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A cultural challenge for medicine

By Mindo - 07th Dec 2021 | 107 views

Top view of stethoscope and calendar on the green background, schedule to check up healthy concept

As the diversity of the medical profession increases, and retention becomes ever more critical, the need for flexible training for doctors is paramount. However, as Catherine Reilly heard, doctors face considerable barriers in this area

Flexible training in Irish medicine is “still unusual”, noted the authors of a recent study in the Irish Medical Journal (IMJ) examining trainee knowledge and perceptions of less than full-time (LTFT) training.

Some revealing comments were made by trainee respondents in the study, which was conducted by doctors from RCPI’s Faculty of Paediatrics. One trainee described LTFT training as “culturally frowned upon”. Another said they feared being seen as “less able” for full-time work or “less committed” to their career if they sought flexible training.

The authors concluded that “a cultural shift within training bodies and with trainers should be encouraged to recognise LTFT training as an acceptable pathway for all trainees”. It was noted that LTFT training “has been recognised
as an important tool for the creation of better work-life balance and avoidance of burnout in the medical workforce”.

The HSE’s national supernumerary flexible training scheme is one of the few routes to flexible medical training. It provides 32 places annually for a workforce of over 4,800 trainees (and not all are eligible). The scheme has several limitations including an emphasis on providing half-time posts and these issues were raised by respondents to the IMJ study.

But inflexibility extends far beyond the HSE scheme and deep into the conventions of medical training.

A number of trainees who spoke to the Medical Independent (MI) highlighted a lack of creative solutions for doctors with caring responsibilities or health concerns. A rigidity in training structures was causing major personal and financial hardships for some trainees, heard MI

There were doctors, for example, who wanted to work full-time (often out of financial necessity), but whose rotations removed them from essential support networks (including childcare), with considerable financial and personal implications and indiscernible benefits to training outcomes.

Another theme that emerged was a divergence between the public statements of training bodies in support of flexible training – and the difficult and delicate process for some trainees when making requests for greater flexibility. The doctors who spoke to MI under condition of anonymity were not suggesting that trainees should never have to move during training, but that more flexibility was achievable and necessary – for the wellbeing of the doctors themselves and the health system that needs them.

A trainee in the early stages of their scheme, who has a young toddler, told MI she was sent to a far part of the country at approximately three months’ notice (although she was advised of her subsequent locations for an 18-month period). This is an experience typical of many schemes and, as the trainee noted, not a family-friendly process.

“Trying to find a house and a creche with only a few months’ notice, in this day and age, is just impossible,” according to the trainee, who described training structures as traditionally designed around single males.

The trainee, who came through a graduate-entry medical degree programme, had an established family life. She said this was not considered in the allocation of rotations. The trainee and her family made the move to the new location, over 250km from their home, with limited childcare support for the initial months. Childcare is “very hard to find and lots of places are saying ‘we have no toddler spaces, but if you are thinking of having another baby let us know and we will put your name down’. That is the level of preparedness you need for childcare.”

As matters stand, the trainee is facing the same challenges for their upcoming rotation. The trainee, who is happy to work full-time, is considering the possibility of continuing their training in the UK, which would involve being based in one region.

“I will look at applying to the UK. If it is between that and moving around every corner of Ireland, I’d rather go to the UK and have some sort of a base. We will see.”

She added: “The training bodies have to offer some acknowledgement of the difficulties posed by this and justify why they are not willing to offer flexibility or start thinking of ways that training can be done with reduced rotations or better compensations.” As an example, the maximum amount that trainees can claim from the HSE in relocation expenses is just €500 per annum.

The trainee concluded: “I don’t know how they are going to change it, but it does need to change, especially if you are looking at more graduate-entry doctors and female doctors qualifying. We are already losing doctors to abroad for better opportunities anyway. It would be nice if they acknowledged the ones who are still here.”

IMO position

The reasons for the slow roll-out of flexible working and training arrangements were “multifactorial” and included a ‘cultural’ resistance within medicine and the health service, according to Dr Rachel McNamara, Chair of the IMO NCHD women in medicine working group and a member of the union’s NCHD committee. In regard to NCHDs, she said flexible working should be an option for trainees and NCHDs in service posts, who number over 7,700 combined (including interns).

