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Postgraduate medical training in the United Kingdom is about to go through its biggest change in decades. Gaz Lewis looks at the changes and its implications for a career in global health.

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So the long haul is finally over. Five years of blood, sweat and tears, with maybe an extra year thrown in for a few more letters at the end of your name. Your job is sorted and your bank balance is in line to start looking considerably healthier. Now begins your induction into the world of work and the path to your desired specialty.

The route to pursuing a career in global health has always appeared rather unclear to me before researching this article. It can be done both in and outside medicine. The title of ‘Dr’ does not automatically restrict you to that vocation. But nearly all of us will start in the new Foundation Programme when we qualify, and so the path we undertake has the potential to be considerably different to those who have gone before us. This article aims to give an overview of what the new foundation programme entails, and how the proposed system after this could be applicable to a career within medicine that involves International Health.

What happened previously

Previously, the structure of a medical career resembled the outline in figure 1. By this structure, you would embark on your chosen specialty after your SHO posts. In all posts you could expect to be able to pursue some element of international health. But if you would like it to be the main thrust of your career, it is most likely that you would purse the academic line, or NHS public health medicine and community health path.

Figure I: : Previous Medical Career Structure (www.bma.org.uk)

The new foundation programme

Compare the above with what has been proposed for the new structure. No longer do all graduates have to pursue the same career hierarchy. To begin, the PRHO and first SHO year will be replaced by ‘F1’ and ‘F2’ years. Essentially, F1 will be the same as the PRHO year, with the principle objective being that the newly qualified doctors prove competency to practice and gain registration with the GMC at the end of the year(1). In contrast, the F2 year has the potential to be quite different from the first year of SHO training. Three 4-month rotations, in order to gain a broader experience of several specialties are the current proposals(1).

What happens afterwards?

After the end of F2, medical graduates can then choose one of three paths to suit them best, which are outlined in figure 2. They are separated into 3 broad categories:

Specific Specialty Programme: If you are of a driven and focused nature, determined on your chosen career destination, then you can apply with others and compete to gain a specialist training position immediately after F2. If successful, no further applications for posts would be required – unlike at present where after SHO you’d apply for SpR posts, then consultant posts. You would train for as long is necessary to acquire a consultant level of competency in that profession. However you would not neglect other areas of medicine. Although your training would be geared towards your chosen specialty, you would also gain experiences in other areas, possibly related to the specialty you choose.

Broad Based + System Based Programme is for those who know the general area in which they want to work, but have not narrowed it down to a particular specialty. Gaining experience of a wide range of fields before deciding on a specialty is the thrust behind this option

Figure II : What might happen with new structure(2)

There are some issues that are a worry about the post foundation years, in particular the year immediately afterwards. To an extent the foundation programme is quite generic, and so the scope for selecting the right candidates for training posts may be difficult and awkward. There is then the potential of people ‘hanging-around’ in a job for a year to build up the CV, and fears that this may create a bottle-neck when trying to get onto training programmes(2). However, this is no different from the current system where SHO’s have been rotating for a few years before gaining an SpR post, and the emphasis on getting people into training earlier is the key to the new programme and appears to be satisfied by the new proposals.

How does this apply to a career in Global Health?

The proposed changes and the structure of careers outlined above could give great opportunities for anyone wishing to pursue a career in global health. With the term in itself implying a broad-based area, the broad-based programme could be ideally suited to global health careers. Already there are rotations in Global Health around in other countries, if only available to a select few. The Brigham and Women's Hospital, a Harvard affiliated hospital, have begun to offer a ‘Global Health Equity’ residency, which aims to ‘train physicians the new field of health disparities that stem from economic and geographic barriers(3)’ Unfortunately you have to have completed your ‘PGY1’ (first qualified year after American medical school) at that particular hospital to apply. But this shows the potential for incorporating such subjects into the new system here. However, although there are mentions of several areas to do with global health: maternal and child health, public health and so forth, there has been no specific reference to a global health broad-based programme. Whether this is in the melting pot has not yet been revealed, and could perhaps be an area for campaigning action.

Flexible training schemes are not new, and it is important that at the very least they are accounted for in the new system. Again, the potential to provide a broad based training system specifically for global health is there, adapting part time contracts to allow work in, for example, foreign posts and NGO’s which would bring greater experience and training to those in this field.

Overall then, the potential is there within the new structure to have a much easier route into a career in global health. The devil is now in the final detail.

References
1. Wong L, Fiddler AM, Sharma R, Ram A. Laying the Foundations. BMJ Careers 2005;329(7481):3-5.
2. Cohen D. What happens after foundation programmes? BMJ Careers 2004; 329(7477): 217
3. Knott, R. Social Medicine & Health Inequalities: Howard Hiatt Residency in Global Health Equity and Internal Medicine 2004. Available at http://www.brighamandwomens.org/socialmedicine/gheresidency.asp (accessed 28/2/05)

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