Why UK Junior Doctors Defer Postgraduate Training

JOURNAL OF CONTEMPORARY MEDICAL EDUCATION, 2019 VOL 9, NO. 3, PAGE 66–74 10.5455/jcme.20190325094530

ORIGINAL RESEARCH Open Access Why UK junior doctors defer postgraduate training Gareth Huw Jones1, Melanie Dowling1, Shirley Remington1, Jeremy Brown2 1Health Education England North West, Manchester, UK 2Faculty of Health, Social Care & Medicine, Edge Hill University, Ormskirk, UK

ABSTRACT ARTICLE HISTORY Objectives: National surveys have identified a declining trend in UK Foundation Year 2 Received March 25, 2018 doctors (FY2s) entering directly into training positions. Last year, less than half entered Accepted September 17, 2019 training directly. We aimed to investigate the reasons why current FY2s choose not to Published October 12, 2019 enter training directly. KEYWORDS Methods: This is a qualitative study using semi-structured interviews. We used thematic framework analysis to code the data into themes for analysis. Postgraduate medical Results: “Feeling unprepared for training” and “lack of flexibility” were the two main education; work-life balance; specialty training; themes identified from the interviews as the reasons to delay training. A lack of clinical career choice exposure and career advice were cited as the reasons to feel unprepared. Flexibility was very important in terms of family considerations, working abroad, and financial reasons which were felt to be absent from a rigid training program. Conclusion: Defering training after FY2 appears to have become normalized in the UK. Many other international training programs appear less structured than the UK and expect juniors to spend time in non-training jobs prior to entering training. It is impos- sible to say which system is superior but it appears no system can dictate the speed of postgraduate medical training.

Introduction The UK program (UKFP) organize an annual - national junior doctor survey to monitor the career mandated the reduction in junior doctor working aspirations of the next generation of clinicians [1]. to 48 hours a week along with the rules on peri Over the last 7 years, there has been a concerning ods of rest. This was introduced between 2004 and trend of year on year decline in FY2 doctors enter- around2009, before the time which of juniors the current were workingtraining upwardmodel: ing directly into training positions. Only 37.7% of of 90 hours a week. This was introduced roughly last year’s FY2s made the transition. In 2011, this - - ducedModernising mainly Medical because Careers of concerns (MMC), about which signif was- - icantimplemented numbers in ofthe junior UK in doctors2005 [2,3]. languishing It was intro for figure was 71.3% [1]. Large numbers of FY2s leav ing to work in Australia is a commonly held misbe lief. According to the UKFP survey, only 11.3% had ayears specialty in non-training training (ST) jobs scheme. at Senior The House aim of Officer MMC theeither last secured 10 years. or The were big applying changes for have jobs been outside in those the (SHO) grade while they waited to be accepted onto UK a figure that has remained relatively static over vs. was to add structure to these early junior doctor FY2’s taking a career breakvs. 2.3% from in 2011)medicine [1]. (14.4% years and streamline training by moving toward a 4.6% in 2011) and those taking up non-training- competency acquisition model with “fully trained” rentjobs inUK the postgraduate UK (17.6% training model came to be. 2Consultants years after providingmedical school more and service is made delivery up of [4].six It is important to understand how the cur The foundation program (FP) represents the first

The European Working Time Directive (EWTD) 4-month rotations through different specialties. Contact Gareth Huw Jones [email protected] Health Education England Northwest, Manchester, UK.

© 2019 The Authors. This is an open access article under the terms of the Creative Commons Attribution NonCommercial ShareAlike 4.0 (https://creativecommons.org/licenses/by-nc-sa/4.0/). Factors influencing UK doctors career

