Why we built an alternative IMT pathway

For the past few years, I’ve been quietly running an experiment. 

It started as a local response to a simple observation: we had brilliant FY3s, FY4s and international medical graduates working across our hospitals in central London who were more than capable of progressing into specialty training – but weren’t. 

Some couldn’t secure an internal medicine training (IMT) post because competition ratios for specialty training places were growing so quickly. Others were stuck in locally employed jobs, working hard but gaining little structured educational value. And I was also observing that some doctors were being informally ‘signed off’ for IMT competencies with almost no evidence base at all.

It didn’t feel fair. And more importantly, it didn’t feel safe.

So, at Guy’s and St Thomas’ NHS Foundation Trust (GSTT), and now at Imperial College Healthcare NHS Trust and elsewhere, we decided to do something practical – we created a structured, high-quality, alternative IMT pathway.

We pulled together a group of motivated consultants, IMT tutors and service leads and asked them: if someone doesn’t have a national training number but is clearly capable, how do we give them a real chance to progress? Our answer was simple: to mirror IMT as closely as possible with: 

• a formal rotation covering ICU, geriatrics, acute medicine, cardiology, nephrology and more
• the same curriculum and being assessed against the same annual review of competency progression (ARCP) decision aid as national IMT
• access to teaching, simulation (where possible), local ARCP panels and educational support
• a clear expectation that residents would be treated and assessed as an IMT doctor. 

We also wanted the programme to feel personalised in a way that large, national structures sometimes can’t. We already know many of these doctors as FY3s and FY4s – we understand their strengths, their anxieties and their ambitions. That continuity creates a richer learning environment than the traditional 6-month hopscotch through unfamiliar teams. As we recruit and retain doctors for 2 or 3 years, we are invested in them, and they in us. 

We’ve now supported a growing number of colleagues into IMT3 and subsequently into Group 1 or Group 2 specialties. Imperial is also recruiting doctors into a similar programme. When designed well, these pathways offer fairness, structure and career progression.

‘Watching someone grow over 2 or 3 years – not just clinically, but in confidence – is one of the most rewarding parts of my job. It’s exactly the apprenticeship-style learning that many of us experienced years ago, now adapted to modern training standards.’ – Dr Dan Furmedge, consultant physician 

However, there are challenges which we can’t ignore:

• PACES inequity: doctors on alternative pathways aren’t prioritised for exam slots, although this is improving as the PACES backlog has significantly reduced. 
• Timing of sign-off: we’re asked to commit to ‘anticipated outcomes’ before ARCP is complete. However, this is no different from a formal training programme, where residents apply for posts based on their projected success at ARCP. 
• IMT3 availability: because IMT3 recruitment is still nationally controlled, we can’t always guarantee a third year locally – even when the doctor is thriving – as it depends on local availability of appropriate posts.
• Quality variation: some trust and health boards may not yet have the infrastructure or educational governance to deliver programmes safely.

These programmes are emerging because national pathways no longer meet workforce needs or the realities of modern medicine. The system is adapting from the ground up.

If we want to do this well – and protect doctors and patients – then we need to provide leadership, rather than simply observe change happening around us.