Returning to trauma and orthopaedic training with SuppoRTT

Iris Kwok, Zoe Little and Kash Akhtar

Iris Kwok is an ST8 trainee on the Royal London rotation. She has a specialist interest in foot and ankle surgery and trauma. As a departmental rota coordinator and registrar representative, she has helped trainees transition back to work following time out of training.

Zoe Little is an ST7 trainee on the South West London rotation, aspiring hand surgeon and mother of two young girls. Having returned to training twice following maternity leave she is keen to improve the experience of returning trainees and helped deliver the KSS/London T&Ospecific SuppoRTT courses.

Kash Akhtar is a Reader in Orthopaedic Surgery and Surgical Education at Barts and the London Medical School (QMUL). He is also an Honorary Consultant in Trauma & Orthopaedic Surgery at Barts Health NHS Trust. He is the Training Programme Director for the Royal London Rotation, a member of the Specialist Advisory Committee and on the BASK Executive Committee. His clinical practice is in knee surgery, with a particular interest in multiligament knee injuries and his research interests are focused on psychomotor skills, simulation and non-technical skills.

The landscape of orthopaedic training is continually evolving, with an increasing number of trainees taking time out during their training. Fortunately, the current training pathway has a degree of flexibility to facilitate and nurture this diverse and well-rounded workforce.

Trainees can take time out of training for a variety of reasons – to undertake academic research, to pursue interests outside of medicine (for example, setting up a business or participate in competitive sport), taking parental leave or fulfilling family responsibilities, studying for an MBA or higher educational degree, or needing time out for personal sickness. This is thus an issue that impacts both male and female trainees alike, and can occur at all stages of training.

An interruption in training can have an impact on ones’ clinical skills, knowledge and confidence on return to work, particularly in a craft-based speciality such as trauma and orthopaedics. Previously, trainees were expected to return to full clinical duties with on calls and emergency operating in full swing, often in a completely new trust. This has potentially serious implications for patient safety, trainee confidence and rate of return to training altogether. These issues have been well-described in other surgical specialties1.

According to a study on return to work on Higher Surgical Trainees in 2018, the most common concerns trainees had surrounding returning to work following time out of programme were operative skills and skill fade, diminished confidence and the ability to manage worklife balance2. In recent years, increasing emphasis has been placed in ensuring safe and supported return to clinical practice after a period of time out. The Bawa-Garba case in 2015 that shook the medical profession brought the issue of patient safety to the forefront. This was formally addressed following the ACAS agreement in 2016, stemming from safety concerns of returning trainees raised in the Junior Doctors Contract. The SuppoRTT (Supported Return to Training Programme) programme was therefore established by HEE in 2017 to address these issues across all specialties and provide a structured process for trainees and trainers. 11 offices across England are responsible for establishing and implementing the programme within their local areas.

As a large amount of resources have been put into this programme, with £10 million recurrent annual funding from the Department of Health and Social Care, trainees should be aware of what the programme offers in order to utilise it fully when needed.

What the SuppoRTT programme offers

The programme is accessible by all trainees who are returning to work after absence from training for three months or more, regardless of the reason. Up to £3,000 of funding is available per trainee to support their return to work, including:

• Attendance on courses

• Working in a supernumerary capacity or enhanced shadowing in clinical sessions

• Participation in simulated clinical training

Funding is not reimbursed to the trainee directly but is provided to the department to cover course expenses or any supernumerary and/or locum cover required to support the trainee’s safe return to clinical work.

Before taking time out: When possible, for predictable out of programme activities, a pre-absence meeting is held with the trainee’s Educational Supervisor (ES) or Training Programme Director (TPD), after which a form is completed by the trainee on the HEE website at least 3 months before taking time out.

During time out: The trainee is encouraged to register online with the SuppoRTT programme during the period away from training.

Before returning to work: The trainee should arrange a meeting with the ES or TPD approximately 8 - 12 weeks before their anticipated return date, and a pre-return form is completed. A return to training plan should consider:

• Supervised clinical sessions for a period of time

• The use of keeping-in-touch (KIT) days, of shared parental leave in touch (SPLIT) days

• Courses or training days to refresh skills and knowledge

• Phased return to work and flexible working arrangements where appropriate

• Preparation for next Annual Review of Competency Progression (ARCP)

After returning to work: A return review meeting is held with the ES or TPD towards the end of the supervised period to address any concerns and arrange any further targeted training.

