Matching scheme madness

There is a great job advertised in the region at the moment. It rotates between this teaching hospital and a district general, where previous registrars have been well trained and enjoyed the experience. The post is open to suitably qualified applicants from all over the world—except, it seems, my excellent registrar.

He cannot apply because he is “on the scheme” already. His post rotates to a different district general hospital. He cannot apply for the job he would prefer, even though he is not due to rotate for nine months, and could easily give the statutory three months' notice. Apparently transferring within the scheme might be possible at the discretion of the postgraduate dean, but there would have to be a good personal reason to be allowed to change.

Matching schemes must be set up so that they are not too large and so that people are not locked in

What is a good reason? A sick child? Getting married? Living with someone? What about living with seven other people in a hippy commune? What about simple personal preference?

Should postgraduate deans and regional advisers really have to judge the relative merits of junior doctors' personal circumstances? A fundamental principle of the Human Rights Act allows everyone a private life. Senior doctors should not be making decisions about a junior's career progression based on perceptions of his or her private life, yet matching schemes and rotations increasingly force us into doing just that.

The world of medical training is changing fast. We are seeing a proliferation of rotational training and matching schemes. There are schemes that will run over huge geographical areas, even, it is proposed, the entire country. There will be one advert, once per year, covering a vast range of jobs in a particular scheme or specialty. Doctors will be expected to set out their preferences for jobs, but eventually to accept whatever they are given. If they subsequently want to change, they can appeal to the postgraduate dean, but the implication is that they will not usually be successful.

When I ask why changing jobs within a rotation, or applying to move to a different region, is so difficult, I expect to be told that registrars have training tailored to their needs, and that to allow a change would damage this. Instead the reasons seem to be based on administrative complexity, hurt pride, and misplaced views of equality: we don't want to organise more appointments committees, we feel insulted if our registrars are not happy with their rotation, and if they are allowed to change it is unfair preferential treatment. We are told that fixed, matched rotations are an improvement on how things used to be, and much more “fair.”

I am not convinced. In the old days a doctor applied for senior house officer jobs, then a registrar job, then a senior registrar job. If you were good you had a decent chance of getting the jobs in places and specialties you wanted, and if you weren't you did not. You researched the posts you were considering and did not apply for one that you did not want, or in a place you did not wish to go. Ultimately if you were not getting the jobs you wanted, it was your own responsibility to reassess your choice of specialty and/or location. Now it seems that we are heading for a situation where all junior doctors can do is express a preference for what they want to do with large chunks of their lives and hope for the best.

Matching schemes have, of course, been around for years. They can be excellent. It is hard to think of anything better for sorting out short term house officer posts in a small location such as a teaching hospital with which the applying medical students are familiar. Using matching schemes for long rotations over a larger area makes filling jobs administratively easier, but for the doctors going through them it reduces their ability to control their lives. An applicant might want to express a preference for two years in specialty A in town X, but only if his or her partner can work in the same town at the same time; if specialty A wants to send the applicant to town Y, he or she might rather take a job in specialty B back in town X. Life is complicated. Matching schemes cannot possibly take the complexities of an individual's personal circumstances into account. They assume that all we are interested in is pursuing our career, and that everything else will fit round it.

This is a dangerous assumption. All the evidence suggests that the new generation of doctors wants a sensible work-life balance. Many wish to work part time regardless of traditional reasons like looking after children. Many are married to each other and need to find two complementary jobs. Few will enjoy taking their chances on huge matching schemes, risking years of commuting between jobs they didn't really want.

Rotations and matching schemes may be easy to administer, but they must be set up so that they are not too large and so that people are not locked in. We must design sensible ways to allow doctors to move between and within schemes without having to make a case based on their private lives. If we don't do this doctors will melt away, preferring a life where they retain some control to the bonded service our training schemes look set to impose.