Medical Careers (MMC) was to streamline and modernise medical training with a view to improving patient care and safety ( In doing so, it introduced major changes to specialty training not seen since the Calman reforms in 1995. These had bee introduced to align the UK system of specialist training with the requirements of the European Union directive on medical training.1

Since August 2007, competitive entry into run-through registrar programmes guarantees specialty training ranging from four to six years (depending on the specialty) before attaining the certificate of completion of training (CCT).

Integrated specialty training is one of the consequences of this revolution in British postgraduate medical education. In certain specialties, there is a move to encourage broader exposure to affiliated specialties in the early years of registrar training, while retaining regular contact with one’s chosen specialty by means of weekly clinic attendances or educational sessions. Our experiences as two newly appointed specialty registrars are highlighted to give a flavour of what integrated specialty training has been like thus far.

Richard Seah’s view

“Sports and exercise medicine (SEM) is a new medical specialty in the United Kingdom. Specialty recognition by the government in February 2005 meant that it has only been possible to enter a formally recognised training programme very recently. The inaugural four year specialty registrar training rotation in SEM coincided with the launch of the new Modernising Medical Careers’ training posts on 1 August 2007. SEM run-through training is different from all the other medical specialties in this aspect as there is no previous specialist registrar equivalent programme to compare it to.

Entry into the SEM registrar run-through training programme is competitive and occurs at specialty training year 3 (ST3) level. In London, this is divided geographically into the East and West Thames training rotations. My first year on the East Thames training rotation involves six months of emergency medicine at Royal London Hospital, followed by six months of SEM at the centre for sports and exercise medicine, Mile End Hospital and Queen Mary College, University of London.

Like most other trainees who entered the inaugural SEM specialty training rotation, I had completed training in another specialty (general practice) before obtaining a masters degree and faculty diploma in SEM (see the website of the Intercollegiate Faculty of Sport and Exercise Medicine— Before I entered the run-through programme, I was involved in research and spent six months working as a fixed term specialty training appointee in SEM in north London.

Unlike some specialties that are organ specific (for example, cardiology, dermatology), SEM is a medical specialty that is person and situation specific (for example, looking after the injured sportsman who wants to play in the first team again; helping an athlete prepare for her next major competitive event). This philosophy lends itself well to integrated training, where broad exposure and experience in specialties closely allied to SEM is essential. These allied specialties include emergency medicine, trauma and orthopaedics, public health medicine and epidemiology, general practice, musculoskeletal radiology, rehabilitation and disability medicine. SEM specialty registrars are expected to gain ample experience in all these areas during their training rotation.

I currently work as a junior registrar in the emergency department, with the usual responsibilities of looking after patients in the resuscitation room, major and minor units, and short stay wards. My last experience of working in the emergency department was as a senior house officer in Oxford seven years ago, so I felt quite rusty at the beginning.

After the initial orientation and settling-in period, I felt confident to supervise and teach junior staff on routine clinical issues. Situations and dilemmas that I had not encountered before in emergency medicine were discussed with more experienced emergency medicine registrars and consultants either on the shop floor or during weekly teaching sessions. I have an allocated consultant mentor whom I meet regularly to review my training aims and objectives.

My participation in SEM is maintained by attending weekly educational teaching sessions where possible, although it is recognised that SEM-specific exposure during certain integrated job postings is less than during other parts of the four-year training rotation.

I am enjoying the experience of working in emergency medicine once more. It did take me a while to get used to working a full-shift pattern again. There is no doubt that some of the skills and knowledge I have acquired are very relevant to my role as a sports physician. It has also made me realise that I have missed the camaraderie and banter that comes with working in a large and busy department.

Progression to ST4 level in SEM usually involves integrated training posts in public health medicine and general practice, although there is some flexibility dependent on each individual trainee’s preferences and previous training experience.”

Cheong Hung Lee’s view

“My pathway into neurosurgery has been challenging but typical of many trainees. I had gained a broad base of basic surgical experience, including emergency medicine. I had completed my surgical membership examinations, carried out formal research, and even worked in neurosurgery as a locum appointed trainee registrar in the old specialist registrar system.

With the introduction of Modernising Medical Careers, neurosurgery became an eight year rotation (ST1-ST8). The first three years (ST1-ST3) are heavily involved in integrated training with allied specialties that include intensive care, ENT, neurology, and emergency medicine. ST4-ST8 training is entirely dedicated to neurosurgery.

My entry into the new system was at the ST3 level and involved six months of integrated training as a junior registrar in emergency medicine before returning to a further six months of neurosurgical training at ST3 within the same hospital.

Like many colleagues, I initially viewed this posting in emergency medicine with scepticism. In principle, emergency medicine could provide abundant and varied experience for a basic surgical trainee but would I gain anything from a repeat period in this allied specialty?

I therefore started the post with a certain apprehension. I soon recalled my old emergency skills, however, and became comfortable in managing common clinical presentations and performing simple minor procedures. Supervision of junior members of staff in routine clinical situations has been rewarding, especially in teaching procedures such as suturing techniques, chest drain insertions, lumbar punctures, and the application of plaster casts. The department is well organised and the nature of the specialty means support by consultants and more senior middle grades is readily available on the shop floor.

I have a dedicated consultant mentor who actively participates in my training through regular formal and informal meetings. It was not clear initially how best to focus my training with relevance to neurosurgery. We soon formulated a plan of action, however—my exposure to trauma has been reviewed with formal consultant assessment on a regular basis, and discussions of case scenarios are often held in our departmental teaching sessions. I have been involved in several neurosurgical audit projects and participated in compiling a departmental database of interesting case images for teaching purposes. This has allowed review of many interesting intracranial and spinal cases, which should improve my skills in viewing radiological imaging and provide an accessible store of work for future presentations.

My formal specialty teaching comes from weekly clinical meetings held within the local neurosurgery department and monthly regional teaching sessions. Exposure to these formal teaching sessions is limited by clinical commitments but increased access to these meetings is being discussed at present with a view to improving future trainee experience. Study leave to attend courses and conference presentations has been actively supported.

There have been difficult times. The intensity of working a full-shift pattern has been tiring, and prolonged lack of neurosurgical operating exposure has frequently challenged my enthusiasm. The nature of the emergency department, however, means that I have interacted with specialties from all areas. These interactions have allowed renewed insight into the current management of various clinical conditions, no doubt benefitting my general management of patients once back on the neurosurgical wards and in clinic.

The neurosurgery and emergency departments have both been supportive of my job posting and there is certainly scope for increased integration between the two specialties to enable improved training for future neurosurgical trainees.”

Advantages and disadvantages of integrated specialty training

  • Broad and varied work experience

  • Interesting working week

  • Fosters good working relationships with closely allied specialties

  • Allows insight into problems faced by other specialties.

  • Flexibility required to adjust to different work patterns and work environment

  • Early planning required to optimise benefit to trainee of job posting.

Teething problems

There is much to recommend integrated specialty training. As with any fledgling undertaking, there will invariably be teething problems, which can be resolved with patience and innovative thinking. It will be interesting to see what implications the Modernising Medical Careers inquiry and the finalised Tooke Report (which suggests dropping run-through training) have on integrated training in the long term.2 Our experiences suggest that a pragmatic approach, which combines the positive aspects of a run-through programme with integrated specialty, could succeed, provided there is flexibility within the system to recognise and respond to a trainee’s individual training needs.


  • Competing interests: None declared.