COVID-19 and its impact on the clinical specialty training recruitment process: lessons learned and the shape of future specialty recruitment in the UK

On 23 March 2020, Health Education England made the decision to postpone and then later cancel face-to-face national recruitment interviews in response to the COVID-19 pandemic. ¹ Candidates applying to medical specialty training (ST3+) were subsequently appointed based on their self-assessment scores with emphasis on selected domains in the new self-assessment model. This has generated significant discussion among trainees, especially as the recruitment process used in previous years included portfolio/self-assessment, clinical and ethics interview stations, in person. All specialties except those that have completed formal face-to-face interviews were required to adopt this new model. This may have proven quite challenging in specialties where interviews had already started but were yet to be completed by all candidates before the nation-wide lockdown came into effect. This was the case for gastro-enterology, respiratory medicine and clinical oncology. This could arguably lead to a dissonance between the original face-to-face interview scores and candidate ranking based on this new but yet validated self-assessment model.

In a typical pre-pandemic application year, the process is a tried and tested system which often runs like clockwork across specialties. Vacancies are advertised between November and March each year, where applicants are expected to apply between this window. Longlisting and then shortlisting commence shortly after. Specialties such as general practice, radiology, obstetrics and gynaecology, and a number of other specialties invite longlisted candidates to take the multi-specialty recruitment assessment, which consists of professional dilemma and clinical problem-solving sections. Successful candidates then go on to the interview stage. Specialties such as neurosurgery, which is typically a run-through programme with new trainees recruited at ST1, may also advertise vacancies for applicants with previous core surgical or neurosurgical training and at different stages of training. Recruitment at this later stage is often more competitive and with the expectations to have passed the membership of the royal college of surgeons if applying at the ST3 stage.

Shortlisted candidates from various specialties are then scheduled for a face-to-face interview. Many specialties adopt a national recruitment pathway where all applicants across the country attend a centralised interview while others adopt a regional or local recruitment approach, where regions or deaneries have different interview arrangements. At this interview, there are number of interview stations, specially designed to test different skills, knowledge, candidate’s competence and how they meet the minimum standard requirements to succeed as a trainee in that specialty. Some hand-skills based specialty such as surgery might require the candidates to showcase their skills in basic surgical techniques while others expect you to give a brief power point presentation or answer questions pertaining to a published research article. These various systems though not perfect have been tried and tested over the years and some of these systems have been carefully designed with inputs from academic psychologists and from the private sector, for example from a company called work psychology group. ² This pandemic has led to dramatic changes to the ways we lead our lives, some of these changes are here to stay. It also provides an opportunity to learn how to improve current ways of doing things, taking into account the potential for major socio economic events such as these in the future.

A discussion point among trainees with the new self-assessment/portfolio based model was placing higher emphasis on domains such as audit and teaching ahead of ‘commitment to specialty’, ‘undergraduate or post graduate degree’ and published research in the specialty. To be clear, quality improvement project and teaching are vital in improving patient outcomes, promoting an evidence-based approach to medicine and improving the quality of education among doctors but should these be ranked higher than a clear commitment to clinical and academic pursuits/excellence for that subject matter? Given the scepticism reported over the availability of published evidence on the validity of this new self-assessment model. ³ Some of the doctors caught between these two recruitment models were trainees who took time out to do a higher degree or fellowship, generated good quality research output and went on conferences to present their work, gathering accolades and prizes along the way. The change in selection model meant that trainees who could have scored well due to their research and additional qualifications were disadvantaged.

By the time the lockdown was put in place, the majority of specialties had already collated the self-assessment scores for all applicants. However, few specialties such as clinical oncology, general surgery and vascular surgery acquired self-evaluation data after it became apparent that self-assessment and portfolio station will now become major criteria for candidate selection. Self-assessment/portfolio station, which would have made about one-third of a candidate's score, were now used to determine candidate appointability. The subjectivity of self-scoring may mean that some applicants may under-report their achievements out of concerns for probity or due to the understanding that it plays a relatively less consequential role in the application process before the pandemic. Had they known the weighting of self-assessment would change after the fact, would they have put more time and effort in showcasing their achievements? This remains unclear. The GMC's Good Medical Practice guidelines on probity (point 64) stated: ‘You must always be honest about your experience, qualifications and position, particularly when applying for posts’. ⁴ The step-by-step guide to self-assessment and the portfolio station document ⁵ by Health Education England also stated ‘in the event that you have realised that you have over-scored yourself in your “self-assessment” you should contact the recruitment office as soon as possible by submitting a query with full details to the applicant support portal’. However, there was no advisory for under-scorers. Quantitative outcome data on application psychology or recruitment outcome for this year might still be premature but it will be good to see how this may have impacted candidate recruitment. Latest data from Health Education England show the number of candidates who accepted training posts in clinical oncology was 41 in 2019 while it was 38 in 2020. In general, there was a statistically significant smaller proportion of applications that have had an offer made in 2020 as compared to last year. Furthermore, the data showed Asian-British applicants fared slightly better in 2020 with an odds ratio of 1.058 (p = 0.0495). ⁶ There needs to be further analysis to understand the broader impact of the pandemic on all applicants and the individual specialties.

