The gap between foundation years and specialty training

Peak of a trend?

The UK Medical Careers Research Group, led by Michael Goldacre of Oxford University, has been surveying medical graduates since 1997. The results of their cohort studies of graduates from 1999 to 2005 showed that just under a quarter of the doctors were not in specialty training four years after graduation, a figure that was fairly constant across the year groups.4 This consistency of attrition in the workforce led them to comment in the BMJ last year that “junior doctors are no more likely now to abandon their training and leave the profession than they have ever been. Now, as in the past, doctors’ medical career trajectories do not invariably take a straight and relentless course from qualification through specialist training.”5

However, the most recent figures indicate that we may be seeing a larger number of junior doctors in alternatives to specialty training. This trend is seen among trainees at the South Thames Foundation School, only 65% of whom applied to specialty training in 2010 (down from 79% in 2008).67 Is this just a spike in the trend? Does it reflect the changes in postgraduate training? And what are doctors doing as alternatives?

A rigid training structure

The two year foundation programme emerged from its precursor, the preregistration house officer year, partly to meet the requirements of the European Working Time Directive. It was heralded as “an opportunity to develop experience in a wider range of specialties through four month placements.”1 However, the level of choice among trainees over these varied experiences is limited. Furthermore, with rotations dictated by your foundation application score, the choice is more limited for those at the lower end of a fairly arbitrary hierarchy. Some rotations in FY2 add little value to training; in particular, FY2 can include rotations in which trainees are supernumerary for four months in specialties that are not their preference.

The specialty applications take place early in FY2. The streamlined, structured nature of specialty training, introduced through Modernising Medial Careers, is too rigid for those doctors who simply do not know what to apply to. They fear picking the wrong specialty too early and facing a difficult, competitive reapplication to an alternative specialty or a narrow training experience that does not allow for further evaluation of alternatives. Taking time out of training to gain experience through flexible positions (trust jobs, locum work, work abroad) before committing to a specialty seems desirable in this position.

Tough applications

Competing for specialty training in the NHS is, for most doctors, a challenge. This year, more specialty posts were made available, and as a result competition ratios stayed the same as in previous years. However, there is always a substantial proportion of doctors who do not gain a post. This year 10 946 applicants applied for 7830 specialty training year 1 posts.8

Some doctors reject the posts offered to them, particularly if the location offered is unacceptable. “I can do better next year” is a common line of thought applied to specialty applications, not just by those dissatisfied with their initial offers. As specialty applications approach, some doctors realise that their CVs don’t meet their maximum potential. If you want to beat the competition, your application needs to stand out from the crowd; extra points are awarded for publications, audits, conference presentations, and a clear, evidenced interest in the chosen specialty. For those who do not decide on a specialty until later in foundation training, this can seem like a daunting task to accomplish in a short period. The limitation of annual application means that the only options are applying prematurely or waiting another year.

The scrabble to produce a sparkling specialty application needs an effort far beyond the confines of the basic foundation programme—a programme that was intended as competency based training and, as John Tooke noted in his famous inquiry into postgraduate medical training, that is “unlikely to encourage or reward striving for excellence.”9

Gap year experience

To step on to the specialty ladder is to move between two quite different stages in life. These little niches of time are a rare gift in the average working life, and the chance to combine new work experiences and life experience is often achieved through travelling abroad.

Heading to New Zealand and Australia is a longstanding favourite for post-foundation year doctors. No entry exam is required, and the medical councils actively seek UK doctors, with many companies advertising opportunities. Working hours are low, and some doctors report getting more hands-on work experience, enhancing their skills, and building confidence.

Goldacre and colleagues reported from their cohort studies of 1999-2005 that a steady proportion of 1 in 20 doctors were working abroad four years after qualification.4 The New Zealand Medical Council records the total number of new provisional registrations from UK doctors annually (not specific to post-foundation year) and has found the rate of new registrations each year to be stable for the past decade.10 Its figures do show, however, that the percentage retention of UK doctors one, two, and three years after registration in New Zealand has almost doubled over the past decade.11 Although this is not specific to post-foundation year doctors, it does show that retention of UK doctors in New Zealand is increasing: doctors are staying longer.

If the NHS is to benefit from the skill set of doctors gaining experience abroad, as Richard Marks from RemedyUK prophesied last year, “the system needs to be such that it’s easy for them to get back.”2

Implications for trainees

How does taking time out before specialty training application reflect on the trainee? Speaking to BMJ Careers, Liz Berkin, deputy medical director of the Joint Royal Colleges of Physicians of the UK Training Board (JRCPTB), says: “Taking a gap year between foundation training and CT/ST1 [core training/specialty training year 1] should be seen as a positive initiative, benefiting both the trainee and the NHS. The year allows trainees to gain new skills or consolidate existing skills, which are usually welcomed at CT/ST1 level. It also gives the trainee the opportunity to think further about their ultimate career choice if not already decided.” The box gives further advice from the JRCPTB.

Wider implications

It’s easy to justify the needs and benefits, to the individual, for out of training experiences at this stage in a doctor’s life. But where does this leave the wider NHS workforce?

It is inevitable that the flow between two fairly rigid training structures (the foundation programme and specialty training) is prone to turbulence. But how much laxity and flux in the workforce concentrated at this point is sustainable? In the past doctors have left training temporarily after their house jobs, but with this proportion now reflecting a third of the year’s workforce, this may present an issue for workforce planning. In light of the NHS reforms, and the potential need for an increased general practitioner workforce for GP commissioning, monitoring the outcomes of FY2 training is key.

Crucially, if nearly a third of doctors are moving out of UK training after the foundation programme, should we listen to what this is telling us about postgraduate training in the UK? We think the message is clear: there needs to be more flexibility in training at this level. Doctors need a greater degree of ownership over their training.

In the past training pathways were unclear. Currently, however, the opportunity to choose a varied experience—to carve your own path and change your mind—is limited. The foundation programme is not providing the varied experience needed to link to specialty training; it introduces redundancy and inflexibility into these early experiences, particularly in FY2. The Tooke report9 dealt directly with these issues: its recommendations included abolishing FY2 as it stands, in favour of four core training stems (replacing current FY2/ST1/ST2) with the option of transferability. This is a model that would provide clear training pathways while reducing the pressure to commit prematurely to one of the 57 specialties. With the future of the NHS in the hands of current foundation trainees, early training experiences cannot be so restrictive.