Intended for healthcare professionals

Opinion Dissecting Health

Scarlett McNally: Fixing training for postgraduate doctors

BMJ 2023; 383 doi: (Published 31 October 2023) Cite this as: BMJ 2023;383:p2499
  1. Scarlett McNally, professor
  1. Eastbourne
  1. scarlettmcnally{at}
    Follow Scarlett on X/Twitter @scarlettmcnally

A recent general meeting of the Royal College of Anaesthetists voted to demand better postgraduate training for doctors.1 Rotational training for doctors can have huge negative effects on morale, patient care, educational opportunities, and home life.1

Improving the quality and availability of postgraduate training posts for doctors is key to having a viable NHS and a healthy population. Four months on from the publication of the NHS workforce plan,2 we should admit that it overlooked training doctors. We need doctors who can uniquely manage complexity and plan personalised care—crucially, understanding when to avoid excess healthcare and overmedicalisation.

Postgraduate training for doctors is broken, and they don’t feel valued. Doctors in postgraduate training spend much of their time on administrative tasks rather than on learning and gaining skills. Most rotas have gaps, and there’s a vicious cycle of antisocial hours, commuting, overwork, administrative overload, and burnout. Postgraduate training posts have increased by only 14% since 2014, while applicants have increased by 68%, partly as a result of more medical school places.34 The NHS has never increased training numbers in response to the European Working Time Directive that decimated rotas in 2009,5 nor recognised the reality that over half of doctors graduating are women of childrearing years who are more likely to take parental leave or need flexible working.6

The competition ratios for medical training places are shocking. There’s only a one in four chance of getting into some specialties, meaning that 75% of doctors who apply are turned away from emergency medicine, anaesthetics, or obstetrics and gynaecology.4 Training places should be increased to prevent losing excellent doctors who could be staffing departments, followed by decades spent as consultants who can lead teams. Many doctors not currently working, or taking a career break, could be coaxed back to the NHS in a part time role if they had adequate support. I’ve seen one WhatsApp group with 650 doctors on a career break.

So, we must be radical and demand more postgraduate training posts for doctors, with appropriate funding, and create new part time funded roles for returning doctors. We can convert some posts for “locally employed doctors” into training posts and establish new fully funded posts for postgraduate training. And we can harness the skills of specialist, associate specialist, and specialty (SAS) doctors to help with educational supervision and ensure that they too feel valued.

This approach will pay for itself, as doctors’ expertise can help avoid costly overmedicalisation. Doctors carry the burden of risk and have to balance this with the complexity of each patient. The UK’s ageing population means that polypharmacy and multimorbidity are increasingly rife. Deprescribing is hugely effective—and cost effective—but it requires the judgment that doctors use every day.7 Similarly, shared decision making requires experienced doctors who can respond appropriately to uncertainty. A study in emergency departments showed that doctors had fewer avoidable hospital admissions, ordered fewer scans, and had significantly lower costs than other staff.8 When developing new roles we should focus on additional support staff—including secretaries, doctors’ assistants,9 care coordinators, and social prescribers—to enable doctors to work as effectively as possible.

We should invest in doctors and their postgraduate training to rebuild a stronger, more sustainable NHS.


  • Scarlett McNally is a consultant orthopaedic surgeon and president of the Medical Women’s Federation.

  • Provenance and peer review: Commissioned, not externally peer reviewed.