The gap between foundation years and specialty training
Authors: Caroline Smith, Li Low
Publication date: 21 Feb 2012
Caroline Smith and Li Low ask why a third of UK foundation doctors are not entering specialty training
Postgraduate medical training in the United Kingdom underwent a conspicuous facelift in 2005. The aim of this modernisation was to enable doctors “to progress more quickly and in a more structured way” to their desired careers, “reducing time spent in unnecessary or inappropriate training.”
However, six years on, it seems that UK foundation trainees are finding it harder than ever to find their place within this structure and are choosing to, or being forced to, delay the start of their “quick progression” through specialty training.
In 2010 one fifth of specialty applicants had come from graduation years before 2008. The UK Foundation Programme Office was commissioned to look in detail at the outcomes of foundation year 2 (FY2) doctors: the resulting survey, published in November, shows that only 70% of FY2 doctors went straight into specialty training, leaving almost a third of the year group outside formal training (table).
|Career destination||% of total|
|Specialty training in UK||70.6|
|Run-through training programme||34.7|
|Core training programme||33.6|
|Fixed term specialty training appointment*||1.1|
|Specialty training deferred for higher degree||0.1|
|Specialty training deferred for statutory reasons||0.5|
|Destinations outside UK specialty training||29.4|
|Locum appointment for training (LAT)||0.5|
|Specialty training outside UK||0.8|
|Service appointment in UK||2.3|
|Other appointment outside UK||7.6|
|Still seeking in UK||6.5|
|Still seeking outside UK||3.8|
|Permanently left profession||0.2|
|Total with known destination||100|
*Counts towards training for run-through specialties, maximum 1 year duration of appointment
Source: UK Foundation Programme Office.
Peak of a trend?
The UK Medical Careers Research Group, led by Michael Goldacre of Oxford University, has been surveying medical graduates since 1997. The results of their cohort studies of graduates from 1999 to 2005 showed that just under a quarter of the doctors were not in specialty training four years after graduation, a figure that was fairly constant across the year groups. This consistency of attrition in the workforce led them to comment in the BMJ last year that “junior doctors are no more likely now to abandon their training and leave the profession than they have ever been. Now, as in the past, doctors’ medical career trajectories do not invariably take a straight and relentless course from qualification through specialist training.”
However, the most recent figures indicate that we may be seeing a larger number of junior doctors in alternatives to specialty training. This trend is seen among trainees at the South Thames Foundation School, only 65% of whom applied to specialty training in 2010 (down from 79% in 2008).  Is this just a spike in the trend? Does it reflect the changes in postgraduate training? And what are doctors doing as alternatives?
A rigid training structure
The two year foundation programme emerged from its precursor, the preregistration house officer year, partly to meet the requirements of the European Working Time Directive. It was heralded as “an opportunity to develop experience in a wider range of specialties through four month placements.” However, the level of choice among trainees over these varied experiences is limited. Furthermore, with rotations dictated by your foundation application score, the choice is more limited for those at the lower end of a fairly arbitrary hierarchy. Some rotations in FY2 add little value to training; in particular, FY2 can include rotations in which trainees are supernumerary for four months in specialties that are not their preference.
The specialty applications take place early in FY2. The streamlined, structured nature of specialty training, introduced through Modernising Medial Careers, is too rigid for those doctors who simply do not know what to apply to. They fear picking the wrong specialty too early and facing a difficult, competitive reapplication to an alternative specialty or a narrow training experience that does not allow for further evaluation of alternatives. Taking time out of training to gain experience through flexible positions (trust jobs, locum work, work abroad) before committing to a specialty seems desirable in this position.
Competing for specialty training in the NHS is, for most doctors, a challenge. This year, more specialty posts were made available, and as a result competition ratios stayed the same as in previous years. However, there is always a substantial proportion of doctors who do not gain a post. This year 10 946 applicants applied for 7830 specialty training year 1 posts.
Some doctors reject the posts offered to them, particularly if the location offered is unacceptable. “I can do better next year” is a common line of thought applied to specialty applications, not just by those dissatisfied with their initial offers. As specialty applications approach, some doctors realise that their CVs don’t meet their maximum potential. If you want to beat the competition, your application needs to stand out from the crowd; extra points are awarded for publications, audits, conference presentations, and a clear, evidenced interest in the chosen specialty. For those who do not decide on a specialty until later in foundation training, this can seem like a daunting task to accomplish in a short period. The limitation of annual application means that the only options are applying prematurely or waiting another year.
The scrabble to produce a sparkling specialty application needs an effort far beyond the confines of the basic foundation programme—a programme that was intended as competency based training and, as John Tooke noted in his famous inquiry into postgraduate medical training, that is “unlikely to encourage or reward striving for excellence.”
Gap year experience
To step on to the specialty ladder is to move between two quite different stages in life. These little niches of time are a rare gift in the average working life, and the chance to combine new work experiences and life experience is often achieved through travelling abroad.
Heading to New Zealand and Australia is a longstanding favourite for post-foundation year doctors. No entry exam is required, and the medical councils actively seek UK doctors, with many companies advertising opportunities. Working hours are low, and some doctors report getting more hands-on work experience, enhancing their skills, and building confidence.
Goldacre and colleagues reported from their cohort studies of 1999-2005 that a steady proportion of 1 in 20 doctors were working abroad four years after qualification. The New Zealand Medical Council records the total number of new provisional registrations from UK doctors annually (not specific to post-foundation year) and has found the rate of new registrations each year to be stable for the past decade. Its figures do show, however, that the percentage retention of UK doctors one, two, and three years after registration in New Zealand has almost doubled over the past decade. Although this is not specific to post-foundation year doctors, it does show that retention of UK doctors in New Zealand is increasing: doctors are staying longer.
