The Postcode Lottery of Medical Training

How it feels to pack up your life at the whim of an algorithm…

I woke up one April morning staring at my laptop screen with tears in my eyes. A computer algorithm had decided that for foundation training I was going to be moving 200 miles away from everything I knew to the rolling hills of West Wales.

So there I was, on the phone with my mother who was desperately trying to console me, explaining that at least it was my 17th choice and it could’ve be lower. “At least you got a job,” she said, as though that was supposed to help. You won’t be surprised to know it didn’t.

Every medical student is aware of this possibility, but to some degree, we don’t really think it will happen to us. It’s far harder to accept the reality that you could be sent anywhere in the UK, regardless of circumstances, than it is to sign-up to play the UK Foundation Programme postcode lottery.

But should you draw the short straw, you’re shipped out wherever the algorithm sees fit, with only a slim chance to appeal.

For me, this turned graduating from medical school into somewhat of a military deployment. Grit your teeth, keep a stiff upper lip, Keep Calm and Carry On…with that discharge summary.

You may have dreamt of a big city hospital, or staying in the same town as your friends or partner. But instead, you could end up hundreds of miles away, all thanks to a computer algorithm.

It’s almost ironic—years of hard work, reduced to luck of the draw. In it’s defence, the system promises fairness, but it’s tough to feel that way when you’re headed to somewhere you’ve never even heard of.

Since removing the situational judgement test and educational performance components from the application process, a small percentage more of applicants do get one of their top choices. However, the price for this has been a complete forfeit of any ability to personally influence the outcome.

Having come out the other side of foundation training with only a few battle scars, I have managed to get a medical job in an area I wanted. I went the old-fashioned way - a CV, job application, and interview. It’s made me wonder: shouldn’t all medical jobs work more like this and less like a game of bingo? A system where experience, choice, and suitability actually matter?

However, perhaps this is simply too much to ask for from a large national programme if we also highly value fairness and standardisation? But I do dare to dream…

The Terminology Time Machine: Outdated Terms In Medicine

Ever been on a shift, reviewing patient documentation, and thought, Did I just step into a medical time machine? You look in the notes to see: ?HONKS. You double-take. Honks? You’re pretty sure that’s a car sound, not a medical term. The registrar leans over: “It’s HHS! What year is it?!”

For those who missed the memo, HONKS (Hyperosmolar Non-Ketotic State) is now known as HHS (Hyperosmolar Hyperglycaemic State). A small change, but enough to throw you back a decade or two.

The thing is, our medical language is a constantly moving target. It seems like every time you turn around, some term gets retired and replaced—leaving outdated terminology. Remember manic-depressive disorder? That term got swapped in 1980(!) for bipolar disorder. Or how about NAFLD? That’s now MASLD (Metabolic Associated Steatotic Liver Disease). It’s not just our patients who get regular updates on their condition; our terminology does too.

These rebrands aren’t just for show. They reflect shifts in understanding, disease associations, and a more inclusive, accurate approach to diagnosing and treating. But they do leave us asking: Are we caught up, or are we walking around with outdated diagnoses in our heads?

Why Gaps in Foundational Knowledge Can’t Be Plastered Over

The foundations of medial education are important for fast and slow thinking…

This week’s BMJ featured a fascinating piece inspired by Daniel Kahneman’s Thinking, Fast and Slow, a book that feels oddly relevant to medicine.

Doctors should know all about fast thinking, or as we tend to call it - pattern recognition: quick, automatic, and mostly correct. It’s the kind of thinking that lets you recall the IV dose of co-amoxiclav without batting an eye—your brain practically prescribes it for you after doing it hundreds of times. But fast thinking, as useful as it is, can sometimes stumble when faced with things outside the usual patterns.

Then, there’s slow thinking: deliberate, methodical, and built on reasoning from the very foundations. This is the mode you enter when a case stops you in your tracks. It might take time, but it’s precise. Slow thinking is what lets you pause, sift through the clinical noise, and unravel the complexity with the quiet confidence of someone who knows their craft.

The BMJ captured this perfectly with the phrase: “Doctors know what to do when they don’t know what to do.” Anyone can pull up a guideline (in their head or on the trusty intranet) and automatically follow it, but the true skill lies in recognising when the situation calls for deviation—when the guideline’s rigidity might not serve the patient’s best interest. That’s the art of medicine: knowing when to think slow.

But to think slow, you need strong foundations. Physiology, anatomy, pharmacology—these are the basics we mastered in medical school and that form the bedrock of clinical reasoning. They’re what make our medical degrees unique, allowing us to treat patients holistically and not just by the book.

This is why the idea of shortened medical degrees and the proliferation of non-medical degrees sends shivers down the collective spine of the OnCall community. If we start prioritising speed and efficiency over depth, we risk producing doctors who are adept at following protocols but lack the ability to reason their way through uncharted territory. Papering over gaps in foundational knowledge isn’t just risky—it’s dangerous.

“Convinced there isn’t a greater feeling than when the anaesthetics reg couldn’t get the cannula that they spend 5 minutes berating me about on the phone”

“Good rule of thumb that was passed down to me: Never cheap out on anything that separates you from the ground. Mattresses, footwear, car tyres, chairs etc.”

“The new Locum rates at University Hospital Birmingham… Forget the widely discussed F1 rate for a moment. The Consultant core locum rate is £75/h?! How little self-respect you must have to continue working at that hospital. This is how much they value you and your time”

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In every teaching session or governance meeting, we hear about the benefits of “flattening the hierarchy.” But are we only getting one side of the story?

The idea is to encourage everyone to speak up when they spot something amiss, free from intimidation—who would argue with that? But does that mean all opinions hold equal weight? The NHS hierarchy isn’t arbitrary; it’s built on experience and expertise. Can we name any thriving business, organisation, or military group that doesn’t have a clear hierarchy? There must be a reason for that.

Somewhere along the way, it seems we’ve mixed up the idea that “every voice is valued” with “every opinion is equal.” Flattening the hierarchy should be about respect and open communication, not erasing the hard-won wisdom of experience. We’re curious—what does the on-call community think about this distinction?