Dr Rachel McNamara

Many hospitals and teams consider that it would be difficult to accommodate a doctor who is training flexibility or job sharing – or it would not fit into how things are usually done.

“But that has to change from the IMO point of view. We are heading into year three of a pandemic, there are going to be more and more people that will feel the effects of the last two years and they will either need to take career breaks or we have to give them some sort of a flexible option to retain our workforce.”

There needs to be buy-in from “multiple stakeholders” including training schemes, hospitals, departments, and the HSE. In the UK “there are targets [for flexible training] in each deanery and at the moment they are sitting anywhere between 5 and 20 per cent”.

Dr McNamara said there must be a variety of flexible training posts available and these posts should be accessible throughout training. She also noted one of the difficulties was ensuring flexible trainees do not end up working fulltime, given that unrostered overtime is “commonplace”. Additionally, the concept of job-sharing needed to be developed and promoted.

She told MI flexible training cannot be discussed without reference to the fact many trainees are required to move multiple times during their schemes. Dr McNamara said retention of doctors will be enhanced by recognising that their lives “outside of work do matter and are important”. She noted that an increasing number of doctors have entered medicine through graduate-entry degree programmes and are more likely to have long-term partners (with their own established careers), mortgages, and children enrolled in creches, which have long waiting lists.

“If you want to move up the ladder towards consultant, you are expected to up sticks and move, whether it be [every] six months or every year. I have known colleagues of mine who have commuted two hours to and from work every day just so they could stay at the house where their kids are…. They have to do it because they are not in a position to pay mortgage and rent, their partner or spouse is not able to up and move their career across the country.

“I know a good few colleagues who do need to live apart from their families for a time and that is additional rent, forcing people to make very difficult decisions. If the system can be kinder in that scenario, it could be more beneficial to all….

“The system is still very much suited to somebody with no attachments and no external responsibilities and ultimately
we are losing out on a very rich diversity of people within the workforce.”

She knew of doctors for whom training structures had dictated their specialty choice; for others it has contributed to major difficulties in relationships and living conditions. In a broader sense, NCHDs are working in an “unyielding system” with consistent overcrowding.

The “additional difficulties” placed on doctors by lack of flexible working “certainly doesn’t help”.

Dr McNamara also noted there were “a good few disciplines” where it appeared flexible training was not really
“entertained”. “We need a broader scope of specialties involved, we need to be setting targets, we need to start increasing the amount of people on flexible training year on year….

“We need to work with departments to identify what are the barriers to implementation of flexible training in this workplace and just start working through them. There is a responsibility there with departments, the training bodies, and with NDTP [National Doctors Training and Planning], to promote and facilitate less than full-time training among a wider variety and large number of departments.”

Dr McNamara underlined that the system needed more doctors and “we will be able to attract more staff if we are showing a bit of humanity”.

Forum

Former RCSI President Mr Ken Mealy, Chair of the Forum of Irish Postgraduate Medical Training Bodies, told MI the Forum’s new 10-year strategy included a clear commitment to support flexible training.

“But you do run into difficulties,” he continued. “The main one is if you do less than full-time training, it is going to prolong your training. That is obvious. If you take something like surgery, for instance, where you have an eight-year training programme, and you do less than full-time training, then you are going to extend that training to make it 10 or 12 years. That is a huge challenge for trainees. Some of the other training programmes wouldn’t be as long, but it is a huge dilemma.”

He agreed that greater availability of flexible posts above half-time (eg, 0.6, 0.8 whole time equivalent [WTE]) would be helpful in this regard. Mr Mealy believed the training bodies were open to considering such posts.

Combining professional training with having a family or taking time out for personal or health reasons was a challenge, said Mr Mealy. In surgery, as across medicine, there are increasing numbers of females (comprising 56 per cent of all trainees in 2020/21). Currently, in year one of core surgical training, the percentage of females is 40 per cent; in year two it is 44 per cent, and in higher specialist surgical training it is 34 per cent.

