Personal views: Plus ça change ...
Authors: Usman Azam
Journal: BMJ (1998)

Over 10 years ago a disgruntled registrar in obstetrics and gynaecology wrote a personal view about training in the specialty (BMJ 1987;294:570). I thought it would be interesting to reflect on the intervening decade. 

I decided on my choice of career quite early on and have been working in it for five years. Like most of my peer group I have experienced anxiety and frustration, and uncertainty about career developments has not helped. 

As a preregistration house officer I remember when the ideas surrounding the Calman reforms were germinating. Consultant staff initially embraced with enthusiasm the formation of a real structured training programme for hospital specialties. “You’ve got it made—five years of higher training and you’ll walk into a consultant post. Just go out there and get a national training number.” Ah! The NTN, that elusive number, the pursuit of which I spent many restless nights contemplating. How would I obtain that magical combination of numbers that would unlock the secrets of Pandora’s box—namely, career satisfaction and job security? 

I progressed up the hierarchical ladder in my senior house officer years and sought advice from senior colleagues. But how can someone advise you about a system in its infancy, the full potential of which cannot be visualised, and which they had never experienced?

I felt the need for change and headed up the A1 to the north east. But here I found the same problem—namely, the development of a career bottleneck. The rat race was on in earnest. I tackled every on-call session with a masochistic attitude. I had made the decision to get on the treadmill in pursuit of a prize without appreciating what the reward would be. But at times I came close to falling off that treadmill. I compared my life with that of general practitioner colleagues who could see the light at the end of the tunnel. 

Then each region was rationed with a finite amount of NTNs. Those lucky souls already in the system were given a number. After appropriate advice I obtained an acting registrar post, which six months later helped me to obtain an NTN. 

Now at 29 and in my second year as a Calman trainee I reflect on the changes that have occurred since the time when previous cohorts of trainees pressed for better working conditions and practices. I cannot help feeling confused and frustrated about the future, just like the registrar of a decade ago. 

Calman training is the new Holy Grail. But have things changed so much? Specialist registrars in obstetrics and gynaecology continue to face an uncertain future. The most important change has been the reduction in junior doctors’ hours of work. I feel no remorse, however, in taking a half day, as the battle fatigue prevalent 10 years ago after a night on call still exists. 


Have things changed so much in 10 years? The immediate concern of my predecessor was how to obtain a senior registrar post. Once achieved, the consultant post seemed an inevitability. In practice, there was a crude ad hoc relationship between senior registrar posts and consultant availability and, anyway, the senior registrar contract was open ended—the senior registrar just hung around until a suitable job materialised. 


“I am fearful of the creation of Calman clones”



The Calman changes have changed the pressures, which will emerge over the next few years. All trainees will have attained a certain standard of competence. But how do you choose a potential consultant from a stack of identical curriculum vitae? The reforms do not allow room for flexibility, as was first envisaged. The idea that regions could be traversed to broaden horizons and acquire new clinical skills with relative protection of the NTN is proving to be a myth. The pursuit of subspecialty training is and will become an unobtainable dream for most of my peer group. I am fearful of the creation of Calman clones—a body of skilled individuals with little scope for individuality. 

The pressure to obtain further letters after your name has not changed. Side stepping into quality research in order to obtain an MD (still seen by most as a prerequisite for a consultancy) is proving difficult. Job security for five years is enticing, but with the prospect of unemployment for the first time in our specialty because of the lack of consultant expansion, how soul destroying must this be for newly accredited trainees who have invested 10 years of their postgraduate adult life in the specialty? 

We have exchanged one bottleneck for another. Today’s Calman trainees are worried that the consultants’ jobs will not exist and that if they do they will be ill prepared to fill them. With an excess number of individuals on the specialist register, unscrupulous trusts could create cheap bridging jobs—junior consultants. This grade would be used to form the consultant based service of the “modern, dependable NHS” envisaged in the government’s white papers. 

It is up to us as trainees to attempt to halt the negative aspects of Calmanisation that seem to be seeping through the specialties. The new deal on junior doctors’ hours and the Calman reforms may have reduced the stresses of some onerous rotas, but stress still remains. As trainees we are an influential group who should insist that Calman works on our behalf and lives up to its expectations. 

And what became of that disgruntled registrar who wrote that personal view in 1987? That troubled soul who likened himself and his peers to Somme veterans with battle fatigue? He is now a consultant. I am his Calman specialist registrar.