T&O-specific return to training

Other specialties have been more progressive in delivering specialty-specific return to work training. For example, the Royal College of Anaesthetists has an established national programme called Giving Anaesthesia Safely Again (‘GasAgain’). This award-winning programme is structured to provide strategies for managing a safe return to work. This includes simulation scenarios to refresh an anaesthetist’s skills, alongside a series of workshops with short lectures to update clinicians on the latest developments in the world of anaesthesia. The course provides essential updates (such as resuscitation, patient safety checks) whilst giving returners the opportunity to build their confidence managing common and unusual emergency scenarios again. The course is delivered four times a year across the UK.

T&O is still in the early stages of developing a specialty-specific return to work programme. In October 2020, three orthopaedic trainees from Southwest Thames and the Kent, Surrey, Sussex (KSS) rotations piloted what we believe to be the first T&O-specific return to training course, supervised by Shirley Chan (Colorectal Surgeon and Supported Return to Training Champion for KSS School of Surgery) and Sarah Siddiqui (HEE’s National Supported Return to Training fellow for 2019-2020). This was tagged onto the already-established South London and KSS T&O ‘Reg Ready’ course which was running every October for new incoming ST3 trainees.

All London returning trainees were invited to attend the course. In the morning, returning trainees joined the Reg Ready course, where common trauma and on call scenarios were discussed in an interactive ‘quick-fire’ format. There was also a session on ‘How day-to-day clinical work is different in COVID-19’, as some trainees were out of training at the time of the first wave of the pandemic.

The afternoon was specific to trainees returning to training only, where a small group session of eight participants discussed various issues pertaining to return to training and returning to on call work. The experiences of three trainees who had previously returned after time out were shared. Concerns were discussed in an open, relaxed and friendly manner. Other aspects of training such as how to juggle and navigate LTFT training, and how to access helpful resources were also discussed.

The course was attended by both male and female trainees, with reasons for time out from training ranging from research work to personal sickness, to maternity and parental leave. The course received extremely positive feedback, and all participants were glad that they attended this prior to re-commencing work.

The second iteration of the course took place in April 2021 and was run virtually due to COVID-19 restrictions - this allowed trainees from all over the country to take part, and also included a session on updates to orthopaedic guidelines as well as a mock trauma meeting. Again, the feedback was excellent and the virtual nature of it did not seem to be a barrier to the participants being willing to express and discuss their concerns about return to training.

As a trainee returning to training in COVID-19 times, the opportunity to be supported in trauma operating and on calls was invaluable. This programme helps trainees rapidly get back up to their pre-absence level, which may have traditionally taken much longer, especially if the trainee is returning as LTFT.

Facilitating a smooth return to training

General return to work guidance has been published by the Academy of Medial Royal Colleges3 , however, there is currently no surgery or T&O-specific guidance. Although individual circumstances and requirements need to be taken into account (such as the level of training and experience prior to taking time out of training, where the trainee is in relation to sitting their FRCS Tr & Orth exams and so forth), suggestions for a safe return to work in the initial ‘settling in’ or enhanced supervision period for a trainee include:

1) Having the option to return to a hospital and department which is already familiar to the trainee – rather than rotating to a new hospital.

2) Doubling up with another trainee for on calls.

3) No out-of-hours on calls, such as overnight shifts.

4) Being supernumerary in outpatient or fracture clinic – so that the trainee is not under undue time pressure to see patients.

5) Doubling up with another trainee with trauma operating – to help get used to conducting an effective theatre team brief, setting up the patient and image intensifier, familiarisation with implant equipment and kit, etc.

6) Having a mentor in the department –this could be a consultant or a fellow colleague who is already known to the trainee.

7) Regular meetings (e.g. weekly) with ES and at the end of the enhanced supervision period.

This ‘settling in’ period would typically last for one month, but should be tailored according to the individual’s needs and discussed between the trainee and the individual department prior to return to work. The rota coordinator and service managers should be involved with this discussion.

Future directions

Perhaps it is time for us trauma and orthopaedic surgeons to take our cue from other specialties (anaesthetics4, obstetrics and gynaecology5 and the paediatrics6) and embrace the ever-changing landscape in surgical training with an increasing number of trainees taking time out of training. More work should be put into the development of formal T&O-specific return to work guidance and courses, so that T&O trainees nationwide could benefit from a safer, smoother return to training. As overall numbers of returners at specific time points are relatively small, this could take the form of a virtual meeting.

Additional resources

• JCST: Guidance on the Management of Surgical Trainees Returning to Clinical Training After Extended Leave: www.jcst.org/-/media/files/jcst/key-documents/return-to-work-guidance-final.pdf.

• HEE SuppoRTT programme: www.hee.nhs.uk/our-work/supporting-doctors-returning-training-after-time-out.

• SuppoRTT return to training: https://mysupportt.com/.

References

References can be found online at www.boa.ac.uk/publications/JTO.