Medical Training Application Service

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The Medical Training Application Service (MTAS) was an on-line application system set up under the auspices of Modernising Medical Careers in 2007 and used for the selection of Foundation House Officers and Specialty Registrars, and allocating them to jobs in the UK[1]. Its implementation was heavily criticised both in the press and within the medical profession, and its operation was marked by the resignation of key staff and serious security breaches. The system affected junior doctors, and so every qualified doctor in the UK who had not yet attained Consultant status.

Contents

[edit] Overview of the system prior to MMC

Prior to the introduction of Modernising Medical Careers (MMC), junior doctors who had completed their initial training after medical school (formerly the Pre-registration house officer or PRHO grade) could apply for posts as a Senior House Officer (SHO). They could apply for as many posts as they wished, and would be selected by their future employers based on their CV / application form and interview. They could devise their own training programme or apply to be part of a training rotation - usually entailing changing jobs every six months, but staying within the same specialty and hospital. Whilst training, an SHO would be encouraged to take professional exams to enable them to become a member of a Royal College. Once this was achieved, they could apply for jobs as a specialist registrar. The lack of formal structure between the PRHO grade and the specialist registrar grade led to SHOs being labelled as a "lost tribe"[2].

With increasing numbers of junior doctors in the UK, competition was fierce. It was not uncommon for 250 applications to be made for one popular post[citation needed]. The process was also perceived to lack transparency[citation needed].

[edit] MTAS application process

Under MTAS, junior doctors who had completed the PRHO grade, and more recently the Foundation House Officer grades, along with those who already had up to several years of experience working at the old SHO (next grade up) level, were invited to submit an electronic application form on the MTAS website. Applications could be made to one specialty in four geographic areas (called 'Units of Application' or UoAs), or to two specialties in two UoAs, or four specialties in one UoA. There were twelve geographical areas: one each for Scotland, Wales and Northern Ireland; one covering the whole of London, Kent, Surrey and Sussex; and eight others. The completed application forms were used for selection for interviews. Candidates who were not eligible (for example, not having practiced medicine for a number of years, or not being registered with the UK General Medical Council) were rejected at the 'longlisting' stage, with the 'shortlisting' stage designed to pick out the best applicants.

[edit] Scoring of applicants

The application form consisted of shortlisting questions with space for 150-word answers. One of the changes promoted by the new system was that little (25%) importance was given to past experience, achievements, or examinations passed in the specialties, while the majority of the weighting for selection was based on the 150-word answers in the electronic application form (75% weighting). This was in sharp contrast to the previous CV-led process where past experience, achievements and examinations passed in the specialties were used to shortlist candidates for interview.

The interviews were again designed to be unbiased, in that, once selected for interview, the application form would be ignored, and CVs would not be allowed at interview. Instead, defined questions with explicit marking schemes gave scores to the candidate's answers by looking for certain phrases and keywords. Again, the emphasis here was on removing possible bias due to a candidate's past achievements and experience, and focusing only on the performance at the standardised interview.

After the first round of interviews, there was a plan for a second round of applications. Candidates who were unsuccessful in both rounds would have no further opportunity to gain access to a training job in the UK for the year ahead, as MMC meant it was impossible to recruit junior doctors after the single specified start date.

Application forms were released in February 2007, with two weeks to complete and submit. The first round of interviews were due to be carried out in February, March, and April 2007 with applicants finding out whether they were successful in May. The second round was to take place after this, finishing in late June 2007.

[edit] Theoretical benefits of MTAS

In theory, the new application system centralised the application process, reducing the workload for consultants in shortlisting candidates for interview, and the workload of candidates applying multiple times for different posts.

Unfortunately in practice the centralised system failed, with MTAS withdrawn after the matching process, and the workload for consultants was hugely increased, as evidenced in several of the resignation letters prompted by the procedure[3].

