Covid-19 has forced the profession to rewrite the rules on career progression but any changes must be evidence based, say Hannah James and Giles Pattison

Traditional career pathways in medicine are being rapidly adapted during this covid-19 pandemic. The proverbial rule book on assessment has been thrown out of the window and career-impacting decisions are being made in ways that were unimaginable just a few weeks ago. 

Medical school entry will be decided by predicted grades, rather than actual A-level results, and many final year medical students are graduating early after sitting heavily modified and reduced finals examinations.

The rapid re-writing of the rules on assessment extends through to speciality recruitment in the postgraduate setting.

Health Education England (HEE) has said in a statement¹ that substantive specialty training appointments for August 2020 will be made almost entirely based on trainee self-assessment for specialties which have not already completed the interview process.

This includes Internal Medicine Training (IMT) at CT1 level, and all specialities that are recruiting at ST3 and ST4 level. 

Following the HEE announcement, many trainees expressed their concern over the reliance on self-assessment scores for selection. Concerns over the lack of published evidence on the predictive validity of self-assessment, potential issues with equality in selection, and the lack of accountability have all been raised.

Trainees are a resilient group and are not unused to encountering moving goalposts in postgraduate training. Nonetheless, medical educators should hold the selection processes to the same high standards of evidence, rigor, and methodological transparency that we have come to expect from the clinical research.

General surgery and vascular surgery, specialities that have not already collected self-assessment scores as part of the prior pre-interview application process, will be validated using a “small amount of clinical input” in a “high trust model.”¹

IMT will prioritise domains that have “been shown to predict success from previous recruitment rounds.”¹ No further details are provided and it is therefore impossible to objectively judge the robustness of these methods.  

General practice is far ahead of other specialties in having rigorously and publicly demonstrated the validity of its assessment-for-selection methods, and there is an impressive battery of high-quality, contemporary research evidence justifying the current methods available to candidates on the GP recruitment website². 

Public health have published similar objective longitudinal validation studies on their selection process.³

Applicants can be reassured that adaptations to the specialty selection process are being made by leading clinical educational experts, operating under considerable time pressure, to avoid the arguably greater harm to trainees of delays in recruitment.

There has also been prominent recognition of the wider impact of the pandemic on trainees from HEE, with impressively rapid and comprehensive provision of guidance on everything from trainee wellbeing to contingency planning for ARCPs.⁴ All this points towards the emergency speciality selection proposals from HEE being trainee-centred in their design.

However, a more explicit recognition of the limitations of the current proposals and transparency in reporting the validation methods for self-assessment would go a long way towards reassuring applicants.

Trainees are expected to demonstrate insightful awareness of their own limitations and their training and assessment bodies should adopt the same approach. 

We hope that there will be positive changes in the postgraduate education sphere as a result of this difficult time. However, once the pandemic is finished and the health service is back on an even keel we must invest in research to build a robust evidence base for our speciality selection processes.

Hannah James is a specialty trainee in trauma and orthopaedics and doctoral researcher in postgraduate surgical education at Warwick University @hannah_ortho

Giles Pattison is a consultant paediatric orthopaedic surgeon at University Hospitals Coventry & Warwickshire NHS Trust @pattison_giles 

Declarations: HJ holds a Versus Arthritis educational research fellowship, Grant number 20485. No competing interests declared.

 

1. HEE statement on Covid-19 Specialty Recruitment Plans – March 30 Update.
2. Research & Evaluation of the GP Selection System – General Practice (GP) National Recruitment Office, NHS. 
3. Pashayan N, Gray S, Duff C, Parkes J, et al. Evaluation of recruitment and selection for speciality training in public health: interim results of a prospective cohort study to measure the predictive validity of the selection process. J Public Health (Oxf). 2016 Jun; 38(2): e194-200. doi: 10.1093/pubmed/fdv102. 
4. Health Education England