Recruitment - FoundationFY1 is the first Trainees of these (FTs). years The and FP FY2 aimed the second.to pro- These junior doctors are collectively known as - We approached FY2s at their weekly hospital teach ing to explain the project, issued them with inten vide a wide basic grounding in clinical practice and betion audio to participate recorded formsand transcribed. and information Transcriptions booklets a broad exposure to career opportunities, with the on the project. This explained that interviews would FP acting as “a bridge between medical school and specialty training [2].” Following the FP doctors, would contain no identifiable information and seecomplete a doctor between rotate through3 and 8 yearsseveral of different supervised hospi ST.- audio files would be deleted oncen transcription tals.ST is On typically completion in one of ageographical set training, curriculumregion but willand excludecompleted. FY2s All enteringinterested training FY2s signed from anbeing intention inter- examinations a doctor is deemed fully trained and to participate form to take part ( = 18). We didn’t- eligible to apply for permanent job as a Consultant. In the UK, a Consultant is fully accredited by the viewed to reduce selection bias and hear alterna- tive insights. Of the 18 FY2s that agreed to take part 11 answered the video call, confirmed consent ver relevant governing body to work in their specialty ballyProcedure and were interviewed. post-graduatewithout clinical training supervision. scheme to the UK. Their medicalInternationally, graduates Australiaspend one has year the mostcalled similar Post- graduate year 1 (PGY1) experiencing different Pilot interviews with two FY2s were conducted to- ensure the interview structure produced data to expected that on completion of PGY1 junior doctors satisfy the aim [7]. The final tool was revised fol specialties before entering training. It is, however, lowing the pilot. specialties in a public or community hospital, as Interviews were conducted via Skype, which was trainingwill spend jobs at are least in high another demand year and rotating very compet through- themore research convenient team for for the its intervieweesability to promote compared a more to face to face. Video was preferred to telephone by simultaneously addressing service needs [5]. This - isitive. similar This isto desired the UK to system build theirprior experience to MMC. In while the scribed.trusting interviewThe lead environmentauthor conducted [8]. all 11 inter- Netherlands and Germany, junior doctors achieve The interviews were audio recorded and tran full medical registration on completion of medical - school enabling them to enter specialty training views to maintain consistency. Open questions and a - usedpre-prepared to create structure common werecodes. used We adheredto keep the to estab interview on theme. Thematic framework analysis [] was directly, although most choose to work in non-train lished techniques of data capture and analysis to Aiming positions first to build experience [6]. - ymousensure transcripts credibility andindependently transferability. to add Two reliability authors training positions directly upon completion of the (GHJ and MD) independently interrogated the anon FP.To explore the reasons why UK FY2s do not enter to the results [10]. In areas of disagreement, the two Method Resultsauthors deliberated until agreement was reached. Ethical considerations seven male and four female FY2s. Thematic analysis Semi-structured interviews were carried out with England’s Research Governance Committee. This study was approved by Health Education - Design and setting stratedof the transcribed in Table 1. interviewsNine FY2s generatedout of our a cohort series of codes, grouped into two thematic categories demon

elevenFeeling wereunprepared not entering for training a training position. We used semi-structured interviews rather than focus groups or questionnaires. We felt interviews - ing job in a speciality if they had not experienced it would give everyone an equal voice and produce average sized UK district general hospital in July Several FY2s were not willing to apply for a train 2017richer just insights. before We the conducted end of foundation the interviews training. in an during the FP. This was despite having an interest www.jcmedu.org in it: “I wanted to get more experience before I got67 Gareth Huw Jones, Melanie Dowling, Shirley Remington, Jeremy Brown

