Training matters: the need for kindness, flexibility, and leniency

The covid-19 pandemic has had a substantial impact on many aspects of human life, including that of doctors in training. A number of important changes to their daily working schedules have been implemented to help combat the viral outbreak. Training has necessarily played second fiddle to the clinical needs of the hour. Virtually every trainee who was due to rotate to different clinical placements in April had the move postponed. [1]

Non-physician trainees have been seconded to medical teams en masse to bolster the frontline workforce. Medical students have been fast-tracked through registration hoops so that they can volunteer for newly created Foundation interim year 1 posts. [2] Some GP trainees have found themselves relocated from primary care placements to acute hospitals. Hundreds of trainees who were “out-of-programme” or undertaking research projects have interrupted activities to return to clinical practice. Many less-than full-time trainees have increased their work commitments voluntarily. Others have found themselves in the “shielded” group but continue to provide vital service remotely.

Educational courses and training days have been cancelled and most postgraduate examinations postponed until at least the autumn. [3] Hand in hand with the above, has been a dearth of adequate opportunities for work-place based assessments because the trainers themselves are working in full time clinical practice.

Unsurprisingly, there is much confusion and uncertainty as to what will happen to training and career advancement in the coming months. Doctors at critical progression points in training in particular feel they are in limbo. [4] While they understand the need for patience and pragmatism during an exceptionally complex situation, they would like clear and explicit guidance from the UK’s statutory education bodies as soon as is practical. Some changes have already started. The Annual Review of Competence Progression (ARCP) has changed and a new series of codes specific to covid-19 are in place. [5] Recruitment and selection methodology for core training and higher specialities has been restricted to online applications and “self-scoring” with the requirement for formal interviews waived since March.   

These modifications are to be broadly welcomed and more are to be encouraged. In the current situation, it is crucial that the Royal Colleges and postgraduate medical bodies appreciate the challenges that trainees face and allow maximum discretion and flexibility for assessment and curriculum requirements. We must do our best to make things easier for trainees. Indeed, many will have been exposed to extremes of emotional and psychological strains. Treating them sympathetically is the least we can do and we must not inadvertently punish or penalise them. A proportion will require extensions to their training programmes which should be accommodated where possible within the existing formal Health Education England framework rather than abandoning them to fill the same posts under locum conditions. This will not only ensure that we do not create another “lost tribe” of doctors who were left in limbo by changes to training processes, but provide reassurance to NHS employers too. [6] This is not to say that patient safety ought to be compromised for the sake of trainee progression or retention. However, an approach that is just, lenient, and facilitatory is needed. 

There is additional unease amongst trainees in the UK on tier 2 visas which requires urgent attention. The government announced an automatic extension to such visas from October, but it is unclear if it includes doctors who are without continuous employment or a suitable sponsor in the interim. [7]

It has been wonderful to witness first-hand the camaraderie and team spirit that has been on show in recent months. Health professionals of every grade have given it their all at a time of monumental stress. Would it not be amazing for it to continue and be preserved longer term? Without doubt there is a renewed affection for the NHS and admiration for key workers, as witnessed by the outpouring of public praise. As a direct consequence of the pandemic, it is reported that the number of people seeking to start a career in medicine has soared. [8] This augurs well for admissions to medical schools in the forthcoming years. Perhaps another positive for trainees and trainers will be an ongoing simplification of procedures and processes when it comes to recruitment, completing e-portfolios, and trainee reports, with a focus instead on demonstrating confidence and capability in practice. The value of exposure to critical care medicine for so many more trainees cannot be underestimated either. Online teaching and learning resources are being developed regionally and locally like never before and will continue as key components of training programmes henceforth. This is an opportune moment to make further alterations and to maximise trainee involvement in important decisions that will impact directly upon their future. This is especially true of curricular and quality improvement changes that are already afoot e.g. in Internal Medicine Training (IMT) and Improving Surgical Training (IST).

In the meantime, as senior clinicians we continue to provide comfort and hope to patients with covid-19 and to their relatives, and do all that we can to remove their fears and anxieties. At the same time, we must of course not forget the trainees by our side. They are also frightened and concerned for themselves and their loved ones, with some justification. Such emotions are understandable and not to be ignored. In these trying and unprecedented times, trainees will look to trainers not just for leadership, but also reassurance, calmness and support. Postgraduate bodies and medical schools as well as the consultants and GPs need to ensure that we are up to the mark and do not fail our next generation of doctors. 

Fraz Mir, Head of School of Postgraduate Medicine, Health Education England, East of England

Sarah Cowan, ST6 in Acute Medicine and ICM, Chief Resident Addenbrooke’s Hospital, Cambridge

Kate Read, Deputy Postgraduate Dean, Health Education England, East of England

Ian Barton, Deputy Postgraduate Dean, Health Education England, East of England

Matthew Knight, Associate Postgraduate Dean, Health Education England, East of England

Bill Irish, Postgraduate Dean, Health Education England, East of England