Training Posts Today, No Consultant Jobs Tomorrow

Why fixing the bottleneck in specialty training is only half the solution

No one will be a stranger to the current lack of speciality training posts in the UK. The bottlenecks continue to worsen as the BMA puts pressure on the relevant authorities to increase training programme posts.

In response, the government at least appears sympathetic, with Wes Streeting committing to a further 1000 speciality training posts, whilst stalling on how exactly he will implement this. But amongst the speciality training post debate, we seem to be forgetting a key part of the puzzle.

Show Me the Money?!

Let’s imagine the government finds an extra £100 million or so underneath a sofa cushion and overnight they created a speciality training post for every single doctor applying.

Thousands of new training posts created, what a dream! No doubt this would appease many resident doctors and may even keep the BMA at bay for the government.

However, the “win” of creating additional speciality posts would only be half the story, and after anywhere between 3-10+ years later a new trap would be waiting… the consultant bottleneck.

Expanding consultant numbers is considerably more expensive for the NHS than expanding speciality training posts. If you have a bunch of doctors who have completed years of speciality training, only to idle around with no hope of a consultant job, you have a much greater problem.

You’ve created a workforce that is hugely valuable and skilled (and often quite aware of this) and you have invested in the training needed to get them to a place of seniority.

Imagine the frustration of an post-CCT (insert your chosen specialty) doctor, on their second fellowship after devoting over a decade to training, only to discover that consultant jobs are no where to be seen for years to come.

Losing doctors at this stage is a far greater tragedy than earlier attrition, as more has been invested in them by this point. These doctors have peak expertise, and alternative employment opportunities abroad are attractive. They may simply want to get off the perpetual hamster-wheel of training and look for opportunities outside of medicine.

SHO bottlenecks are a huge pain, and they are costly, but they carry less downside for the doctor, who can switch specialties before investing too much, with less downside for the system that has invested in them up until that point.

Retirement Can Wait

The shortage of consultant posts is going to be further compounded if more senior consultants continue working into older age because of a number of factors including a gloomy economy, rising cost of living, loss of alternate retirement income streams such as investments and potential erosion of the state pension

Some suggest that we need to completely rethink the unwritten contract of medicine, where every doctor that graduates expects to have a consultant job one day, should they want one.

If the current bottlenecks exist, some uncomfortable questions need to be confronted: Should every doctor expect (or be entitled to) a consultant role?
And if the answer to this isn’t ‘yes’, perhaps it’s time we look at creating a more flexible model of senior (non-consultant) specialists?

Have You Considered The ‘Second-Hand Phone Call’ Bias?

Medicine sometimes forces us to utilise our clinical knowledge without ever directly seeing the patient.

This often takes place over the phone as nurses, colleagues or other specialties ring for advice whilst you’re halfway through a sandwich, or possibly even in bed.

We’re forced to diagnose via second-hand descriptions, guided by the words of someone else. For many, this makes them uncomfortable. However, without a baseline level of trust in the person calling, our job is impossible. There is simply not enough time in the world to personally review every patient you are called about.

So we rely on second hand descriptions, but think about what this means… Another doctor’s language and tone can completely bias our judgements. A confident or nonchalant handover or referral can disguise a sick patient; a quiet and slow handover can overstate risk.

We are rarely ever taught about this ‘second-hand bias’, yet it shapes patient safety on a daily basis, especially in a world where remote healthcare is becoming more prevalent.

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When Well-Intentioned Words Miss the Mark

Patients don’t always hear what you mean—how do we bridge the gap between medical language and patient understanding?

How many times in a consultation have phrases or words almost automatically slipped off your tongue? Throughout our careers, we develop linguistic habits that become second nature.

Our words are one of the most important tools that we own in medicine. They serve to inform and reassure our patients, but we rarely reflect on our rhetoric choices.

Once our words are spoken, they escape our control. We can’t speak on behalf of all doctors in our profession here at On-Call, but we can say that most of us communicate with the best of intentions. Yet sometimes, despite these intentions, what we say can come across patronising, dismissive or rude in the minds of our patients.

Take the phrase: “Oh, it’s nothing to worry about” or “You’ll be fine” - be honest, how many times have you used these phrases? Clinically, when we use these phrases, we are trying to convey that the diagnosis is not too serious.

