The specialty you join depends on your score, with paediatrics requiring a lower mark than surgery, for example. Problems arise because ranking devalues those specialties at the bottom. Specialties with lower pass marks become less popular because they are seen as “cop-out specialties.” Inevitably, all but in the highest echelon feel dissatisfied.

Controversially, rankings for training posts are not solely dependent on achievement in this exam. Doctors are further discriminated into four classes: A—female, B—you or a first degree relative is a veteran of the Iran-Iraq war, C—two years’ work as a rural general practitioner, and D—the rest.

In most specialties, 50% of positions are reserved for female doctors, and they will be accepted if they get 90% of the mark of group D (see CMAJ 2002;166:645). War veterans in contrast only have to get 80% of the mark achieved by non-combatants, as a sign of appreciation for their fighting. The same applies to doctors who have spent more than two years working as general practitioners in a rural area. The unfairness of this method is compounded by the fact that the number of applicants in class D is roughly equal to those in A, B, and C; therefore, competition among Iranian men is fierce.

So are UK medical students justified in their furore over MTAS? British medical students argue that ranking students in each university into fourths is unfair because different medical schools have different criteria and different standards of achievement. But these concerns pale into insignificance in comparison with what Iranian medical students experience. At least UK medical students can partly control their ranking, whereas Iranian medical students cannot decide their sex or whether their relatives chose to fight in a war. Would you prefer the Iranian or British system?

Miriam Longmore is a second year medical student at Somerville College Oxford.

We are very pleased that Richard Lehman is back with us after a break. As before, his ever popular journal blog will be published weekly.  This week, Richard gets off to a splendid start by covering a range of subjects from Greek nymphs to footstools and defecating…

JAMA  25 Mar 2009  Vol 301
The problem of pain was the subject of CS Lewis’s first attempt at popular theological argument, prompting a fellow don at Magdalen College, Oxford in 1940 to remark that “the problem of pain is quite bad enough without Lewis writing about it.” It is indeed easier to write about pain than to endure it all the time, as I’m told that Lewis acknowledges - I would look it up myself, but I fear for the safety of nearby ornaments. Every pain is different, but there are some generic aspects to chronic pain management which we tend to skimp on in primary care, and that is the issue which this US trial attempted to address. The intervention was administered by a psychologist and an “internist”, and usually involved a face-to-face assessment with specific treatment recommendations plus a 4-session workshop encouraging self-management and activity. The gains, though significant, were sadly modest at the end of 12 months for these patients with chronic musculoskeletal pain.

NEJM  26 Mar 2009  Vol 360
Oddly enough, the human foreskin carries a theological pedigree almost a long as the problem of pain, though I am not sure whether CS Lewis ever wrote on the subject. God is found commanding its removal to Abram and his household as early as Genesis Ch 17, whereupon Abram becomes Abraham; Paul, apostle of Jesus to the Gentiles, later prudently decided that God no longer demanded it, whereas Muhammad, who was made of sterner stuff, got out the knife once more for all his followers. The rather curious result is that the foreskin is regarded a sacrosanct in certain European countries, including Britain, but is routinely done away with as soon as possible in large parts of the Middle East and also - for less obvious reasons - the United States of America. Africa falls between, and of course circumcision has been in the news a lot as a possible means of containing the spread of HIV. This study examines its effect on two other sexually transmitted infections - herpes simplex virus 2 and syphilis. Such is the popularity of the procedure in Uganda that randomisation was between immediate and delayed circumcision, rather than no circumcision at all. The immediately circumcised duly showed fewer of both infections. Expect changes in African health policy that will produce bagsful of foreskins to rival those brought back from Philistia by David, who later became the legendary King of Israel (see 1 Sam 18.25).

More uncomfortable reading for male readers of the New England Journal: 38,343 annual digital rectal examinations and PSA tests in the intervention group, thousands of transrectal prostate biopsies, hundreds of radical prostatectomies and lots of radiation above the genitals. And after 7 years, the result of all this prostate screening? 50 deaths from prostate cancer in the screened group and 44 in the control group. This was - and still is, since it is only half-complete - the US trial called PLCO, where the PSA cut-off for biopsy was 4.0. Treatment data are not given, and the study goes on: it has not been stopped for futility. But it’s not looking good.

The study called ERSPC by contrast is really a series of linked trials in European countries with differing recruitment and randomisation procedures and a PSA cut-off of 3.0 in every country except Finland. At 14 years from randomisation, there was no difference in prostate cancer mortality, but at fifteen years the control group suddenly fares a lot worse (see Fig 2); and if you take the mean of about 9 years, you get a 20% difference in favour of screening. This benefit was limited to those under 70, and to prevent one death from prostate cancer you would have offer screening to 1410 men and submit 48 to surgery and/or radiotherapy. Digital rectal examination and PSA are just not good enough for the detection of the prostate cancers that matter. The trials go on, but I think the strategy is dead.

There aren’t many effective interventions for chronic obstructive pulmonary disease, but one that seems to produce real improvements in quality of life in trial settings is pulmonary rehabilitation. This article is a straightforward description of how it’s done in the USA. “The successful coordinator has excellent interpersonal skills, since (at least initially) a primary task is to motivate people to do what they find unpleasant.”  Most people with COPD show an initial benefit, but this declines after a few months. Keeping people doing things they find unpleasant is never easy.

Lancet  28 Mar 2009  Vol 373
Body mass index is one of many measurements in medicine that enjoys a popularity beyond its modest deserts, but at least we have data from lots of prospective studies which are pooled here to give an estimate of cause-specific mortality in 900,000 adults. At a BMI below 22.5, smokers die much faster and thus give all thin people a spuriously bad prognosis. If you read the Summary you will get the opposite impression due to misuse of the word “inversely”. Cardiovascular mortality tends to rise steadily with all levels of BMI, but a little middle age spread does no harm to overall prognosis provided you stay below 30. Once BMI goes over 40, you are looking at a drop of life expectancy of 8-10 years, similar to life-long smoking.

This nationwide study looked at the rate of epilepsy in every little Dane who bashed his or her head in childhood and was taken to hospital. The risk varies with severity of injury, as you’d expect: kids with skull fractures, or with impaired consciousness for less than 30 minutes, have a twofold risk of later epilepsy, while severe brain injury with unconsciousness of over 30 minutes results in a sevenfold risk.

If you have renal cell carcinoma, your only real chance of long-term survival is that somebody will chance to spot it before you have any symptoms. Even this is no guarantee: more small renal masses are being removed each year because of incidental detection on scanning, but still mortality has increased. So this seminar on the subject concentrates on two ends of the scale: the optimal management of small renal masses and the management of metastatic renal cell cancer. Here there is modest progress, much hyped in the press; bevacizumab does prolong life usefully in a significant proportion of patients.

BMJ  28 Mar 2009  Vol 338
When I became a GP, obstetrics was still a routine part of our job, though I quickly abandoned the role of accoucheur without the slightest regret. The last time I tried to stop premature labour was before that at the Middlesex hospital, where on the instruction of my senior registrar I exhausted that hospital’s entire stock of injectable ethyl alcohol. The lady in question enjoyed her intravenous treat and duly stopped contracting. This most ancient of tocolytics does not get a mention in this review of adverse reactions to drugs given to stop labour, but the beta-adrenergic drugs we used more commonly do get a bad mention here, whereas something called atosiban gets the all clear, and nifedipine lies somewhere between.

Depression scoring systems were devised and validated in research settings and then imposed on British GPs via the QOF system for every patient newly presenting with depression. Two studies of their use are presented side-by-side here; the first one finds - surprise, surprise - that doctors try to administer these things but do not base their treatment decisions on them; and the second finds that on the whole, patients don’t mind filling them in. Such is the mighty evidence base for giving doctors financial incentives to use depression questionnaires.

This article on chronic constipation in adults shows what it calls the correct position for defecation, illustrated by a pensive naked man sitting on a white lavatory with his feet supported by a footstool. A courteous American correspondent of mine, Jonathan Isbit, would half approve. Jonathan says he was inspired by my first piece in the BMJ, a Personal View called “In Praise of Hunch Backing” to back his hunch that many bowel diseases and almost all constipation are the result of modern man adopting the sitting position to defecate. Jonathan would have our knees much higher while defecating than a mere footstool can ensure. Squatting over a hole in the ground, we would prevent appendicitis by pushing our right knees into our iliac fossae and prevent colon cancer, diverticulitis and constipation by getting our rectus muscles into bowel-squeezing action. However, careful placement of the feet is necessary, so as not to give the word “footstool” a whole new meaning.

Arch Intern Med   23 Mar 2009  Vol 169
There have been dozens of trials of vitamin D supplementation for the prevention of non-vertebral fractures and if you pool them all you get equivocal results. However, if you carry out a meta-analysis by oral dosage, there’s a clear difference between trials using a low dose of vitamin D and trials using more than 400u daily. People over 65 reduce their fracture risk by at least 20% if they take a decent amount of vitamin D.

Eating large quantities of red meat is a bad thing for global resources and also a bad thing for people, according to this simple but enormous study of self-reported food intake in 500,000 Americans aged between 50 and 71. There was a 30% difference in mortality between the groups reporting the highest and the lowest red meat intake, when adjusted for a wide but possibly insufficient range of confounders. The extra deaths are from cardiovascular disease and cancer. But you can eat white meat - meaning chicken, I think - not just with impunity but with benefit.

If you are interested in hypertriglyceridaemia, then here’s some detailed epidemiology for you to revel in from 5610 people aged over 20 studied in NHaNES 1999-2004. As usual, it’s a confusing picture, especially as there was no standardisation of sampling conditions, and only rather vague associations emerge, chief of which is physical inactivity.

If you have a close relative who has had venous thromboembolism, your own chances of getting one are at least doubled, according to yet another important study of the subject from Leiden. In fact it’s usually more useful clinically to factor in a family history than to take blood for a so-called thrombophilia screen.

