Now I know what I don't know: how to reform the foundation years to fit 21st-century medicine

Abstract

The two-year Foundation Programme was introduced in the UK as a structured way to deal with the lack of training, support and difficulties with career progression associated with the old senior house office (SHO) grade. Although it provides a clear curriculum and structure for career progression, there is growing dissatisfaction among participants about the difference between the aspirations of the Foundation Programme and the realities of working as a foundation doctor. In particular, the erosion of the traditional team structure, difficulties with the system of assessment and a feeling that the career structure is now too rigid has led to a situation where doctors are being forced to choose their specialty training too early and often with little experience in the specialty. To what extent is the Foundation Programme fit for purpose? This will be considered together with suggestions for future reform.

Introduction

The importance of keeping calm; there is always time to eat and drink; how to write at superhuman speed while balancing three sets of heavy notes. As a new foundation year 2 doctor these are some of the things that immediately popped into mind in answer to a question about how to reform foundation year training. Trivialities aside, they reflect a more serious point about medical training and whether our current foundation years are really adequate preparation for entering specialty training and performing as competent doctors. In other words, to what extent are the foundation years ‘fit for purpose’?

The story of the Foundation Programme

The Foundation Programme evolved out of the 2002 report Unfinished business by Professor Sir Liam Donaldson into the problems associated with the senior house officer (SHO) grade.¹ In particular, this report identified the poor job structure, lack of training, inadequate support and difficulties with career progression associated with the SHO grade as it was.¹ The report proposed a two-year foundation programme that would allow all doctors to develop ‘core or generic skills essential for all doctors’. This would then be followed by ‘eight (or so) broad based, time capped specialist training programmes’. The aim of such reform was to remove the situation in which doctors spent years stagnating as SHOs while unsuccessfully applying for a variety of higher training posts. Instead, the aim was to provide a clear structure for career progression, which would mean that ‘doctors in training would move seamlessly through the grade subject to satisfactory performance and assessment’.

What is the point of the Foundation Programme?

The Foundation Programme, therefore, was developed to deal with a specific set of problems relating to the SHO grade. However, as the first two years of a doctor's working life, it must also have broader aims relating to developing safe, competent and efficient doctors who are ready to progress to the next stage of their training. This is reflected in the self-stated aim of the Foundation Programme, which is to ‘form the bridge between medical school and specialty practice training’.² In particular, the programme aims to provide opportunities for new graduates to:

• develop and gain confidence in their clinical skills, particularly when they are treating acutely ill patients, so that they can reliably diagnose and care for seriously ill patients

• display professional attitudes and behaviour in their clinical practice

• demonstrate competence in these areas through a thorough and reliable system of assessment

• have the opportunity to explore a range of career opportunities in different settings and in different areas of medicine.²

Are these aims being met? To what extent are they appropriate for the training of modern doctors?

What are the strengths of the Foundation Programme?

As a participant in the Foundation Programme, my impression is that a gulf remains between the aspiration and reality. This is not to take away from some of the very real progress that the Foundation Programme has made. Career structures are now extremely well defined, and a clear linear progression can be seen right the way through to completion of training. Together with the European Working Time Directive (EWTD), the Foundation Programme does, to a certain extent, provide a bridge from medical school to working as a doctor and, thankfully, relegates the 100-hour working weeks to something of the past. At its best, the system of educational and clinical supervision allows doctors to progress and thrive, while supporting and catching those for whom the transition from medical student to doctor is more fraught. The best of the foundation jobs also allow a junior doctor to develop and practice their clinical skills in a controlled and supervised environment, with the support of a team for when difficulties arise.

What are the problems with the Foundation Programme?