[edit] Problems with MTAS

[edit] Theoretical problems

Theoretical concerns behind the process include:

  1. The MTAS system was based on five academic papers all produced by Fiona Patterson[4][5][6][7][8]. The papers were based on a very small sample size and made clear that the correlation between successful completion of the MTAS form and having the competencies required to be a successful doctor was 0.35, or poor.
  2. It was decided to make a 'clean break' with the old system of Senior House Officer training by making all SHOs currently in training apply through the system. These doctors were between six months and six years into their training in a particular speciality. Many had higher qualifications such as membership of the Royal College of Physicians (MRCP) or had taken part in research in their chosen speciality. It was a common misconception amongst more senior colleagues that SHOs would essentially be reapplying for their old jobs. Given the centralised nature of the selection process, this was not the case. Tabulation of the number of jobs at each level revealed that there were far fewer posts in the upper ranks of training than there were doctors already at that stage[citation needed], which left many doctors partially trained and without a career under the new system.
  3. Since geographical units of application were so large, candidates had to be prepared to work in a huge area of the country, or to compromise on their speciality since they were warned that making fewer than four choices would place them at a disadvantage. This was extremely hard for those who had family or financial ties.
  4. Because interview and selection took place centrally, rather than at the employing institution or hospital, specialist institutions had no input into the particular skills and attributes needed to work in particular posts.
  5. An application via MTAS was seen as an endorsement for Modernising Medical Careers, leading to a moral dilemma for those disagreeing with the system but obliged to apply in order to have a chance of a job.

[edit] Implementation problems

  1. The system used horizontal marking, whereby each of a single candidate's responses were marked by a different set of markers. Unfortunately, candidates were not informed that this would occur, and many had assumed the entire form would have been marked by the same markers. Consequently, candidates that cross referenced their answers across the form (e.g., by writing "as detailed in my answer above") failed to score marks compared to candidates who did not do this.
  2. The online application system frequently became overloaded which meant that potential applicants were unable to log into the site, complete or submit their forms. The application deadline was extended by 48 hours to enable candidates to submit their forms[9]
  3. Some forms were "lost" in the online system. Over 1,000 West Midland deanery application forms were "lost" for a week by the system[citation needed]. They were "found" and graded. However, concerns were raised that other forms may have been "lost" by the system.
  4. The "double-blind" system for marking failed. Each form should have been marked independently by two consultants. This system ensures that a mistake by one marker is covered by the second marker. Unfortunately, the MTAS system allowed the second consultant who marked the application form to see the mark the first consultant had given[citation needed]. Anchoring theory states that if this happens, there is a significantly increased probability that the second marker will give a very similar score to the first marker, removing the impartiality a double-blind marking system offers. Further, the second marker had the ability to change the mark given by the first marker[citation needed].
  5. Not all forms were marked by consultants. Many deaneries asked non-medical staff to help them meet their deadlines. It is unclear whether these non-medical staff were appropriately trained to mark the papers, and whether applicants were disadvantaged or advantaged if their forms were marked by non-medical staff.
  6. Exceptional candidates received no interviews. A large proportion of candidates who had already passed professional exams, had PhDs or research experience in the relevant specialty and many with considerable clinical experience were not shortlisted for interviews[citation needed]. This was largely due to the weighting of questionnaire responses over academic and clinical achievements.

[edit] Security concerns

The security of the system failed, with personal details including phone numbers, home addresses and sexual orientation of junior doctors publically available for several hours to anyone with the right URL. [10] The following day it was reported that applicants had been able to see each other's files by changing two digits in the personalised web address given to each individual, and the system was suspended.[11]

[edit] Implementers

According to information on Doctors.net.uk, the contract for the IT implementation of this system was given to a £6.3 million joint venture between Methods Consulting Ltd and jobsite.co.uk, a company run by three brothers: Keith, Graham and Eric Potts[citation needed].

[edit] Attempts to repair interview process

The allegations of widespread execution problems led to a review and a rolling program of sweeping changes, leaving the junior doctors in the system unsure of where they stood for long periods. The review stated that everyone should be entitled to keep any previous interviews in hand and also have an interview for their first choice if this was in England, with Wales and Scotland deciding to interview all applicants for all posts. Applicants for English programmes were able to make any of their four initial choices into their new first choice if they wished, in order to maximise the number of interviews they would have. This extra round of interviews was called Round 1B. Estimates are that there were 30,000 extra interviews requiring at least 15,000 consultant hours of interview time[citation needed].