Having been unwisely drawn into a public argument about diabetes, I have only one hope of getting everybody to agree with me, and that is to keep saying nice things about metformin. It’s the only treatment which can actually be shown to improve outcomes in type 2 diabetes without any shadow of doubt, and every patient with this condition should be persuaded to take it unless the gastrointestinal side-effects are completely intolerable. The key to its action is probably to reduce insulin resistance, and the trial here attempts to gauge its value in type 2 diabetics who require insulin. This important fact fails to get a mention in the title of this paper, which also claims to report “long-term” effects, though the mean follow-up was 4.3 years. Over this relatively short period, patients randomised to metformin lost weight, had better glycaemic control, needed less insulin, and had fewer macrovascular adverse events. But unfortunately, as in so many diabetic trials, the investigators chose to lump all sorts of dubious “microvascular” outcomes into their primary end-point and thereby failed to reach statistical significance by dilution.

Plant of the Week: Daphne odora

Daphne, you will remember, was the nymph who eluded the amorous attentions of Apollo by turning into a tree. This was a popular subject for artists and sculptors like Bernini (see The Mirror of the Gods  Malcolm Bull, 2005) and even for the first composer of a German opera, though sadly we have lost the music which Heinrich Schütz wrote in 1627 to be sung by his tree.

Many plants were once given the name of Daphne, but for some reason Linnaeus settled the title on a genus of low shrubs, little resembling the nymphs of Thessaly except perhaps in their gorgeous perfume. Of all the daphnes, this small evergreen plant is perhaps the most ravishingly scented, though there are many competitors among her sisters and cousins. In fact it is possible, with reasonable care, to enjoy the scent of different daphnes throughout the year. Let us begin like the Iranians at Now Ruz, the spring equinox:

March-April: Daphne odora, D blagayana
April-May: D tangutica, D collina
May-June: D x burkwoodii, D cneorum
June-July: D x hybrida, D sericea
July-Oct: D x transatlantica, D x napolitana
Oct-Nov: D susannae
Nov-March: D bholua, D jezoensis, D mezereum

The trouble is that one or other of these will invariably die on you just when you most look forward to it. D odora is relatively robust, though tradition has it that the clone with yellow-edged leaves, Aureomarginata, is the only one reliably hardy in English gardens. I have just bought a handsome Japanese clone called Sakiwaka with good plain leaves and I’ll let you know how it gets on next winter.

The shake up in medical training this year means not only are doctors coming out of Foundation Year II looking for posts, but so are all those who were still in Senior House Officer jobs. With the debacle over the computerised system, abandoned mid-way through the process, and the switch to individual deaneries handling appointments directly, there has been some delay. Round II is not due to finish until October.
Sian Thomas, deputy director of NHS Employers assured the public that there would not be a crisis: “Information gathered from employers indicates that trusts have been able to appoint very good doctors to specialty training posts this year and that the relatively small number of vacancies remaining can be covered through use of locums and other temporary staff cover.”
But the BMA sees things differently. It says that in England alone, around 30,000 doctors are due to be starting new posts — around 10,000 in foundation programme posts, and 20,000 in specialty training posts. The numbers starting new jobs on 1 August this year is significantly higher than in previous years, it says.
“The impact of Modernising Medical Careers on patient care is currently unknown,” said the BMA in a statement. It said this was largely because the SHAs have not published their plans, so there was no way of being sure about continuity of service on 1 August. “In some trusts, doctors are reporting that all routine operations are being cancelled,” said a spokesperson.
But it sought to allay fears that the changeover might result in more risk for patients: “The large number of doctors starting new jobs does not in itself mean that there will be an impact on patient safety,” said the BMA. “Research in the past has found no evidence that hospital deaths increase on 1 August. The vast majority of doctors are dedicated professionals who will never neglect their patients - their poor treatment at the hands of this system does not mean they will work to a lower standard.”
NHS Employers admitted that the next few weeks would be challenging. “But they are well prepared to ensure that both trainees and patients are looked after,” said a spokesperson. “The quality of applicants has been very high this year and trusts have recruited the best doctors to the available posts.”
About 1000 posts out of 15,600 in England are yet to be filled and further training posts will be released later in the year, the organisation said. For those junior doctors working in the NHS who have not secured a post, career counselling and guidance was available, including a new medical careers website was due to be launched in the next few weeks.
Trusts report being able to redeploy many of those who have not secured a post until the recruitment process comes to an end this October.
According to the BMA, the government has said that doctors currently working in the NHS will have their employment protected until the end of the recruitment process in October and that will be around 1000 additional short-term training posts for doctors who remain unappointed then, and an unspecified number of non-training posts.
But the BMA says many doctors have already left the UK preferring to take their chances elsewhere, including in Australia and New Zealand.
The latest details about Round 2 training opportunities are available at the Modernising Medical Careers website.

According to the Department, there were 29,193 applicants for junior doctor training posts in England and of these, 27,849 were eligible to apply for one of the 15,600 vacancies within MTAS. But 25,000 applicants were already working in the NHS.

A total of 15,554 training posts had been made available in round one, 11,816 of them run through training posts and 3,559 fixed term appointments. A further 179 academic posts were also available.

A total of 13,168 training posts had been accepted at the end of round one. Of these, 10,804 are run through (RT) posts and 2,262 of them are one year fixed term specialty training appointment (FTSTA) posts. It leaves 2,320 unfilled posts for applicants in round two. In addition, a further 1000 one-year training posts will be made available to those doctors unable to secure a post at the end of round two, which will end on 31 October.

The figures published so far do not make it clear how many of those who applied were in staff and associate specialist posts, how many were existing SHOs and how many of them juniors. So it is not possible to work out how many doctors currently working in the NHS are facing potential unemployment.

Those in SAS posts will not be unemployed if they fail to secure a post under the current process, but doctors coming out of foundation training or those currently in SHO grades could find themselves jobless. Nor is it clear how many of the eligible applicants were overseas applicants. The figures would indicate that as many as 14,249 eligible applicants had graduated overseas. However, many of these may have been working in the NHS already, often for many years. It is unclear how many medical graduates may have been trying to apply from outside the UK.

Of the 13,600 UK graduates who applied, 9,336 (almost 70 per cent) have accepted a post at the end of Round One.

Health Minister Ann Keen said: “The high fill-rate is good news for patients, the NHS and deaneries across the country and has been achieved despite this year’s problems with implementing the national recruitment programme.
“We are working hard with the NHS on this second round of recruitment, and on the development of a package of support for those appointable applicants who have yet to find a post.”

The Department has announced a package of support for those appointable junior doctors who have not found the right posts following Round Two. It includes:
- some 1,000 extra one-year and GP training posts;
- access to career information about future training options via local Deaneries. (Applicants who are already in NHS Employment will also be able to access career support from their employer.)
- a careers website for junior doctors to support their decision making when looking at future careers
- educational grants allowing appointable but unsuccessful applications who are in service posts to pursue their clinical education and improve their chances of successfully applying for specialty training next year.

The following summary of the statistics has been published by the DH and a full breakdown of the details is due to be posted on the Modernising Medical Careers website:

England Summary of Round 1 Acceptances
Excluding Defence Medical Services

Acceptances data correct as of Round One close on 26 June

All Round 1 Posts:
All 15,554
RT 11,816
FTSTA 3,559
Academic 179

Applicants:
All 29,193
Eligible 27,849

All Acceptances
All 13,168
RT 10,804
FTSTA 2,262
Academic 102

Fill Rate
All 85%
RT 91%
FTSTA 64%
Academic 57%

Round 1 fill-rate by specialty (Royal College groupings)
Royal College Fill rate (percentage of posts filled at close of Round One

Anaesthetists 75%
Anaesthetists/Physicians 76%
Emergency Medicine 82%
General Practitioners 98%
Obstetricians and Gynaecologists 74%
Ophthalmologists 81%
Paediatrics and Child Health 83%
Pathologists 91%
Physicians 85%
Physicians/Pathologists 92%
Psychiatrists 82%
Radiologists 99%
Surgeons 79%

Round fill-rate by Unit of Application (Deanery)
Unit of Application Fill-rate (percentage of posts filled at close of Round One)

Eastern 84%
Leicestershire, Northamptonshire and Rutland 80%
London/KSS 89%
Mersey 91%
North Western 92%
Northern 77%
Oxford 77%
Severn 88%
South Yorkshire & South Humber 74%
Southwest Peninsula 74%
Trent 64%
Wessex 83%
West Midlands 77%
Yorkshire 94%

680 junior doctors responded to the survey, of whom 94% said they felt more stressed than they would normally and put this down to MTAS.
Three in 10 doctors said they had made more mistakes at work in the last six months, and 43 per cent said they cared less about patient care.

The survey also found that a third of respondants had increased the amount of alcohol they were drinking. 23 per cent said they had taken more sick leave than normal. Disturbed sleep, loss of appetite and tearfulness were also reported and more than half said they had “a sense of future hopelessness”.
The Telegraph reported Professor Dinesh Bhugra, Dean of the Royal College of Psychiatrists and one of the authors of the study, as saying: “These findings are extremely worrying. We have discovered that a normally robust and highly committed group of professionals is feeling very demoralised.

“The government has a moral obligation to ensure that the next generation of doctors does not feel disenchanted.”

Professors Morris Brown and Steve O’Rahilly held a press conference in London on Tuesday (19 June) to highlight the problem. They released the results of an online survey of 1300 applicants, of whom 49% had not at that stage had job offers.
Professor Brown said the results showed that those who had not had offers were more likely to have a first class degree or a distinction. He said it was effectively a ‘”selective cull of the best”.
Two doctors affected by the situation were at the press conference. One, Sarah (who did not give her surname) had an MS Fellowship and DPhil from Oxford. She has been working on the Maudsley rotation and wants to pursue a career in psychiatry.

She has had one job offer, but for a fixed term staff appointment, not a training post. “It’s just a career grade position,” she said. “I’m not really sure what it is going to lead to. I wanted to try to change the face of psychiatry and the way mental health services are delivered. I’m not sure I can do that from a career grade post.”
Another doctor, Matt, has a first class honours degree, then moved on to degree in medicine at Cambridge. He is currently working on his PhD with a leading cancer specialist.

