2024 Speciality Competition Ratios: The MSRA - Friend or Foe

How the MSRA is contributing to inflating competition ratios across the board

Doctors, brace yourselves. The 2024 competition ratios are out, and the results are about as fun as a bleep at 4:59pm on a Friday. The system is filled with bottlenecks, leaving some of the most passionate and talented doctors unable to step into speciality training.

No speciality has escaped unscathed. Take Core Psychiatry Training (CT1) for example: the ratio is now a staggering 9.45 applicants per post. For context, back in 2014, it was just 1.3.

One culprit here is the MSRA (Multi-Specialty Recruitment Assessment), which has gone from a simple screening tool to the gatekeeper of speciality training. The problem? The MSRA is a written exam, and while it may test knowledge, it doesn’t exactly scream “holistic selection process.” Psychiatry, more than many other fields, thrives on communication and interpersonal skills. Yet, we're choosing future psychiatrists based on their performance in a written test.

Even more baffling, the MSRA allows candidates to sit one exam and apply to multiple specialities. While that might sound efficient, it’s creating inflated ratios across the board. Suddenly, aspiring psychiatrists, GPs, and obstetricians are all competing in the same exam hall—and they may not even know which speciality they’re truly passionate about. It's like spinning a wheel of fortune and hoping it lands on the right speciality.

To continue with the example of psychiatry, it’s a field that demands passion, patience, and a deep understanding of human behaviour. We need doctors who can show a track record of dedication in their portfolios, not just a single exam result. What we don’t need is a system where someone can just ‘try their luck’ by applying to multiple specialities.

So, is this really the system we want? One where a written test trumps previous experience, passion, and suitability for the role. Or should we rethink the way we select the next generation of specialists—before the ratios reach heights we can no longer explain with coffee and sarcasm alone?

The Magical Sterile Wedding Ring 

We all know the drill: the infection control team cracks down on wristwatches while we take unnecessarily long detours to avoid their glare. “But where’s the evidence?” we ask, only to be ignored. Sure, there’s a theoretical argument that watches could act as a vector for bacteria, but the same goes for fob watches, tablets, and mobile phones—all of which bring the greater risk of requiring touch to operate and are used even more nowadays.

The Oncall Community would understand if the rule was to remove watches during clinical procedures, but staff are asked to remove them in canteens and corridors too. Wristwatches aren’t any more of a threat than plain wedding bands or touchscreen devices, neither of which are banned.

It’s not like the NHS genuinely believes that wedding rings magically repel germs using the power of the sanctity of marriage. Yet, the wedding band gets a pass, while the watch, just trying to tell you when your next break is due, is suddenly the villain.

Are We Hiding Behind the Phrase 'Evidence-Based'?

When to trust the data and when to listen…

We live in an era where the phrase “evidence-based” is thrown around everywhere, and everyone’s doing it! In many ways, this isn’t a bad thing. After all, for something to be “evidence-based”, society must first value, well, evidence. That’s the silver lining, right?

But let’s rewind a bit. Evidence-based medicine (EBM) didn’t just drop into our laps from nowhere. It emerged in the late 1980s as a sort of rebellion against the reigning “expert-based” or anecdote-driven approach to healthcare. Back then, medicine was ruled by whoever had the greyest hair in the room. If Professor So-and-So said it worked, that was enough.

Fast forward to today. EBM has revolutionised how we treat patients. We’ve poured millions of pounds into systematic reviews and guidelines, which have improved patient care in unimaginable ways. Thank you, NICE guidelines.

However—and this is where things get interesting—the phrase “evidence-based” is now sometimes wielded like a magic wand to shut down conversations or to impose decisions. Ironically, the very first page of the NICE guidelines reminds us to not be robotic about it. We are told to consider the values and preferences of patients. Yes, evidence is crucial, but so is the art of listening to a patient's story, respecting their wishes, and recognising that not every clinical decision can or should be purely dictated by the data.

So, while evidence-based medicine is a major triumph (and we wouldn’t dream of practicing without it), let’s not slap an “evidence-based” sticker on every decision and walk away. Patients are more than algorithms, and their care is more than the sum of all the relevant meta-analyses.

What if the 1st line treatment in a guideline is not compatible with a patient's co-existing health conditions, personal preferences or quality of life desire? How have we forgotten this simple truth - guidelines are there to guide… 

“Don’t fret about your mandatory hospital BLS induction, think about the ST7 anaesthetist behind you learning what CPR is”

“How is it that we consider it acceptable as a profession to allow graduates from anywhere and everywhere to apply on an equal footing to UK graduates for higher speciality training”

“Just looking at these inflated competition ratios… I really love my parents, but man they really should have had me sooner”

Email us to share what’s on your mind in our next issue!

Weekly Poll

Last week’s poll:

Would you like to see a return to the firm structures in clinical practice?

Have an idea for our next poll? Let us know!

6 hours into your busy on-call shift, you hear bed 16 break into a series of demands at the new foundation year doctor. ‘Do as I say, I pay your wages’ echoes around the ward. Public sector workers seem to be particularly vulnerable to receiving this sentiment from ill-advised members of the public. Make sure to arm yourself with one of the following: 

1. ‘Well, in that case, can you make sure the ward computer with two working keys is replaced by monday’ 

2. “I’ll settle for my current pay if you get round to approving my leave”

3. “Perfect, we need a new CT machine down in A&E”