Our report this week on problems with specialty trainee year 3 (ST3) applications is merely the latest in a litany of mediocrity to afflict doctors at every single stage of their careers. In the past few months it has transpired that there may not be enough foundation places for medical students, then that a quarter of foundation doctors are not applying for specialist training, and now that specialist trainees are being turfed out of their training two years in.

At every point the medical career structure can go wrong, and is going wrong, often spectacularly.

But what is striking about this latest news is that so many senior power brokers seem so un-struck by it. Indeed, the Department of Health has responded to application ratios of almost 15:1 by saying that surgery is simply competitive. The fact that not one core trainee year 2 general surgeon was even interviewed for an ST3 post in the whole of the north of England is not seen as a problem in some quarters. There is a mantra, from trainers and trainees alike, that competition is good; that surgery has always been tough; that a year in research or gaining skills is beneficial.

And to a degree they are right. Healthy competition is good for standards, and surgery is extremely popular. An application ratio of 2:1 or even as high as 4:1 could be argued as desirable, and is not historically unusual. Doctors know that and even welcome it to a degree. But 15:1? That number hides an even more stark reality that in some deaneries the real chance of progressing directly from year 2 to year 3 of training is nil. And each year this goes on, the number of backlogged doctors who have reached ST2 level simply increases, meaning future ratios could well get worse.

This much competition is not good for anybody.

Doctors involved have embarked on a career under one premise and ended up with a different and invariably worse reality. It is horribly misleading to claim that a doctor is applying from year 2 to year 3 of a training programme when to all intents and purposes such a move does not happen. If another year or two of experience is so evidently necessary then why is it not part of the training?

But far worse is the reality that many, indeed most, of these doctors have embarked on surgical training with no hope of reaching a consultant post at all. They are instead to be funnelled into career grades and cheaper support roles.

At best it is poor planning, and at worst dishonest.

The alternative, of course, is for these trainees to cut their losses and go back two years to see if they can enter another specialty: this brings us to the second big problem.

Every individual represented in the 15:1 ratio has spent years going through one of the most expensive training programmes of any industry in the world. The sums of wasted education represented each year in these figures runs well into the millions.

I’ve no doubt that they will enter their second choice specialty with a number of new perspectives that may be useful or insightful, but they are entirely unnecessary. We’re effectively throwing money at crippling the morale of junior doctors in our health service.
So what needs to happen?

There’s no magic bullet to fix this. Medical workforce planning is a notoriously difficult art. The Tooke Report was a good starting point for training structures,(1)  and the recently created Centre for Workforce Intelligence is a welcome arrival, but certain core issues need tackling urgently.

Firstly, the Department of Health must address the dichotomy of whether junior doctors are supposed to be the consultants of tomorrow or cheap labour for now. It’s hardly a new question, but with mounting pressure for a more consultant delivered service, not least from this year’s Temple review on the effect of the European Working Time Directive on training, it’s a question finally gaining momentum and urgency.(2)

Secondly, professional numbers are torn between what the government, deaneries, colleges, and individual hospitals want and need, with a myriad other interest groups pushing and cajoling to be heard. Although 2007’s Medical Training Application Service was not the best advertisement for a national system, there is a desperate need for wider oversight. There seems little point in a government designing a system that takes no notice of individual hospital service needs—there needs to be more joined up thinking.

And, thirdly, there needs to be much more honesty around what is achievable in a medical career. What has struck me most about this investigation was the difficulty of getting hold of training figures. Many were blocked from us because the Department of Health refused our freedom of information requests and individuals were stopped from speaking with us. If actively searching for this information is so tough, I have little confidence that it is being comprehensively presented to doctors early in their careers.

1 Tooke J. Final report of the independent inquiry into Modernising Medical Careers. 2007. www.mmcinquiry.org.uk/draft.htm.

2 Medical Education England. Review of EWTD and impact on training. 2010. www.mee.nhs.uk/our_work/work_priorities/review_of_ewtd__impact_on_tra.aspx.

This blog was originally published on the BMJ Careers website as a commentary.