He’s had one job offer — like Sarah’s it is just for a fixed term staff appointment.
“I know what I want to do and I know where I want to do it,” he said. But the constraints of the MTAS application form made it impossible for his academic credentials to be rated as highly as they should, he claims.
As round 1 comes to an end this week (June 22) it’s hard to know how many posts will be filled. The Department of Health has undertaken to notify all applicants of available posts — including non-training ones — by the end of the following week (June 29). It’s unclear how many of these will be unfilled posts either held back, or not filled, from round 1 and how many will be additional posts created by trusts to ensure there are no gaps in service provision.

NHS Employers has issued guidance to trusts about how they should handle the impending crisis. It includes details on how best to manage any changes in the existing workload of staff to ensure they comply with the working time directive. See
http://www.nhsemployers.org/workforce/workforce-2560.cfm

“I am also concerned about the arrangements for selection of junior doctors into run-through surgical training programmes. Surgery has unique requirements in terms of recruitment – the criteria for selection include diagnostic skills, clinical judgment and manual dexterity. It is neither practical, nor indeed safe, to select junior doctors with a view to a career in surgery without the opportunity for assessing whether they have the full mix of professional skills required.
He said it was “with the greatest reluctance” that he was pulling out of the group.

Yesterday health secretary Patricia Hewitt announced that an extra 200 specialist training posts would be made available for those unable to secure training posts. A further number of non-training posts would be available she said.The BMA said this did not go far enough, with 12,000 applicants under MTAS unlikely to secure training posts.

“Creating more temporary posts on its own is not an adequate solution” said Jo Hilborne, chair of the Junior Doctors Committee. “We need to know that there will be more opportunities to get into long-term training in years to come, and increased flexibility to move between specialties and regions.”

All applicants are due to be told the outcome of their first round interviews by 7 June. They will be offered posts on the basis of their ranking, irrespective of the candidate’s order of preference. They will have until 23.59 on 10 June to accept or decline any initial offers. Candidates have been advised to make their decision straight away to give them ‘the maximum possible time to finalise your personal arrangements’ or ’so that the training opportunity can be passed on to one of your colleagues’.

Any remaining unfilled posts will be offered between 11 and 22 June, with applicants given only 48 hours to respond.

Round One will close on Friday 22 June, at 23.59.

However, Mr Justice Goldring said medics were justified to feel angry. He described the MTAS system as a “dreadful mess”, adding that its premature introduction had had “disastrous consequences”.
Remedy UK had gone to court over MTAS which has caused so much anger among junior hospital doctors. Remedy had originally argued that the computerised system was so flawed it should have been scrapped completely. But then it argued in court that the interviews carried out so far in round 1 should only be for temporary posts.
Mr Justice Goldring said the premature introduction of the new application system had had disastrous consequences - and although the legal challenge had failed, many junior doctors had “an entirely justifiable sense of grievance”.
He added that individual medics might still have good grounds for appeal under employment law.
A spokesman for Remedy UK said the group would not be appealing the decision. “Obviously we are very disappointed,” he said. “We still feel that careers will be harmed by this situation.”
Health Minister Lord Hunt said the government would now be working to establish the best possible way forward to match doctors to posts.
“We understand the uncertainty that problems with the system has caused junior doctors and their families, and acknowledge the criticisms that the judgement contains,” he said.

“In consultation with representatives of the medical community, including junior doctors, we will continue to work to establish the best possible way forward in order to match trainee doctors to posts.
“We feel strongly that the process of making job offers should go ahead in the interests of both doctors and patients.
“We understand the uncertainty that problems with the Medical Training and Application System have caused junior doctors and their families, and acknowledge the criticisms that the judgement contains.
“We need to ensure that lessons from what has happened are learned and learned thoroughly. That is why the Secretary of State has asked Sir John Tooke to establish an independent review of the process so that the best possible mechanisms are in place for the training of our junior doctors.”
The ruling means that the first job offers, which had been held back until the outcome of the hearing, will now be sent to candidates. However, the BMA has reiterated its concern for the thousands of doctors who will not get posts.
Responding to the judgment, Dr Jo Hilborne, chairman of the BMA Junior Doctors Committee, said:
“We hope the Department of Health will not claim this as a victory when the careers of thousands of doctors remain in doubt because of government failures. The High Court is absolutely right to criticise their handling of this mess, and to point out that our concerns about it were ignored.
“The harsh fact facing us now is that there are not enough jobs. There are 12,000 doctors who will not get training posts through this system, and they must be our priority. We have demanded that the government guarantee that no doctor will be unemployed as a result of this process and called for funding for extra training posts.
“We now hope that doctors will unite to fight for these aims. The past week has been incredibly painful for the medical profession. It’s time for us to start healing the wounds and move on.”
The BMA has requested an urgent meeting with the health secretary to demand further action.
But the Royal College of Surgeons is concerned there has not as yet been confirmation of additional training places for surgeons. It says it cannot support job offers being made until agreement has been reached on the increased numbers for specific surgical specialties and an agreement on the location of those training posts.
“I believe we are close to securing a rescue package from the Department of Health which will bring competition ratios for specialist surgical training in line with previous years,” Bernard Ribeiro, President of the Royal College of Surgeons, said. “This will save good surgical trainees for the NHS who would otherwise be lost. We must not jump the gun on this and put trainees in the position of having to choose a training post not knowing whether other posts would be made available. What we need now is absolute clarity for our trainees.”

His letter, written with Carol Black, chairman of the Academy of Medical Royal Colleges, caused a furore among BMA members over the weekend and led to Mr Johnson’s decision  to stand down on Sunday (20 May).

A number of comments about whether it was right he continue as chairman were posted by BMA council members on the association’s website, he told the BMJ. It’s understood he was placed in a position where he had little choice but to resign.

Many junior doctors had been furious that the BMA representatives on the MTAS review group had gone along with the proposal to continue with the existing interviews, despite the fact they were based on the flawed MTAS computer system. At one point it looked as if Jo Hilborne, chair of the Junior Doctors Committee, would lose a vote of no confidence, but she managed to weather that storm.

Mr Johnson claims his letter was merely reiterating existing BMA policy. What seems to have most annoyed BMA members was the paragraph in which he and Carol Black said they ”restated their support for the Chief Medical Officer and his role in improving junior doctors’ training”.

“The Chief Medical Officer seems to be a bit of a hate figure within the BMA at the moment,” Mr Johnson said. “I think it is my job to support any member that is being got at and isn’t in a position to support himself,” he added referring to the fact the Chief Medical Officer, a BMA member and architect of the medical education reforms, was under attack from Remedy UK— along with health secretary Patricia Hewitt.

He defended the comments he made on MTAS, arguing that what he wrote was in line with the BMA’s policy:

“MTAS may not be a very good system but we’ve got to be pragmatic,” he said.  The BMA had accepted the current round of interviews should go ahead, albeit on a flawed application system, because:  ”Doctors have to be in training posts by August.”

The suggestion by Remedy UK, up until the eve of their court case, that the interviews carried out so far should be scrapped, was not accepted by the BMA he said. “The rather flawed system has got to go ahead,” he said.

 ”I think modernising medical careers has a lot of faults,” said Mr Johnson. “But in the  past SHOs had no hope of promotion and were just going from job to job.”

But given the sensitivity of the MTAS issue — with many junior doctors threatening to leave the BMA over the line it had taken — Mr Johnson’s letter was bound to offend many association members.

He told the BMJ that he did not consult the BMA before writing to The Times. “The BMA policy is that we support MMC,” he said. “We can’t have a policy we are ashamed of. I don’t have to consult every time I write a letter.”

Mr Johnson said it was “completely untrue” that he wasn’t angry about what had happened over MTAS. “But I don’t regret coming to the aid of a colleague.”

Mr Johnson was probably going to stand down from the BMA next month in any case, after being at the helm for four years. “I was feeling for a long time that four years was enough,” he said. “But I wouldn’t have chosen to end it in this way.

“It’s got to the stage where it is actually damaging the association. There have been a few resignations and if your own council members are being critical of you, that is a situation where I am no longer helping.”

He defended his decision to support the CMO, although many members feel this put the BMA too close to government. “The BMA is always seen as a bit of the establishment. There will always be members who say the BMA isn’t doing enough.

“I’ve no doubt at all that my letter was the correct thing to do.” 

Round 1 interview set up through MTAS and which have already taken place, or which are due to take place, will still be valid.

Ms Hewitt has announced that local deaneries will notify junior doctors of the outcome of the round 1 interviews, rather than trying to continue any further with MTAS, and that selection for round 2 will be done by local deaneries, not via MTAS.

In her written statement to the Commons today Ms Hewitt outlined her concerns at the security breaches that had occurred with the MTAS site and said these would be reported to the police.

“Given the continuing concerns of junior doctors about MTAS, the system will not be used for matching candidates to training posts, but will continue to be used for national monitoring,” she said.

She went on to explain that, subject to the outcome of the current Judicial Review, the first offers for hospital specialities in England would be made on or after 21 May 2007, with all initial offers made by early June.

Her announcement came the day before Remedy UK was due to launch a legal case against the Department of Health against the flawed application process.

Dr Andrew Rowland, vice chairman of the BMA Junior Doctors Committee, welcomed the Department’s decision:

“The Department of Health has at last seen sense and effectively abandoned the unfair, discredited, and shambolic MTAS system,” he said. “We are extremely concerned that the Health Secretary believes criminal offences may have been committed as a result of security breaches.”

The BMA opposes any suggestion that interviews that have already taken place should be written off.

“Some people have called for the system to be scrapped altogether and for the tens of thousands of interviews that have taken place to be written off,” said Dr Roland. “This would be disastrous for doctors, for patients, and for the NHS.”

But Remedy UK — which accepts it is too late to re-run the interviews — believes any appointments made as a result of these should only be on a temporary basis.