The strengths described above do not represent the reality for most doctors working in the Foundation Programme. During the first foundation year, we most certainly ‘developed and gained confidence in our clinical skills’. However, rather than being able to gradually develop these skills during our first year, we are expected to be able to deal as competently with challenging situations on our first day as on our last. I think that most of us in the Foundation Programme will be able to relate to at least one experience during which we felt completely underprepared and unsupported when dealing with an unwell patient. Although I am a wholehearted supporter of the EWTD, it has, unfortunately, resulted in an erosion of the team structure and a greater gulf between what is expected of the foundation doctor during the day and when working out of hours. Inevitably, the current rota system means that junior doctors often do not know the senior doctors with whom they are working, which often makes one feel more alone and less able to call for help when help is needed. The ability simply to run something about which you are not entirely sure past a friendly team member who you know well is something of the past. Foundation doctors undoubtedly are better supported during normal working hours than the pre-registration house officers (PRHOs) of the past. However, the current situation has created a strange dichotomy in which we are given less responsibility and opportunity to learn during the day, yet are still expected to be able to cope single-headedly with 80–100 ward patients out of hours. Initiatives such as the introduction of the national shadowing week for all new foundation year 1 (FY1) doctors from this year will certainly help. However, the transition from medical student to doctor remains a huge gulf that doctors have to cross each year, with some invariably not making it. It is difficult to see how doctors can be allowed to develop their clinical skills in a more supportive environment while we still rely on the lone FY1 doctor on call to deal with more than 100 patients out of hours and with little senior support.

The concept of the ‘thorough and reliable system of assessment’² will almost certainly have been met with a laugh by many in foundation training. The Foundation Programme certainly has the laudable aim of being a competence-based system of assessment that is standardised nationally. In this way, doctors who are struggling should be identified and appropriate action taken. In reality, however, assessment is based on the electronic portfolio, which is extremely difficult to use and requires hours to ‘link’ spurious evidence with curriculum statements via a virtually unusable website-based programme. Finding senior doctors willing to fill in the mini-clinical examination (mini-CEX) and directly observed procedures (DOPs) assessments required to pass the Foundation Programme is a time-consuming struggle. When one eventually finds a friendly senior doctor willing to complete these assessments, rather than being an objective assessment with constructive feedback, they are a brief tick-box exercise that provides little opportunity to improve in future. It is not unusual that the assessor will select ‘satisfactory’ for all tasks, irrespective of their actual opinion of the trainee, rather than assess a particular observed encounter. I doubt whether this would detect any doctors struggling with their introduction to clinical practice. In an attempt to address this, these assessments have been renamed ‘supervised learning events’, with the aim that they become formative encounters and provide on-the-spot and constructive feedback rather than being pass or fail assessments. Without a greater amount of protected time for these assessments for both junior and senior doctors, it is difficult to see how they will radically alter the situation.

One of the key aims of the Foundation Programme was to deal with the ‘lost tribe’ of SHOs (who were finding progression to specialty training virtually impossible) by providing clearly defined stages of career progression.¹ Foundation doctors would have the opportunity to experience a range of specialties, including those that would not traditionally have been part of junior doctor training, in order to allow decisions about future specialisation to be made. The stages of career progression have become more defined, which is certainly a good thing. However, the situation seems to have gone too far, and there is a feeling among FY2 doctors that they are being forced into a rigid career structure far too early. Although the talk of an ‘exodus’ of junior doctors leaving medicine is certainly overstated,³ we have created another ‘lost tribe’, this time of FY2 doctors, who are unsure about the next career step and are choosing to step away from the clearly defined career structure. Junior doctors are often being asked to choose specialties with little or no experience of working in that specialty. Although the Foundation Programme contains a variety of specialties, they are often grouped in a nonsensical fashion, and allocation to rotations occurs while the applicant is still at medical school and depends on the score in their initial application. There is little flexibility to swap rotations, so they are often filled by those with little interest in the specialty, while another doctor with a strong interest in that area misses out. The system should allow a greater degree of flexibility so that these doctors can continue in training while they make up their mind, rather than being forced into the cold of locum positions. Otherwise, we are merely recreating the same situation that the Foundation Programme was created to resolve.

