The call for flexibility should lead to a review of foundation and specialty training pathways.

I Agree

Dear Editor

As highlighted by Rimmer [1], the annual report from the GMC into the state of medical education and practice demonstrated the need for flexibility throughout medical training [2]. This is not the first time the chief executive of the GMC has stated this, doing so back in 2019 [3].

This repeated acknowledgement of the need for flexibility should prompt us to review the postgraduate training pathways as defined by the Modernising Medical Careers initiative (MMC) in 2005. One of the objectives of the MMC was to streamline UK postgraduate medical training as well as “[addressing] the uncertain career prospects of the ‘lost tribe’ of Senior House Officers” [4].

The MMC initiative has led to various problems. Firstly, the rising number of doctors choosing to not join a specialty training programme upon the completion of FY2, and instead undertaking a post-foundation training break (PFTB), or ‘F3’ year(s), has implications for workforce planning. The fact that so many doctors take a PFTB should demonstrate that doctors do not wish commit to a specific pathway too early and require time to confirm their specialty choice [5].

Secondly, as reported in the BMJ earlier this year, there are growing competition ratios in specialty training at various points [6]. The decision to take a PFTB may become necessity, rather than choice, to secure a specialty or core training position due to increasing competition.

Thirdly, the fixed timepoints by which to apply to the next step of training has led to bottlenecks [6]. The recent increase in medical student places, coupled with the lack of changes made to either foundation or speciality training places, is only going to exacerbate these bottlenecks.

Given these problems, and the call for greater flexibility, it is perhaps worthwhile to remind ourselves of the recommendations made by the Tooke report [7], published in 2008 in response to the MMC proposals. The first recommendation made emphasised the need for greater flexibility early in doctor’s careers. In particular, it recommended the uncoupling FY1 and FY2 with the latter being incorporated into a three-year core training post covering broad areas (e.g. medicine, surgery, or general practice). The aim of these posts would be to individualise doctors training and facilitate movement between programmes, should the doctor wish to change specialty.

This change could reverse the growing number of doctors taking a PFTB and address the dissatisfaction which doctors have both with the foundation and speciality training programmes. Numerous articles have implied that changes to these programmes would help retain trainees [8]. I hope that we will see positive changes made to postgraduate medical training. Otherwise, we will still be calling for greater flexibility in another 15 years.

1. Rimmer A. NHS must let doctors work more flexibly throughout their careers, says GMC BMJ 2023; 383 :p2650 doi:10.1136/bmj.p2650
2. General Medical Council. Workforce report: The state of medical education and practice in the UK. Nov 2023.…
3. Rimmer A. Make medical training more flexible to accommodate doctors’ changing needs, says GMC BMJ 2019; 367 :l7021 doi:10.1136/bmj.l7021
4. Department of Health. Modernising Medical Careers—The Next Steps: The Future Shape of Foundation, Specialist and General Practice Training Programmes. Department of Health; 2004.
5. Church H, Agius S, Jenkins L. The post-foundation training break (“F3”): evaluating its impact on postgraduate medical training. A report of independent research funded by the General Medical Council and Association for the Study of Medical Education. 9 June 2023.….
6. Best J. The growing bottlenecks in specialty training BMJ 2023; 382 :p1732 doi:10.1136/bmj.p1732
7. Tooke J. Aspiring to Excellence. Findings and Final Recommendations of the Independent Inquiry into Modernising Medical Careers. London: MMC Inquiry; 2008.
8. Church, HR, Agius, S. The F3 phenomenon: Early-career training breaks in medical training. A scoping review. Med Educ. 2021; 55: 1033–1046.

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Electronic Publication Date: 
Friday, November 17, 2023 – 09:44
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The call for flexibility should lead to a review of foundation and specialty training pathways.

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Newcastle University, Newcastle-Upon-Tyne, UK
Academic clinical fellow in respiratory medicine, internal medical trainee year 2
Newcastle University
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