Ms Hewitt’s announcement today was old news, said Matt Jameson Evans of Remedy UK, which is bringing the legal action against the Department. “We knew round 2 was going to be done by local deaneries.”

The vast majority of posts would be filled on round 1, he said, which is where Remedy UK claims the Department has abused its power. He says the announcement will not affect Remedy UK’s case, which was due to be heard on Wednesday (16 May).

Ms Hewitt’s written statement follows:

In my oral statement on 1 May 2007 I notified the House that there had been two security breaches of the medical training application service (MTAS) that arose on 25th and 26th April.

MWR Infosecurity has now completed a full security review of the MTAS system. Action has been taken by the contractor (Methods) to address the weaknesses identified. Both MWR and CESG (Communications Electronic Security Group), the national technical authority for information assurance, have confirmed that appropriate and sufficiently comprehensive action has been taken. The site was therefore re-opened last week, restricted to postgraduate deaneries only, to support the next steps in the recruitment process.

Because the investigation has made it clear that criminal offences may have been committed, the MWR analysis and report have been given to the police.

Ongoing Recruitment process

Following the recommendations of the review group chaired by Professor Neil Douglas, every eligible applicant for postgraduate medical training has now been guaranteed at least one interview for their first preference post. An additional 15,500 interviews have therefore been arranged as part of Round 1 and are now taking place. I am extremely grateful to the consultants who have made themselves available for these additional interviews.

The review group met again on 9 May to consider the process of offering posts to candidates who are successful in their Round 1 applications. The group agreed that offers for the current round will be managed locally by individual deaneries, on the basis of published MMC guidance.

Offers will be made to successful candidates on a phased basis as
interviews for each specialty are completed. Subject to the outcome of the current Judicial Review, the first offers for hospital specialities in England will be made on or after 21 May 2007, with all initial offers made by early June. This process of making offers will continue until late June 2007, at which time Round 1 will close, ensuring that candidates and employers have time to prepare for appointments commencing on 1 August 2007.
Given the continuing concerns of junior doctors about MTAS, the system will not be used for matching candidates to training posts, but will continue to be used for national monitoring.

As we have stressed before, not all training posts will be filled in the
current round and there will therefore be further substantial opportunities
for those who are not successful initially. The review group has agreed
that this further recruitment will be locally planned and managed by the
deaneries. An announcement of the process will be made shortly.

Deaneries are continuing to work with the NHS and the Postgraduate Medical Education and Training Board to establish what additional training posts will be made available beyond the 23,000 training posts already available across the UK.

The BMJ understands that the big teaching hospitals are being asked to identify temporary positions that can be made available from August for doctors unsuccessful in obtaining ST3 and ST4 posts.

As many as 10,000 such posts may be needed it the figures from the BMA are anything to go by. These posts would be ‘staff’ positions – in other words, they would not be on the career structure towards a consultant post.

The news comes as junior doctors begin to hear the outcome of their first round interviews. It is still unclear how many posts will be held back for the second round. Unless deaneries have deliberately decided not to fill a certain proportion of posts, this could leave some unsuccessful applicants doctors with very limited options at round 2.

Trust personnel officers are seizing the opportunity to create additional posts — which are to be centrally funded to avoid the political embarrassment of having doctors unemployed.

One internal memo seen by the BMJ says that these staff posts will chiefly be equivalent to ST3 and ST4 level and will be for one or two years initially. They would, it says, offer the potential to transfer into a career grade post at a later stage.

Staff are being asked to identify posts which either they had educational approval for but could not fund, or where they could take on an additional trainee without it affecting the training of existing career grade staff.

Funding these additional posts at £30,000 per year each could cost the government as much as £300m in the first year alone.

However a spokesperson for Modernising Medical Careers questioned the 10,000 figure, stating that many of those who failed to get specialist training posts were already working in staff grade jobs in the NHS, so would not be unemployed.

But the true figure has still to be confirmed. NHS Employers refused to comment, passing the matter onto the Department of Health. It is understood a statement is due to be made early next week about the outcome of the first round of interviews.

Meanwhile a group of consultants, led by Professor Morris Brown of Cambridge University, has written to his colleagues nationwide, alerting them to the growing concern among both consultants and junior doctors at the MTAS interviews.

Professor Brown has carried out an on-line poll of 3500 doctors, which showed that 81% of 813 Consultants and 85% of 2422 Juniors who replied wanted a consultant boycott. He also suggests delaying the 1 August start date for the new specialist training posts.

“In our poll,” he writes, “80% of both seniorities would like doctors to stay in their current post. The main downside is a delayed start for the new FY1s, who should be compensated; but at least they have a future ahead of them, whilst 10,000 FY2s and SHOs unsuccessful in their single MTAS interview face a permanent end to their career in hospital medicine.”

TO go to the poll questionnaire, visit www.cai.cam.ac.uk/people/mjb14/

See also a rapid response from Professor Brown at: www.bmj.com/cgi/eletters/334/7601/0?ck=nck#165660

She had already explained on Friday that there had been a breach of security on the MTAS website and that the site had been closed down pending investigation.

Candidates’ personal information had been loaded on to the site at about 8.30 am on Wednesday 25 April and the deaneries were notified of the relevant web page address for at 9.30 am.

“In making the information available to the deaneries, the MTAS contractor, Methods Consulting, failed to provide the usual and essential password security protection,” she said. Once Channel 4 News discovered the breach, they contacted the Department, and the loophole was closed.

Ms Hewitt said that during the time the web page was visible without a security password, information on foundation programme applicants was accessed from 21 different internet addresses, mostly belonging to postgraduate deaneries. Many of the other accesses in that time were from Channel 4 News, she said.

” There is no evidence that members of the public or other commercial interests, apart from staff at ITN and Channel 4 News, accessed the site,” she told MPs.

She said that Methods Consulting had taken action with its staff following the security breach. But she intended to pursue further action over Channel 4 News’ actions:

“We have already reported the situation to the Information Commissioner. I will also report it to Ofcom and draw it to the attention of the chairman of Channel 4 and ITN.”

She went on to explain that on Thursday 26 April, it emerged that applicants could randomly access another candidate’s messages on the messaging facility.

“In view of the two lapses, the IT contractor, Methods, immediately appointed an approved security company, MWR InfoSecurity, to carry out a full security review and penetration testing,” she said. “Some weaknesses were identified and MWR InfoSecurity has been working with the contractor to rectify them.”

She added that Communications Electronic Security Group, the national technical authority for information assurance, was also advising the Department.

“The MTAS site will be re-opened as soon as we have the necessary security assurances,” she said.

“I apologise again to junior doctors or foundation programme applicants who have been caused anxiety or, in some cases, inconvenience as a result. I will, of course, continue to keep the House informed of further developments.”

Conservative health spokesperson Andrew Lansley said he knew of 14 examples where junior doctors have gone on to the site to try to book interviews and had seen their preferences changed.

“They have seen interviews being booked for two weeks prior to their application; they have seen double interviews; they have seen their eligibility disappear; and they have been told that there are no vacancies, but when they have telephoned, they have been told that there are choices. The system is not working,” he said.

Meanwhile the BMA called for reassurances that no medical student had been affected by the breach and that it would not happen again. Dr Andrew Rowland, vice chair of the Junior Doctors Committee, said it was a disgrace: “We are not confident the evidence provided today is enough to say there is a cast iron guarantee that no members of the public accessed the site.”

They also voted unanimously that the National Audit Office should investigate the waste of public money which the whole system has caused.

Some 250 delegates attended the meeting in London. “People were angry and insensed by MTAS,” said Tom Dolphin, deputy chair of the committee. “Junior doctors are feeling that they have been betrayed by the government, and that the reforms have been done so badly that it is difficult to see a way forward.”

Following an emergency motion to the conference, delegates mandated their representatives to continue to be in talks the review group of MTAS, under the auspices of Professor Neil Douglas. They have agreed that the chair of the committee, Jo Hilborne, should argue for all doctors throughout the UK to be interviewed for each of their four chosen posts. This would ensure candidates in England were treated the same as those in Scotland, Wales and Northern Ireland.

Delegates also called for all Modernising Medical Careers training to be postponed for a year until the MTAS problem was sorted out.

Tom Dolphin, who proposed the motion calling for the two ministers’ resignation, said it was important the ministers accepted responsibility for the situation that had developed.

“The government was warned,” he said. “They need to accept responsibility and to resign.”

A motion of no confidence in the Modernising Medical Careers team was not heard because the emergency motion took its place. Calls for MTAS to be scrapped entirely were also rejected by delegates.

“This breach had no impact on the current recruitment of junior doctors into specialty training,” health secretary Patricia Hewitt told the house.

“The data was accessible only for a short period of time on 25 April.  Details of the website address were leaked to the media.  The MTAS team removed the data as soon as the error was brought to their attention.  The Department, of course, deplores such leaks.”

She said the department had decided to suspend the site temporarily while they perform full independent security tests. It means applicants wanting to confirm interviews in the next few days will have to do so by telephone, rather than using the website.

“We expect the suspension to have minimal impact on the current round of recruitment into specialty training,” she said.

“We take security very seriously and the breaches are under urgent investigation by the Department.  This investigation will seek to establish how the security breaches arose, who accessed any data without authorisation and what steps need to be taken to prevent a recurrence.”

A spokesperson for Modernising Medical Careers said it was intended that the interview booking section of MTAS would be available to applicants again very soon and with the minimal disruption to their application process. 

“Specialty and GP applicants will receive an email to let them know when the system is up and running again. We expect that this will be by Monday, 30 April,” she said.

Meanwhile the BMA’s chairman, James Johnson, has written to the Prime Minister Tony Blair warning that unless the government addresses the matter urgently, concerns can only increase among medical students and junior doctors.

His letter highlights new flaws in the system, including UK doctors incorrectly being told that they could not apply for posts because they did not have the “correct immigration status

Channel 4 News ran with the story yesterday, after discovering that the URL of the page containing all this information was not password protected.