Due to the disruption to the timetable of royal college examinations, some clinical specialties allowed candidates who were yet to pass the membership of the Royal College of Physicians Part 2 written or Practical Assessment of Clinical Examinations Skills (PACES) to be eligible for a training number if they rank high enough; however, with a caveat that they are expected to pass these exams before proceeding to ST4. ⁷ This may inadvertently place further pressure on trainees in specialties such as clinical oncology where they are already required to undertake four modular exams by the end of ST3.

This pandemic should bring about new thinking on how doctors are assessed for competency or knowledge and how to develop ‘pandemic’ or ‘disaster-proof’ clinical staffing and recruitment systems without watering down quality or compromising patient safety. In some other countries with advanced healthcare institutions, yearly trainee assessments are undertaken in the form of computer-based multiple-choice questions in combination with self-assessment.^8–10 These stop-gap measures could help assess each trainee's individual learning needs more closely and help nip any problems in the bud quite quickly. It also ensures a minimum standard of training or knowledge across the board for cohorts of trainees. Trainees may then be encouraged to take the college exams only when they are ready and prior yearly assessments could form a chunk of the exam outcomes.

General medical training commonly referred to as core medical training (CMT) in the UK was a 2-year training programme that provided broad training in various sub specialties in medicine. Trainees commonly spend either four or six months in rotations such as cardiology, renal medicine, elderly care, respiratory medicine and many other sub specialties, to acquire core skills and knowledge in these areas. Recently, the new shape of training review ¹¹ advocated some key changes to general medical training in the UK. One of the key conclusion from the report was the UK will continue to need doctors who are trained in more specialised areas to meet local patient and workforce needs. It was also intended for medicine to be a sustainable career with opportunities for doctors to change roles and specialties throughout their careers. ¹¹ In order to achieve this progressive change, general medical training for most sub-specialties (group 1 specialties) was extended by one year. Core medical training was renamed internal medicine training (IMT). Though well intentioned however, due to the unfortunate coincidence of the pandemic, the transition from the two-year to three-year training added another uncertainty to the equation. 2020 was meant to be the last year after which some specialties (neurology, palliative medicine and genito-urinary medicine) will be re-grouped as group 1 specialties and hence undergo mandatory IMT3 year. ¹² So, if some of these candidates were unable to secure a training post that year, they may find themselves in a situation where they have to either change their specialty interests or add one extra year of training. Many may argue it is not too much to ask, especially if it means getting more rounded generalist training. However, people should have the opportunity to make such choices. Furthermore, prior to the pandemic, there were assurances by the royal colleges that core medical training graduates over the preceding years will be guaranteed an IMT3 position; however, this was no longer the case due to uncertainties brought about by the pandemic.

Data from 2013 to date show there has been a gradual decline in number of applicants for the core medical training and ST3 medical specialty training programmes. ¹³ Data have shown that the core training programme is not providing enough applicants to feed into various clinical specialty programmes and subsequently insufficient to fill the number of vacancies at consultant level. 2019 represents the lowest number of round 1 applicants into core medical training, ¹³ which traditionally has been the round with the higher number of applicants. In the same paper, they stated that, worryingly, there has been a steady decline in the number of CMT2 trainees transitioning into higher medical specialty training (ST3) within one year of core medical training completion. This was from 42.4% (n = 711) in 2012 – highest number on record – to 32.6% (n = 487) in 2017. ¹³ Unfortunately, the pandemic has further muddied the waters and arguably limited the training opportunities available to many candidates.

There are no clear answers to this conundrum. Some have argued that the national recruitment should have been delayed while others argued more training numbers should have been created for this unique circumstance. Especially as there is a significant backlog of waiting lists in almost every specialty and more doctors will be needed. We should all work together to ensure the huge amounts of tax payers' money spent on training (on top of student loans) are used to create value within the health system and support our aging and arguably ailing population. Hopefully, we can find ways of attracting many doctors who have left medicine as a career, to come back into the new and reformed training programme.