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Out of Programme Time: Maintaining Clinical Skills

There are many reasons why trainees choose to take time out of programme (OOP).  Examples include the pursuit of further education and scientific research or to take advantage of teaching opportunities. This benefits the profession by enriching the experience and aptitudes of trainees, ensuring we have a diverse range of skills in our future consultant body. However, anyone who has taken time out of clinical training will know how quickly the routine of hospital life and work becomes unfamiliar. Additionally, medical practice is constantly evolving with new pharmaceutical products and clinical guidelines regularly introduced.

The provision of excellent, up-to-date, safe and dignified medical care to older people should always be at the centre of our working lives, however diverse our future roles may be. Thus, the potential decline of clinical competency whilst out of programme may concern some trainees and present a barrier to considering a PhD or other project. To enable trainees to overcome this barrier it would be useful to have a clear idea of what the national training colleges and post-graduate medical deaneries expect of trainees, who need to maintain clinical skills whilst focusing on academic or other non-clinical interests. It would also be informative to have an idea of the strategies adopted by others who have taken time OOP.

Currently there is no formal guidance on this issue. It becomes an individual choice with factors such as year of training, total time spent out of programme and ease with which continued contact with clinical services can be achieved. The ‘Gold Guide’ is the reference document for post-graduate specialty training in the United Kingdom and was produced as a result of the Modernising Medical Careers initiative.  The Gold Guide makes clear that trainees out of programme should attend an annual review held at their deanery (ARCP/ RITA), to ensure on-going commitment to specialty training and facilitate communication between the deanery and trainee.  However, there is only brief and general guidance relating to the maintenance of existing clinical competencies. The guide acknowledges that trainees often retain a clinical element during OOP time and the extent of this may determine recommendations for future training on return. Therefore, it is reasonable to assume that it would be unusual to undertake a three year research programme with no clinical contact for the entire three years, without an annual review board considering the impact this may have had on clinical performance. The guide also advises trainees to individually seek more specific advice from their training programme director. Engaging closely with the local deanery and programme director when considering OOP projects is always a good idea, but this approach does not provide uniform, gold standard guidance that trainees can follow.

This may change in the future. Dr. James Adams, Consultant Geriatrician at University Hospital Southampton and Head of the Wessex School of Medicine, recently attended a meeting of all the national heads of schools for post-graduate medicine. Arrangements for return to clinical practice after periods of OOP time, ill health or maternity leave were discussed. Dr Adams reports:

‘……there is some diversity between specialities as to the arrangements to assess trainees or provide opportunities to update skills before return to full time duties. Specialities with significant technical skills within practice, e.g. The Royal College of Anaesthetics, appear more robust in reassessing trainees and insisting on retraining/extension to CCT following prolonged absence from mainstream clinical training.  There are plans to harmonise some practices across specialities but it would be regarded as normal practice to review trainees out of programme for more than 12 months, to explore their clinical experience during this time and any retraining required. There should also be the potential for recommendations for adjustments to CCT dates in some circumstances if the retraining need is significant.’

So, how does it work in practice?  I undertook a PhD programme in a region distant from my clinical deanery. Thus, the local teaching hospital, post-graduate medical education programme and elderly medicine department were not familiar. However, all were welcoming and I was invited to take part in regional training days and to integrate into the local department as an honorary registrar. My research fellowship allows up to one day per week to be dedicated to clinical training. It is worth noting that this time could be used to attend clinics relevant to sub-specialty training e.g., continence which can otherwise be hard to fit around a full time clinical rota. At present, I undertake a general outpatient clinic approximately once per fortnight and attend weekly departmental teaching sessions and radiology meetings when possible.  This may sound light, but time spent in clinical activities has to be balanced against the demands of my PhD. A PhD is not a part-time undertaking and it can be easy to prioritise clinical work at the expense of study. Therefore, the balance is delicate! I am currently in the first year of my PhD and expect to increase clinical work towards the end of my research time, in preparation for return to the wards. Other trainees also report that updating ALS skills or paying a visit to the Medical Admissions Unit before returning to the wards can boost confidence and facilitate the transition back.

In summary, it is important to maintain clinical skills whilst out of mainstream clinical training.  To reflect this, the expectations of our national training colleges and post-graduate deaneries are likely to become more formal and standardised over the coming years.  However, even when undertaking a project distant to familiar clinical environments it is possible to integrate and engage in local clinical activities, to keep up-to-date.  Furthermore, on return to full time practice the experience and additional knowledge gained through out of programme activity will feedback into clinical work.  This will add new skill and confidence to the services we deliver, ultimately benefitting patients.

Dr. Victoria Keevil
SpR in Geriatric Medicine
Wellcome Trust Clinical Training Fellow

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