Breaking down barriers to flexible training in trauma and orthopaedics

Caroline HM Bagley, Rob Gregory and Paul Harwood on behalf of the SAC in T&O

Caroline Bagley is an ST8 Orthopaedic Trainee on the NE London UCLH Rotation. She has a specialist interest in Foot and Ankle Surgery. Having successfully worked LTFT for much of her specialist training she has mentored many other trainees considering flexible training.

Rob Gregory is a Consultant T&O surgeon who works in Durham. He has a longstanding interest in surgical training, is currently Chair of the SAC for T&O and is a recent Trustee of the BOA.

Paul Harwood is a Consultant Orthopaedic Surgeon specialising in trauma and limb reconstruction at the Major Trauma Centre in Leeds. He has a particular interest in medical education and is the Deputy Training Program Director and the Joint Head of Year 3 MB ChB undergraduate program at Leeds University Medical School. He is a member of the Trauma and Orthopaedic SAC, including a responsibility for LTFT trainees.

Training in trauma and orthopaedics must evolve to attract the best trainees from across the diversity spectrum. The traditional route of fulltime training progressing to consultant practice does not suit everyone. As Neil Mortensen said, “We have to have a profession where it’s acceptable to work part time, flexibly. It must be acceptable to have some time in and out of the profession as your personal circumstances require. It’s a matter of self-preservation.”[1]

The option to work less than full time (LTFT) opens the door to a more diverse workforce. A doctor who trains LTFT works reduced hours, calculated as a percentage of full-time training, with resultant pro-rata extension of their total training time to meet CCT requirements. It has been reported that LTFT foundation trainees are less likely to be appointed to Core Surgical Training (CST), that female CSTs are more likely to have adverse outcomes at ARCP, especially if LTFT and LTFT CSTs are more likely to fail the MRCS. At present only 4% of orthopaedic trainees work LTFT but demand is increasing. Since 2021, the JCST made LTFT training available to all trainees for personal choice.

Our survey examines attitudes and potential barriers to flexible orthopaedic training.

A survey of UK trainees

A voluntary, confidential, online survey was distributed to all orthopaedic trainees in the UK via BOTA and the TPD’s forum. The survey was designed to understand the experiences of trainees who had or were presently working LTFT, the attitudes towards LTFT training and its impact on others, and any perceived barriers to LTFT training.

What the trainees said

One hundred and sixty responses were received from 1,196 training posts (13%). 56% of respondents were male and 42% female (3% preferring not to say). 68% were Caucasian, 14% Asian, 5% of multiple ethnicity, 6% from other ethnic backgrounds, with the remainder preferring not to say. 44% had dependent children and 13% dependents other than children. Responses were received from trainees at all stages of higher surgical training. Four respondents (2.7%) had worked LTFT prior to higher surgical training (HST), 86 (57%) had considered working LTFT at some point in HST. Of these, only 27 (31%) had gone on to work less than full time. Figure 1 summarises reasons the respondents gave that they had not undertaken LTFT training. Of 118 trainees who have not worked LTFT, 72 (61%) said they might consider doing so in the future.

Figure 1: Reasons trainees have not gone on to LTFT training.

Attitudes of all trainees to LTFT

A series of questions explored all respondents’ attitudes to LTFT, responses are summarised in Figure 2.

Figure 2: Responses to question posed to all respondents on their attitudes to LTFT.

Experiences of trainees who have worked LTFT

Further questions explored the experiences of those who have worked LTFT. Of the 27 respondents, 5 were previous and 22 current LTFT trainees. Responses to these questions are summarised in Figures 3-5. Overall, 48% felt LTFT working had a positive impact on their training with 30% feeling negative and 22% feeling it made no difference. 41% felt LTFT training had a negative effect on their future career prospects, 37% felt it made no difference whilst 22% felt it had a positive impact.

Figure 3: Responses to questions posed to LTFT respondents on their experience of the organisation of their LTFT training.

Figure 4: Responses to questions posed to LTFT respondents on their experience of the supervision of their LTFT training.

Figure 5: Responses to questions posed to LTFT respondents on their experience of the working with hospital management.

Thematic Analysis

Thematic analysis of open questions was undertaken, including responses from all trainees regardless of previous experience of LTFT. This approach identifies common patterns in the responses in a systematic manner and groups these into themes so they are easier to understand. The results are summarised in Figure 6. More detail of this analysis, along with a sample of the direct quotes from which the themes and subthemes were derived, are found in Appendix 1.

Figure 6: Results of inductive thematic analysis (Braun and Clarke) of open questions posed to trainees on experience of working as and / or alongside LTFT trainees.