Although this address should only have been known to those who were authorised to access the site — primarily those interviewing candidates — the URL was leaked. This made it possible for anyone who had been given that address to go straight to the page, bypassing the initial home page.

As soon as the Department of Health became aware of the security breach, early yesterday evening, they put a password on the page. But in the meantime confidential information about junior doctors — including their religion and sexual orientation — could have been viewed by anyone who knew the URL. 

Dr Jo Hilborne, chairman of the BMA Junior Doctors Committee, said it was a breach of security “on an appalling scale”.

“What little faith anyone had left in this shambolic system has just evaporated,” she said. “The ease with which anyone could have accessed highly sensitive information about thousands of people is frankly shocking.  The BMA has raised concerns about the security of the MTAS website on more than one occasion.  The Department of Health had months to put it right and failed.  There can be no excuse for this.

The action, organised by Remedy UK, coincided with an opposition debate on the MTAS debacle.

Conservative health spokesperson Andrew Lansley called on the government to create additional training posts for those senior house officers who during 2007, 2008 and 2009 would be moving from the old style training into the new training structure. And he called on the recently announced Review Group, led by Sir John Tooke, to “listen to the medical profession in reviewing the structure of Modernising Medical Careers to ensure that the original principles, including flexibility, are sustained and command the confidence of the medical profession.”

Some of the angry protestors who were in the public gallery intervened during the debate and were warned by the Speaker that they could face eviction if they continued to do so.

In her response to the opposition-led debate, the Secretary of State Patricia Hewitt tried to clarify the continuing debate about how many training posts were available and how many doctors might not gain places.

“About 23,000 postgraduate medical training appointments are available across the UK this year,” she said. “Of those, 3,000 are being filled by recruitment to general practice, and just over 19,000 places are available on MTAS at the moment, with a further 700 to be added to the system.

“Of the 32,000 or so eligible applicants for those training posts, about 30,000 are already working in the NHS, about 6,000 of whom are completing their foundation programme, and about 8,000 of whom state on their applications that they are working in non-training posts—trust jobs, staff jobs, locum posts and so on.

“About 16,000 say that they are working as senior house officers, but because of the deficiencies in the present system, many of those posts are not proper training posts either.”

Although many of those in non-training posts would not get onto training, they would continue to have a job, she said. She added that the Department of Health was working with the royal medical colleges and the NHS to establish the need for additional training posts, including one-year placements and more senior posts.

Ms Hewitt had outlined the remit of Sir John Tooke’s review of MMC earlier in the day. These include looking at the selection process, ensuring the medical profession is involved with and supportive of the proposals, and the level of choice available to those applying for run-through training.

The BMA says the government’s failures in workforce planning have created this mess.

The document, apparently from NHS Employers, which represents NHS trusts, was leaked to journalists on Friday, much to the consternation of the organisation’s deputy director, Sian Thomas.

“It is disappointing that discussions being held within the review group are being leaked as there are many and wide ranging issues being considered,” she said.

Apparently the suggestion was one among many proposals for how trusts might help offer advice and support to those doctors who failed to obtain a post in this year’s training recruitment. It has been suggested that as many as 10,000 doctors could be without jobs at the end of the process, but this, says Ms Thomas, does not reflect the fact that many of those who applied for speciality training are already in staff posts.

“The 10,000 figure is based on the difference between applicants and training places,” she said. “There are many applicants from outside the NHS or working in service posts who saw this transition year, with more training programmes available, as a one off opportunity to get into NHS specialty training, which is seen worldwide as high quality and lucrative.

“Speciality training posts are always very competitive and there are always more applicants than places available,” she said.

She added that if doctors currently in staff (also known as trust) posts were successful in getting onto specialty training posts, they would create vacancies which other, less successful, candidates could apply for. These staff posts do not offer the same automatic career progression towards a consultancy post.

“There are many options open to applicants who do not secure a training place,” she said. The options put forward in the report to the MTAS review group included not only staff posts in the NHS but locum work and spending a period of time working outside the NHS — possibly working for a voluntary organisation.

“Similar discussions have also been held nationally with regard to other groups, particularly nurses and physios which resulted in the publication last week of a joint programme of work between TUs, DH and NHS Employers,” said Ms Thomas.

“Volunteering and working overseas has always been popular among NHS staff, with the relevant experience, who have a lot to give and a lot to gain from a period of working in other countries.

But the idea got short shrift from the BMA’s junior doctors’ representative, Jo Hilbourne, who is on the review group.

“It’s extremely worrying that NHS managers do not know how many posts are available for the thousands of junior doctors applying for them,” she said. “It’s even more alarming that they are preparing for medical unemployment on such a large scale.

“The government can no longer deny the seriousness of this crisis. As a matter of urgency, the Health Secretary must guarantee that no doctor in training will be denied a career in the NHS as a result of poor workforce planning.

“If our most talented doctors are forced out of training, they will head overseas or leave medicine entirely. They will lose out on their dreams of becoming consultants and GPs in the NHS. Their patients will lose out on the right to be treated by the best doctors. And taxpayers will get no return on the millions of pounds spent on medical training.

“The government’s failure to plan the NHS workforce created this mess.

And she announced another review, this time of the whole of the Modernising Medical Careers policy, rather than just of MTAS. It would look into ways of strengthening the policy for next year, she said.

“I apologise unreservedly to them for the anxiety that has been caused,” said Ms Hewitt in a formal statement to the House of Commons today.

She then announced that Professor Sir John Tooke, Dean of the Peninsula Medical School, would chair the review. Professor Tooke is also Chair of the Council of Heads of Medical Schools and Chair of the UK Health Education Advisory Committee.

She said the new panel would build on the work of the current MTAS Review Group, led by Professor Neil Douglas.

“We are now some two years into the Modernising Medical Careers initiative which started with the successful launch of Foundation Programmes in 2005. I believe, therefore, that the time is now right to undertake a wider review of Modernising Medical Careers. It is an important programme and we must apply the lessons we have learned to a wider context.”

Ms Hewitt insisted that process underlying Modernising Medical Careers was sound. But it needed to be looked at in the light of what had happened this year.

“The review will clarify and strengthen the principles underlying MMC to ensure that they have engagement and support from the medical profession and its leaders,” she said. ”I want the review particularly to look at how the processes involved in delivering Modernising Medical Careers meets the needs of the service, employers and doctors in training.”

Further details of the review group would be made as soon as possible, she said.

When pressed by Conservative health spokesperson Andrew Lansley to give more information on the number of places which would be available — and the numbers of doctors who might not be able to find a place — she reiterated that the many of those applying for posts were already in jobs within the NHS. Talk of thousands of doctors without jobs was “complete nonsense” she said.

“Of course there may be a situation where some whose application for run through training is not fulfilled,” she said. They would find themselves having to stay in staff jobs.”

And she hinted that there might be some more posts created in some specialties to cope with the demand for places. She said that NHS employers had been asked to look again at the number of training posts available in certain specialties “to see whether they would wish to change the numbers.” 

The BMA welcomed the fact it would be an independent review but said action was needed now to tackle the shortage in training posts this year. Dr Jo Hilbourne, chairman of the BMA Junior Doctors Committee, said the association had warned for years that Modernising Medical Careers had been rushed in too quickly.

“The government’s handling of the training reforms has been appalling,” she said. “It’s depressing that it’s taken a disaster on this scale for them to listen.

Calling for urgent action on the current crisis, she said there were 34,250 doctors applying for 18,5000 training posts in the UK.

“We need solutions that ensure that no doctor in training loses out on a career as a result of government mistakes or poor workforce planning,” she said.

The BMA welcomed the fact it would be an independent review but said action was needed now to tackle the shortage in training posts this year. Dr Jo Hilbourne, chairman of the BMA Junior Doctors Committee, said the association had warned for years that Modernising Medical Careers had been rushed in too quickly.

Matt Jameson-Evans, from Remedy UK, was concerned that the MMC review should include representation from junior doctors. “Remedy has a part to play in this, shoulder to shoulder with the BMA,” he said.

But the latest announcement does not affect the situation this year, he said.

“It doesn’t affect the legal action we are taking,” he said. “It doesn’t resolve the problems that we have currently got.”

Matt Jameson Evans, speaking for the organisation, said they had yet to receive a response from the lawyers at either the MTAS review team or the deaneries to their proposed legal challenge.

He argues the system being proposed is unfair because different candidates are being treated differently.

“That’s no way to launch people’s future career,” he said. “You’ve got people interviewed for the same job months apart. They will have different sorts of interviews, and different interview panels. There is no equity there.”

He said they would not be challenging the plans to go ahead with appointments to jobs starting in August. But they will suggest that these appointments should merely be temporary ones. “They should be accredited towards training, but be renegotiated for February,” he suggested. Jobs starting in February could be made on the basis of a fairer appointments system, he said.

The firm of lawyers dealing with their case, Leigh Day and Co, are well known for their clinical negligence and human rights work.

Mr Jameson Evans said they would be putting the Remedy UK case forward as an employment issue rather than a human rights one.

He was not prepared to comment on how the legal action was being funded.

There will be special transitional arrangements to cope with the large number of Senior House Officers and others in non-training grades wanting to enter year 3 specialist training posts, said Bernard Ribeiro, President of the Royal College of Surgeons and a member of the review group.

It announced late this afternoon that candidates for posts in England who have already been interviewed would not have to opt ‘blind’ for one post, without knowing the outcome of the interview, or what the competition was.
Instead, all interviews offered will count, says the MTAS review group. But applicants will only be offered one position, based on which was their preferred post.

The decision of who gets what will be taken centrally. Interviewers — who are not aware of where they lie in the applicant’s preference list — will notify the centralised MTAS computer of which candidates they are willing to offer a position to. The computer then matches this data with details of which position applicants most wanted, according to what they put highest on their list. It will then offer successful applicants just one job each, based on which of the posts they have been offered that they wanted the most. All applicants will be notified what, if any, post they have been given on the same day.