Table 1. Thematic codes grouped into two main categories based on analysis of the interview transcripts. Category 1 Feeling unprepared 2 No Flexibility exciting. Better work life balance. Plus, the money is for training better as well”—FY2 J. Codes 1.1 Clinical experience 2.1 Friends and Family Family planning later in life was another reason 1.2 Career support 2.2 Financial why FY2s wanted to travel before entering training.- 1.3 Employment rules 2.3 Travelling/ Working abroad “I’ve got no ties down here at the moment, if you do thatUK-based later on innon-training your career, jobs,it could commonly be more diffipaid cult”—FY2 A into core surgical training. I’ve never had a surgical by the hour (locum) were financially beneficial to - FY2s. Being paid more enabled them to work less- itySHO outside job”—FY2 of the A. Somesix allocated FY2s were specialities aware of “tasterin the dentand this debt was and important save up for for house their workdeposits life orbalance. exam weeks” as a way to do work experience in special Being paid better also enabled them to pay off stu foundation programme. Those who did manage to fees. “The exams are expensive and I’ve got student do this work experience only managed a couple of Discussiondebt to pay off”—FY2 H days and felt this to be too short: “Taster weeks— that would have been really helpful for me”—FY2 B. Feeling unprepared for training There was also a frustration that the majority of Choosing one’s specialty is a huge decision that time during the Foundation Programme was spent thecompleting job doesn’t paperwork give the rathercorrect than amount having of exposurehands on clinical experience: “Doing paperwork like 80% of most FY2s interviewed were not ready or prepared to make. What “life is like” as a consultant is an to commit”—FY2 E. The FP didn’t give the junior important career consideration which is often not doctors a true reflection of what a Consultant job- dorealized not apply during as they the FP.have Application not yet experienced for specialty all was like in that speciality. training is about halfway through FT so many FY2s A poor understanding of the employment reg hadulations a spouse for training or partner jobs wasapplying another for commonlyjobs, they six rotations. Others take a year out to work in a cited reason to take time out before training. If FY2s specialty which they didn’t get to experience in the- FP. “Taster weeks” of work experience in a choice often wanted to delay applying for their own job of specialty were brought in to provide this expe until they knew where their spouse or partner’s job rience but according to our cohort are difficult to was. They were unsure whether a dual application achieve and provide only a flavor of the career. ruleswith asurrounding spouse or partnerspeciality was and possible. location The transfers FY2’s Mentorship of FTs appears to be lacking in the interviewed reported a poor understanding of the FP. This may be down to the mismatch between FTs amout ofto hours5 pm. shiftThis workingreduces andopportunities Consultant for job junior plans once a training job had started: “(If transfer) rules doctorswhich are to attend not exclusively experiences, but such mostly as clinic weekdays or the 8- were a bit clearer then that would make applying No flexibility easier”—FY2 G - sultantsatre, which and better opportunities reflect the for reality career of discussions. a specialty. RecentSimultaneously, surveys thisof junior reduces doctors interactions and consultants with con Specialty training was perceived as very rigid by - the FY2s interviewed. They were worried that once- rimental to training [11,12]. training had started there would be no opportunity support this theory and felt shift working was det to take a training break or switch location if life cir cumstances changed. Every FY2 we interviewed Today’s FTs are faced with a large burden of- expressed a desire to travel and work abroad. It- torsclerical has tasks,fallen whichgiven that is multifactorial. the numbers Oneof medical might was generally felt that it was better to travel with- wrongly believe that the workload for junior doc ingno familyup a training or professional job for fear ties. of It negative was felt stigmathat trav by in the year 2,000 to above 7,500 in 2012 [13]. The seniorelling mightclinicians not and be possiblefuture employers. during or Travelling after tak graduates increased in the UK from below 5,000 at any one time has conversely fallen dramatically number of junior doctors physically on the wards and working abroad was believed to be exciting, fun 68and financially lucrative: “Being abroad is just more over that time. ThisJ Contemp is because Med Edu of • two 2019 factors. • Vol 9 • IssueFirst, 3 Factors influencing UK doctors career introduced. Second, the unintended consequence - ofthe abolishing halving ofthe working SHO grade hours mean since today’s EWTD juniors was ingmedical for a students training willposition apply in for a positionsspecialty of directly their pass through to specialty training in less years with a hospital and build up experience until apply- compared to their predecessors. Simultaneously, ing training is typically because the application processchoice [6]. is competitive In these countries, and time the is required delay for to enter build patient is felt to have increased. Patients in today’s up experience. In the UK, completion ratios have ageingthe amount UK population of clerical have work more associated complex with health each - ties experiencing gaps. The delay in the UK as our resultsfallen across demonstrate all the specialties cannot be with blamed some onspecial over NHSneeds IT and systems together are frequently with increasing cumbersome beuracratic and competition but in part because of poor experience proneregulation to failure, means morefurther clerical increasing tasks the per burden. patient. during the FP (internship). forced instead to sit in front of a computer complet- No flexibility FTs can go all shifts without speaking to a patient, opportunity in performing referrals, investigation requestsing clerical and tasks. discharge While letters we acknowledge this needs to learning be bal- In his report titled “Unfinished Business,” which preceded MMC, Liam Donaldson, the Chief Medical Officer at the time, suggested a time limited, broad- acuteanced clinical with adequate care responsibility patient interaction. reducing specialty Studies based program to address the unstructured “SHO”- have described how excess clerical work reduces- grade. He emphasized the importance of flexible sure, it can be expected that junior doctors feel training that facilitated movement between train anxiousexperience about [14]. future With underperformancea reduction in clinical in a expo cho- theing pathwaysdesign of thewith current sufficient training opportunities program forand part- it is time training [3]. This report heavily influenced- atsen medical specialty. school Research is improved looking it specifically reduces the at stressFTs is interesting that we are re-visiting the themes iden- lacking but we know that when clinical experience tified as pitfalls a decade ago. Extrapolation of this principle supports the previ- Many junior doctors undertaking early postgrad felt by junior doctors when starting the job [15]. manyuate training starting are families, at a stage moving in their geographical lives when theirloca- is another reason to feel unprepared to apply. personal circumstances are rapidly changing, with ous point of increased performance anxiety, which Training programs are perceived to be rigid by tion, starting a new job, or looking to travel abroad.- easierIt would to understand be helpful and to today’smore accessible. FY2s if training Career ing for further training for fear of being trapped in a rules such as deanery or specialty transfers were junior doctors, which discourage them from apply and junior consultants being utilized more as career guidance should be improved with senior trainees specialty that later turns out to be ill-suited. A good- work-life balance is important to today’s junior mentors. They are likely to be best placed to advise vs.doctors with recent graduates valuing domestic cir on the training pathway, interview requirements cumstances higher than their predecessors (43% and end job specification. We should be concerned reported 20% said internationally. it held a “great In Germany, deal” of 50% influence of medi on- thethat clerical despite burden a 4-month appear rotation to be havingsome FY2s a detrimen do not- career choice) [16]. This phenomenon has been talget effecta real onfeel clinical for a specialty. exposure. Anti-social This presents hours a realand challenge but is essential to the NHS that junior cal students would like the option to work part time in order to spend more time with family and they care standards. disliked rigid hospital hierarchies [17,18]. doctors are retained and well trained to maintain Family planning is a key consideration in the lives of many junior doctors. It undoubtedly influences internshipThere are (rotating only a fewthrough countries a mix worldwide of specialties) (UK, areathe timingbefore starting of training a family. application, This may withforce them couples to atAustralia, the beginning New Zealand,of their postgraduate and Ireland) training. that use The an holdobviously off applying wanting for to a be training in the job same until geographical one in an rationale for an internship is robust as it should appropriate area comes along. Inter-deanery trans- - fers are available to mitigate for this problem but - anteed.enable newIn countries doctors insightnot offering into different an internship, special employers. ties. As our research shows this insight is not guar are not easy to obtain and not widely advertised by www.jcmedu.org 69 Gareth Huw Jones, Melanie Dowling, Shirley Remington, Jeremy Brown

