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Time Out: A Move Away From Traditional Physician Training Programs

On a crisp Monday morning in September, I sit in a lecture theatre in the basement of a globally-reputable — albeit very much London-centric — university. I have my student card, new pencil case (for which my ever-supportive boyfriend deserves a mention in providing), old backpack, and a glut of arbitrary paperwork and identification documents to hand. My timetable dictates my whereabouts for the next term; the freshers’ fair outside the seminar door loudly echoes through the walls.  

The thing is, I’m not 18 (however much I wish this were still the case), and this isn’t my first freshers’ week (a term in the United Kingdom for the first week of the university year). This is, in fact, my third run at a professional qualification: A Master’s degree in pharmacy came first, followed by graduate-entry medicine. And here I am now, in my ninth year of higher education — albeit interspersed with various practical ventures into the world of work — chasing the ever-elusive knowledge dragon. As my father often tells me, my brain is ridiculously expensive. He would really now rather I be spending my hard-earned money on something more sensibly tangible, like property. Yet I am very much not alone in pursuing an unconventional career path, as the other 97 students in the room with me can attest. All of them are physicians, also taking time away from traditional training to be lectured on the intricacies of tropical medicine and hygiene for the next three months. From the 32 of the cohort who are U.K.-native, almost all are post-foundation training without a specialty training number, and many holding an “F3” post. 

To clarify, the National Health Service (NHS) is the overarching employer of medical graduates in the United Kingdom. The first two years of any new doctor’s training within the NHS is known as “foundation training” (in the United States, this would probably be equivalent to the “rotations” typically completed before obtaining an MD). Foundation training involves rotating through six different speciality placements of four months’ duration (i.e. three per year), and includes several internal medicine, general surgery, emergency and family medicine posts. The idea is to provide broad-based training and exposure to all new doctors, train them in new skills, and provide them with an idea of what speciality they would then like to pursue (a very different procedure than in the United States, where this decision is made before graduating medical school). Thereafter, U.K.-based doctors generally apply for training in their chosen field, which provides them with a registrar post (largely equivalent to residency in the USA). Registrar jobs generally run for between three to seven years’ duration, until you reach consultancy level (largely equivalent to “attending”). 

“F3”, by contrast, is the colloquial term given to the continuation of foundation training without actually entering speciality training. Generally, it means that doctors can take time out of a fixed job to work unscheduled hours, travel and on the whole try other things beyond a medical remit. What I find most revelatory about this, and my diploma cohort, is that taking an F3 year (or more) is not forced on the physician due to training number shortages, or rejection of the medical profession outright. Indeed, these clinicians are very much their own independent career operators, making mindful choices about their career trajectories.

A clinical lecturer friend of mine, now nearing the end of his medical career, addresses an interesting point in noting the rise of the F3 doctor and those who shun traditional training pathways in favor of more avant garde — or simply better paid and more flexible — working options. His own training path stretching back to 1970s middle-England, and followed a much less rigorous approach of simply hoping to gain a job wherever, whenever, for as long as possible post-qualification until someone simply told you to stop, or offered you something better. There was no such thing as foundation training, nor any sort of national (or, indeed, local) teaching and training structure to be followed. It was on-the-job learning at its most primitive. One could only hope that by asking the right people, and being in the right place at the right time, you would secure the type of role you had hankered after in your preceding soft-knocks schooling. 

This move away from training numbers and the formerly strict hierarchical ascent of junior doctor to consultant reflects something of a paradigm shift within the system of U.K. medical training. This has especially been the case since 2016, from whence health care in the United Kingdom has experienced an unprecedented amount of turbulence. Indeed, aside from repeated strikes held by junior doctors in light of the British government’s decision to enforce a new employment contract, the more recent widespread political discord resulting from Britain’s decision to leave the European Union, have left the future of the NHS — and its workforce — in a questionable position. Previous shortfalls in U.K. staffing and training have led to a heavy dependence from an overseas workforce, and as the largest employer in the United Kingdom, more than 10% of its workforce is still sourced from within the European Union. Though officials have been quick to quell rumors that E.U.-derived NHS workers will face difficulties regarding employment rights in the future, guarantees are in short supply in light of the confusion that has since arisen over “Brexit.”

Professor Jane Dacre, President of the Royal College of Physicians, has also spoken out, claiming that “health care professionals from Europe and around the world … are feeling anxious and confused about how welcome they are and will be in the future.” No wonder, then, that the next generation of physicians is looking elsewhere for job security, as well as satisfaction.

