Medical Training Application Service

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 speciality and hospital. Whilst training, an SHO would be encouraged to take professional exams to enable them to become a member of one of the medical royal colleges. 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] During the MTAS crisis, however, "The Lost Tribe" was used to refer to doctors who were not able to proceed using the new computer system and as a result were left with no career at all, and so in a worse situation that the original "Lost Tribe" the system had been intended to help.

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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 speciality 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 practised 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.

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 questions on which the majority of the score was based were heavily criticised both at the time by the medical professionals obliged to answer them and subsequently in the independent review of MMC led by Professor John Tooke. The report commented:

"Free-text boxes encouraged plagiarism and commercial websites sold responses. Plagiarism was common but the promised plagiarism software did not function initially. Even when it did, plagiarism detection was relatively unhelpful as it could identify similar responses but could not identify whether the applicant composed or copied the text and thus could not be used to exclude applicants. In addition, the word limit was felt to be too restrictive by many.^[3]

Shortlisting was widely regarded as uneven and unfair, with the Tooke Report noting: "Some excellent candidates not shortlisted. Many very poor candidates were shortlisted."^[3] A number of local schools withdrew from the process in protest, with the North Central London School of Anaesthesia noting "It is our professional duty as shortlisters to make sure that the appointment process is carried out correctly and that all candidates are considered equally and fairly. There have been a series of serious procedural errors during the process[...]There has been a general recognition that round 1 of MTAS has been unfair and ineffective."^[4]

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.

As with other areas of the scheme, the interview process attracted several criticisms at independent review as they were "felt by many to be too formulaic and politically correct rather than sufficiently probing to demonstrate differences in competencies and abilities", they were frequently too short ("In many cases the time allocated to interviews was the minimum of 30 minutes which some interviewers felt was insufficient"), and they failed to reward those with high academic achievements, who "were particularly disadvantaged by a non-CV based process."^[3]

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.

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: "The Consultants involved in shortlisting have all worked long hours, often at weekends or during half term holidays, and have done their utmost to cooperate[...]Most of us had 48 hours in which to carry out shortlisting of up to 650 applications.".^[4]

Summarize Fact Check

Theoretical concerns behind the process include:

1. The MTAS system was based on five academic papers all produced by Fiona Patterson.^{[5][6][7][8][9]} 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,^[10] 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.

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^[11]
3. Some forms were "lost" in the online system, and parts of other forms were not visible to markers.^[3][4]
4. The "double-blind" system for marking failed. Each form should have been marked independently by two consultants to ensure mistakes by one marker are covered by the second marker. Unfortunately, some forms were only marked by one consultant.^[4]
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 speciality and many with considerable clinical experience were not shortlisted for interviews.^[3] This was largely due to the weighting of questionnaire responses over academic and clinical achievements.

The security of the system failed, with personal details including phone numbers, home addresses and sexual orientation of junior doctors publicly available for several hours to anyone with the right URL.^[12] 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.^[13]

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 10 June 2007. Round 2 started on 22 June and was organised locally as the MTAS system was offline. Round 2 continued until 31 October 2007, three months after the process should have been completed. The guidance from MMC indicated that any junior doctor in substantive employment on 31 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 31 July will continue to have employment while they progress through Round 2".^[14]

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]}.