A Long Road to Nowhere: The Endless UK Medical Training Pathway

Should UK Training Pathways be Shortened?

The question of whether medical training in the UK is too long has become a staple of hospital canteen debates and online forums. To reach the rank of Consultant after leaving secondary education requires five to six years of medical school, followed by two years in the foundation programme and anywhere between three to eight years of speciality training. We know this timeline also assumes a perfectly linear progression with no time taken for research or reapplication.

As UK doctors look to their international colleagues, many wonder if these extra years are truly necessary. This edition of On-Call examines the considerations behind our lengthy journey to consultancy and whether it is truly needed.

The Generalist Lives On

While the United States serves as a common point of reference, many nations, from Italy to India, use significantly shorter pathways than the UK. Proponents of the British model argue that a specialist who has spent years acquiring broad clinical knowledge is better equipped to manage the multimorbidity of an ageing population. They would say that there is an inherent value in a neurosurgeon who once managed acute medical admissions during their foundation years.

However, this is countered by the argument for efficiency, which acknowledges our transition toward hyper-specialisation. Modern medicine is no longer a world of simple interventions where ACS is treated with Aspirin and hopes and prayers; it is filled with vast complexity where we are not merely orthopaedic surgeons but foot and ankle specialists. We must acknowledge that the sheer volume of medical information makes true generalisation nearly impossible.

Forcing a future dermatologist to spend years managing respiratory failure incurs a significant opportunity cost. Even if we accept the logic of generalisation, we must ask where the law of diminishing returns begins to apply. With many foundation doctors filling in feedback reporting a lack of teaching and learning in their rotations, we must question if we are prioritising service over actual clinical maturation.

The Cold Logic of Economic

From an economic perspective, resident doctors function as the middle management of the NHS. If training were shortened to five years, the healthcare service would be forced to pay Consultant wages for work currently performed at a lower price point.

We can’t compare a single aspect of different systems without looking at the whole either. The UK government subsidises medical education and maintains a single employer market through the NHS; it has a vested interest in extending the training status of its workforce.

This maximises the return on investment before an individual reaches the higher earning and more autonomous tier of consultancy. Contrast this to the US model, where students often incur annual tuition fees of fifty to sixty thousand dollars, and the system is not as beholden to a single taxpayer-funded entity

Is The Grass Greener?

We must also consider the intensity of the training itself. Under the European Working Time Directive, UK trainees are capped at an average of forty-eight hours per week. Our colleagues in the United States often work on schedules that many would deem unsafe. This has birthed the term "golden weekend" to describe the rare occasion where a resident is actually outside of the hospital.

So do all these extra years make us safer? There is weak empirical evidence to suggest that it creates any superior patient outcomes. A 2017 BMJ paper compared the outcomes of patients treated by US-trained doctors against those treated by internationally trained doctors and found that, whilst there was no difference in readmission rates, internationally trained doctors had a slightly lower mortality rate (11.2% vs 11.6%). Although the absolute difference of 0.4 percentage points appears small, when applied across millions of patients, it could become consequential.

But, because training pathways are generally shorter outside the UK, it’s hard to know from this study whether training length had any impact on the results.

Predatory Journals are Corrupting Medicine

Academic publishing culture in medicine has changed significantly since open-access journals entered the scene and passed publishing costs to the authors. In practice, this cost is passed to universities and grant-giving bodies, but this shift allowed financial predators to see the model as a way of making money.

The number of these predatory journals continues to grow. Anyone who has engaged in academic work has likely received emails in their inbox containing telltale red flags. The following list of email greetings is not exhaustive but should get your alarm bells going:

• “Esteemed X”

• “Esteemed Prof”

• “Dear Esteemed Colleague”

• “Greetings For the Day!”

These messages often come from journals you have never heard of and are laced with flattery that is not typical of the academic world. They plead for submissions on any topic spanning any branch of medicine. Writing in the BMJ, Dr Sam Shuster decided to reply to some of these emails and was told he would be expected to cover a $2000 publication fee. He was able to get that fee down through haggling, however. Quality is also an issue, as these journals are characterised by very short times to publication.

As these journals continue to proliferate, more false information will be placed before our eyes. It has never been more important to read through references and not accept the “X et al” as gospel. The only way we can fight back is to raise awareness of these egregious practices.

Clarke’s Registry: How About a Public Database For Morally Sensitive Procedures?

Clarke’s moral-compatibility matchmaker raises awkward questions about governance, stigma, and access

There are some procedures that are classified as more morally sensitive. Despite general good practice dictating that clinicians try to put aside personal beliefs when treating patients, some issues spike the senses more than others. Assisted dying and abortion are just a few that have taken the headlines many times.

