Going out-of-programme as a specialty trainee: procrastination or optimisation of training?

Out-of-programme activity among UK trainees

There are nearly 5,500 medical registrars holding a NTN within the UK.² Determining exact figures on the number of medical trainees OOP at any one point is difficult due to the constant changes that occur in OOP activity in different deaneries, but is believed to be in the order of 15–25% based on subspecialty trainee reports.^3,4 Studies have highlighted that many trainees wish to undertake a period of research or extended clinical training but barriers, such as the difficulties in procuring funding or lack of research ideas/trackrecord within a department, may dampen this enthusiasm. In addition, a lack of direction or clear information about what options are available within a training region may also limit the trainees' perspective. Finally, personal, domestic and social circumstances may understandably result in travel limitations (for example, seeking an opportunity abroad or even out of region) and can impact on decisions to go OOP.^5,6

What are the options when considering time OOP?

There are currently four different types of OOP activity that a specialty trainee may undertake (Table 1). Time permitted to undertake these OOP activities varies but usually ranges between one and three years, subject to the necessary approval from the postgraduate dean. OOP career breaks (OOPC) are usually granted to specialty trainees wishing to pursue interests outside of medical training or who require time away from the training programme due to ill health. Permission to undertake this type of OOP activity is usually granted for two years but can be extended in exceptional circumstances. Detailed analysis of this type of OOP activity is not covered in this review but can be obtained from the Gold Guide.¹

Why undertake OOP research (OOPR)?

Most specialty registrars who undertake an OOPR will not be seeking a long-term academic career. However, research remains popular with trainees, with 68% of specialist registrars and specialty registrars wanting to undertake a higher degree in research in a recent Royal College of Physicians (RCP) survey.² Career progression needs to be acknowledged as a major reason as to why many trainees want to undertake research.⁷ Publications in peer-reviewed journals, presentations at scientific meetings and attainment of a higher degree, such as an MD or a PhD, are often important criterion for shortlisting committees and enhance a curriculum vitae (CV).⁸ However, there are additional advantages to undertaking an OOPR including both personal and professional development. Participation in full-time research enables trainees to gain an understanding of differing research techniques, statistical application and promotes skills in critically appraising research of others, necessary for the foundation of a trainee's own clinical practice.⁹ Personal development can be achieved during an OOPR by developing project management skills, writing skills, finance and budgeting skills. In addition, as a result of the OOP a trainee may gain confidence and expertise in a particular subspecialty area.^9,10 While there are appreciable benefits of undertaking an OOPR, there can be potential disadvantages to undertaking this form of OOP activity and these are highlighted in Table 2.

How do I organise an OOPR?

Most specialty registrars have a clear idea of their subspecialty interests after one or two years in their specialty programme. Planning to go OOP at this point may represent the optimal time to undertake an OOPR as this provides adequate time to return to the training programme to recover clinical skills, complete and submit thesis and papers for publication, well in advance of application for consultant posts. It is also preferable but not essential that the topic or research in the OOPR relates closely to the trainee's subspecialist career aims. This will ensure enthusiasm for the research project, which is essential to success and enjoyment of an OOPR. After identifying an area of interest, it is essential to identify an appropriate supervisor and objectively determine the potential supervisor's credentials. Adequate supervision during research (or indeed any other OOP) is crucial to success. Gauging academic success of a potential supervisor can be achieved following discussions with previous researchers from within that department. Sometimes much can be learnt from what previous research fellows don't tell you–so ask open questions and listen carefully to the answers! Further assurances can be gained by a Medline review of the supervisor's previous publications, knowledge of how previous candidates were funded and the number of previously supervised and ‘completed’ (awarded) degrees. Most OOPR activity is undertaken in academic departments in the UK but a small number of trainees do elect to do research in district general hospitals or within non-academic units in teaching hospitals.

Research during an OOPR can usually be divided into three types: basic medical science research (laboratory based), clinical research and epidemiology and health services research. Determining the type of work to undertake during an OOPR may depend upon a trainee's wishes, time allowances, supervisor's expertise and funding type. Trainees would be advised to consult peers and senior colleagues prior to a decision on whether to undertake clinical or laboratory-based projects during an OOPR. Three years is usually the maximum time allowed to undertake an OOPR and usually requires registration for a higher degree (eg a PhD, MD or master's degree), with the degree type being determined by the type and duration of the research study.¹

