When should doctors gain full registration with the General Medical Council?

Karen Mattick is a Professor of Medical Education, Co-Lead for the Centre for Research in Professional Learning at the University of Exeter, and Director of the Postgraduate Certificate in Academic Practice. She has over twelve years’ experience as a medical education researcher and educator. He she ask when junior doctors should gain full registration with the GMC…?

Having been heavily involved in establishing and developing successful UK Medical Schools, we believe more can still be done to prepare and support medical students in the transition to becoming junior doctors and encourage them to stay working as doctors in the UK.

Currently only 70 per cent of junior doctors feel they were well prepared for their first junior doctor role. And, in the UK, we are fast losing doctors in some areas of medicine through emigration, career breaks and early retirement, sometimes through mental ill-health.  Change is needed – but it must be the right kind of change, undertaken for the right reasons.

So what would the right kind of change look like? For us, this is about providing the best possible education and support to medical students and junior doctors, in order to achieve the best possible patient care.

With this in mind, as a team of academics from Cardiff, Exeter, Dundee and Belfast researching the preparedness of graduates for medical practice, we explored the implications of a recommendation made by an independent review of medical education, to award full registration for graduates to practise medicine as soon as they leave medical school.  This is a year earlier than the current point of registration, which includes a further ‘hands-on’ placement year. Our research team wanted to provide evidence to probe this recommendation and the ramifications it could have for education and patient care in the UK.

We conducted interviews with 185 doctors, health professionals and patients, and heard that the implications were far-reaching. Even if the graduation at registration recommendation is not adopted, it is clear that we can do more to adapt to a changing healthcare environment and respond to some of the challenges the sector faces, simply as best practice to support trainee doctors in a particularly demanding period in their careers.

At the moment, medical schools remain responsible for aspects of doctors’ training in the first year of practice. In this period new graduates receive provisional GMC registration, meaning they can only practice under close supervision and with some restrictions. Around 40 per cent of these junior doctors are employed by NHS Trusts that are remote from their medical school, potentially hundreds of miles away. They are both physically and psychologically far removed from Medical School. This can lead to fragmentation of support during a critical phase of training.

In the current system, doctors apply for full GMC registration only after completing this first year of practice. It takes at least four further years (sometimes much longer depending on specialty) for doctors to complete training and become independent practitioners.

Until they are fully registered, junior doctors cannot usually work abroad or take up temporary locum work.  But, with increasing numbers of UK graduates and applications from eligible European and International medical graduates, the Foundation Programme has been oversubscribed since 2011.

Suitable UK medical school graduates now regularly fail to secure Foundation Programme Year 1 (F1) jobs on the first pass and are put on a reserve list to await a place. Graduates without an F1 job have limited opportunities to progress their medical career in the UK, risking graduates leaving medicine or moving abroad to train. Heart-breaking and highly political headlines of talented students who have worked hard for years, in a degree heavily subsidised by the taxpayer, being forced into alternative careers, are now a very real possibility.

Changing the point of registration would help to address concerns about fragmentation of support and could potentially help with oversubscription but it would introduce other concerns. Provisional registration provides a ‘safety net’ year, in which new doctors can find their feet under close supervision and senior doctors can identify struggling trainees. Although the daily practice of newly qualified doctors might not change, full registration would imply higher expectations from the outset, making the transition even more daunting.

Our interviewees also raised concerns about medical schools making recommendations about full registration. Medical students are generally not embedded within the multidisciplinary healthcare teams their later employment will demand. They can undertake limited activities, which makes it difficult to assess their capabilities in clinical practice and professionalism in the workplace with confidence. Some felt that medical schools were reluctant to fail underperforming students and that universities were more focussed on producing graduates than on patient safety.

One surprise in our data was that participants did not raise the implications for four-year graduate entry medicine programmes, currently run by some medical schools alongside the standard five years for non-graduates. The implications for these programmes are profound, however, since European legislation requires a minimum duration of basic medical training of five years and 5,500 hours. Graduate entry programmes currently use the F1 year towards this count so, unless aspects of a first degree could be counted, these programmes might become untenable.

By thinking through the implications of a future change to the timing of registration, we have highlighted improvements that can be made to medical education. At a time when the training of doctors is under intense scrutiny, we hope this evidence will help shape the future by providing earlier practical experience to students, which would be beneficial right now for medical students, trainees and patients.

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