The Medical Training Review (MTR), published in October 2025, is the biggest shake-up of postgraduate medical education in nearly two decades. Much like the Calman reforms and Modernising Medical Careers, this report is interesting as it basically asks whether whether small changes are needed to improve things, or whether a fundamental rethink into how doctors are trained is required. The spoiler is that we are beyond the small tweaks stage and more significant reform is required. For emergency medicine (EM), this will obviously have some implications as we have our own training speciality training program, but we also rely on and train doctors with career pathways that don’t lead to a CCT in EM. The bottom line is that any significant reform will imapct on EM.

This blog is my early thoughts on the review and not the college perspective (I am currently Dean). That will come later once the various different parts of college have time to consider the implications and more importantly the actions that come next. The College repsonse is now agreed and you can read it here.

What the MTR says

The report identifies four big problems with current training:

1. Inflexibility. Early career doctors feel locked into rigid pathways with little ability to adapt training to their career needs or personal lives. I certainly see this amongst many RDs I interact with. It’s esepcially hard for those who have famiy/personal commitments that are not enough to mandate a specific adustment.
2. Artificial divisions. The sharp line between those “in training” (with numbers) and those outside it (LEDs, SAS doctors) no longer reflects reality. Many doctors get substantial training in non-training posts. In EM our services have many LED/SAS docs in them. Perhaps more than many other specialities so this is particularly pertinent to EM.
3. Bottlenecks. Competition ratios are higher than ever, especially in popular specialties. This makes career planning unpredictable and adds stress for trainees. In the last recruitment round there wre 14 applicants for each EM training post. That number has been rising year on year. This creates real problems for RDs but also for the application process itself.
4. Loss of team structure. Doctors at all levels want to feel part of a team. The old “firm” model had problems, but the current fragmented rota-based system doesn’t provide continuity or belonging. This is an interesting one as the concept of ‘team’ is really strong in many EDs, but it’s not the firm model that we remember from surgical/medical rotations. I’m very much in favour of promoting teams and positive work based culture, but that would need an EM perspective to make it work for us.

The review also highlights:

• Growing reliance on international medical graduates (now 27% of those in training, and much higher in SAS/LED roles).
• Increased demand for flexibility (25% of trainees are LTFT, rising year on year), and rising as people transit through training (much higher in ST6 than ST1).
• A need for training to focus on generalist skills, multimorbidity, frailty and mental health, not just specialty silos. Well we are specialist generalists so no real change for us, although it does mean that EM is an ideal training ground for those who want to retain generalist skills.
• A call to view training and service as part of the same continuum, not a trade-off. This makes sense, and will require a philsophical shift by both trainers and RDs. I’ve always said that most learning does not take place in formal teaching sessions. It takes place during routine clinical shifts. So for me it’s more about defining how, when and where learning takes place as opposed to scheduled teaching time (which is also important, but is not the only time people learn).

The report is over 60 pages long and covers a lot of ground. Obviously I think you should read it all, but if you don’t have time skip to the bottom of the page and read the 11 recommendations as these set the scene well.

Where we are now in EM training

The current RCEM 2021 curriculum is structured around 12 Specialty Learning Outcomes (SLOs). These range from core patient care (resuscitation, trauma, paediatrics, mental health) to leadership, supervision, research, and quality improvement. Training is competency-based, divided into core, intermediate and higher phases.

It already includes:

• Explicit focus on frailty, mental health, and team leadership.
• The need to supervise and support the wider ED workforce (including ACPs and PAs).
• Flexibility via ACCS routes and transferability across acute specialties.

In many ways, RCEM anticipated the GMC’s Excellence by Design agenda and the Shape of Training themes. But the MTR suggests this still won’t be enough. The curriculum is closely aligned to the formal training program, but the MTR suggests that a wider approach to include a broader range of learners may be required. It may well be that a curriculum review will be on the horizon, but knowing how much work that may entail means it’s not something we should jump into too quickly.

What will need to change for EM

So what might we need to think about?

1. Flexibility in entry and progression
   • Might there be more portfolio routes into EM training for SAS/LED colleagues, recognising prior experience?
   • Core training may become less rigid, with modular opportunities to move between acute specialties. That seems to be a feature of the MTR, but that would clearly be a really different way of training, and what would the final product be? Would it still be a uniformly trained consultant or something more variable?
   • We would need to define how equivalence is judged against SLOs outside traditional numbered posts. This could present a whole range of problems (and opportunities), but at the end of it all we must ensure that training is of a high standard and that equivalence really is equivalent. I suspect the GMC will push all colleges hard. on this if it comes in.
2. Blurring the training–non-training divide, if that happens then,
   • How do we ensure that LEDs and SAS doctors get structured access to training opportunities.
   • EDs will have to think of themselves as training environments for all doctors, not just those with NTN numbers.
   • Educational supervision models may need expansion (more faculty development, protected time, and resources).
3. Reducing bottlenecks
   • More medical graduates + fixed numbers of training posts = growing competition.
   • For EM, which already struggles to recruit and retain, this may mean expansion of higher training numbers or alternative credentialing pathways to CCT.
4. Recreating team structures
   • The “firm” won’t return, but EDs will need stronger continuity of supervision and mentorship.
   • This fits with RCEM’s emphasis on developing consultants who can set the culture of the ED and lead teams.
5. Greater focus on generalism and population health
   • EM is well placed here, we already deal with multimorbidity, frailty and undifferentiated presentations.
   • Expect more emphasis on integration with community services, population health and reducing health inequalities.
6. Excellence returns
   • Recommendation 10 states that we need to recognise excellence in medical practice. I’m pleased to see this recognised as such an important aspect to medical practice. We do need to develop and support those who want to lead and develop our speciality (think leadership, research, clinicial, education and more).

