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Logo of bmjThis ArticleThe BMJ
BMJ. 2007 December 15; 335(7632): 1222–1223.
PMCID: PMC2137050

The future for trainee doctors

Martin Marshall, clinical director

The Tooke report has identified the challenges, now the profession must respond

Medicine has always been a highly competitive career option, attracting some of the brightest and best of each generation. For those who succeed, the rewards go beyond job satisfaction and social standing. Few careers guarantee the same level of income and security of employment. Fewer still offer the same high odds of getting to the top of the professional ladder by becoming a consultant or principal in general practice. After years of good fortune, these benefits are seen by most doctors almost as a right. Other professions must look on with envy.

The fallout from the current reforms of postgraduate medical training, Modernising Medical Careers (MMC), is shaking these expectations to the core. The tacit understanding that some specialty training programmes were more popular than others has now been turned into the hard reality of competition ratios.1 In 2007, there were 53.2 applicants for each post in the third year of specialist training in cardiothoracic surgery, whereas fewer than one person applied per post for a similar number of jobs in clinical immunology. Next year is likely to be even more competitive, with an overall competition ratio of three applicants for each post, compared with two this year. As a result of these high levels of competition and the intent of MMC to eliminate the “lost tribe” of junior doctors,2 applicants are starting to recognise that they may have to choose less popular specialties at an earlier stage. A substantial number of graduates in the United Kingdom may fail to get into an approved training post in any specialty.

The respective roles of junior doctors and consultants are also changing, as the European Working Time Directive dictates a shorter working week, and the focus on protected learning time reduces the time that trainees spend seeing patients. This has led to consultants doing much of the work that was traditionally done by their juniors. To cap it all, the dream of reaching the top of the profession after years of self sacrifice is now being challenged with talk of a “sub-consultant grade” refusing to go away, despite the best efforts of the BMA.

These threats to traditional expectations have resulted in demoralisation and anger, not just among junior doctors but across the profession. This response is understandable but not helpful. However damaging the events of the past year for all concerned, Sir John Tooke’s independent inquiry into the MMC provides an opportunity for the profession and the Department of Health to accept some stark realities, to demonstrate far sighted leadership, and to act.3

The interests of patients, the service, and the profession will be met only if several deficiencies in policy are sorted out swiftly. Chief among these is the need for more effective workforce planning,4 in particular tackling the disconnect between the policy of self sufficiency in the medical workforce and the open door policy that allows international medical graduates to apply for training posts on the same terms as UK graduates. In 2007, this resulted in 3687 UK graduates failing to get training posts. The choices are stark—either home grown graduates should be given preference, as is the case for most other developed countries, or the UK needs to reverse the 60% expansion of medical school places that has taken place over the past decade.

No less challenging is the need for greater clarity about the shape of future careers for doctors, as this should influence the structure and the content of specialist training. More specialists are likely to work in the community alongside generalists. This will require a different set of knowledge, skills, and attitudes, not just a change of location.

As unpopular as it may be in some quarters, the profession needs to accept that post-training career progression should take the form of a pyramid—rather than the current square, which allows most doctors to progress to the top. If no consensus is reached at a national level over this matter, then increasingly independent employers will inevitably drive change at a local level, particularly in the hospital sector. Enough flexibility exists within the current consultant contract to allow them to do so without the need to renegotiate terms and conditions. More flexible models are likely to prove popular with doctors who want to concentrate on clinical practice rather than extended professional roles or who want greater career flexibility.

Most junior doctors accept that medicine is competitive and see this as a good thing. However, they want to be confident that the criteria on which they are competing are fair, valid, and reliable. The perception that this was not the case in 2007 was the trigger for the MMC crisis, though emerging evidence suggests that the recruitment process was more discriminating than many critics have claimed.5 Having established a fair process, junior doctors deserve better careers advice and mentorship than many have previously received. Medical schools and professional bodies need to rise to this challenge, and urgent work is needed to match career choices not only to individual aspirations but also more closely to aptitudes and the needs of the service.

Few in the medical profession have wanted to see a silver lining to the medical training application service cloud, but one does exist. Postgraduate medical education is now firmly on the agenda of ministers, policy makers, and National Health Service managers. We are now starting to see a real debate about matters that were previously ignored, notably the purpose, size, and shape of the medical workforce. The Tooke report provides a window of opportunity; the profession must respond.


Competing interests: MM was deputy chief medical officer in the Department of Health, England, until November 2007, and he was the lead for the MMC programme from March 2007.

Provenance and peer review: Commissioned; not externally peer reviewed.


1. National Health Service. Modernising Medical Careers. ST 2007 competition ratios 2007.
2. NHS. Unfinished business—proposals for reform of the senior house officer grade. London: Stationery Office, 2002
3. Tooke J. Aspiring to excellence. Findings and recommendations of the independent inquiry into Modernising Medical Careers London: Aldridge Press, 2007
4. House of Commons Health Committee. Workforce planning. Fourth report of session 2006-7.
5. Carr A, Patterson F. Evaluation of short listing data. Education South West (Peninsula Institute). 2007. June 14. [Unpublished report.]

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