In the last newsletter, we outlined the current proposals of ‘Modernising Medical Careers (MMC)’, and speculated on what this could mean for a career in global health. Gaz Lewis continues his assessment with the current plans of the Royal Colleges the post foundation years and the options for working abroad in specialist training years.

Modernising Medical Careers
In February this year, the BMA produced “The Shape of Specialist Training Aspirations for Seamless Progression”1. It gives in-depth analysis and recommendations for MMC after the foundation years (see last newsletter’s article), and what should be implemented to ensure this new structure achieves its goals. Principally, the aim of MMC is to stop or minimise the number of doctors ‘hanging around’ while waiting for a place in higher specialist training or changing specialities late, and starting all over again, because they couldn’t find a post in their chosen speciality. But although the BMA report gives some good recommendations of what should be done, it does not set out its implementation.

Figure 1: Example of a career structure for direct path training (1)

Figure 2: Example of a career structure for broad-based training (1)

Where are we in implementing post-graduate training beyond the foundation years?
The Post-Graduate Medical Education & Training Board (PMETB) is an independent body, created in 2003 to be responsible for “the standards and quality assurance of all postgraduate education, training and assessment in medicine and dentistry in the UK”2. It replaces the Specialist Training Authority (STA) and the Joint Committee on Postgraduate Training for General Practice (JCPTGP). The aim of its creation was to bring postgraduate training under one roof post MMC reform. However, the organisation isn’t due to take over its responsibilities until September 30th this year. It states on its website that from July 2005 to July 2006 it will “consult with stakeholders on the future shape and direction of postgraduate medical education and training in the UK and will develop a plan from that”3.

Given that PMETB is not up and running yet, it is unsurprising that the Royal Colleges are biding their time on what will happen in the post-foundation years. Several colleges have expressed concern about a ‘run-through’ grade replacing the basic specialist training and advanced specialist training that takes part during the current SHO and SpR years respectively. The principle behind this grade is to streamline the years required in training, making them more efficient. It seems that the introduction of the European Working Time Directive (EWTD) is one of the main concerns regarding this.

There are doubts expressed on several college websites, be it in official statements or minutes from various meetings, about whether the quality of training will be maintained, let alone advanced when there are a fewer number of years, and fewer potential hours within those years. These concerns have been echoed by the junior doctor’s conference, which stated “it is irresponsible to propose the shortening of training until the impact of the reduction of hours imposed by the EWTD has been properly evaluated”4. As a purely speculative point, some forms of education within the scheme could be counted as outside of working hours, but it remains to be seen if any other more amenable solution could be found.

Aside from these concerns, all the Royal Colleges can really do is sit and wait for the PMETB to arrive. This is not to say they are unprepared for its arrival. It appears quite clear that discussions are going on within them about what reforms are needed and how they should come about. Below is a summary of what plans for post-foundation years have currently been discussed:

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Pathways in different specialties after the Foundation Programme

Obstetrics and Gynaecology – Proposals are being considered for competitive entry from Foundation into a three-part specialty-training programme. Part one would use a comprehensive competency-based curriculum allowing all trainees to become equipped with the defined skills of a resident obstetrician. After undergoing a rigorous assessment, those unsuccessful in securing a place in the second part of the training would have the opportunity of leaving the specialty with a range of attributes transferable to another discipline. Successful entry into stage three would allow for the development of special skills, sub-specialty expertise or progress into an academic career.

Anaesthetics – Work is currently being carried out to deliver a new competency assessment programme in the specialty, designed to ensure seamless seven-year progression. The training and exam syllabus has already been replaced with a manual-based system for specific grades, but work remains to be done on the specifics of specialty selection post-Foundation.

Physicians – Proposals have been agreed across the three Royal Colleges of Physicians in the UK for competitive entry into a two or three year basic training programme. Pilot studies have already been carried out for an assessment programme which would use a variety of performance, knowledge and competency tests to identify the trainees for higher specialist training.

Primary Care – The specialty training programme being developed will see appointment post-Foundation to a three-year, first phase specialist training programme. Selection will be through open competition, twice-yearly, using a national process which will assess a range of behavioural characteristics in addition to clinical knowledge and expertise. There will also be higher specialist training following successful PMETB certification at the end of year three.

Surgery – An intercollegiate approach is being taken across the UK’s Royal Colleges of Surgery. The post-Foundation period will focus on a discipline-oriented, but not discipline-specific probation period. There will be competitive testing and further assessment ahead of appointment to first year specialist training. Further examination, ongoing assessment and review will be carried out ahead of CCT award.

Academic Medicine – Academic events and research project options could be incorporated into the first year of the Foundation Programme. Opportunities for integrated academic placements would follow in Foundation year two, ahead of entry into specialist training path which would include dedicated academic placements, clinical and academic mentoring and flexible funding that follows individuals rather than posts.

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Working in Global Health
So now I come to working in International Health within the new structure. The new curricula for F1 and F2 have recently been published. The aim at the end of these curricula is for graduates to have a generic set of skills applicable to a modern medical career. According to the NHS information page on MMC, F1 will be “similar to the current PRHO year, although there will be greater educational coordination between placements”6. F2 years will build on the skills acquired in F1 and also have a greater focus on acute care, while also giving the opportunity for work in both primary care and mental health.