But when these phrases are met with unhappy, stern faces from the patients sat across from us, it is often because they end up believing that the phrase is suggestive of the doctor dismissing their concerns.

Subjective Meanings

This tension raises a fascinating debate about the subjectivity of language in clinical encounters. We, as clinicians, know our own intentions; what we mean when we say something. But patients don’t have access to our minds, internal context or technical knowledge. They interpret our words through their own experiences, knowledge, fears, and cultural lenses.

In fact, I’m reminded of a colleague who received a complaint from a patient who said they were insulted by the doctor who called them a cow. The reality? The doctor described their symptom as a ‘bovine cough’.

Someone might argue: “I clearly meant well, so how can you hold me accountable if a patient misunderstands me?”

But surely, we can’t conclude that language is solely about intention; there has to be part of language in medicine that is also about reception. To the philosopher J.L Austin, language wasn’t just about trying to represent reality, language was an action or a performative act in itself. One that came with consequences, such as making someone feel comfortable, dismissed, reassured etc.

A phrase like “You’ll be fine” can, for one patient (like a stoic farmer), provide comfort, and for another, feel like a dismissal of their legitimate worries.

So, language is inherently subjective and context-dependent. Individual experiences, cultural backgrounds and emotional states shape how words are interpreted. This makes our jobs incredibly difficult and may lead some doctors to throw their hands up and proclaim that if their intentions were made clear, with medically appropriate language, then their duty has been fulfilled.

These doctors will not entertain being held hostage to the idea that a person can interpret anything however they like, and perhaps they have a point. Language would be pretty useless if there was no stability or uniformity to it.

Indeed, there must be a degree of objectivity to language, but in most of our communication, that can only be part of the story. Whether we like it or not, as doctors, we will never be judged solely on what we meant, but what our words did for our patients.

Language and communication is not simple, it is perhaps one of the greatest clinical skills a doctor can master.

“The On-Call team hopes all of our readers have settled into their new posts and hospitals - and remember, no matter how difficult of a start it has been… it can only get better”

“Clerked in a patient yesterday who told me that following a previous admission three years ago she has not touched coffee. When I asked why, she said that the last time she was told that she had 'coffee ground vomit', and didn't want it to happen again.”

“Is there a more beautiful word/phrase than ‘until proven otherwise’ in medicine - so mysterious, so candid… I don’t want to hear anything from the ‘query’ gang, it doesn’t even come close”

“Time is a diagnostic tool… Discuss”

What’s on your mind? Email us!

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

Violence against NHS staff is on the rise and is a bleak reminder of the risks taken by individuals in our profession when trying to look after the health of society. Front line A&E staff are often the most affected with violence against them almost doubling since 2019, fuelled by long waiting times. This report from the RCN covers the issue.

There has been an recent Urology breakthrough in the treatment of bladder cancer. Are you ready for it, Enfortumab vedotin with pembrolizumab has been shown to be effective in unresectable or metastatic urothelial cancer in both progression-free survival and overall survival compared to conventional chemotherapy. This treatment has been made available on the NHS from Thursday 21st August 2025. Here is the report from NICE.

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Why Do Trusts Have So Many Guidelines?

The ENT nurse pops her head in: “Have you checked out our Necrotising Otitis Externa Trust protocol?” Does everything in this trust have a protocol?, you think to yourself.

When NICE and resources like UpToDate exist, what is the need for all this trust guidance? Most people understand the necessity for local antibiotic guidance due to regional resistance patterns, but what other reasons exist for the incessant trust guidance?

Well the obvious starting point is the acknowledgement that national guidance doesn’t cover every condition, and even where it does, it often needs modification to fit local systems, especially if it concerns follow-up. How many times have you rotated trust only to find that the referral pathways differ completely or certain services simply don’t exist? In these events, modification to local guidance is needed.

Sometimes, a local big-shot consultant steps in and decides that they have (correctly or incorrectly) found huge gaping holes in national guidance. This is often based on good evidence, rather than personal conviction.

But it may also be the case that the national evidence is slow to update, leaving trusts to bridge the gap with their own protocols. So, despite the need to re-learn practice when we rotate trusts, there may often be good reason for local protocols.