Some, including yours truly, may find it difficult to
believe that in August 2015 I expect to begin life as a junior doctor. If everything
goes to plan then I will nervously sweat and mumble and spread infection in a
hospital – like what I currently do as a medical student, only more so (and
with more direct consequences for the ill people I come into contact with).
The most junior doctors in hospitals used to be called House
officers, but since 2005 are now called FY1 doctors – because they are in the
first of two years of the foundation programme. A complicated nationwide online
system is used to match the 7000 or so applicants to their foundation programme
jobs and hospitals. Put simply, each candidate ranks the available jobs in order of
preference and is allocated one based on the number of points they can scramble
together. Points mean prizes, and the prize here is precedence in allocation of your application choices.
I foolishly spend far more time complaining about the application
process (see current whinging blog post) than actually thinking about my own application; the deadline is this week. Now and then I become self-aware
enough to feel a little ashamed of complaining and realise how good we have it
as medical students; unlike almost every other degree programme in the UK nearly all of us that pass medical finals will get a job, somewhere. For the last four
years there have been more applicants than jobs for them but for example
last year in 2014 96% (7114) where allocated
jobs in the first round and places were eventually found for all 235 remaining on
the reserve list.
So bearing that in mind, here is where I whinge at length about the
system, conveniently grouping my complaints into two categories thus:
1) The points system is not perfect
Some jobs and some parts of the country are more desirable
and therefore more competitive than others. You can’t make every finalist happy (see
current whinging blog post) and allocating randomly is clearly madness. So a
system has been devised to rank students from best to worst such that the better
get to go where they want and the worse have to go where they’re told. This is
done by ascribing each student a score out of 100:
The educational performance measure (50
points max)
An applicant gets between 34-43 points for their decile in
their medical school exams to date. I don’t think there’s a particularly strong
correlation between exam score and competency as a doctor, common sense and
teamwork and time management are more important than memorising textbooks (but maybe
that’s me being defensive since I’m not top of the year by a considerable
margin). Also
some question whether the points awarded per deciles should be equivalent across all medical
schools as is currently the case, despite different entry standards, different
syllabuses, and different exams (though this
argument is usually made by those individuals with a snobbishly high regard for
the calibre of their own institution.)
Admittedly this system might change in years to come.
There are up to seven extra points given for other degrees, depending on how
advanced the degree is (bachelors, masters, doctorate) and its classification.
Again the number of points are standardised between degree subjects and institutions
and includes intercalated degrees, all of which vary considerably. I
spent three years getting a degree in biology. It was quite tough, sometimes it
was fun and interesting, and I like to pretend it’s given me some life experience and a bit of
a broader knowledge base, but I’m pretty sure that this doesn’t make me a better prospective doctor. Essentially I’m getting rewarded for being indecisive about my
career.
Finally there are up to two points available for publications, the same number
of points for having your name attached to any pubmed number regardless of its relevance, the quality of content or the journal it's published in. I think this leads to a pretty cynical
approach where research is regarded primarily as a means to build and decorate
CVs, and it is depressingly a feature of the entire medical career structure.
The situational judgement test (50 points)
The other 50 points come from the
situational judgement test (SJT), a curious exam sat by every applicant. It uses 70 multiple choice or ranking-type questions to assess whether a candidate is able to make safe and
sensible non-clinical professional decisions.
Here it is theoretically possible to score anywhere between zero and fifty–
making this 2 hour 20min exam far more important for the job application
process than the performance across an applicant’s entire medical degree (where
the difference between top student and bottom student translates to only 10
points).
In reality the SJT isn’t quite so discriminatory; over 80% of applicants are
within the 10 point band between 35 and 45, in a negatively skewed
approximately bell shaped distribution. The average score in 2014 was 38.95 (SD
4.25). The SJT is perhaps more useful in its function as a safety net - candidates
that score very poorly are flagged up to assess whether they are suitable to
work as a junior doctor despite being able to complete medical school.
