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There is a tendency in medical education at the moment to bring together the postgraduate and the undergraduate into a set of unified frameworks. We see examples in regulatory standard setting—for instance, the UK's General Medical Council has recently released a single framework for the approval of trainers1 and is developing a unified set of training standards2—and in curriculum design where CanMeds 2015 aims to service the continuum of medical education from undergraduate years to continuing professional development and beyond.3
Despite this comforting homogeneity there are some issues, challenges and practices that, although not absolutely unique to postgraduate medical education, arise from a particular set of relationships between trainee, trainer, the training institution, employer, commissioner, regulators (both those of service and education) and, of course, patients and carers. At the heart of the matter is a managed tension between service and training with the learner as employee. Unlike undergraduate students, postgraduate trainees are registered professionals carrying a particular set of expectations on their shoulders while necessarily performing at the limits of their competence. Including learners within the workforce raises some complex issues about workforce planning, recruitment and selection as well as the construction of training programmes. Training ‘in-service’ brings with it a concern for patient safety, so there is a need for supervision and a particular set of educational approaches. In addition, the learner's employed status brings into play some thorny human resource issues as well as a complex triangular relationship with those who ‘own’ the training. All of this is played out within a set of organisational structures that, because of their proximity to politics, are subject to regular review and reform.
The purpose of postgraduate medical training is to provide a particular geography with a workforce that will serve the future health needs of …