qualitative research, supervised the structure of the

Financial considerations also play a key role in career decision-making. University debts are interviews and analysis. The themes identified are haveincreasing disappeared. while privileges Earning oncemoney enjoyed early byin juniorone’s independentlyaligned with previously analyzed publishedthe transcripts studies to andensure the careerdoctors, is suchimportant as free to accommodation pay off university and debts parking, and author’s personal experiences. A co-author (MD)

the same themes were identified to ensure inter- enter the property market. Junior doctors can earn rater reliability. We, therefore, believe our findings more working as a locum or abroad, which appeals Conclusionsare credible and trustworthy. anas aimportant short-term part way of to postgraduateaddress monetary medicine. issues. The Travelling and working abroad has always been This year, the numbers of FY2s progressing directly world is becoming a smaller place and doctors Organization report stated a shortage of 2 million into training dropped to 37.7% the lowest figure are in demand globally. A recent World Health FY2, appears to have become normalized. The main ever recorded. Taking time out of training, after- - doctors worldwide. Improved pay and working tion of better lifestyle are commonly cited reasons reasons cited by the cohort we interviewed as rea conditions along with excitement and a percep - sons not to apply for training positions were linked to feeling unprepared and a perceived lack of flex to leave the UK. A national survey found 60% of ibility in training. Based on existing evidence and junior doctors, 3 years post qualification were “not have failed in its objective to streamline training. reflected in our results, it appears that MMC may definitely intent on remaining in UK medicine.” - Reassuringly for the NHS a recent GMC working Certainly, we know an overly rigid FP with high ser paper reported that nearly 90% of doctors are back Other postgraduate training systems around the - vice demands will deter not attracts junior doctors. in training within 3 years of taking a break after FY2 - [19]. However, with rota gaps and service require - of doctors emigrating for up to three years? world appear to be less complex with less struc ments increasing, can the NHS cope with thousands - sibilitytured stepping-stones to build experience on the beforeway to applyingfull qualifica to a doctors abroad. High-income countries, such as tion. Junior doctors in these systems take respon The UK is not alone when it comes to loosing doctors and patients but it appears that no system high levels of emigration. Commonly, cited reasons cantraining dictate job. the It is speed unclear and which direction system of isjunior better doc for- includeIreland, moreAustria, structured and Iceland, training, have better all experienced pay, better tors and their training. progression [20–23]. From our research, the UK work-life balance, and uncertain domestic career Conflict of interest balance and pay as reasons to emigrate but did not feeljunior unstructured doctors concurrently training or poor cite career better prospects work-life interest. The authors declare that they have no conflict of Subject consent Limitationswere issues. -

All FY2s signed an “expression of interest” docu butA limitation could inform of the future study researchis that it atis froma regional a single or ment following written and verbal explanation of centre. It was never intended to be generalizable the study. This was followed up with verbal consent Datajust prior sharing to the statement interview. medicalnational education. level. The Having lead author recently and been interviewer through (GHJ) is a senior surgical trainee with an interest in The transcript data are available on request from - GHJ. the FP, we felt GHJ would be able to relate to the FY2s- and ask pertinent follow up questions during inter Ethical considerations view. The potential drawback is the perceived ques tioning from a recent FY2 may be seen as leading. By England’s Research Governance Committee on 11th piloting the interview questions to ensure, the most MayThis 2017. study was approved by Health Education pertinent questions were asked we guarded against this. SR and JB, both experienced in publishing 70 J Contemp Med Edu • 2019 • Vol 9 • Issue 3 Factors influencing UK doctors career

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