Hearfield and Collier: We need to do more to help with skill fade after extended leave

There is plenty to think about when returning to work after an extended period of work absence. This is before even considering how a break from clinical practice has affected your ability to do your job when you return.

Understandably, many doctors experience a knock in confidence. Behind this can be the very real concern that skills have faded during the time away. Many of those returning from maternity or parental leave, for example, worry that their concentration will be adversely affected after months of sleep deprivation and baby talk, and have concerns about juggling the various demands of family life.

Both the General Medical Council [1] and the Academy of Medical Royal Colleges [2,3] have published review documents on the issue of skill fade.

Doctors require a wide skillset. Up-to-date knowledge and practical skills are a must, as are interpersonal, leadership, and management skills, as well as cognitive abilities required for complex decision making.

The concept of skill fade is recognised in many industries. [4] It’s an issue that occurs following time off work for any reason. In the aviation industry and legal practice, skill fade can happen as a result of  new technology taking over basic job roles. Skill fade has even been implicated in recent plane crashes as a result of pilots becoming deskilled due to a reliance on autopilot, and not knowing what to do when autopilot fails. [5]

As doctors it can be hard to admit that it may take some time to re-establish our skills.  Both as an individual among colleagues, but also as part of revalidation where the expected trajectory is upwards. Silence over such issues risks exposing our patients to sub-optimal care.

The Academy of Medical Royal Colleges  suggests that since skills can begin to fade significantly after three months away from clinical work and by two years, a doctor requires formal retraining. [2]

The pattern of skill fade is very individual and everyone’s requirements will be different. [1]  It goes without saying that it is our personal responsibility to keep skills and knowledge up to date. [6]

The available evidence suggests that it is dependent on the individual, their prior knowledge and competences, experience and age, as well as the environment to which they are returning. [1]

Anecdotally, trainees may be at an advantage over consultants as they receive regular supervision.  However, they may have to start a new placement with the inevitable expectation to make a good first impression, when they are not performing at their best.

Consultants, GPs, and non- training doctors benefit from experience and knowledge of their own departments and job roles. Yet they may be expected to deal with a higher level of complexity almost immediately which can be a concern. [3] To further complicate matters, subjective assessment of our own performance is a poor indicator of objective performance. [1]

As understanding grows around the many factors at play in skill fade on return to work, thankfully, a systemic view is being taken.  Schemes are being developed at a local and national level, particularly for trainees returning to work. These include update courses, mentorship, “sim” training, reduced clinics, and Keeping in Touch days as well as some helpful generic online resources published by Royal Colleges. [7,8]

For some these are mandatory.  HEE’s SuppoRTT programme is currently reviewing which of these schemes are most beneficial. [9]

There needs to be an acceptance of skill fade as a normal part of all our professional lives. [1]

You can be the colleague who starts this conversation.


Hollie Hearfield: I currently work as a Child and Adolescent Mental Health Services (CAMHS) ST4 in Liverpool. I have returned to work from maternity leave three times.

Competing interests: None



Jennie Collier: I currently work as a Child and Adolescent Mental Health Services (CAMHS) ST4 in Liverpool.

Competing interests: None



  1. Skills fade: a review of the evidence that clinical and professional skills fade during time out of practice, and of how skills fade may be measured or remediated.  Published by GMC 2014. https://www.gmc-uk.org/-/media/about/skills-fade-literature-review-full-report.pdf?la=en&hash=8B32071AF03167EE588EE574F6DCC4C85B1FEF0B
  2. Return to practice guidance Update 2017 published by Academy of Medical Royal Colleges https://www.aomrc.org.uk/wp-content/uploads/2017/06/Return_to_Practice_guidance_2017_Revison_0617-2.pdf
  3. Maternity/ Paternity Survey Results published by Academy of Medical Royal Colleges https://www.aomrc.org.uk/wp-content/uploads/2016/06/Maternity_paternity_survey_200416.pdf
  4. Skill fade- the Ethics of Lawyer Dependence or Algorithms and Technology. B Sheppard. Practice Innovations Newsletter March 2018, Volume 19, Number2 http://info.legalsolutions.thomsonreuters.com/signup/newsletters/practice-innovations/2018-mar/article1.aspx
  5. Role of pilot lack of manual control proficiency in air transport aircraft accidents. Robert Arnold.  6th International Conference on Applied Human Factors and Ergonomics (AHFE 2015) and the Affiliated Conferences, AHFE 2015
  6. Good Medical Practise- Working with doctors Working for patients. GMC 2013 https://www.gmc-uk.org/-/media/documents/good-medical-practice—english-1215_pdf-51527435.pdf
  7. Return to Work Toolkit. Published by Royal College of Obstetricians and Gynaecologists https://www.rcog.org.uk/en/careers-training/workplace-workforce-issues/return-work-toolkit/
  8. Return to Work After a Period of Absence. Royal College of Anaesthetists 2015 https://www.rcoa.ac.uk/system/files/ReturnToWork2015.pdf
  9. Supported Return to training (SuppoRTT). Health Education England. 2018 https://www.hee.nhs.uk/our-work/supporting-doctors-returning-training-after-time-out

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