Applicants will get a chance to revise their preferences — and possibly increase their chances of being offered a post they will be happy with. They will be able to do this between 20-23 April, basing their decision on the existing competition ratios published by Modernising Medical Careers. They can then opt to alter their order of preference — for instance, applying for a speciality or a region where there is less competition than their original first choice.

If an applicant puts in for a revised first choice, they will be guaranteed an interview for that post — even if they have already had interviews for positions on their original list of preferences.

Applicants who have not been shortlisted at all so far will have a chance to revise their order of preference – or reconfirm their original choices — between 20 - 23 April, in the light of competition ratios.

Applicants will then be invited for interview for their affirmed first preference. But, as with those who have had interviews so far, successful applicants will only be offered one post.

Anyone who is unable to secure a position in round one will be able to apply again in round 2. This will be done on the basis of a structured CV and formal interview. It is still unclear what proportion of posts will be held back for round 2. This will be debated at the next meeting of the MTAS review group, on 17 April.

The statement from the review group, which is chaired by Professor Neil Douglas, said: “We recognise that this has been a challenging time for consultants, junior doctors and the service and have heard and appreciated the deep concerns that they have raised.

“Serious consideration has been given to all of the options available, including a full and detailed analysis of pulling out of the current selection process completely.

“In the end, it was simply not a credible option. It would be impossible to place the best candidates in posts and fulfil the service needs in time for August using the old system of recruitment. We believe we have come up with the best available solution for England.”

The review group believes the main concerns are around the selection process rather than Modernising Medical Careers as such.

The proposals mean there may be differences in the recruitment procedures between specialties and in different parts of the UK. The devolved adminstrations – Wales, Scotland and Northern Ireland – have already announced plans to go it alone. Applications for general practice positions have gone well and, apart from a slight change in the timetable, will continue as planned.

Details have yet to be announced for those applying for positions in academic medicine, But applicants will still be considered for any application for a clinical position, in round 1, in the meantime.

The BMA, which had re-entered the review group talks after walking out last week, welcomed the announcement.

“It was never going to be easy finding a way out of the mess that MTAS has created,” said Dr Jo Hilborne, Chairman of Junior Doctors Committee.

“The JDC has been determined to fight for a solution which is fair and equitable. We believe the latest offering from the review group to be a practical way forward, which does not waste the hard work of thousands of applicants preparing for and attending interview. A robust second round of interviews is essential and we will continue to work for this.

“Junior doctors have endured weeks of turmoil. Their lives have been turned upside down by this shambolic and incompetent training application system. This debacle should never have happened and we urge the Government to launch a fully independent inquiry into this sorry mess.”

Dr Jonathan Fielden, Chairman of the BMA’s Consultants Committee, who was also in the talks, said the whole process had to be reviewed for future applicants.

Further interviews will take place during May and candidates will be told the outcome of round 1 interviews by 8 June. David Nicholson, NHS Chief Executive, will write to NHS organisations to ask that applicants and consultants be released to support this process

Professor Douglas encouraged candidates to attend all interviews they were invited to. Details of the procedure will be posted on the MMC website by 16 April.

For further information, go straight to the review group’s letter to applicants at Modernising Medical Careers or click here to see the review group’s statement.

The BMA says an analysis of the figures on the MTAS website shows that the actual number of UK specialist training posts available is 18,518 – not between 22,000 and 23,000 as the government has indicated.

Dr Jo Hilborne, chairman of the BMA Junior Doctors Committee, said junior doctors had been misled:

“Not only has the government failed to design a fair recruitment process, they’ve also misled everyone on the number of jobs available. Even if the application system improves, thousands of doctors are going to find themselves without a training post in August. We really don’t want highly qualified medical staff to be forced to leave the NHS, but if they can’t complete their training in this country, it could be their only option.

The continued delay no doubt adds to the frustration and anxiety felt after last week’s news the Professor Crockard had resigned from Modernising Medical Careers and that the devolved administrations — Wales, Scotland and Northern Ireland — had decided to offer more than one interview.

But by the end of today there was no news from MMC — and a spokesperson said it was unlikely there would be any further announcement until Wednesday or Thursday.

Meanwhile Remedy UK, which is pursuing legal action in protest at the MTAS review group’s plans to offer candidates a single interview only, is refusing to say more about its exact legal case.

‘It would be nonsense to go into the details before the announcement is made,” said Remedy UK organiser Matt Jameson Evans.

But their website says the action is based on the belief that MTAS is ‘fatally flawed’:

“The aim of the challenge is to halt the process pending judicial review, i.e.: a review will decide whether it is legal. In the meantime, this process would require interim measures so that doctors are still employed by August and that hospitals are not left empty,” says a spokesperson.

“MTAS left thousands of doctors without interviews - this was unfair as the system was not validated, application forms got lost, etc.,” she says. “The recent review board suggestion - interviewing all 1st choices only - is unfair on those who have previously been interviewed without the benefit of their CV, as well as the (approx) 11,000 with more than one interview.”

The organisation is calling for junior doctors with first hand experience of the way the system worked to contact them with details, which will be used to support the judicial review.

They want written statements from people who have been interviewed early on, under the original ‘MTAS form interview’; from those interviewed with MTAS form plus CV; and from those interviewed later with ‘CV + probing questions’.

Remedy UK is also hoping to hold a lobby of MPs, possibly on Tuesday 24 April, though the date and details have yet to be confirmed.

Meanwhile a spokesperson for MMC has confirmed that one of the mothers involved in the protests, a member of Mums4 Medics, has taken Professor Crockard, former head of MMC, to the General Medical Council.

Members of the Junior Doctors Committee of the BMA also met this afternoon. bmj.com will update you on the situation as the news unfolds.

They’ve enlisted the help of leading lawyers Leigh Day and Co to bring the action, which they are due to present on Monday — the same day details of the new interview process are due to be announced.

The lawyers issued a letter to Professor Neil Douglas, head of the MTAS review group, on Friday stating that they would be sending a letter to his offices over the weekend, to reach him before Monday morning.

In it they said:

“We are aware that the Review Group intends to publish further details about how the new interview process will operate in the week commencing 2 April 2007. Our client is concerned that the new proposals will involve substantial illegality and unfairness, the full details of which we will set out in the letter we will be sending you over the weekend.

Matt Jameson Evans, one of the Remedy UK organisers, said he was very positive about the challenge.

“Our lawyers are pretty confident,” he said. “I can’t see how the single interview situation in England can go on. There is just so much chaos.”

He said precise details of the challenge would be issued on Monday.

The BMA’s Junior Doctors Committee is also due to meet on Monday to discuss its next steps.

Wales and Scotland have decided they will each stick to their original plan and continue to offer more than one interview to candidates who are appropriately qualified. Reports that Northern Ireland would do the same have yet to be confirmed.

Over 4000 applications have been received from junior doctors who want to work in Wales, said Dr Tony Jewell, Chief Medical Officer for Wales. To date, 2000 of these have been interviewed, but the remaining eligible junior doctors will be offered interviews during the coming weeks.
The Wales Deanery has said it would continue to work closely with the NHS in Wales to ensure that this process is completed well before the introduction of the new system in August 2007. 

Meanwhile Scotland’s health minister Andy Kerr said: “We’ve consistently said we will do what is right for Scotland in light of local circumstances. Offering interviews to all eligible candidates for each post applied to in Scotland will ensure NHS Scotland gets the right people for the right number of jobs.

He sent a letter last night to the Chief Medical Officer, Professor Sir Liam Donaldson, saying he did not feel he could stay and watch what was happening to junior doctors, who seem to have been forgotten in the whole process.

A spokesperson from MMC said Professor Crockard was very sorry that it had come to this. “He stongly believes in medical education and the future of junior doctors. He felt they were going to be potentially disadvantaged.

“He just became despondent that his principles were not being adhered to,” said the spokesperson. “He just didn’t feel it was going the right way.”

In a formal statement issued late on Friday Professor Crockard said:

“I can confirm that I have resigned from my position as National Director for Modernising Medical Careers with immediate effect.

“I care passionately about medical education and training.  In 2003, I moved from my position as Director of Education at the Royal College of Surgeons to join the MMC team.  At the college, we developed a competency based curriculum.  When I joined MMC, we used the same principles to develop a curriculum for a new two-year training programme called the Foundation Programme which was launched in 2005. 

“It is now widely considered successful and fit for purpose.  In addition the doctors completing the Foundation Programme this year seem as if they will match well into the new specialty training programmes. 

“The principles of MMC are laudable and I stand by them. More patients should be treated by trained doctors, rather than doctors in training. We should ensure our doctors are trained to explicit standards of competence and that they have a clear, transparent career structure to follow.

“The recruitment of doctors into these new training programmes is separate to the development of the educational standards that MMC has been working to deliver. This recruitment process, through the MTAS system, undeniably needs to be reviewed. This process was developed outside my influence.

“Moving to the last few weeks, I have become increasingly concerned about the well intentioned attempts to keep the recruitment and selection process running.  I accept that in many areas and in many specialties, this round of recruitment and selection has been acceptable.  But the overriding message coming back from the profession is that it has lost confidence in the current recruitment system.

“In the interest of the most important people in the whole process, the junior doctors, this must urgently be addressed.

Modernising Medical Careers  is a Department of Health agency charged with improving medical education for the benefit of patients and doctors alike. Its brief was to reform postgraduate medical training.

But MTAS, the computerised application system which has caused all the problems for junior doctors applying for posts starting this August, was not in the hands of the MMC. Instead the project was run by a separate Department of Health agency. Professor Crockard had no control over it.

The MTAS review group, chaired by Professor Neil Douglas, and which met this morning, expressed its regret at Professor Crockard’s decision, said the spokesperson.

As yet it is unclear what the ramifications of Professor Crockard’s resignation will be. Statements are due this afternoon from the Chief Medical Officer in Wales and the Director of NHS Education for Scotland. If his decision triggers other academics to pull out of MTAS, the system could collapse, though it seems unlikely the government would let that happen at this stage. BMJ will bring the latest news as soon as we get it.