How will we need to respond?

For UK emergency medicine training, this review is both challenge and opportunity. Some practical shifts are likely. None of the these are agreed and they may or may not happen, but these are the sort of things I am thinking about at the moment, some of these

• Curriculum revision? – the 2021 SLOs may need refreshing to embed flexibility, portfolio progression, and wider definitions of “training environments.”
• Faculty expansion? – more trainers, more protected time, and recognition that we are training all doctors in the ED, not just our specialty trainees. Who is going to train and fund them?
• Credentialing and recognition? – clearer, fairer pathways for SAS/LED colleagues to progress towards EM consultant roles. So what will a traditional training program look like and will it remain the preferred approach?
• Workforce–training alignment? – if EM is to grow its consultant base, we need funding and posts aligned with population demand. That’s not just numbers but also geography. How will we balance the needs of a population and the desires of qualified clinicians who may not want to live and work in the places with the most need? Could that be incentivised perhaps?
• Wellbeing and sustainability? – rota design, supervision, and cultural change to rebuild the sense of belonging that trainees want. Many EM departments are already innovating here. We hope to see lots of good practice shared and adopted with the MTR as a lever to make that happen.

Final thoughts

The MTR doesn’t tell us what to do as it’s clear that this is the diagnostic phase. But the message is clear: incremental tweaks aren’t enough. Emergency medicine has always been a specialty at the frontline of service and training pressures and so we will undoubtably be involved in any future change. We are an agile speciality staffed by very resilient, adaptable and innovative clinicians and so I can see EM leading a lot of the changes proposed.

Although we don’t yet have all the details, and we will need to see what the next phase of MTR looks like, it’s reasonable to ask us all, and especially those in leadership positions to answer the following…

If we had to redesign training for our specialty today, from the ground up, how would we do it?

So how would ‘you do it’? I’d really like to know.

vb

S

The recommendations

1. Recommendation 1: We recommend that a reform of postgraduate medicaleducation and training is undertaken as a matter of urgency.
2. Recommendation 2: Addressing bottlenecks at all points in training anddevelopment should be considered urgently. This will have to include consideration of the right ratio between new international graduate entrants to medicine in the UK and those who are already working and training in the NHS, taking into account the workforce need.
3. Recommendation 3: Training should become more flexible.
4. Recommendation 4: All doctors working in the NHS should be supported to progress and the differentiation between ‘training’ and ‘service’ roles should be made less rigid for doctors early in their careers. We recognise, however, that progression will not be at the same rate for all doctors.
5. Recommendation 5: The output from the review of rotational structures must be incorporated in the wider reforms.
6. Recommendation 6: Reform of medical training must consider the need to provide a medical workforce across the country for the whole population equitably. This means changes in medical school places and training places should take account of where medical need is growing and will grow in the future; this is seldom wealthy metropolitan areas. We recognise that there is a tension between this need and the geographical preferences stated by resident doctors.
7. Recommendation 7: A strategy to deliver educators who are supported and enabled to train the future medical workforce in a fit for purpose environment and with transparent funding should be a fundamental part of NHS reform. Training reform should aim to make the role of the educator less rather than more bureaucratic.
8. Recommendation 8: Resident doctors training in craft and procedure heavy specialties must have time to develop procedural skills, particularly early in their training.This includes requiring the independent sector to provide training if the NHS is commissioning and paying for the procedures it undertakes.
9. Recommendation 9: We should work with the other UK nations to support the GMC’s review of standards and outcomes and subsequent review by colleges of postgraduate training curricula, including considering changes from the 10 Year Health Plan. This will include maintaining generalist skills while specialising; and ensuring digital skills for all doctors, which are essential for future patient care.
10. Recommendation 10: The recruitment to medical training should be reviewed to ensure it supports future models of training delivery and training flexibility and is fair and equitable to all candidates, while aiming to recognise excellence in medical practice.
11. Recommendation 11: Clinical academic medicine is essential for the delivery of healthcare now and in the future, both in academic centres and across the NHS. This workforce should be developed to meet the current and future population health needs, particularly in primary care, community and public health settings.