In regard to female trainees who wish to have children, Mr Mealy said he was encouraged by the number who have done so during their surgical training. He said these trainees are “determined young individuals who want their family, but also want a career, [and] they find ways to work around it”. Nevertheless, Mr Mealy said he was “not trying to pretend for a moment there are simple solutions around all of this”.

Mr Mealy confirmed that female surgical trainees generally took a small amount of maternity leave. They usually took “a couple of months out” and completed a further six-to eight weeks at the end of their training scheme, “but that is the sort of commitment many of our trainees have.”

He commented: “There is a considerable body of opinion in the professional bodies that we have to accommodate young trainees, whether they be male or female, to support them having families during their training period and accommodate [them] – do they need an extension to their training period, or do they need periods of time off, remembering most of these individuals are very, very driven, very competitive, and tend to look for short periods of time for support when they need it. I don’t believe there is any ideological block to this among the training bodies.”

For trainees who want or need to work full-time, and who have family responsibilities and supports in a particular
area, is there room for more flexibility in their rotations?

Mr Mealy said most training schemes, as he understood it, attempted to give trainees as much advance notice as possible for their rotations. “Certainly in surgery, they try and tell trainees where the next two or three years will be, so they have some sort of security. Yes, they try and take into account where your partner may be, but it really is challenging.

“Take for instance, you have a couple who are both doctors, one training in surgery and one training in internal medicine, psychiatry, or general practice, to find alignment between the two training programmes so both can
go to Galway for a year or two years, or to co-ordinate that, is a challenge.

“There has been a commitment from the training bodies to try and address that to the best of their ability. There is
an understanding this is a big problem for trainees and there is a commitment to try and address those [issues] in the
coming years by the training bodies working closer together.”

Greater regionalisation in surgical training is being explored, according to Mr Mealy. He added that service commitments are a factor in surgical rotations as well as exposure to the required range of procedures.

Asked about consultants’ views on flexible training, Mr Mealy said “you will always have individuals who will say ‘this is very disruptive to my practice’”. However, he believed most were “delighted” to have trainees and would do their best to ensure they were accommodated.

He added: “We have further to go, but there has been a sea change in our understanding that we need to be trainee-centric in terms of the training programmes.… This whole concept comes up at Forum meetings all the time, that it is a ‘buyer’s market’ out there. We have to support trainees to have satisfying training careers, otherwise we won’t have trainees and we won’t have consultants.”

In terms of greater financial support for trainees in rotating around the country, Mr Mealy said this was an issue for the employer rather than training bodies, although the latter could advocate for such measures. The HSE provided
some support for training costs, but it was not enough, he added. “One would advocate that the true costs of training are covered more appropriately.”

Anaesthesiology

This newspaper contacted several training bodies on the issue of flexibility during training. Mr Martin McCormack, CEO of the College of Anaesthesiologists (CAI), told MI the postgraduate training environment in Ireland “must adapt to trainee needs” and this would require “meaningful improvement in training structures and trainee experience and outcomes”.

“While the CAI will continue to prioritise the educational aspects of training, it is committed to working with the other stakeholders to meet the challenges of more flexible and family friendly contracts, to provide flexible training and career paths, to eliminate any gender, age, or ethnic bias in training, and to care for the health and wellbeing of our trainees.”

There are three main categories in which the College offers flexible training: Sharing a (full-time) training post; a LTFT training post; and a supernumerary post under the HSE scheme. “Our College policy on flexible training makes it explicit that individual circumstances will be considered,” he added.

In the CAI’s current cohort of 242 trainees, just three doctors are availing of LTFT flexible training. There are also seven doctors in training “who have expressed a wish to stay within a particular region due to childcare responsibilities (or other exceptional circumstances) and, in each case, this has been accommodated”, stated Mr McCormack.

The CAI, the RCSI, and the ICGP are undertaking research investigating the challenges facing trainees who require
flexibility during training and attitudes from trainees and consultants to LTFT work practices. In addition, the CAI is
trialling a pilot LTFT project across two major academic teaching hospitals this year “to provide further support to such trainees for whom the traditional model of LTFT training is inadequate”.