This is what led Dr Clarke to coin the idea of a registry that will act as a “Matchmaker” for moral compatibility. Imagine a platform with Doctor profiles, fit with a profile picture and accompanying bio that provides enough of a “Moral fact-file” to guide patients on the type of procedure that the clinician offers. Patients will be presented with a healthcare professional who is pre-verified to perform the procedure, and they will bypass the objectors entirely.

Doctors are also given the chance to opt out of procedures for moral or religious reasons and not violate their conscience. They are shielded from having to say “no” to a patient’s face. Clarke calls this a “Win-Win” using consequentialist logic. Surely everyone is a winner?

The Classic Logistical Friction

This sounds fairly intuitive on paper, but when one thinks about the logistics behind its implementation, some issues arise. The obvious initial question would be to ask: Who is responsible for maintaining such a list? Would it be the government’s job? A private medical board? And how often would maintenance be needed if a doctor changes their mind on a moral dilemma?

Some doctors may also be concerned about the visibility risks of sharing moral opinions that are freely accessible to all members of the public. The more liberal and secular a society becomes, the more likely it is to have favourable attitudes on topics such as abortion. Acknowledging this, many doctors may not wish to sign up to a platform to share views that British society may class as contrarian in nature.

The Monopoly Power

Let’s imagine you are looking for a wedding cake, but the baker refuses to sell you the cake because they disagree with your lifestyle choices. Resisting the urge to argue back, you may choose to go to the bakery across the street. But medicine doesn’t quite work the same way. If the only doctor capable of performing the procedure in a 100-mile radius refuses the procedure, the patient is effectively trapped.

For some, being a professional is a package deal, not an “a la carte” menu where you can pick and choose the duties that align with your moral playbook. Society has given doctors the prestige, the salary and the exclusive right to practice medicine, and in return, the doctor should say that they will provide medical care to the public according to the laws of the land, putting the patient’s health and legal rights above their own private convictions. Professors Julian Savulescu and Udo Schüklenk are proponents of this “Social contract” view that holding a medical license and the right to object are fundamentally incompatible.

Additionally, we all know that when an objecting doctor “passes the burden” to their colleague, they are essentially seen as saying “I want to keep my conscience clean, so you must take on the moral weight, the legal risk and the workload”.

“Push for a nationwide campaign on anatomical bony prominences. My last 4 months in ED have presented me with patients that I discharged with a diagnosis of Lump being Xiphisternum and Mastoid Process.”

“Amazing to think that the 6% who voted no in the BMA ballot effectively saved the ballot from failing.”

“Let’s assume John randomly tests positive for a rare fatal disease that only affects 1 in a million people. The doctor later tells him the test has a 97% accuracy rate. John (a university statistician) replies with a smile, “oh what a relief”… Why is John smiling? This is a classic story of base rates and false positives. 97% accuracy means 3% of results are wrong or false positives. Imagine testing 1,000,000 people. 1 of these people has the disease, and 999,999 do not. Of this second cohort, 3% test positive whilst not having the disease, meaning 30,000 will be false positives. This means even if one tests positive, the chance of them actually having the disease is 1 out of 30,001.”

“Our job can often get in the way. Just a reminder to hold on to those people around you who are good.”

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Some things to review when you’re off the ward…

All across the country, young patients with cancer diagnoses are forced to undertake long commutes to reach one of the 13 specialist centres for their appointments. The government is launching a £10 million travel fund for young people (under the age of 24) with cancer to cover travel costs for their families. Read the full piece from the BBC here.

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“Is This The Way To… Amarillo Kingston Hospital”

ONS data reveals the average UK worker spends 56 minutes a day commuting, which roughly equates to a half-hour journey each way. That is a hidden five-hour shift every week that we rarely bake into our pay packages. We face enough of a cognitive load given the work we do once we actually arrive at work, so what is the cost for Doctors of all this extra commuting?

The reality is that all commutes are not created equal. If you are part of the On-Call community in London, fighting the school kids for a space on the 57 bus to Kingston is an exercise in remaining calm before your shift even starts. Yet for others, the drive to a rural practice is a key factor in their ability to keep a clear headspace. It is a rare moment of independence where they can turn on The Rest is History podcast and decompress before reaching the madness on the wards.

Recent data from Good Business Journey suggests the average British car commute drains £421.42 monthly (from fuel, parking, and other associated costs). Opting for the trains adds an average of £91.30 to that figure. Of course, the figures conveniently ignored the sunk costs of getting your car on the road in the first place.

While we can manage long distances for a short rotation, permanent long commutes are often unsustainable. Compile on erratic shift patterns and a fragile support system to come home to, and the unsustainability increases.

So, is your journey a protective buffer for your mental health, or is it the primary driver of your burnout?