If the NHS is to benefit from the skill set of doctors gaining experience abroad, as Richard Marks from RemedyUK prophesied last year, “the system needs to be such that it’s easy for them to get back.”
Implications for trainees
How does taking time out before specialty training application reflect on the trainee? Speaking to BMJ Careers, Liz Berkin, deputy medical director of the Joint Royal Colleges of Physicians of the UK Training Board (JRCPTB), says: “Taking a gap year between foundation training and CT/ST1 [core training/specialty training year 1] should be seen as a positive initiative, benefiting both the trainee and the NHS. The year allows trainees to gain new skills or consolidate existing skills, which are usually welcomed at CT/ST1 level. It also gives the trainee the opportunity to think further about their ultimate career choice if not already decided.” The box gives further advice from the JRCPTB.
Advice from the Joint Royal Colleges of Physicians of the UK Training Board
Most CT/ST1 person specifications limit previous experience in the specialty to 18 months, so gap years must not result in longer specialty experience
Trainees should provide suitable documentation of the skills and knowledge gained
Trainees must keep track of recruitment plans, which occur early in the training year. Although most specialties run a second round of applications, vacancies cannot be guaranteed
Trainees should justify their career path to date. If a gap year seems to have been taken because of a lack of decision making, organisational skills, and so on, recruiters may view it negatively
Trainees should apply for a post in the same academic year in which the post will start; it is not usually possible to gain a post and then defer during the gap year
A gap year that includes experience in the prospective specialty will be an advantage in applying to that specialty
It’s easy to justify the needs and benefits, to the individual, for out of training experiences at this stage in a doctor’s life. But where does this leave the wider NHS workforce?
It is inevitable that the flow between two fairly rigid training structures (the foundation programme and specialty training) is prone to turbulence. But how much laxity and flux in the workforce concentrated at this point is sustainable? In the past doctors have left training temporarily after their house jobs, but with this proportion now reflecting a third of the year’s workforce, this may present an issue for workforce planning. In light of the NHS reforms, and the potential need for an increased general practitioner workforce for GP commissioning, monitoring the outcomes of FY2 training is key.
Crucially, if nearly a third of doctors are moving out of UK training after the foundation programme, should we listen to what this is telling us about postgraduate training in the UK? We think the message is clear: there needs to be more flexibility in training at this level. Doctors need a greater degree of ownership over their training.
In the past training pathways were unclear. Currently, however, the opportunity to choose a varied experience—to carve your own path and change your mind—is limited. The foundation programme is not providing the varied experience needed to link to specialty training; it introduces redundancy and inflexibility into these early experiences, particularly in FY2. The Tooke report dealt directly with these issues: its recommendations included abolishing FY2 as it stands, in favour of four core training stems (replacing current FY2/ST1/ST2) with the option of transferability. This is a model that would provide clear training pathways while reducing the pressure to commit prematurely to one of the 57 specialties. With the future of the NHS in the hands of current foundation trainees, early training experiences cannot be so restrictive.
Case study 1: Jananee Sivagnanasundaram
Trust senior house officer, stroke/neurology, St George’s Hospital, London, and South Thames foundation trainee 2008-10
I found the task of deciding on a career path only a year after graduation to be very daunting. I experienced a good variety of medical rotations in my foundation years and knew the next career step for me would be core medical training. Competition for specialty and core training is tough, especially if, like me, you are applying to London as your first choice. After completing the interviews in February, it was a painful three months waiting to hear from the London Deanery; they informed me I had not got the post.
What should I do now? I had not applied to different specialties, so there was no plan B. I signed up to the NHS Jobs site, and soon it became part of my daily routine checking for available posts close to home in London. The application system through NHS Jobs is fairly simple: you fill in an online application form and get selected for an interview. And this is how I have got to my current trust post of clinical fellow in stroke/neurology at St George’s Hospital. I work mainly on the busy hyperacute stroke unit, which is one of eight such units in London.
There is plenty of support from seniors and many opportunities to attend teaching sessions, lead your own teaching sessions for the plentiful supply of St George’s students, and get involved in research (as the unit is also the lead centre for the South East Stroke Research Network).
For FY2s who find themselves in a similar situation to me, I would recommend a similar trust post. You can gain invaluable experience in a field of your choice and use your time wisely to gain points for your CV, work towards membership exams, and have guidance and supervision from your consultants and registrars, which may not be possible with ad hoc locum work.
Case study 2: Pippa Howell
Locum senior house officer in accident and emergency and paediatrics at Royal Perth Hospital, Australia, and South Thames foundation trainee 2008-10
During my foundation programme I was undecided whether to apply for general practice or paediatrics. I know of several friends who chose specialty training immediately after foundation training, changed their mind halfway, and had to start from the beginning again. I was keen to avoid this and decided to take the opportunity to go travelling and gain some useful experience.
I had always wanted to work in Australia and New Zealand. My friends worked in Perth last year and found the experience to be extremely positive. Perth is also renowned as one of the windiest spots in the world, and as my boyfriend and I are keen windsurfers, Perth seemed to be the ideal destination. We applied, had a phone interview, and were both fortunate to secure jobs we wanted at the Royal Perth Hospital.
So far, most of my work has involved working in accident and emergency and short placements relieving doctors who go on annual leave. I have learnt lots, and my Australian colleagues have been extremely supportive. I thoroughly enjoy the great work-life balance, and even though Australia is a long way from home we have met many other British doctors working here. It is also a good excuse for family and friends to visit. Currently I intend to stay here for 18 months before I return to the UK to begin the specialty application process.
I definitely have no regrets about my decision, and I am absolutely loving it!
Competing interests: None declared.
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Caroline Smith foundation year 2, South Thames Foundation School, London, UK
Li Low foundation year 2, South Thames Foundation School