Meanwhile, there was an ironic twist for review group chair Professor Douglas, who  is president of the Royal College of Physicians of Edinburgh. 

The council of his Royal College has said it believes MTAS has failed doctors and wants candidates appointed on the basis of interviews supported by CVs. It encouraged consultants to continue with the interview process but wants to see a review of the new system.

The statement went out in the name of the council’s vice president, Professor Peter Brunt, rather than that of Professor Douglas.

Dr Mike Jones, Dean of the College, would not comment on Professor Crockard’s resignation. He would only say that the College intended to continue with the appointment process.

“We have to make sure junior doctors are appointed,” he said. “We are being guided by the review group.”

Professor Alan Crockard, National Director of Modernising Medical Careers, issued the advice to all applicants by email on Friday 23rd March.

“I understand,

 
Bernard Ribeiro, president of the college, said its council was “increasingly concerned” that patient care may suffer if consultants are asked to give up time in clinics and operating theatres to interview “the thousands of candidates let down by MTAS.”

He continued with a thinly veiled warning to the government that waiting list targets would potentially be at threat: “We must now have assurance from employers that consultants will be released to undertake the necessary interviewing and the Department of Health must acknowledge that this will mean cancelling clinics and other non-urgent duties at short notice. Chief Executives must be made aware that our consultants will need support to see this new appointment process through.”

Mr Ribeiro said he welcomed the decision not to short list candidates via the MTAS system, but instead to use the formal interview process. Doctors and surgeons had demonstrated that structured interviews are the only valid method for selection, he said.

“I am particularly pleased,” he added, “that the Review Group has accepted my view that the operational details of the rescue package must vary from specialty to specialty, thereby taking particular account of the specific requirements of surgery as a craft specialty.”

He said that Deaneries that had already started their interviews would have to make an assessment about the interviews that have already taken place.  

“In some cases Deaneries will be confident that they have carried out probing interviews with CVs and portfolios and can carry on; other Deaneries may not be confident that their interviews are consistent with the new guidance from the Review Group and may need to start again.  

“I understand the anguish that this may cause those candidates who have already been interviewed, but I have worked closely with our trainee organisations and feel that it is the fairest way to treat all candidates.”

Despite calls for applicants to be given four interviews, not just one, Professor Elisabeth Paice, Dean Director of the London Deanery, insisted that — given the MTAS shortlisting process had been thrown into disrepute — the only fair approach was to offer every applicant the same opportunity to have one interview.

“It would not be feasible or in the interests of patient care to offer multiple interviews to all applicants,” she said.

“Applicants who are unsuccessful in their interview will have the opportunity to enter a clearing process in Round 2, or to apply again during the course of the year as vacancies arise.”

Meanwhile Tom Dolphin, representing the BMA’s Junior Doctors’ Committee, advised those who have more than one interview lined up to press ahead with them all.

“You must go to your interviews,” he said.

He said although the competition ratios which had been published gave some kind of guideline to the most and least popular specialties, they were of only limited use.

“As soon as you open it up to competition again, they immediately become historic,” he said. “Some people may jump ship and opt for something where there is less competition which will skew the figures. It’s no way of choosing a career.”

The BMA would, he said, continue to press the Academy of Medical Royal Colleges to pull out of the talks. Strike action, though, is out of the question. Legal advisors say that junior doctors’ employment status rules it out.

At Remedy UK’s website, one stressed-out participant sums up the whole saga as a complete farce.

“ONE interview, ONE shot at a life long career in MEDICINE?!” they write. “And they will publish the ratios for each speciality which is a must of course and I hope they publish the numbers of posts available per speciality at each level, but with ONE interview! How stressful is that?!”

The current members of the review group are as follows:
Professor Neil Douglas (Chair) Vice Chair of the Academy of Royal Medical Colleges and President Royal College of Physicians of Edinburgh
Clare Chapman Director General of Workforce, Department of Health
Professor Alan Crockard National Director Modernising Medical Careers
Dr Paul Dimitri Chair of the Academy of Medical Royal Colleges – Trainees Group
Professor Sir Liam Donaldson Chief Medical Officer England
Dr Jonathan Fielden Chair of the Consultant & Specialist Committee, BMA
Nic Greenfield Director of Workforce (Education, Regulation and Pay)
Professor Sheila Hollins President Royal College of Psychiatrists
Dr Judith Hulf President Royal College of Anaesthetists
Dr Tony Jewell Chief Medical Officer Wales
Professor Martin Marshall Deputy Chief Medical Officer England
Neil McKay Chief Executive East of England Strategic Health Authority
Mr Bernie Ribiero President Royal College of Surgeons of England
Dr Mike Watson Director NHS Education for Scotland
Dr Paddy Woods Senior Medical Officer N. Ireland

Proposals issued by the review group last night would have limited each junior doctor to just one interview in the current job round.

The BMA’s Junior Doctors’ Committee argues this would disadvantage those applicants who have already been offered more than one interview, as they would have to choose which job they wanted most, and to withdraw from the other posts.

Dr Jo Hilborne, chair of the Committee, said: “We cannot sign up to what has been proposed. Restricting doctors to one interview would not be acceptable to the 11,000 applicants who have already been offered more than one, and would now see these opportunities taken away.”

Given this decision, the BMA Consultants’ Committee representative is also pulling out of the talks.

The MTAS review group yesterday reiterated its decision not to re-run the first round of interviews, which has already taken place for junior doctor jobs. But it had offered a guarantee to all those who have not secured an interview so far that they would receive an interview.
It only became clear today that this would mean they would have just one interview. Each candidate had been able to opt for four possible job choices, but they will now have to select the opportunity they want most, then be interviewed for that alone. Those who are not appointed at this stage would then go back into the application process for an interview at the second round.

In a statement issued last night, Professor Neil Douglas, chair of the group, did not spell out that it would mean only one interview per person. He merely said all candidates who applied through MTAS and were eligible for an interview in their chosen specialty would be guaranteed an interview.

“Under this guaranteed interview scheme,” said Professor Douglas, “candidates will be able to choose which of their preferences to be interviewed for in light of geographic specialty-specific and ST level-specific competition ratios which will be available on the MTAS website.”

He acknowledged this decision would have implications for the selection timetable.

This new approach, he said, was the most equitable and practical solution available. He recognised that extra time and effort would be required for further interviews.

“Therefore first choice interviews that have already taken place should not need to be repeated,” he said.

In effect, it means those who have so far failed to secure an interview at the first stage will now get one. But those who had a second or third interview lined up will be told to pick the interview they want most and stick with that.
Professor Douglas said exact details of the new process would be posted on the MMC website (www.mmc.nhs.uk) in the week starting 2 April.

“In the meantime, said Professor Douglas, “interviews will continue and applicants should attend unless they are confident that this will not be their preferred choice.”

Where an applicant currently has more than one interview lined up, they should consider pulling out of the interviews they are less interested in so someone else can take those slots. But if they are still not sure which opportunity they want, they can, at the moment, go to all the interviews.

Professor Douglas pointed out that the GP selection process had worked successfully under MTAS. But he acknowledged that, in other specialities, there was evidence that the shortlisting process was weak. “We will therefore eliminate this part of the process immediately,” he said.

He said that no job offers would be made until all interviews were completed.

All that the BMA - one of the group’s members - will say is: “We are using all available avenues to apply pressure on the government to come up with an adequate solution to this mess, which has caused anxiety to thousands of young doctors and taken up much of consultants’ valuable time. This includes expressing the seriousness of the situation through the review group.”

Meanwhile the debate over MTAS continues on Remedy UK’s webite, with protestors turning their attention to what should happen next.

John Firth writes: “Assuming that immediate abandonment of MTAS/MMC is not proposed, Remedy UK now needs to develop a consensus about how to proceed. This will not be easy, but must be done, because fractured opposition will be relatively easy for the government to resist.

“Ranting and raving is right and proper when faced with absurd injustices, but Remedy UK must now be clear about what should be done immediately, what sort of medical training system we want to (re)establish, and what tactics to advocate to get there,” he says.

But others, including a member of the support group Mums4Medics, is calling for a day of strike action.

“Whoever is planning the next part of the strategy please urgently consider strike action. This is a serious step to take and you will face the  cry of “disgraceful, putting patient’s lives at risk, call yourselves caring  etc. etc …” but the fact is that, if no-one stops this NOW then future care in our hospitals will be substandard and lives will certainly be put at risk,” she says.

John Firth responds that any plans for strike action must be put through the BMA.

Ms Hewitt reiterated the government’s commitment to a computerised application process, and said the Department of Health would continue to work to ensure that trainee doctors were properly supported and fairly treated, and that the NHS is able to train and recruit the best doctors for the future.

“It is clear that there have been concerns about the selection process, and that the process as a whole has created a high degree of insecurity amongst applicants, and, indeed, more widely in the profession,

The Telegraph is running its own ‘Back our doctors’ campaign to suspend the entire Modernising Medical Careers programme.

It moves the story on with the news that the NHS is spending thousands of pounds on hiring venues to hold the MTAS interviews.

Some interviews, it reports, are taking place at football grounds — Yorkshire interviews are at Leeds United’s ground, Elland Road. Even Newmarket race course is being used for candidates in Eastern England.

But the agenda for most Sunday papers would have already been set by the time the march took place. So it was on Saturday’s television news that gave it the most coverage, not least Channel 4 News at 7pm, which included an interview with Lord Hunt, the health minister handling the crisis.

Lord Hunt stood by his action so far, while saying he obviously wanted to take account of junior doctors’ views on the MTAS scheme.

At one point the numbers in London swelled so much that police had to control the crowds by letting them spill off the streets into a park, said a spokesperson from the Metropolitan Police.

The 2-hour march through central London ended with a number of speakers, including Conservative party leader David Cameron, who — according to reports by the Press Association — told the crowd that the training system was a ‘shambles’.