The initial offers from Rounds 1 & 1B were made by 10th June 2007. Round 2 started on 22nd June and was organised locally as the MTAS system was offline. Round 2 continued until 31st October 2007, three months after the process should have been completed. The guidance from MMC indicated that any junior doctor in substantive employment on 31st July, and taking part in Round 2 will be guaranteed employment until the end of Round 2 in October, "Please note that all applicants who applied to MTAS who are in substantive NHS employment on 31st July will continue to have employment while they progress through Round 2"[12].

There was, however, a general feeling amongst those involved in the system that it was beyond repair and further efforts to do so constituted an example of 'irrational escalation'[citation needed].

[edit] Repercussions

The British Medical Association (the largest trade union body representing doctors) pulled out of the review panel after their announcement that each doctor would only be given one interview[13]. Organisations like the Royal College of Surgeons stated that they had lost confidence in the system [14].

The BMA later rejoined the review and have since lent their support to the proposed changes ("Round 1B"). However, following an outcry by members and a controversial letter [15] to The Times newspaper, Mr James Johnson, Chairman of the BMA resigned on 20th May, 2007, citing his reasons for leaving as the contents of the letter [16].

On 30 March 2007 Professor Alan Crockard resigned as National Director of Modernising Medical Careers. In his resignation letter[17] he stated that he has "responsibility but less and less authority" and that "the overriding message coming back from the profession is that it has lost confidence in the current recruitment system".

On 3 April 2007, during an interview on BBC Radio 4's Today programme, the Health Secretary Patricia Hewitt apologised to junior doctors over the crisis, saying that the application scheme had caused "needless anxiety and distress". The British Medical Association welcomed the government's acknowledgement of the problem but stated that "an apology isn't enough".[18]Patricia Hewitt's apology was repeated to parliament on 16th April 2007, however she stated that, "the problems that have arisen relate in the main to the implementation process and not to the underlying principles of Modernising Medical Careers."[19] Later that month Ms Hewitt was accused by the opposition of failing to express genuine regret over the fiasco[20].

The MTAS website was suspended on April 26 2007 after a Channel 4 News report stated that applicants had been able to see each other's files by changing two digits in the personalised web address given to each individual.[21] At that point the Department of Health announced that this was a temporary suspension.[22]

Ms Hewitt made another apology on 1 May 2007 in the House of Commons [23] after the suspension of the MTAS website due to security breaches that she described as "utterly deplorable"[24]. On 3 May, Hewitt appeared on BBC Question Time where she faced hostile questioning from a junior doctor over MTAS failures.[25]

On May 15, 2007 MTAS was shelved by ministers due to security breaches. Patricia Hewitt said that after the first round of recruitment, the system would only fulfil a monitoring role[26].

A judicial review of MTAS was successfully called for by pressure group Remedy UK, who demanded that the appointments process should be scrapped altogether. The case was heard in the High Court from May 16-17 2007, where the BMA sided with the government despite an overwhelming majority of their own membership opposing MTAS[27]. On Wednesday May 23, 2007 Mr Justice Goldring ruled against Remedy UK, stating that "although far from ideal", the Review Group's decision on amending the appointments process after the first round of interviews was "within the range of reasonable responses", and that the Review Group was "entitled to reach the decision it did given the circumstances facing it at the time". Although he ruled against invalidating the interviews that had already taken place, Mr Justice Goldring added that this judgement did not imply that junior doctors were not entitled to feel aggrieved, as "the premature introduction of MTAS has had disastrous consequences". Remedy UK have said they will not appeal the verdict, in order to avoid further uncertainty for junior doctors. [28][29][30]

[edit] Decline in university applications

University applications to study medicine for the academic year starting in 2008 declined, and this has been linked to the jobs crisis MTAS created[31]

