MMC Reforms: have they put paid to the pluripotent medical student?

Medical students are increasingly aware of the necessity to create an impressive CV, and to make a definite and early career choice. We look at how this is influenced by the Department of Health initiative, Modernising Medical Careers, and how the need to make an early career choice might portend the demise of the traditional ‘pluripotent’ medical student.

Medical students appear to fall into two broad categories: the ‘pluripotent student’ who has yet to declare an interest in any particular specialty, and the ‘specialised’ student who shows a definite commitment to a known specialty, for example, orthopaedic surgery. They are equally ambitious, and undertake extra audits, presentations, and teaching opportunities to enrich their CVs. In a recent survey of 135 final year medical students, 95% agreed that it was not important to have decided on career speciality before graduation. ¹ Whilst this view resonates in medical student common rooms, the pressure for early specialization is becoming inescapable. Moreover, the pluripotent group worries that their specialised peers have the right idea.

In 2005, the Department of Health implemented Modernising Medical Careers (MMC) – an initiative to address concerns about the UK medical workforce and postgraduate training. One of its aims was to streamline postgraduate specialist training by cutting down the time taken for junior doctors to reach consultant level. This demands that graduates commit to specialist training earlier and – only 18 months following qualification – they have to choose from over 60 specialties to which they may have had little or no exposure. A measure to address this issue – the ‘taster sessions’ offered during the foundation years – has been likened to ‘three-minute speed-dating chats from which you have to select your life partner’. ² Because of the intensely competitive nature of specialist training, the time available to explore different career options is limited. A sign on our career paths should read: ‘No Loitering’. The need to stay on the straight and narrow is now unavoidable.

Professional leaders and the Department of Health have discussed the consequences of the MMC changes. Crucially, the results have yet to percolate down to the next generation of would-be doctors. Medical students are not only encouraged to consider their bespoke career path, but to actively pursue these choices through undergraduate research, audit, and teaching opportunities. The drive to display early commitment to a chosen specialty could detract from traditional broad undergraduate training, with the result that medical students are less ‘pluripotent’ and more ‘specialised’ than hitherto. This disadvantage of early career choice and the lack of information about career planning available to medical students and trainees were not overlooked by the Tooke Report on the MMC reforms. ³ Without reliable information, students may be unable to make informed judgements about the likelihood of realizing their career aspirations.

There are, perhaps, advantages for the specialised student. These include a firm commitment to a specific discipline, a focused accumulation of knowledge in that discipline, and the possibility of networking opportunities in a familiar specialty. However, the decision to specialize early may rest on only limited experience in that field, or on the persuasive advice of others. Early specialization risks, as well, the development of a blinkered view of medicine, with diminished engagement in other specialties. Compared with the pluripotent student – who would be expected to have a wider knowledge base and skill set – the specialised student may be less well prepared for foundation year posts outside the chosen discipline.

Advocates of early specialization may overlook the fact that uncertainty is an inevitable part of medical training. The relationship between career preference and eventual career destination has been investigated in the postgraduate setting, and it has been shown that many will train in a specialty different from their initial preference. This may be the result of a lack of availability of training posts, or changes in personal circumstances. A study of 15,759 doctors by Goldacre found that ‘match rates’ for career preferences at one year after graduation and career destination at 10 years were around 53%. ⁴ Almost half of the doctors in the study trained in a different specialty to their initial inclination. Another study found that 30% of those who change specialty move into general practice. ⁵ This specialty, in which a majority of doctors will inevitably work, may inherit many of the pluripotent student groups who feel unable to make an early choice of specialty.

An attraction of medicine is that it comprises a mutable body of knowledge and skills. The post-graduate career structure created by the MMC reforms seems to have increased the pressure on undergraduates to make an early decision about their choice of career specialty. But many will train in what turns out to be the wrong choice, or in an over-subscribed specialty. Change in career pathway should therefore be anticipated, and for the specialised student this might pose greater challenges than for his pluripotent counterpart. It is worthwhile to consider a career focus at undergraduate level, even in the absence of a firm choice of destination. But the real challenge is to balance this early focus with a broad medical training, and to savour the opportunity to indulge in all specialties. Steve Jobs was right when he said, ‘You can’t connect the dots looking forward; you can only connect them looking backwards, so you have to trust that the dots will somehow connect in your future’. ⁶