The final hurdle (and often the most arduous) is securing funding to undertake an OOPR. Two broad categories of funding can support a trainee through an OOPR: ‘hard’ and ‘soft’ money. Hard money denotes funds acquired from grant awarding bodies including medical charities, NHS research and developmental schemes or regional trust funds. Soft money encompasses financial support provided by pharmaceutical companies who may have an interest in the area of the research project or from an individual consultant's personal research funds. Trainees need to be aware that hard money is regarded as more prestigious and attracts significant competition. One further route is to apply for a clinical fellow post. These posts are trust funded with a significant proportion of time involved in service commitment (unselected outpatient clinic and endoscopy lists). The rest of the time is then dedicated to research. Although at face value this may represent the least attractive option, there are advantages. The post is immediate and funding available. This may allow a trainee time to ‘work up’ an idea before applying for full funding. If a trainee wants to concurrently enhance their clinical skills and experience then this type of post may also afford such an opportunity. The authors' own experience of such posts has been positive with two previous fellows both appointed through such a scheme. Both individuals were awarded their MDs and published up to 20 publications (more than five original data papers). Nevertheless despite this subjective opinion this type of post has the potential of being nothing more than a ‘pair of hands’ and involves significant service commitment while undertaking research. Time management is crucial to success.

Given the considerations necessary to secure an OOPR, trainees would be advised to explore potential research opportunities 12–18 months prior to a proposed start date, ensuring postgraduate dean approval for an OOPR and GMC approval if research competencies achieved during an OOPR are to contribute towards a CCT (maximum of one year). Finally, this long-sighted approach will also ensure that ethical approval has been obtained for the proposed study, this is a hurdle not to be underestimated!

Why undertake an OOPT or an OOPE?

Most trainees undertake an OOPT or an OOPE in order to benefit from an experience that is not achievable from within their own training programme. The activities that constitute an OOPT or an OOPE may often appear very similar but differ depending whether the post will count towards a CCT. The potential opportunities during an OOPT or an OOPE are vast. Trainees may wish to undertake experience abroad obtaining exposure to different healthcare environments, working in either developed countries or potentially supporting healthcare in developing countries, an experience advocated by the Department of Health and royal colleges.¹¹ Trainees may also wish to develop an area of interest or skill within their chosen specialty, for example advanced endoscopic techniques, interventional cardiology or possibly a stroke fellowship, and this can be accommodated through an OOPT or an OOPE.

Many trainees and consultants recognise that attainment of a postgraduate degree can enhance career progression.^10,12,13 At present there are many UK universities offering both full- and part-time postgraduate degree courses specifically targeting medical trainees. Examples include degrees in medical education, public health, information technology and business management. However, fulfilling commitments to clinical work during a specialty training programme and undertaking a postgraduate degree at the same time can be challenging and a period OOP could facilitate this opportunity. Another benefit of this type of time OOP is that it may support trainees not wanting to undertake a formal research degree but who would still like to gain exposure to research and produce publications. The units that offer OOPT or OOPE are often also research active. Thus the trainee can potentially optimise this experience and gain both clinically while enhancing their CV.

How do I organise an OOP for approved clinical training (OOPT) or an OOP for clinical experience (OOPE)?

Potential opportunities for an OOPT or an OOPE can be found via the BMJ's careers website. Alternative sources for information include websites from individual medical societies, international organisations, like Médecins Sans Frontières, individual deaneries and UK universities. If a particular post is not immediately recognised or the experience being considered is abroad, then the trainee would be advised to contact the identified institution offering the experience, to determine the potential for any posts.

Most advertised OOPT/OOPE posts have secure funding in place but offer pay at a basic level. Many trainees who secure an OOP activity undertake additional clinical duties or locum shifts to receive extra remuneration to offset the deficit. When funding is not immediately available, then trainees with the support of their potential departments may need to identify funds from other sources, such as medical charities, medical societies, industry, hospital funds or pharmaceutical companies. This is often a limiting step to trainees securing an OOPE or an OOPT, as this process can take up to several years to organise. There is even the possibility that the ‘promise’ of funding may never materialise despite everyone's best efforts. For this reason any trainee is well advised to have several options or contingency plans and not ‘place all their eggs in one basket’. This should reduce the likelihood of disappointment on the trainee's part. However, such an approach should be openly discussed with potential supervisors in order to avoid any conflict.

After identification of an appropriate post, trainees are advised to discuss their options with their educational supervisor and training programme director, and to seek approval from the postgraduate dean. The postgraduate dean can then advise as to whether competencies achieved during the OOP activity are redeeming enough to count towards a CCT (a decision that ultimately rests with the GMC), constituting an OOPT. If the activity does not fulfill the necessary requisites to constitute an OOPT, an OOPE may be awarded. Other issues that need to be considered prior to being granted an OOPT or an OOPE are visa and work permit issues if travelling abroad, indemnity insurance and giving sufficient notice prior to leaving a training programme. This is currently set at a minimum of three months to allow sufficient time to arrange appropriate cover for the trainee's absence.¹