Medical job progression: the missing link

At present, there is a gaping hole in the application process for higher and specialty training in the medical profession in the UK. The process by which core trainees and registrars are selected does not adequately consider the most fundamental part of being a doctor – how good you are at your job. Applicants are considered based on their teaching experience, the quality and quantity of your research and even interests outside of your profession. Yet clinical ability goes unsung.

Competition ratios for specialty training applications in 2018 ranged greatly across specialties, from 1:0.35 for Psychiatry of Learning Disability training posts to 1:11.0 for Allergy Medicine. The average across all specialties was 1:2.61. This illustrates the difficulty that nearly all applicants in the UK will have to face in achieving a post in their chosen specialty. It therefore follows that the application process must be stringent to ensure all trainees have a chance to fairly vie for their desired post. ¹

The recruitment process for core training and specialist registrar training posts is done on a numerical basis. Points are awarded to candidates based on their teaching, prizes, presentation, leadership, quality improvement projects, publications and added degrees.^2–5 The cumulative points then determine whether or not you will be invited to interview, where points are awarded based on your performance. In the interview, one might have the opportunity to show good feedback or references, but this is minimally weighted in comparison with the other domains assessed. Given that all specialties include ‘professionalism’ as a necessity in person specifications, it is surprising there are so few opportunities to demonstrate it. ⁶

This gap in recruitment criteria causes problems for fair career progression and also patient safety. Reverence for a candidate’s teaching, participation in quality improvement, leadership and research credentials may encourage some to focus more on these lucrative domains over their clinical abilities. In an increasingly pressured clinical environment, the workload for the less career-minded team members may increase, yet providing them with no conciliatory advantage in their applications.

So what is to be done? We would not argue that these other facets to a medical Curriculum Vitae should be given any less leverage – but that your clinical acumen should be given more. A clinical feedback process is already embedded within the portfolio, but yet no points are awarded for professional feedback in any recruitment processes for higher training.

To incorporate the feedback system into the recruitment process, it is important to iron out any problems with the current system. Feedback should be standardised across foundation, core and registrar training and include ‘grades’ to quantitate the candidate’s performance in different aspects of their work. This is currently in place for core training and registrar training. Regrettably, the multi-source feedback platform for foundation doctors has no area to highlight excellence and a disheartening ‘no concern’ is the best one can hope for. This does not allow trainers to acclaim those who go the extra mile for their team members and patients.

Another aspect of the current feedback system which needs upheaval is the choice of persons who give it. At the end of each rotation, meetings with your clinical supervisor and educational supervisor provide feedback on your performance. More often than not, this gives you the views of one supervisor who has worked with you and one who has not. The ePortfolio’s ‘multi-source feedback’ system is the only opportunity to learn the views of your the colleagues in the multidisciplinary team. Unfortunately, this exercise is only mandatory for one of your three annual jobs. Moreover, the colleagues who provide this feedback are persons you have selected: the staff who you know and like.

If we are to use feedback as a measure of aptitude, those who complete the feedback should be randomised. It has been shown that feedback from fellow doctors at the same level were three to four times less likely to indicate concern, compared to senior doctors or other ward disciplines.^6,7 This suggests that choosing those who feed back on your performance may bias the result. We propose that the choice of who completes your multi-source feedback should be taken out of the hands of the trainee. Instead, the feedback form should be sent to a random selection of the multidisciplinary team and anonymously completed. Should this reach someone who, by reason of the florid nature of ward life, did not know the trainee, the recipient would simply select an ‘I don’t know this trainee’ option, and the form would automatically be sent to another random staff member.

Multi-source feedback should be mandatory for every rotation within a training programme, to ensure the trainee has the continuous incentive to work as an amenable team member. As multi-source feedback has been shown to improve performance, more regular feedback would allow the trainee to derive this benefit.^6–8 Feedback also enhanced trainees’ self-knowledge and promoted performance expectations. ⁹

With the advent of these changes, having ensured fair and wide-reaching feedback is given to everyone throughout the entirety of their training years, it would be reasonable to incorporate this into the process of grading candidates for further training. The feedback received during your career could give every candidate a score. This score would translate as points on your application as with the other domains and thus affect the likelihood of being invited to interview.

In conclusion, including this section in the application form would necessitate regular feedback to allow trainees to learn from the opinions of others. This would also ensure that there is even more incentive to help your colleagues and maintain professional and efficient conduct at work. Finally, it would ensure the selection of trainees for more senior roles takes into account their professional aptitude – clinically, practically and within a team.