Likewise, retaliating strikes on part of the junior doctor workforce in protest have certainly remained controversial, and it appears that the dissent from NHS training numbers may be a passive attempt at ongoing reprisal. The figures are stark, according to the UK Foundation Programme 2018 Career Destination Report. Less than 38% of junior doctors continued into standard training, down from just 42% in 2017 and compared to a staggering 71% in 2016. Since 2011, the number of applicants pursuing core training posts has more than halved from 34% to just 16.8% by 2018 as is similarly the case for run-through training posts (34% down to 18.1%). Many of those interviewed for the report also cited their intentions to take a year out even at the beginning of commencing foundation training (for those doctors commencing work in 2016, at the time of the new contract implementation). In all, less than 50% intended to continue directly into specialty training.

Certainly, in many ways, this functions as a metaphor for the temperament of the United Kingdom’s medical workforce, and a growing counterculture of dissatisfaction with the medical profession in its failure to modernize as efficiently as other disciplines in our rapidly-changing millennial age.

Almost half of U.K. workers now own or co-run businesses along their primary line of work, with a tendency more towards portfolio-based careers. This, in turn, begs the question as to why would anyone still opt to relentlessly race to the top (with the “top” also ambiguous and ever-changing), without at least pausing for thought along the way.

Burnout is also cited as a common reason prompting the move, though is a well-known thorn in the side of the medical profession the world over, including the United States. Long, stressful hours; geographical separation from friends and family; financial strains (including the costs of supplementary exams, courses, travel and relocation); and emotional wear and tear are all thought to be potent contributory factors for those wanting to take time out. However, it now appears to be happening at progressively earlier stage in one’s medical career.

The implications of this shift could be arguably bleak — the U.K. shortfall in doctor numbers hovers around the 10,000 mark, and with less than half of doctors continuing into conventional training this could mean an even more strained future for the NHS. Certainly, growing criticisms have ranged from accusations of compromising patient safety, to ensuing longer working hours for those already in training and a return to previous work-life balance-poor conditions. Ultimately, this may warrant a move towards examples set by other countries such as Singapore and Nepal, whereby doctors in training are contractually obliged to work in those health care systems for a set number of years post-qualification. However, this could also serve to worsen any sense of dissatisfaction by an already disillusioned workforce. Similarly, not much is known about how work contracts in the NHS will be affected directly, as, until the referendum, working hours for health care staff in particular fell under the 2003 EU Working Time Directive. This directive stipulates that EU employees are restricted to a working week of no more than 48 hours — though they can “opt-out” if they choose — which was considered an important landmark at the time for maintaining patient safety. Prior to this, working hours for doctors, in particular in the United Kingdom, were largely unregulated, coupled with staff shortages and low training numbers. 

Is it a “snowflake” generation of physicians fearful of any real responsibility or decision-making onus who are increasingly choosing to “opt out” for a breather? Or is it higher expectancy from a job that demands so much of us, in all aspects of our lives and continues to do so without adequate compensation? On the contrary, has physician training ever actually followed a set pattern for more than a decade? Does this reflect the next step in the evolution of medical training, in keeping up with the pace of modern life paralleled with ever-advancing medical developments, technology, skills and knowledge? The option for doctors to determine their own career breaks in the ascent to consultancy may be a moderate tactic that seeks to reinvigorate and stimulate those feeling uncertain of their next steps, rather than having them feel driven to leave the profession altogether. 

Many have criticized the “brain drain” of U.K.-trained doctors emigrating to other nations such as the United States, Canada, Australia and New Zealand, but an altruistic view would be that the global talent pool retains its trainees, rather than them ceasing to practice altogether. Those in favor of Brexit have argued that lifting these restrictions will allow surgeons, for one, to undergo up to 3,000 hours of extra training. However, it is unclear how this will be factored into existing training programs, and whether it will result in a return to overworked and overtired health care staff. 

As such, the chance to take control over one’s own hours, geography and even pay grade appears to be increasingly appealing to the upcoming ranks of trainee doctors stepping off the figurative hamster wheel. But while this may benefit the individual, the real problems of a displaced workforce will be felt further down the line for the organizations formerly recruiting them. The implications here are not just for business, but for the welfare of those remaining, the patients and their families who find themselves tangled up in a health care system better resembling a McDonald’s drive-thru than a streamlined treatment center. Time will tell, but by then, it may also be too late.

Image credit: typing paper by Dean Hochman is licensed under CC BY 2.0.

Grace Hatton, MPharm, MBChB, DTM&H Grace Hatton, MPharm, MBChB, DTM&H (3 Posts)

Fellow Physician Contributing Writer

Junior Clinical Fellow in London

Grace is a UK-qualified physician and holds honours degrees in both pharmacy and medicine. She has worked as a research scientist in the fields of drug delivery, gastroenterology and hepatology; runs two organisations pertaining to sustainability in healthcare; and holds fellowships with both the NHS Clinical Entrepreneur Programme and the Royal Society of Arts. In spite of all of this, she still can't afford London house prices. It's a mad world.