On the face of these statements it would appear that placements in public health are not high on the agenda – unless they come under the scope of primary care. However, it is possible at present to do an SHO rotation in public health. While it would be in the spirit of these reforms to offer some sort of global health training, in practice this may prove difficult to organise in the early years of F1 and F2 while the programmes find their feet. However, as I have observed previously, once a graduate is past the foundation programme, there should be an equal if not enhanced opportunity for spending some time in a global health placement straight away, as the structures, in the form of flexible training schemes and specialist public health training, are already there. It is to be hoped that after the foundation years have settled in there could be similar things in them.

So what do the Royal Colleges currently have to say and how well do they aid finding information on flexible training and working abroad? Flexible training is a well-established part of medical training now, and information regarding it is well catered for and talked about on all college web sites. However, a flexible training contact is something that must be sorted out with your local deanery or trust. It is also important to note that flexible training as a junior doctor is more difficult to negotiate, namely because of the expense of these types of contracts to employ by trusts7.

The information on international work is more varied, and is outlined in Table 1. All have information for doctors from overseas wishing to work in the UK, but not the other way round. Some have specific sections about working overseas and most have either international committees or networking bodies. In particular, the Royal College of General Practitioners and the Faculty of Public Health have very strong commitment to international work for their members.

Table 1: Facilities and Information on working abroad on the main Royal College Websites

Royal College/Faculty	Information/Opportunities	Address
Physicians	International Office acting as networking base for overseas doctors and UK doctors wishing to work overseas	http://www.rcplondon.ac.uk/college/international
Surgeons	Link to ‘The international network for learning and teaching surgical skills’	http://www.rcseng.ac.uk/international/
General Practitioners	International Committee with specific sections on working overseas as a UK doctor	http://www.rcgp.org.uk/international/index.asp
Paediatrics and Child Health	International task force set up in 1997 to establish a register of British paediatricians willing to work in war and disaster zones and to develop training programmes and mentoring schemes for them	http://www.rcpch.ac.uk/international/projects.html
Obstetricians and Gynaecologists	Section called ‘working abroad’ that gives the names of three organisations/charities that might be considered. No formal international section	http://www.rcog.org.uk/index.asp?PageID=987
Psychiatrists	Large international section with links to many organisations but no specific advice on working abroad	http://www.rcpsych.ac.uk/college/inter/unit.htm
Public Health	Large ‘International Public Health’ section with a specific working abroad area and an explicit committal to help their members in searching for international work by forging world-wide links. International Committee with five year plan to aid this.	http://www.fphm.org.uk/policy_communication/ international_public_health/default.asp

It is pointed out by nearly all colleges that working abroad can even be counted as a training year, although at the moment it appears that this needs to be arranged rather than their being any specific training programme which includes a period spent abroad. All sites are encouraging on foreign work, but there is a clear emphasis on considering if you would learn the skills required for work in the UK with whichever placement you had in mind. Obviously this depends on whether or not you would be gunning to include foreign work as part of your medical training or whether you fancied a change of scenery.

So overall, there is a lot of uncertainty still surrounding the advent of post-graduate education beyond the Foundation years. The Royal Colleges have no specific plans and the final structure of their individual specialities training is unlikely to be put in place until they finish consulting with the PMETB in July 2006. However, current information and facilities for working abroad are catered for to varying degrees by all colleges and this along with flexible training are encouraged for those who wish to do so. It is entirely possible for these facilities to be put to use in creating training posts in either the proposed broad, specialities or systems based training schemes that include some time working in the international arena. Whether or not such a thing will be possible in the Foundation years remains to be seen. The increased involvement of the colleges in junior years, particularly F2 as their specialities are incorporated more into it, means this may be possible, although the availability of flexible training may be more difficult due to a lack of funding for this type of job structure at junior level.

Gaz Lewis
Careers and Postgraduate Education
gareth.lewis@almamata.net

References
1. Calvert S, Eccles S, Carney S. The shape of specialist training: aspirations for a seamless progression. London; BMA Junior Doctors 2005.
2. Holsgrove, G. Current developments in postgraduate education. Royal College of Psychiatrists 2005. Available at: http://www.rcpsych.ac.uk/traindev/postgrad/current.htm (accessed 6/6/05)
3. PMETB. FAQ’S: PMETB - the future of postgraduate medical education and training. PMETB 2005. Available at: http://www.pmetb.org.uk/pmetb/faqs (accessed 8/6/05)
4. Junior Doctors Committee. Modernising medical careers: policy statement and call for action made at the Junior Doctors Conference. London 2005. Available at: http://www.bma.org.uk/ap.nsf/Content/ mmcstatement2004?Open Document&Highlight=2,modernising,medical,careers (accessed 8/6/05)
5. Cohen D. What happens after foundation programmes? BMJ Careers 2004: 329 (7477) 217-9
6. MMC WebPages. FAQ’s. NHS 2005. Available at: http://www.mmc.nhs.uk/faq. asp?m=3#123” (accessed 8/6/05)
7. Eccles C. Junior Doctors Annual Report. BMA Junior Doctors 2005. Available at: http://www.bma.org.uk/ap.nsf/content/jdcannualreport2005 (accessed 6/6/05)