He said the Conservatives would treat doctors ‘like human beings’ and that he would call the government to account for its modernising medical careers policy.

“The government have said they are holding a review,” he said. “It’s got to be a proper review, not a paper exercise, and if they can’t get it right they’ve got to scrap it.”

Remedy UK organiser Matt Jameson-Evans also addressed the crowds which spilled across the square at Lincoln’s Inn. Banners waved in the sunshine – among them ‘Murdering Medical Careers,’ ‘Modern Medical Crisis’, ‘My training your healthcare’ and — perhaps the most amusing —‘Hewitt Blue It’. Cheers and raised hands greeted Matt’s speech that this was ‘not the end, but just the beginning.’

Not all of them were junior doctors. Some nurses had turned out to add their support and more mature protestors (including some sporting Daily Telegraph t-shirts in support of the march) included medics and the parents of those affected.

Peter Hunter, a former consultant at the Royal Shrewsbury Hospital, wanted to add his voice to the protest.

“The crisis in junior doctors’ training is the most serious since the start of the NHS in 1948,” he said. “It is a complete and total farce. There have been some very good candidates and they haven’t even had an interview.”

He criticised the amount of central control the government was trying to place on the application process:

‘The Soviet Union broke up because they tried to run the country from the centre — it is physically impossible,” he said.

Sam Bennett, in his fifth year of training at Kings College Hospital London, was there to protest at the problems with MTAS. He’s not had an interview after the first round. “It has really surprised me,” he said. “I’ve had decent jobs so far, and ticked most of the boxes.”

He turned up because he ‘wanted to do something’ and was hoping the second round would allow him to attach his cv and other supporting evidence.

Jo Maynard, from St Thomas’ Hospital, was one of the luckier ones. She’s got an interview for a paediatrics post somewhere in the London region.

“But the process was disastrous,” she said. “The questions they asked in the application process were just general, not even based on the specialty you’d chosen.”

She was there to support colleagues less fortunate than herself. “You get your degree, do what you’re meant to do, then they bring a computer that just says no to you.”

Judy King, one of the organisers from Remedy UK, said she’d been delighted at how well the march had gone. “It certainly shows there’s a lot of grass roots opposition to this system. David Cameron was great — and said all the things we wanted him to say.”

But she said despite the hard work being put into reviewing MTAS, the announcement made last night of how the system might be improved for round 2 applications still didn’t go far enough.

“If you accept the system is flawed you need to fix it and start again,” she argued. “It needs to be fair for everybody.”

The Department of Health said the group had made the following recommendations:
* All eligible applicants for their third or fourth year of specialty training (ST3 and 4) will be guaranteed an interview for their first or second choice of training post. This includes those who have been offered only their third or fourth choice at the moment.
* All applicants for the first year of specialty training (ST1) who have not been shortlisted for any interviews will have their application reviewed. Where candidates meet the selection criteria they may be offered an interview in Round 1. If not, they will be offered career guidance and support to enter Round 2.
* All applicants for second year specialty training posts (ST2) who have not been short-listed for interview will be offered a face-to-face review with a trained medical advisor to determine whether they meet the short-listing criteria. Those who meet the criteria may be offered an interview in Round 1. Those who are not selected for interview will be offered career guidance and support to enter Round 2. 

  

Those applying for ST1 posts who failed to secure an interview in the first round will be advised in the coming week how the review of their application will be handled.

The group has also recommended that data on the numbers of available training places and the competition ratios should be made available at www.mtas.nhs.uk

But Health Minister Lord Hunt warned there would inevitably be more trainees than there were training posts available:

“Consultancy posts are much sought after which is why we have more applicants than posts. This will lead to some young doctors being disappointed they can’t specialise in their first choice but this has always been the case. The NHS still needs doctors and they have vital skills that can be put to good use elsewhere.”

Meanwhile Remedy UK, which is behind the marches, has issued a firm rebuttal to any suggestion that it is backed by a political party.

“We are five people (4 junior doctors and wife of a doctor) who like many of our colleagues, have lost confidence in the implementation of MMC,” it says in a statement on its website.

“There are rumours circulating that we are backed by a political party. This is nonsense. We are not affiliated with any political party or receiving any donations from any political organisation,” it states.

Among the MPs pledged to attend the march, is shadow health secretary Andrew Lansley who will to tell marchers that modernising medical careers undermines the morale of the medical profession

“A consultant wrote to me on Wednesday and said that doctors today were “lions led by donkeys”,” he was expected to say. “He’s right. The appalling shambles made of Modernising Medical Careers risks undermining the morale and the future of the medical profession. What is the point of expanding medical school places and then destroying the career progression of juniors?

“I have also been appalled by the collapse of the Medical Training Application Service (MTAS) and the absurdity that those shortlisting applicants cannot see a full CV and attach so little weight to actual clinical and academic achievement.

“We have called on the Review to be a root and branch review. If necessary, they must revert to the conventional interview processes and tell the Government they must make extra training posts. We cannot, we must not, abandon thousands of junior doctors; we must ensure that they can fulfil their vocation, for them and for our patients.”

And Liberal Democrat health spokesperson John Pugh has called for the entire process to be suspended:

“This recruitment round must be suspended immediately in order to salvage any remaining confidence in the system. How can interviews continue when the selection process is clearly flawed?” he asked.

“The government seemed seduced by the technology which is further evidence of their inability to deliver intelligent workforce planning.”

But she says she wants to see improvements in the MTAS computer system to make it easier for consultants who are doing the shortlisting to use, and to enable students to see how their application is progressing.

Professor Paice told the BMJ that, despite the protests, panels were going ahead with the interviews, which were going ‘pretty well’.

“We’ve been interviewing since 28 February,

The review group, headed by Professor Neil Douglas, Vice President of the Academy of Medical Royal Colleges and President of the Royal College of Physicians of Edinburgh, has already recommended that the first round of applications should continue — although Remedy UK, organisers of the march, are calling for the process to be scrapped entirely.

The review is due to be completed by the end of March, so that any changes can be made in time for Round Two, which begins on 28 April 2007.

One of the founders of Remedy UK, Matt Jameson Evans, insists the march is not just about MTAS. “It’s about the whole process on Modernising Medical Careers,” he said. “We want MMC halted.”

Today’s meeting is unlikely to do that but it should look at what needs to be done to strengthen the interview process, so applicants can provide CVs and portfolios. The group will also be looking at changes to the application form and the scoring system for the second round.

Whether that goes far enough to appease the majority of the marchers remains to be seen.

The BMA has, with Remedy UK, taken out a full page advertisement in The Times today to publicise the event. And the BMA’s publications department has switched into banner manufacture mode, producing 1,800 placards with several campaigning messages, including ‘Jobs 4 Junior Doctors’.

Meanwhile many academics continue to add their voices to the growing protest. Yesterday The Guardian ran a letter from 38 clinicians and academics accusing those behind MTAS – and the Modernising Medical Careers programme of which it is part  – as having introduced the changes ‘by government diktat without involving those experienced in medical education and training’.

Professor John Bell, President of the Academy of Medical Sciences, and Professor Sir John Tooke, Chair of the Council of Heads of Medical Schools, have added their voices to those of other academics, stating that the new system of application to specialist medical training ‘has paid scant regard to the determinants of academic potential’. 

And the President of the Royal Society of Medicine, Baroness Ilora Finlay, has described the Modernising Medical Careers application process for junior doctors as ‘flawed and chaotic’.
 
“Thousands of excellent junior doctors fear seeing their dreams in tatters despite years of hard work,” said Baroness Finlay.

She went on to warn that whatever happens, there are no guarantees for those seeking jobs:
 
“The greatest tragedy of all is that medical unemployment is with us and whatever the appointment system, there are not enough jobs in the long term. Even those that get trained have no assurance of a consultant post at the end of it all.” 
The review, she said, must report “fully and openly”. The full editorial will appear in April’s issue of the Society’s Journal.

“They are coming from all over the country: Newcastle, Manchester, Yorkshire, the south coast,

Thursday 11 January Modernising Medical Careers issues its guide to junior doctors on how to apply online – via one single application form – for jobs in August. The new system it says will ‘simplify the process for doctors in training and will enhance their ability to identify training vacancies across the UK.’
Monday 22 January MTAS (the Medical Training Application Service) opens for first online applications
Thursday 25 January: Applicants to certain specialties in the London and Kent deaneries are asked to delay their applications due to problems among those wanting to apply to four specialties.
Saturday 3 February: Modernising Medical Careers announces that, due to problems with the computer system, the deadline for applications is to be extended, initially from noon to 2pm on Sunday 4 February, and then to 9am on Monday 5 February. Some applicants have problems saving their application to the site.
Monday 26 February: shortlisting for the first round of posts was due to have been finalised – two days later than originally planned
Tuesday 27 February: A meeting of COPmeD (the Conference of Postgraduate Medical Deans) realises there has been ‘variable practice in long-listing regarding the checking of competences achieved and career progression’ and later more guidance to address this is issued via Modernising Medical Careers.
Wednesday 28 February: Interviews for junior doctors seeking posts starting in August was due to start — but many doctors did not know whether or not they had an interview. Some felt they should have had an interview but were not offered one. Others were offered interviews for specialties they were not qualified for, or on dates that clashed. The deadline for receiving interview notification was extended to Monday
Friday 9 March: The Department of Health announces a review of the appointments procedure, with BMA and Royal Colleges represented on the group. It plans to improve the process by allowing CVs and portfolios to be considered. Those overlooked in the first round can have their application reviewed by a trained advisor from a deanery. Candidates who complete this successfully will be given an interview, the health minister Lord Hunt states. He refuses to scrap the first round of interviews, but the changes will apply to the second round.
The DH accepts a recommendation from the review group that information about competition rates by speciality, entry level and geography should be made available to candidates.
Saturday 10 March: Junior doctors’ leaders at the BMA vote overwhelmingly for the scrapping of the Government’s new Medical Training Application System and a return to the old appointments system for junior doctors.