Discussion

The results of this survey provide insights into LTFT higher surgical training in trauma and orthopaedics. The opinions expressed here are important, however we must be mindful that only 160 responses were received. This represents less than 20% of potential respondents and may be subject to selection bias. These views may therefore not be generalisable to the whole group.

Less than full time surgical trainees have traditionally been perceived as less-than fully-committed to their career, driving a fear of discrimination [2]. Unfortunately, this belief persists, with 53% of respondents to our study stating that anxiety around potential negative effects on their career put them off applying to work LTFT. This finding is supported in a recent survey of female surgeons, where a third of participants felt flexible pathways were looked down on [3]. Adverse perception of LTFT from TPDs and trainers was identified by a majority of all trainees in our study when asked about barriers to requesting LTFT training (65% and 33%). Conversely, most who had worked LTFT felt the attitude of their TPDs (74%) and trainers (78%) was positive, indicating that some anxieties about stigma may be outdated. More worrying was that only 59% of those who had worked LTFT felt supported by their peers. This perhaps relates to the fact that 47% of the entire group reported that they had covered additional clinical duties for LTFT colleagues at the expense of training activities. A principal challenge to normalising LTFT training is covering the deficit in service created. It is unfair to expect full-time colleagues to increase their workloads and creates understandable resentment amongst both groups. Extra support for departments is required to help design work programmes that accommodate the needs of all concerned.

Concerns regarding quality of training whilst working LTFT were also highlighted. Whilst 74% of LTFT trainees felt their training needs had been met, more than 67% reported having to work outside of their designated hours to achieve their training requirements. Furthermore, 57% stated that they were given reduced pro-rata non-clinical sessions (for example, research and administration time) compared to their full-time peers. Despite a commitment by the JCST in 2017 to improve LTFT training [4], it appears that many orthopaedic departments still struggle to accommodate LTFT trainees and create pro-rata training opportunities. 26% of respondents had negative experiences with hospital management and only 22% felt management understood how LTFT training worked and were supportive. This further supports the view that departmental management teams need to be educated and supported to provide good training experiences whilst covering clinical commitments.

Access to LTFT pathways may also be an issue, 19% or respondents were put off applying because the process was too complex whilst only 33% felt they had been given sufficient support planning LTFT training. This exposes a need to clarify the application process.

The BOA is committed to improving diversity. Whilst numbers are growing, orthopaedics still struggles to attract female applicants [5]. 64% of medical school applicants are female dropping to 20% of Orthopaedic SpRs, and 7% of Orthopaedic Consultants [6]. Improved flexible training attracts more female applicants as training coincides with the natural time for having young children. Demand for more flexible training options is not just coming from women [7]. Applications for LTFT training are increasing across all specialities from both genders – 96% of applicants were female in 2008 and 80% in 2014 [8]. Retaining the best trainees is as important as recruiting them. Trauma and orthopaedics reported the highest trainee drop-out rate of all surgical specialties [9,10]. Losing a trainee late in their carer pathway comes with significant cost. Structured LTFT programmes could help prevent trainees from leaving. This is supported by the results of our study, where the 61% of respondents said they would potentially consider LTFT working in the future, a significant proportion of these being male.

The respondents in this study were at varying levels of training and from a wide range of training programmes. The over representation of female and LTFT trainees compared to the whole training population does suggest responder bias. Nevertheless, results are concordant with previous studies. Many of the issues identified were also highlighted in the 2017 JCST LTFT Policy Statement [11]. Where our survey differed was that, for those trainees who trained LTFT, their experiences were mostly positive. 78% disagreed when asked if they had experienced bullying because of their LTFT status. This shows a significant improvement from the 2015 study by Harries et al., though our survey is smaller and looks only at orthopaedic trainees [8]. 48% felt that overall LTFT training had been a positive experience whilst 22% felt that it had made no difference to their training.

Conclusion

Trauma and orthopaedics is committed to recruiting the best possible trainees. Access to quality flexible training is one way of improving inclusivity. This widens the pool of potential applicants and helps with trainee retention. It is wrong however to make assumptions about which groups of people might wish to pursue LTFT training. This option should be open to all in order to support a modern workforce and increase trainee wellbeing. A cultural change whereby LTFT training is accessible and accepted will help normalise it. Educating and supporting trusts to provide for LTFT trainees will not only improve LTFT training, but also make trauma and orthopaedics a more enticing training programme that attracts ‘the best’, creating a more diverse and stronger workforce.

References and Appendix

References and Appendix 1 can be found online at www.boa.ac.uk/publications/JTO.