The doctors wishing to avail of the pilot are a mixture of trainees on the scheme and NCHDs working in the same department, but not on the training scheme. The College is accommodating “flexibility within the pilot” with some doctors electing to work 0.2, 0.6 or 0.8 WTE posts, for example. Since the introduction of ‘run-through
training’, the CAI has endeavoured to give at least two years prospective rotations to each trainee. Where possible, it tries to limit moves during the six years to two different regions.

Mr McCormack noted that not all clinical sites were approved for anaesthesiology training and each Hospital Group/Community Healthcare Organisation did not have the “full range of quality training opportunities” to be self-sufficient as an independent training scheme/deanery model.

Psychiatry

The College of Psychiatrists of Ireland (CPsychI) has 330 trainees in total, comprising 280 basic specialist trainees (BSTs) and 150 higher specialist trainees (HSTs). Three psychiatry trainees are on the HSE flexible training scheme; one trainee is in a permanent part-time HST post; four trainees are job sharing; and four trainees are in LTFT working, eg, four-day week.

In cases where trainees wished to stay within a region due to childcare responsibilities (or other circumstances), was this accommodated? “Yes, in general all our BST schemes operate on a regional basis and all our HST trainees may base themselves in a particular region,” according to Dr Aoibhinn Lynch, the College’s Dean of Education.

“Even in HST, where there is a requirement for HSTs to spend one year outside their main training base (usually in a city), we try to allocate a post which is within commuting distance so the trainee should not need to move residence. All trainees get the opportunity to make a choice on their training posts and to change their mind. All trainees are given multi-year allocations of training posts so they have notice of where their posts will be over the course of the
training scheme.

“With the exception of a small number of sub-specialty areas which operate on a national basis (eg, forensic psychiatry) it is possible for all trainees to complete their training in a particular region. The only limitation is the number of training posts available in a geographical area, and this is the only reason why a trainee may be allocated to a post outside the region where they live – but this happens very rarely.”

Attrition rates in psychiatry training were “very low”. In higher training it averaged at one trainee per year. The College asks trainees for their reasons for leaving the scheme and, where this information is disclosed, it has included personal reasons, a change in specialty, and moving abroad to continue specialist training.

According to Dr Lynch, “once aware of any particular needs that a trainee has, [the College] will try to accommodate these needs where possible. Trainees with disabilities have regularly been accommodated (for example in exams or continuous assessment). The CPsychI Vice Deans, tutors, educational supervisors and HST mentors play a vital role in supporting and advocating for particular trainees’ needs. Also, the trainee committee regularly bring trainees’ issues to the Dean or to the postgraduate training committee where they can be discussed and solutions explored.”

“During the Covid-19 pandemic, there have been particular difficulties for those trainees with underlying medical conditions who cannot work face-to-face. The College has allowed virtually all training activities to be carried out by distance and, to date, each of these trainees has been able to progress in training.”

Dr Lynch said issues such as salary, overtime payments, pension contributions, or other contractual matters relating to the terms and conditions of employment for part-time trainees, were “dealt with by the employer and not by the training body”.

“The CPsychI requirement of training sites is that all trainees should receive the terms and conditions of the current HSE NCHD employment contract. Of note, there is no reference to job sharing in the HSE NCHD contract, nor are there any specific HSE guidelines for HR departments in implementing job sharing for trainees (or consultants for that matter).”

Surgery

Asked about flexible training in surgery, an RCSI spokesperson said: “RCSI is aware of the importance of providing flexible working arrangements for trainees, as reflected in our training programmes.

“Outside of the HSE flexible training scheme, RCSI trainees can make requests for flexible training to the training programme directors and these requests can be facilitated depending on the nature of the circumstances of the trainee and with local agreement with the hospitals. Additionally, we have developed and implemented policies on job sharing and post reassignment to support trainees flexible training requests.”

The spokesperson said the HSE flexible training scheme has a limited number of places and is oversubscribed each year. “There were no successful candidates from surgery this year. The College is supportive of this scheme and actively promotes it to trainees in several ways.”

