Meritocracy in psychiatry training: abandoning the common good

Psychiatrists

Put bluntly, National Health Service England (NHSE)'s Distribution of Medical Specialty Training Programme risks perpetuating elitism in psychiatry.¹ This is a failing in our shared but misplaced value in meritocracy. In this brief letter, we discuss the potential pitfalls of NHSE's current plan and offer the beginnings of an alternative solution.

The origins of meritocracy

Meritocracy in the modern discourse tends to be understood as synonymous with ideas of social mobility and equality of opportunity, but it has not always been this way. The first published use of the term ‘meritocracy’ in English is ascribed to Alan Fox, British employment sociologist and activist.² Fox's 1956 essay which coined the term argued that meritocratic systems (which had long existed but lacked formal nomenclature) held limited egalitarian value and are, in fact, counterproductive to such a cause. Social equality, he argued, would not be achieved when ‘the gifted, the smart, the energetic, the ambitious and the ruthless are carefully sifted out and helped towards their destined positions of dominance’, as in a meritocracy.²

The term gained popular traction two years later with the publication of The Rise of the Meritocracy, a bestselling satire by British sociologist, activist and politician Michael Young.³ Young, like Fox, used the term with critical intent. His essay imagines a dystopian future in which those excluded from success in a meritocratic system revolt against high-IQ elites who, steadfast in their conviction of entitlement, had lorded it over everyone else to the point of rebellion.³

Meritocracy in medicine

Recruitment to medical training posts is rooted in meritocratic ideals. Welcomed as a departure from the plutocratic, nepotistic and aristocratic ideals of old, meritocracy refers to a system whereby individuals are selected or rewarded on the basis of ability and achievement, rather than factors such as social class, wealth or connections. The Royal College of Psychiatrists has enthusiastically endorsed this approach, referencing its commitment to meritocratic principles in its Equality Action Plan, and titling its manual for prospective trainees ‘Be the best. Be the brightest. Choose Psychiatry’.⁴

Such meritocratic principles are not without their contemporary critics. Michael Sandel, professor of political philosophy and justice at Harvard University, argues that meritocracies do more than align people's roles with their skills and abilities; they bestow upon the successful a sense of moral deservingness which is rarely well placed.⁵ Parents have figured out ways to confer privilege on their children in meritocratic systems, much as they did in the aristocratic systems that preceded them. What follows is a sense of hubris among the winners and, consequentially, resentment among ‘the losers’. The idea that ‘I deserve my success’ and that ‘you deserve your failure’ is corrosive, Sandel argues, of the common good.⁵

NHSE and the intelligentsia

NHSE recently announced its plan to relocate training posts from London in an attempt to ‘level up historical, regional health inequities’ across England.¹ The move will see London lose 136 psychiatry training posts by 2030, far more than in any other medical specialty.¹ What NHSE has failed to address is that by reducing training numbers in London so dramatically without challenging the meritocratic principles underlying the selection process, competition ratios for the remaining London places will skyrocket. Soon, London's ‘unparalleled specialty training and learning environments, innovative research projects and exposure to industry experts’ may only be accessible to a small number of hyper-elite trainees who, concerningly, may believe their position is wholly deserved. ¹ Might Young's dystopia be realised in the microcosm of medical specialty training? London trainees already enjoy access to the finest facilities in the land and outcompete almost every other deanery in terms of pass rate in MRCPsych exams.⁶ For the lucky few who snatch the highly coveted places in future years, a wealth of opportunity awaits. Having to share their resources with far fewer trainees may lead to the emergence of a two-class system in psychiatry – the elites and the non-elites, London and the rest.

Correcting the course

Sandel offers a radical alternative to the status quo.^5,7 Institutions with far more applicants than places should sieve out those unqualified for their positions, and from the rest, admit by lottery. A similar system has been devised for the UK Foundation Programme with the introduction of Preference Informed Allocation.⁸ For specialty training, the lottery could be weighted to ensure appropriate diversity within the cohort. This approach makes clear a difficult truth to both the winners and losers: There is a lot of luck involved in ‘success.’^5,7

For a less radical solution, Michael Marmot's principle of proportionate universalism may be applied.⁹ Invest in improving poorly performing training programmes most, and in a graded way towards the best, so that trainees can choose to train outside London without sacrificing quality. Rather than forced relocation of trainees outside the capital, instead offer enhanced training opportunities elsewhere, and drive up the quality of training in regional England to match that offered in London. NHSE speaks of ‘levelling up’, but under its current plans, seriously risks losing the best and brightest to other specialties or worse, creating a two-class system ripe for revolt.