Applications for ENT training roles in every country require certain criteria to be met. In the UK, ST3 recruitment applications have scores allocated to research experience. In this opinion piece, the authors share their assessment of the potential issues around the research requirements for entry into UK ENT training, and potential solutions. ENT & Audiology News welcomes opinions and discussions from colleagues in the UK and abroad on their own lived experience and suggestions (Twitter @ENT_AudsNews or Facebook/EntAudiologyNews).
In the UK, entry to core surgical training and higher surgical specialty training occurs through a competitive national selection process [1,2]. This process is generally divided into two components: portfolio and interview. The portfolio is a summation of evidence detailing a trainee’s surgical experience and exposure to aspects of clinical governance such as clinical audit and quality improvement, education and training, and research [1]. Candidates are ranked according to their portfolio score and invited to a formal interview. The combination of the portfolio score and interview score then determines which candidates are offered surgical training posts [1].
What’s the problem with national selection?
With the ever-increasing number of eligible candidates, there appears to have been increased precision of the information delivered in the portfolio criteria and an elevation of the portfolio requirements to gain top marks. In response, candidates may have to work harder and smarter to achieve these points, thus increasing the competition for desired posts. Competition is generally perceived positively as it drives innovation and elevates the standards of our candidates, however this is not always the case.
An area of the portfolio that tends to garner significant attention is the research section. At all levels, the portfolio sections for national selection panels have a focus primarily on the number of publications and the position of the named author when it assesses research acumen. In the current iteration of the ENT ST3 portfolio criteria, research publications accounts for approximately 18% of the total portfolio score (n = 17/95). These points are likely to be highly significant when ranking posts because the portfolio section accounts for about 50% of total score and the candidates invited for interview tend to perform similarly. Hence the portfolio score can be a key determinant [3,4].
A concern with this system is not just the fact that it primarily distills research experience to its products. The key issue is the fact that it does not account for an intrinsic interest in research and the ability to perform research well. Academic society is well aware of the fact that the vast majority of published research will not stand the test of time for various reasons, including inadequate methodology, no clinical or real-world applicability and prestige bias [5,6]. There is no doubt that the driver behind the publication of many studies in such a saturated environment includes the potential for expanding the current body of research through the dissemination of findings, the clinical implications of said research, the opportunities for career advancement and the personal satisfaction or accolades from the achievement. Therefore, although the current system aims to create clinicians who can analyse the evidence base and apply it to their practice, presently it may simply be favouring candidates who are able to get their paper past reviewers irrespective of the quality of the work.
"The key issue is the fact that it does not account for an intrinsic interest in research and the ability to perform research well"
Furthermore, this effect may be seen downstream in medical students, as it becomes apparent when they enter clinical undergraduate training that a focus on publications appears to be a major driver in securing their desired job. This could prove detrimental as it sets a precedent for students and future doctors to simply work towards low-to-minimal-impact research and submission to journals with rapid turnaround times from submission to final decisions. Unfortunately, this adds to the body of research that is not particularly relevant and provides minimal to no impact on clinical reasoning or execution.
How do we solve it?
There is no one solution to this issue. On one hand, abolishing the current system of appointing surgical posts is possible. However, this is unnecessarily disruptive and could leave the training system in disarray. Furthermore, a switch to a different training post allocation system may not necessarily result in the best possible candidates being appointed for higher surgical training posts. Perhaps a way forward would be to acknowledge how the current processes could be adapted to take a more holistic view of how research acumen is assessed.
One such way of doing this could be to weight each publication according to the positive impact it provides. By consideration of the journal, its peer review process (single blind or double blind) and its readership, the benefits the research adds to the current body of literature could be more accurately contextualised. This could help shift trainee focus away from the nature of high-volume, low-quality publications and towards high-quality, high-impact publications. Another approach could be to change the focus of the research section from number of publications to the acquisition of research skills. Assessment on the understanding of research methodology and their applications to clinical practice may be a more valid way of assessing a candidate and provide a better representation of ideal candidates. This is already formally assessed at interview prior to entry into higher surgical training through critical appraisal of research articles. However, adding this to the annual review process may provide a better representation of trainee progression and insight into how those skills will be applied in the future.
"Perhaps a way forward would be to acknowledge how the current processes could be adapted to take a more holistic view of how research acumen is assessed"
Interestingly, a similar approach to this appears to be taking root for medical students as they transition to foundation doctors. Recently, it has been announced that the UK Foundation Programme Office has made changes to the foundation programme scoring by discarding the points allocated to educational achievements such as additional degrees and publications effective from 2023 [7]. This is on the basis that the opportunities to undertake additional degrees are inconsistent and the increased uptake of additional achievement has resulted in less differentiation between applications [7,8]. It can be argued that this development negatively impacts the research community by driving students and early-stage clinicians away from developing academic and research skills. However, it is entirely possible that this change alleviates the pressure to publish in a saturated environment and, hence, reduces the ongoing flux of low-quality, high-volume publications. The effect of this change is yet to be seen but will become apparent in the next few years as new foundation trainees progress through their careers.
In summary, national selection enables stratification of eligible candidates in order to identify those most suited to higher surgical training. However, the research section of the portfolio in its current form may not accurately distinguish between candidates who have developed research skills that will be beneficial to their careers from those who have low-quality, high-volume publications. There is no definitive solution to this issue but considerations about the focus of marking and assessment of research skills could be important first steps in addressing this problem.
References
1. Health Education England. Medical Specialty Recruitment 2022.
https://specialtytraining
.hee.nhs.uk/Recruitment
2. Health Education England. Competition Ratios. 2022.
https://specialtytraining.hee
.nhs.uk/competition-ratios
3. Leiberman D, Myat D, Kausar A. ST3 national selection for surgical specialty training in the UK: a comparative analysis. What role does the portfolio play in assessment for entrance onto a Higher Surgical Training programme? RCS Engl. Bull 2021.
4. Health England Yorkshire and Humber. National Otolaryngology (ENT) ST3 Recruitment 2022.
www.yorksandhumberdeanery.nhs.uk/
recruitment/national-recruitment/national
-otolaryngology-ent-st3-recruitment
5. Bazoukis G. Prestige bias--an old, untreated enemy of the peer-review process. Hippokratia 2020;24(2):94.
6. Ioannidis JPA. Why Most Published Research Findings Are False. PLoS Med 2005;2(8):2-8.
7. Tonkin T. Additional achievements ruled out of foundation programme applications. BMA. 2020.
www.bma.org.uk/news-and-opinion/
additional-achievements-ruled-out
-of-foundation-programme-applications
8. Nabavi N. BMA strongly opposes changes to foundation programme applications. BMJ 2020;371:m4837.
All links last accessed October 2022.
