Dr Michael Fitzpatick, Dr Matthew Roycroft and Dr Gareth Hynes (RCP Trainees Committee) explore how to achieve a ‘new normal’ for physician training in the time of COVID-19.
During the COVID-19 epidemic and the seismic changes to the NHS that followed, physician trainees have truly shown their mettle. They moved into unfamiliar clinical areas, joined new rotas at short notice, and covered gaps created by illness. They have left other roles in research and education to help with the clinical efforts, increased working hours, and returned early from parental leave. The snowflake generation have shown their steely resolve and commitment to their patients and profession.
We are now past the first peak, however NHS working practices will be altered dramatically until an effective vaccine is available. As we move to this ‘new normal’ it is paramount that we ensure there is fairness and equity for all trainees across all specialties in the NHS.
Rotas, leave, and the junior doctor contract
Many trusts have had to impose emergency on-call rotas to cope with the epidemic. These have often involved high work intensity, long shifts, frequent night-working, cancelled leave, and breaches of the terms and conditions of the 2016 junior doctor contract. As COVID-19 clinical work diminishes, such working arrangements need to be de-escalated quickly. Annual leave should be taken where possible, or transferred or paid if not. Rotas that comply with the 2016 contract should be reinstated, with the much-needed protections that they confer. There is also an opportunity to improve training and working arrangements, and develop rotas in liaison with trainees and unions that follow well-established recommendations which can improve wellbeing, and work with, not against, circadian biology (BMA. BMA Fatigue and Facilities charter. 2018.).
Each region and specialty will need leeway in deciding which trainees return to normal working patterns first, due to operational priorities. However, the process should be transparent, involve appropriate consultation, and be, as far as possible, fair and equitable. Certain trainees are a particular priority, such as those who have cut short parental leave, or who have increased working hours from being less-than-full-time.
Study leave and teaching sessions
Teaching programmes, conferences, and study leave have been cancelled during the epidemic. Teaching programmes and learning opportunities must now restart. While face to face events are likely to be cancelled for several months to come, employing trusts, Local Education and Training Boards, deaneries, specialty societies, and royal colleges must embrace technological solutions to deliver this content, such as the recently launched RCP Player. Attending such events is an explicit part of trainees’ work, and as such they should have the opportunity to apply for study leave to attend such events, even if virtually from their homes.
Returning to out of programme activities
Out of programme activities, for instance in research, education, and leadership, are of great value to trainees, and to the future consultant NHS workforce. Almost all OOP trainees have returned to full time clinical work, and should be allowed back to their OOP activity. This should be as quick as is reasonably possible, factoring in ongoing COVID-19 clinical work, the expected non-COVID surge of activity, and the backlog of postponed activity. Trainees should expect to receive extended time out of programme at least equal to that which was lost, and, where possible, the time working during the epidemic should be counted towards their clinical time in training. There are numerous other factors to consider for trainees OOP in research, including funding, suspension of research activity, and the nature of their research, and this has been explored in more detail by the RCP and other stakeholders.
Changes to recruitment processes were made earlier this year by HEE and the four nation Medical and Dental Recruitment and Selection team. These changes, including the removal of interview and changes to which criteria were used to rank individuals, were made with the intention of trying to maintain recruitment and progression during the pandemic. However, they have led to considerable dissatisfaction from many trainees, particularly those in the most competitive specialties, who feel that the goalposts have been moved mid-game. If clinical demand and social distancing require ongoing changes to recruitment processes, these must be reviewed with engagement from all stakeholders.
Clinical training and progression
Trainees have not been able to meet certain training requirements during the epidemic, and such opportunities will remain limited for many in the months to come. These include, but are not limited to, professional exams, courses, procedural training, sub-specialty experience, and outpatient working. However, clinical work during such a challenging time will have provided excellent learning opportunities in many of the domains that make a good doctor: leadership, team-working, service development, patient safety, and inter-professional working. Wherever possible, trainees should be allowed to progress at ARCP, and there should be an acceptance that many of the tick-boxes we normally scrutinise will be empty this year. For those at key progression points, every effort should be made to allow trainees in good standing to progress, with the benefit of the doubt given in most cases.
Each specialty training programme will face its own challenges in the months to come. Certain clinical opportunities may simply not be available, and procedural specialties will face particular challenges. Every effort must be made to deliver that training, within the context of the current NHS challenges.
Wellbeing and burnout
It remains unclear what impact the last few months will have on healthcare professionals’ mental wellbeing and health long term. Training programmes are hard, and the challenges of the last few months, combined with the worry and uncertainty of what is to come, will take their toll on trainees’ wellbeing and psychological reserves. We need to be proactive in preventing burnout in our trainee colleagues. Now is the time to reset the medical ‘stiff upper lip’ culture, and embed more mentoring, coaching, and mutual support into how we work and train. Staff wellbeing has, quite rightly, been a priority for employers, and this must continue. We must all role-model the behaviours that create the open, fair, and positive culture we want in healthcare, and call out bullying, undermining, and unprofessional behaviour whenever it appears. The roles of Guardian of Safe Working, Training Programme Directors, trainee representatives, and junior doctor forums have never been so important.
Trainees represent the future of our profession, and have proved their dedication to their patients and the NHS yet again during the COVID-19 epidemic. We must do everything in our power to pay back their dedication, and strengthen the medical covenant between our trainees and the wider profession.