[edit] Notes and references

  1. ^ MTAS. Retrieved on 2007-03-26.
  2. ^ Dillner L. Senior house officers: the lost tribes. BMJ 1993;307:1549-51. (11 December)
  3. ^ Resignation from MTAS Appointment Panels. Central London School of Anaesthesia. Retrieved on 2008-04-01.
  4. ^ Silvester J, Patterson F, Koczwara A, Ferguson E (2007). ""Trust me...": psychological and behavioral predictors of perceived physician empathy". J Appl Psychol 92 (2): 519–27. doi:10.1037/0021-9010.92.2.519. PMID 17371096. 
  5. ^ Randall R, Davies H, Patterson F, Farrell K (2006). "Selecting doctors for postgraduate training in paediatrics using a competency based assessment centre". Arch. Dis. Child. 91 (5): 444–8. doi:10.1136/adc.2005.076653. PMID 16632675. 
  6. ^ Beard J, Strachan A, Davies H, et al (2005). "Developing an education and assessment framework for the Foundation Programme". Med Educ 39 (8): 841–51. doi:10.1111/j.1365-2929.2005.02236.x. PMID 16048627. 
  7. ^ Patterson F, Ferguson E, Norfolk T, Lane P (2005). "A new selection system to recruit general practice registrars: preliminary findings from a validation study". BMJ 330 (7493): 711–4. doi:10.1136/bmj.330.7493.711. PMID 15790641. 
  8. ^ Patterson F, Ferguson E, Lane P, Farrell K, Martlew J, Wells A (2000). "A competency model for general practice: implications for selection, training, and development". Br J Gen Pract 50 (452): 188–93. PMID 10750226. 
  9. ^ Hewitt apologises for junior doctor recruitment crisis. E-Health Insider Primary Care. Retrieved on 2008-03-31.
  10. ^ Security lapse in junior doctor jobs website. The Telegraph (2007-04-27). Retrieved on 2008-03-31.
  11. ^ Doctors' job website is suspended. BBC NEWS. Retrieved on 2008-03-31.
  12. ^ Letter to Applicants from MMC, 8th June 2007
  13. ^ BMA junior doctors leave talks on recruitment system (2007-03-23). Retrieved on 2008-03-31.
  14. ^ Failures of the Medical Training Application Service (MTAS) system (pdf). The Association of Surgeons in Training (2007-03-05). Retrieved on 2008-03-31.
  15. ^ James Johnson and Carol Black, The Times - Letters Section, 17 May, 2007
  16. ^ James Johnson Resignation Statement
  17. ^ Resignation Letter
  18. ^ Hewitt apology for training chaos. BBC News (2007-04-03). Retrieved on 2008-03-31.
  19. ^ MMC360 transcript from parliament, 16th April 2007
  20. ^ Hewitt blasted over training fiasco. Channel 4 News. Retrieved on 2008-03-31.
  21. ^ Exclusive: junior doctors' details exposed online. Channel 4 News. Retrieved on 2008-03-31.
  22. ^ Doctors' job website is suspended. BBC NEWS. Retrieved on 2008-03-31.
  23. ^ Hewitt forced to apologise again over junior doctor recruitment fiasco. The Daily Mail. Retrieved on 2008-03-31.
  24. ^ Hewitt attacked over jobs website. BBC NEWS. Retrieved on 2008-03-31.
  25. ^ Patricia Hewitt attacked by junior doctor on Question Time. YouTube (2007-05-03). Retrieved on 2008-03-31.
  26. ^ Doctor application system ditched. BBC NEWS. Retrieved on 2008-03-31.
  27. ^ Brown M, Boon N, Brooks N, et al (2007). "Medical training in the UK: sleepwalking to disaster". Lancet 369 (9574): 1673–5. doi:10.1016/S0140-6736(07)60754-5. PMID 17512840. 
  28. ^ 'Scrap' junior doctors job system. BBC NEWS. Retrieved on 2008-03-31.
  29. ^ Junior doctors lose court fight. BBC NEWS. Retrieved on 2008-03-31.
  30. ^ Improving Doctors' Working Lives. Retrieved on 2008-03-31.
  31. ^ Medical school loses pole position. Doctors.net.uk (2008-05-11).