I wrote the following as an entry for the Royal College of Physicians Teale Essay Prize 2017. The essay title was: How do trainees engage with the RCP and vice versa? – is this a case of a long distance relationship – how can we make this marriage work better? I did not win, but I am sharing here as a provocation. What should postgraduate education look like, and how do we get there?
The RCP suggests that the relationship it has with trainees is akin to a marriage and wonders how to make it work better. The definition of marriage, matrimony, or wedlock varies between cultures and countries and continues to be debated, but in general it is an institution in which a relationship is recognised, and rights and obligations are established between the participants. People marry for a number of reasons: legal, social, financial, emotional, and religious, and there are different models of marriage which include: arranged marriage, child marriage, forced marriage, and polygamous marriage. Similarly, trainees’ motivations for joining the College are emotional, since being part of a collective engenders a sense of belonging, but also financial, since it is a requirement to progress through medical training to CCT.
It is interesting to consider the parallel histories of the RCP and the institution of marriage. In both, there has been a trend towards equal rights for women, which nonetheless remains a work in progress. Historically married women have had very few rights of their own, being considered the property of their husband. As such they could not own or inherit property, or represent themselves legally. The rights of women to have legal identities of their own, to have control over their own bodies, to not suffer rape within marriage, and to have access to contraception and abortion, have been hard won and remain under threat dependent on the whims of the political party in power. Meanwhile, during the first four centuries of the RCP’s history, women were excluded from membership. It was not until 1909, when a bylaw was passed allowing them to take examinations that they became part of the College at all, and it took until 1934 for the first woman Fellow to be elected. Of the 121 presidents of the RCP only three have been women: Dame Margaret Turner-Warwick elected in 1989, Dame Carol Black in 2002, and Prof Jane Dacre in 2014.
Both institutions have been slow to change but some progress has been made. In terms of legal recognition, most states limit marriage to opposite-sex couples. Yet over the 20th century a growing number of countries and states have recognised inter-racial marriage, inter-faith marriage and same-sex marriage, though these remain illegal in many countries. Another ancient institution, The Church of England, is currently facing a crisis due to opposing views on its stance on same-sex marriage and the marginalisation of LGBT members.
Aside from this worrying historical context, it is relevant to consider how common marriage is among today’s trainees. There were 240,854 marriages in 2013, a huge decrease when compared with the 426,240 that took place in 1972 (the generation of the leaders of the RCP). Analysis by the Marriage Foundation, using the latest Office for National Statistics data, suggests that only half of today’s 20-year-olds will ever marry—52% of men and 53% of women. In addition, divorce rates remain high; there were 111,169 divorces in England and Wales in 2014 – that’s 1 in 3 marriages. In contrast, cohabitation has dramatically increased in the past 50 years; in the early 1960s less than 1% of adults under 50 were cohabiting, compared with one in six in 2010. Generation Y is seeking new structures for romantic and sexual relationships, less constrained by traditional societal expectations of class and gender. Interestingly if the trainee-RCP relationship is a marriage, then polygamy is the norm for the College, which is financially dependent on its many trainee ‘wives’ for its existence, but a rarity for trainees who pay a financial penalty if they wish to be a member of other Royal Colleges.
Doctors are at the more conservative end of the spectrum of their peer group, and many continue to choose to tie the knot. But the spousal role continues to evolve, and the RCP can learn from this evolution in how it should view its own role in the lives of trainees. Spouses historically satisfied a need for resources, safety and security, and for feeling loved and cared for. In modern marriages we also expect support for personal growth and fulfilment and a need for self-esteem and self-actualisation. This has placed significant pressure on modern relationships, with partners expected to be our best friends, confidants, lovers, intellectual challengers, and biggest supporters. Recognition that this is too much to expect from a single relationship is leading to a more honest approach to modern marriage, with people prioritising quality time with others outside the couple, and the needs of an individual fulfilled across a number of relationships with friends and extended family.
So if a marriage is a problematic analogy, is a long distance relationship a more appropriate metaphor for the relationship between trainees and the RCP? The high expectations of each interaction, the long periods of silence between communications, and the frustration that comes with feeling disconnected and misunderstood are familiar. But this still frames the interaction as a romantic partnership. Is there a trainee who pines for the RCP, who constantly checks their phone for a text or email or gets butterflies when fantasising about the next meeting? The use of these romantic metaphors suggests a worrying misunderstanding of the interaction between the College and trainees. It also suggests an equal partnership, which is far from the reality. Trainees are dependent on the RCP for professional recognition and progression, and their fate is determined by their ability to pay for and pass a number of exams, navigate the clunky and inadequate ePortfolio, and provide evidence for a seemingly ever-increasing number of hard and soft skills. The RCP could more plausibly be characterised as paternalistic, determining what is best for trainees and deciding how they should approach ensuring they achieve their potential. But trainees pay for the input of this fatherly figure, a strange setup indeed. We must acknowledge that we are not equal partners, and our relationship does not have the closeness of any familial connection or even friendship.
This is not to say that the relationship is not valued. Although the history of the RCP is not perfect, there are many achievements which instill a sense of pride in its trainee members. It has a proud history in shaping public health policy, from a report on the dangers of excessive gin-drinking in 1726, to the landmark report ‘Smoking and Health’ of 1962. It continues to encourage public debate and inform policy on contemporary issues such as fizzy drink levies, sustainability, climate change, and air quality. The RCP also continues to play a vital role as a voice of physicians. This is particularly true when it comes to education and training, and a number of recent documents are excellent resources for both trainees and educators: ‘Quality criteria for core medical training’; ‘Acute care toolkit 8: The Medical Registrar on Call’; ‘Underfunded, underdoctored, overstretched: the NHS in 2016’; ‘Being a Junior Doctor’; and ‘Keeping Medicine Brilliant’ – all of which bring the voices of trainees to the fore, provide examples of good practice, and give practical advice to Trusts. When representatives of the RCP speak to the GMC, to political parties or to government, the ability to amplify the voices of trainees on issues as diverse as: staffing levels; training pathways; seven-day services; digital records; assisted dying; and the NHS post-Brexit, is vital and valued. The direct support and training provided to clinical and educational supervisors is an essential component of quality-assured training programmes. The relevance and high quality of teach-ins and other educational events, and the ability to watch these online is appreciated. ‘Spotlight’ interviews provide an insight into specialty roles and inspire the next generation of aspiring physicians. The work that goes into making the MRCP(UK) exams rigorous, respected and relevant is valued; the qualification remains a treasured badge of honour for good reason. The RCPs commitment to trainee representation on decision-making committees fosters trust, empowerment and a shared purpose. In addition, innovative programmes such as the Medical Training Initiative model progressive attitudes to migration and inclusiveness, and show the value of a global skills exchange.
Trainees ultimately value the relationship with the RCP, and are hoping there will be no threats of a break-up as a result of this frank exchange of opinions. But perhaps some couples counselling would be beneficial. As any relationship counsellor will attest, communication, respect and compassion are the foundations of a healthy relationship. The RCP should take an honest look at what it does and does not provide for trainees, evaluate how it chooses to spend its’ time and effort, and create opportunities to spend more quality time together. Trainees should consider how they can be more active partners in this relationship, and how they can ensure their expectations of the RCP are realistic when seen as one amongst a number of partners, each of whom has unique qualities and strengths. If we all take this advice to heart we have a healthy future ahead of us as just good friends.