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Editorials

Specialist registrar training

BMJ 2000; 320 doi: https://doi.org/10.1136/bmj.320.7238.817 (Published 25 March 2000) Cite this as: BMJ 2000;320:817

Some good news at last

  1. Graeme Catto, vice principal.
  1. University of Aberdeen, Aberdeen AB24 3FX

    Papers p 832

    The headline news from the NHS has made grim reading this year: funding crises, shortages of beds, and crimes. The public is increasingly aware of our unenviable record of morbidity and mortality from cardiovascular diseases and cancer, and constructive criticism has been replaced by the destructive soundbite. The perception is of an NHS that has gone downhill since the halcyon days of the 1950s—overwhelmed by bureaucracy and initiatives that impede advances in clinical practice.1

    Yet there is another tale to tell. Over the past decade a quiet revolution has occurred in medical education. After the publication of the General Medical Council's recommendations in Tomorrow's Doctors in 19932 all UK medical schools have revised their undergraduate curriculums. Alongside a strong science base, 3 Tomorrow's Doctors emphasised the importance of communication skills, learning through curiosity, understanding public health medicine, and adapting to changing patterns of health care. The burden of factual information really was reduced, and a core curriculum defined. The implementation of these recommendations has not only influenced the medical students but also changed the way in which their seniors undertake both their teaching and their clinical practice.4

    The culture of British medicine was already changing when the GMC issued Good Medical Practice in 1995, outlining the duties and responsibilities of a doctor.5 By emphasising the positive attributes of a doctor, that document has proved influential in defining the standards, including teaching and training, against which a doctor's professional performance can be assessed. The GMC then published recommendations for the preregistration house officer year in 19976 and, with help from the departments of health, ensured their implemention. These developments in the UK were compatible with changes to medical education introduced in other countries.7

    If these developments were broadly acceptable, the Calman reforms of specialist training proved more controversial. They were introduced under the previous chief medical officer, Kenneth Calman, to align the UK system of specialist training with the requirements of the European Union directive on medical training.8 The recommendations included combining the registrar and senior registrar grades into a unified specialist registrar grade, and the curriculum and minimum training requirements for each specialty were defined. Formal educational agreements were designed to emphasise structured learning as well as apprenticeship. Successful completion of the training leads to admission to the specialist register.

    Introduction of the new system, for which no additional resources were allocated, began in 1995 and was completed in 1997. There were concerns that the reduced training time, compounded by the reduction in working hours, would adversely affect the learning experience for specialist registrars. In addition, the reduction in the number of registrars together with their more formal training requirements would increase consultants' workload.9

    In this issue of the BMJ, Paice et al from the North Thames deanery compare the results of two surveys on the impact of the Calman reforms, the first undertaken during the introduction period and the second two years later (p 832).10 Over 3000 specialist registrars took part, giving participation rates of more than 70%. Trainees in all grades recorded greater satisfaction with their current posts. They did not believe that they were acquiring less experience or that job satisfaction had decreased. They also reported an improvement in consultant supervision. Though these results are gratifying—and surprising to some—the data also show that the educational aims of postgraduate training are far from being consistently fulfilled. In some specialties, for example, only a few trainees met their trainer to agree educational objectives; even fewer signed a learning agreement. The surveys sought opinions only from specialist registrars, not their trainers.

    Nevertheless, this report from the largest postgraduate deanery, responsible for training 25% of UK specialist registrars, is helpful in providing information in an area beset with anecdote. The Calman reforms were initially introduced as a matter of public policy to make Britain's system of postgraduate education compatible with Europe's. Paice et al have sought to evaluate their educational impact. Such evaluations of policy decisions are to be welcomed whatever they reveal.

    So what now? Can we relax in the knowledge that these changes will continue to bring benefits over the next few years?11 Almost certainly not. This report shows that the improvements depended on increased consultant input. Evidence from other sources, including regional taskforces and GMC visits to medical schools, 12 indicates that the increasing clinical workload is making it hard to sustain improvements already achieved, far less maintain the momentum towards creating consistent, high quality postgraduate training. Moreover, the greatest improvements seem to have been made in the preregistration house officer and specialist registrar grades. What are we doing, for example, to help senior house officers meet their expectations of early professional training?13 If we have learnt anything from the past decade of reform it is that the postgraduate training of doctors can't simply be fitted in round service: it takes planning and hard work.

    Acknowledgments

    GC chairs the GMC's education committee.

    References

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