2013 SJT results distribution
Given that I have not taken the test yet (I’ll sit it in
January) I can’t really comment on its particulars, but I suppose that I am relatively
impartial because it hasn’t been used to assess me yet. The test has been used
since 2013,
an inauspicious inaugural year that was distressing for the
applicants as after jobs had originally been declared the tests were remarked, many scores went up or down and so changed the outcome for many.
The SJT is still a relatively unknown quantity, and as such it is fairly odd that
our futures are so dependent on it. The existence of the SJT seems to curiously disincentivise one from working to do well in medical school exams, and adds an almost
completely random element to the application process. We are advised that it is
a test that is impossible to revise for, but that hasn’t stopped entrepreneurial
organisations from offering wide ranges of dubious and expensive preparation materials and training
courses.
2) Choice is an illusion
I am chronically indecisive. I have no clear view of where I
want to be in five years, or what sort of doctor I want to be (if any: plan A is
still scratch card windfall). During my time at medical school I haven’t been able
to exclude many specialties from my list of potential jobs or careers and I’m
not drawn to any particular part of the country for any reason. Plus some people
say I overthink sometimes (see current whinging blog post). I therefore seem to find the applying for F1 less straightforward than many people I know.
The foundation programme is usually six different 4-month
rotations, during each the junior acts as dogsbody to senior doctors in a specific area of
medicine. There are several levels of apparent choice at work before a job is
allocated, firstly the area of the UK (there are 21 “foundation schools”), the
hospital, and the specific clutch of six rotations themselves.
Each coloured block here is a foundation school
The first decision is ranking these in order of preference
So with just these three factors there are many hundreds of possible
combinations available to consider. Unfortunately, outside of the hospitals I’ve
been placed at around Birmingham I have no knowledge of the relative merits of
any other part of the UK, or any other hospitals. And I also have no real knowledge about
what are the differences are between different F1 jobs. More uncertainty is introduced because all foundation jobs
are “subject to change”; I know of people who ended up frustrated with three
completely different FY1 rotations to the three they applied for (and were
allocated to).
Further considerations that might affect how much you would
want a job include the team you will be working with and the consultant you’d
be serving under –unfortunately both of which are impossible to know until you start
work. You might also attempt to guess where your friends might end up, which is at least as confusing as attempting to predict the future for yourself.
According to the
Mental Capacity Act 2005 (completely unnecessary tenuous reference) a person’s choice
is valid only if they fully understand the benefits, risks and alternatives of
a decision. I don’t feel at all confident that I meet this charge. There is a
huge amount of information online comparing different areas to work by every
imaginable characteristic, so much information that it becomes impossible to
digest it. Deciding what is important (City or Rural? North or south? Medicine or
surgery? Is it too competitive? Known or unknown? Accommodation? Old friends or
new people? Things to do outside of hospital? And so on?) is difficult and often arbitrary,
and the decision is never completely informed due to the uncertainty that
remains as to the true nature of the location, hospital and job you apply for.
Perhaps most confusing is that applicants rank all the
deaneries before we know our scores – as mentioned above the SJT is shrouded in
mystery and ensures that no one is at all sure how strong their application
will be until after the results. Perhaps I’d apply to a competitive deanery if
I was sure I had enough points to secure a decent hospital and job were I to
get it. But regrettably I still don’t know what I want, and anyway it’s quite
hard to even guess which deaneries and which jobs will be competitive since
this seems to change a great deal from year to year.
So maybe I'm a little defeatist and pessimistic but I feel completely
overwhelmed by the scope of possibility for next year, and I have gained almost no
useful predictions as to where I will want to be, what I want to do or what
level of control I have in effecting my choices. It’s not ideal that I take the
same fence-sitting approach to clinical decisions too. One thing I am sure of
is that after what will be seven consecutive years of being a student I’m really looking forward to getting a job. Any job.
