If you are a UK doctor applying for speciality training, there is no incentive to become an expert in a niche interest. The current recruitment system rewards breadth, not depth, of accomplishment. I believe this stifles the cultivation of diverse interests and contributes to disengagement. A solution could involve full compensation, irrespective of what you are passionate about, and incorporates ‘fit’ between trainees and departments.
The current system has evolved for several reasons, including: (1) it is scalable, (2) it lowers nepotism, and (3) there is no established measure of clinical ability. However, national applications do not allow for tailored job adverts. E.g. A hospital cannot advertise for a ‘urology registrar with particular interest in teaching’.
One problem is that there is no accepted (or implemented) metric to assess clinical ability i.e. how good you are at your “day job”. The highest level of assessment a doctor can obtain at annual appraisal is to “progress at the expected rate”. This is not particularly helpful for distinguishing candidates in recruitment.
Hence, all opportunities for differentiating candidates are in additional criteria. E.g. Publications, courses attended, extra degrees, leadership roles. Everyone is scored against every metric. So, one way to stand out (numerically) is to have done a bit of everything. There is little opportunity to ‘compensate’ by having a particular interest in one domain for another. Yet the strongest teams in all occupations show diversity of thought, background, and expertise.
Some doctors will be more interested in teaching. Some will be more interested in management. Some will be totally focused on their clinical work. Some will want to do a little bit of everything. I believe there is a department out there clamouring for each of these individuals. But, due to the current process, and the rotational system, there is limited scope for consultants to recruit a doctor with the right ‘fit’. Or find someone with a niche interest that will complement their department.
The ideal system would support cultivation of individual interests: the pathologist who already has a PhD in melanocyte biology isn’t encouraged to become ‘rota co-ordinator’ for the benefit of their CV; the surgeon who focuses on learning new procedures doesn’t feel the pressure to take a ‘teach the teacher’ course; the emergency care doctor who likes to teach and do occasional audits shouldn’t worry about not having four publications. And yet, such a system should also not depend on who you know or where you have come from.
I believe that depth should be able to compensate for breadth, and vice versa. I see this leading to two challenges: (i) how do you fairly weigh accomplishment in one domain against another; and (ii) how to facilitate ‘fit’ of doctors with specific interests with departments without nepotism. Solutions could include departmentally-specific job adverts through a national application system ‘tagged’ with desirable characteristics (e.g. medical education). The ranking of candidates would then not be based exclusively on a generic score but stratified by domain. (However, such a design would bias against breadth of interests.)
As with all interesting problems, there are no easy solutions. Yet I feel it is possible to envisage a system that takes steps towards promoting diversity of interest. This would have knock-on benefits by increasing autonomy.
Conclusion
Recruitment for UK doctors in training distinguishes candidates using non-clinical metrics. This design encourages breadth, not depth, of interests. An ideal system would remunerate clinicians no matter how they choose to be excellent and facilitate matching them with departments searching for their expertise.
Caveats
I am aware that there are shades of grey to what I have said. For example, there is an element of distinguishing based on clinical ability in job interviews through ‘clinical stations’. However, I would argue that this is not equivalent to a true assessment of a doctor’s performance day-to-day.
Similarly, though the current system is in part designed to reduce nepotism, it is clearly not devoid of it.
I acknowledge that there is an optimum balance between breadth and depth. The doctor who is totally focused on research must also have some experience in teaching and management in order to work effectively as a consultant. However, I believe that a minimum training requirement does not necessarily need to translate into a selection criterion equally applied to all individuals.
Books I’ve read that have influenced this blog post
Decision making: Thinking, fast and slow, The decision book, The checklist manifesto, Nudge
Career direction: So good they can’t ignore you, Essentialism, Mastery, The squiggly career
Leadership: Great by choice, Good to great, Principles, Creativity, Inc.
Productivity: DeepWork