What can be done to reform the Foundation Programme?

No magic bullet exists to reform foundation training so that a medical student who enters the programme leaves as a competent and confident doctor ready to enter specialty training. It is also impossible to consider the Foundation Programme in isolation, as it is only one part of the long path of medical training – from medical school to specialty training and beyond. There is no way to make training perfect; however, I would like to propose a few ideas that will deal specifically with the problems outlined above.

Firstly, all medical school final examinations should take place earlier in the year, so that they are completed between January and March in the year that the doctor will enter foundation training. Not only would this allow time for remedial teaching and re-sitting of exams without the penalty of another year at medical school, but it would also allow a period that could be focussed on preparing for life as a doctor: a ‘pre-foundation programme’. Although nothing can actually prepare you for your first day as a doctor alone on the wards, a 2–3-month apprenticeship during which the medical student follows the rota and working pattern of an FY1 doctor could certainly help. Some medical schools have adopted this approach already, but it is far from universal. To avoid the dangerous situation of all doctors moving into new jobs on the first Wednesday of August, such job switches could be staggered by a week depending on grade, with new FY1 doctors starting first. This would give them the opportunity to start their job with an experienced team who knows the patients well and could reduce the shock of the transition.

Foundation training should also be extended for another year – to three years in total – but with an uncoupling of FY1 from the other years. The first year of the Foundation Programme should be focussed on core competencies in medicine and surgery, without supernumerary posts such as psychiatry. Foundation years 2 (FY2) and 3 (FY3) should be broad but themed so that a doctor interested in a particular area can gain experience in a variety of relevant specialties. For example, most FY1 doctors know whether they want to follow medicine or surgery, although not which particular specialty, so they could, therefore, choose a medicine-themed FY2 year. There should also be the opportunity for ‘special study module’-type components, similar to those in medical school, including the opportunity to experience research. This would replace FY2 jobs, in which FY2 is largely supernumerary, and allow those who were interested in a particular specialty to confirm their choice. Importantly, by including all of these as part of the Foundation Programme, it would allow doctors to switch between themes while still counting previous experience towards future training. After FY3, the doctor would then enter specialty training. To maintain a broad base and ease the transition into specialty training, the first year should be arranged essentially as an apprenticeship to a current registrar. During this year, the trainee would gain the experience and confidence needed to allow them to work independently in the specialty. Specialties should be open to all doctors who have completed the Foundation Programme, irrespective of the theme chosen, as long as they are able to demonstrate the competence required to enter training in that specialty.

As far as possible, a firm structure should be reinitiated so that doctors are working with senior doctors they already know. In addition to the educational and clinical supervisor, a mentor from FY2 or FY3 should be allocated to all FY1 doctors as a more informal source of support. The system of assessments should also be altered so that sufficient time is allocated to achieve them and make them worthwhile for the trainee. Ideally, the system would include a fortnightly timetabled session with the clinical supervisor to discuss any issues and to allow these assessments to be completed. The change to making them formative should remain, so the results should, therefore, strictly not be available to the Foundation Programme directors dealing with sign off at the end of the year. In order to ensure fair and transparent assessment, a doctor should have to undergo a certain, small number of supervised exam-type assessments with an independent assessor, similar to the medical school's objectively structured clinical examination (OSCE). These should be based on competencies and safety, with a national set of criteria for marking and the option to re-sit the exam following feedback and further work with the clinical and educational supervisor. This would both provide allocated time to allow assessments to be completed and remove the largely random nature of getting them signed off and the marks received.

Conclusion

The Foundation Programme has certainly improved some aspects of the training of junior doctors. However, key areas could still be improved. The current system of assessment is difficult to complete and unlikely to identify struggling doctors, while the career progression funnels doctors into specialties too early in their training. Reforms should be aimed at making assessment fairer and more transparent and allowing greater flexibility of training, so that junior doctors can make an informed choice about their future career.