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The Defence Medical Services, of which the Defence Secondary Care Agency (DSCA) is a part, has a total of 140 specialist registrars in training across all hospital specialties, of whom several are training in hospitals with no formal military connection. Most of these posts are funded by the DSCA and therefore the civilian department has, effectively, a free registrar. However, little is known outside of the Defence Medical Services about who these doctors are, where they have come from, and what can be expected of them. Indeed, is the presence of one of these registrars a blessing or an encumbrance?
Since the Government white paper DCS (Defence Cost Study) 15 was published in the mid 1990s, the Defence Medical Services have undergone a complete overhaul, in both manpower and facilities. The Royal Hospital Haslar in Gosport is the only surviving military hospital, all the others having been closed over the past few years. In their place, the concept of the military district hospital unit (MDHU) has been conceived. These MDHUs are units within an established hospital in which military medical, nursing and technical staff work alongside their civilian colleagues to share clinical responsibilities and workload. In some geographical areas this arrangement also works to offset the increased workload resulting from the closure of nearby military hospitals. The duties performed by junior medical staff in MDHUs are similar, if not identical, to those performed by other doctors at the same stage of training. At the time of writing, Derriford (Plymouth), Frimley Park, Portsmouth and Peterborough are established as MDHUs, soon to be joined by units in Middlesbrough and Birmingham.
The typical military doctor embarking on specialist registrar training is slightly older than his or her contemporaries. (All three services have a mixture of male and female doctors, but for convenience we shall use the masculine pronoun.) Across all three services, new entry medical officers are required to undergo a period of officer training at Sandhurst, Dartmouth, or Cranwell, for the Army, the Royal Navy, or the RAF respectively. This completed, a two to three year period of ‘general duties’ is undertaken, during which experience will be gained as a medical officer to a ship, a regiment, or an air station. During this period, service in field conditions, separation from friends and family, and long periods of time away from home are commonplace, but these minus-points must be set against the opportunities to gain experience of military life, to travel, and to work as part of a highly professional and motivated team. Leadership qualities are assessed before entry as a medical cadet, and are enhanced during this officer-training and general-duties period to produce an officer who commands respect from both colleagues and subordinates and is capable of leading men in battle.
The military doctor will then have embarked on a basic training programme in a specialty or started a general practice vocational training programme, equivalent to those outside the military, and obtained the required postgraduate qualifications. Before being accepted into higher specialist training each candidate must undergo a specialist registrar appointment committee (SpRAC) interview, which is usually held at the same time candidates are being interviewed for civilian national training numbers (NTNs) for that specialty in a region. The military candidate is assessed in comparison with the other applicants, and accepted only if he meets at least the same standard as those appointed to the civilian posts. However, the military candidate is not competing for the same training number, since the Royal Defence Medical College has its own allocation of NTNs. The trainee will then complete a rotation of about 5 years, agreed by the Defence Advisor in the chosen specialty, the Defence Postgraduate Dean, and the Joint Committee for Higher Training in the specialty. Once this is completed, at least 3 years must be served as a consultant in an agreed post or posts, with the option of extending this period if acceptable to both employer and employee.
In times of peace, military hospital specialists work in hospitals in much the same way as their civilian equivalents. But in addition they will also undergo periods of training on military exercises to keep military skills up to date, and will occasionally deploy as part of peacekeeping operations to places as diverse as the former Yugoslavia, Sierra Leone or the Falkland Islands. During time of conflict, military doctors are asked to fulfil a war role corresponding to their specialty. There is a predominance of surgeons, both general and orthopaedic, of anaesthetists and of emergency physicians, to reflect the expected clinical workload in times of conflict. These specialists may be asked to deploy with a field hospital, surgical support team, or the primary casualty receiving ship, RFA Argus, depending on their service. These periods may be viewed by some as uncomfortable or dangerous, and may entail lengthy separation from family, but are an integral and expected part of life in the Defence Medical Services.
In the training of a specialist registrar to be a consultant within the Defence Medical Services, it is sometimes desirable to send him to a hospital without direct links with the military. This may be a centre of excellence within the chosen medical field or a setting that offers research opportunities (or both). For this reason hospital departments may unexpectedly be asked to accommodate a military specialist registrar for a part of his training. Many such hospitals do not know what to expect from the new arrival. The following is a guide to what they may encounter.
In general, the same can be expected from a military registrar as from any other registrar rotating through the post. Nor is there any outward distinction. Though the authors are both Surgeon Lieutenant Commanders in the Royal Navy, in the civilian hospitals to which we are seconded for training we are known as ‘doctor’, along with our colleagues. However, because the Defence Medical Services has its own Postgraduate Dean and in many ways is a region in its own right, the military specialist registrar may feel under less pressure to conform to regional opinion. For this reason, he may find himself used as a spokesperson for the junior staff—a verbal battering ram, so to speak, to voice issues that others may be unwilling to volunteer. He will be accustomed to administrative duties such as organizing rotas, and will be used to presenting issues to a non-medical as well as a medical audience. Because of his experience as a general-duties medical officer, he will have insights into general practice, as well as life outside hospital.
Generally, the biggest obstacle when starting a post within a civilian establishment is that people do not know what to expect. Among those who have had no experience of working in or with the Defence Medical Services, there seems to be a brooding mistrust of all things military. This may spring from the historical situation where military doctors worked in military hospitals, and were therefore segregated from their civilian colleagues. This separation brought with it mistrust—as is only human nature, whether right or wrong. However, as the military hospitals that now exist are in fact part of established National Health Service trusts, the work of the Defence Medical Services is on show for all to see, and in these days of clinical governance there are no longer places in which to hide from scrutiny. In the twenty-first century the military doctor is as accountable as the next man or woman, and strives to provide as good a service as is possible.
The fact that the military doctor does not have to compete for a national training number could be seen as a potential source of consternation within the ranks of civilian colleagues. However, as mentioned above, all military specialist registrars go through the same selection process as a civilian candidate, in front of a civilian panel, to ensure they achieve the appropriate standard before being allocated a number. In reality, most departments are only too keen to accept a military registrar for a section of his training, and a mutual understanding is quickly achieved.
We, the authors, have been asked some bizarre questions during our time in the Armed Forces. Contrary to what some would believe, military doctors have all qualified from normal medical schools and gained qualifications to prove their medical worth. There is no Army or Navy medical school hidden away somewhere, that churns out people who can deal solely with coughs, colds, genitourinary infections and the odd head injury or fractured fifth metacarpal neck. The commonest question asked is, ‘Why is a Royal Naval doctor working in a hospital, not on a ship?’. We hope that question has now been answered.
We believe that having a military specialist registrar in a department is a blessing, and a free one at that. It is of value both to the host department, which benefits from a capable and professional extra pair of hands, and to the individual trainee, who gains valuable training in areas that may otherwise be inaccessible.
Both authors are specialist registrars in the Royal Navy, currently seconded to civilian hospitals for training.