Asked if the College accommodates trainees who wish to stay within a particular region due to childcare responsibilities (or other circumstances), the spokesperson said: “RCSI has introduced a post reassignment process to support trainees who, due to their personal circumstances (whatever they may be), requires a change to the agreed post/rotation. In addition, one of our specialties is currently trialing an approach to regional-based training during the training years of ST3 – ST5.”

This year RCSI introduced a series of additional questions around flexible training in its annual trainee survey “so we can better understand trainees needs in relation to flexible training and we are currently in the process of analysing this report”. The College is also “engaged with a project with all the other training bodies which has substantial trainee input into the future needs of trainees around flexible training”.

The spokesperson said “our attritions numbers in specialty training continue to be extremely low at less than 2 per cent.  The College investigates each unplanned early exit as part of the ongoing quality assurance of our training programme. Our analysis has shown that the small number of trainees who exit the programme do so for a range of reasons and we have not identified any particular trend but we will continue to review this.”

Comment from the RCPI was awaited at press time.

Limitations in HSE flexible training scheme

The HSE national supernumerary flexible training scheme is one of the few means of accessing flexible medical training, but there are a number of limitations on who can apply. The scheme is not open to first year basic specialist trainees and “not recommended” for final year trainees (although “this is at the discretion of the relevant training body”).

Currently, participation is restricted to a maximum of two years and will only be extended by HSE National Doctors Training and Planning (NDTP) in “exceptional circumstances”. According to HSE literature, the most common reasons for trainees applying to the scheme include responsibility for caring for others (eg, children or older relatives); physical and mental health; personal family circumstances.

In July 2016, the number of whole time equivalent (WTE) funded places on the scheme rose from 12 to 16 and there have been no further increases. The number of trainees engaged in the scheme at any given time is set at a maximum of 32.

The scheme’s flexible training posts have generally been set at 50 per cent of full-time, but the HSE’s guidance document for the 2022 application process stated that “provisions can be made to facilitate arrangements outside of 50 per cent of full-time, depending on circumstances”. Overtime is paid at a rate of single time extra until WTE hours are reached, ie, 39 hours per week.

According to HSE data for 2018 to 2020, psychiatry had the largest number of participants at 25. This was followed by paediatrics at 14 and histopathology at eight. The following specialties had no listed participants in these years: Cardiology gastroenterology, general surgery, neurology, and respiratory medicine.

A recent study in the Irish Medical Journal (‘Trainee knowledge and perceptions of less than full-time training’, Howard et al) reported on trainees’ perceived barriers to less than full-time (LTFT) training. The main issues identified were post availability; potential impact on career progression; and availability of only 0.5 posts. Trainees noted lack of flexibility in the HSE scheme, including availability only from July to July and participation restricted to a maximum of two years.

“Trainees felt applications would be rejected if they were not a parent. Some reported perceptions from teams that LTFT trainees are less committed and that trainees can find it difficult to integrate.” For female trainees who had children, the key concerns were salary (ie, loss of earnings), delay in date for certificate of satisfactory completion of specialist training, impact on career progression, and childcare costs.

Male trainees were most concerned about impact on career progression and availability of LTFT posts. “Trainees mentioned salary difference as an issue and in particular noted that the policy of overtime pay at single time extra rate until WTE hours are reached, ie, 39 hours per week, puts LTFT trainees who contribute to a 24-hour call rota at a significant disadvantage in their salaries compared to full-time colleague.”

Suggested recommendations from the study were as follows: Training bodies and the HSE/NDTP should issue “strong statements” of support for LTFT training; expansion of LTFT training options; time limits on the duration of LTFT training should be removed; LTFT training should be open to all trainees; “better engagement” with trainees at all levels; awareness campaigns to highlight positive experiences of LTFT trainees and to give accurate information on potential impact on salary, pension etc; teams should receive education on working with LTFT trainees; a central hub for the coordination of LTFT training options should be considered (possibly through the NDTP).

Meanwhile, the number of consultants working LTFT in 2020/21 stood at 13 per cent, according to an NDTP medical workforce report. A higher proportion of females (17 per cent) worked LTFT compared to males (11 per cent). The HSE was contacted for comment on the flexible training scheme, but no response was received by press time.

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