Post-Certificate of Completion of Training fellowships

• post-CCT fellowships
• postgraduate medical training
• workforce

Postgraduate medical training continues to evolve. Substantive consultant post numbers are lacking in a variety of specialties, including respiratory medicine, to accommodate the ever increasing number of trainees who achieved their Certificate of Completion of Training (CCT). Training time and hours accrued are also being shortened as a result of the European Working Time Directive (EWTD) and a 48-hour working week from August 2009. Although training is becoming competency based, there is a finite amount of time needed to acquire that competency, ie there will never be any substitute for experience based in time.

The Modernising Medical Careers Programme Board in 2007 allocated over 100 12-month post-CCT fellowships to provide extra training not covered in the curriculum but also to help reduce the specialty training (ST) trainee ‘bulge’ assisting in National Training Number (NTN) recycling. It was envisaged that these posts would provide an additional year of supervised specialised experience post-CCT in specialties where there was a strong need clinically and in terms of workforce. Mostly posts in surgical specialties have been awarded so far (about 80) but a few have been created in anaesthetics, obstetrics and gynaecology, psychiatry, radiology, paediatrics and more recently adult medical specialties including stroke medicine, gastroenterology and respiratory medicine. Other specialties have developed variations on this; for example, in neurology, the Association of British Neurologists Training and Education Committee is considering proposing six-month subspecialty fellowships with the possible help of some of the major neurological charities.¹

Opinion about these posts among existing trainees is mixed. Many in current peri-EWTD programmes (ie around the time of EWTD changes) advocate an extension in standard higher specialist training to reflect the reduction in working hours and maintain the standard of CCT. However, most trainees also agree that a limited introduction of post-CCT fellowships might be of great individual benefit on a select basis but also feel strongly that such posts should not become a standard intermediate grade between specialty registrar (StR) and consultant.

So who might such posts appeal to? Trainees who have not yet done a period of research, or who have trained in the peri-EWTD era of shortened hours (where training has to be inevitably focused on all core areas of the curriculum at the expense of optional extras) and/or who are in a specialty where there is a relative shortfall of consultant posts and slow consultant expansion (for example, respiratory medicine, among many others) might potentially want to consider such a post, while waiting for the required consultant expansion and a suitable substantive consultant post. The potential benefits to that trainee might be extra subspecialist skills that are not part of the mandatory specialty core curriculum (practical or clinical) or research experience, service development experience in that post and curriculum vitae enhancement to make that individual more attractive as a future consultant post applicant. It should also be noted that overseas fellowships in centres of excellence in North America or Australasia, for example, have been undertaken by select individuals in the past and perceived as worthwhile in posts not dissimilar to post-CCT fellowships.

Post-CCT fellowships have the support of some professional bodies. The Royal College of Surgeons (RCS) has stated it is the intention of such post-CCT fellows to be able to deliver their subspecialist services within a larger group of specialists within a regional centre and possibly to aid larger research networks to improve the evidence base in their field.² However, they are also clear that completion of such a period of time denotes simply completion of a period of study which should only rank alongside other experience and training to be judged on its merits. Importantly, the RCS also does not see these posts as a passport to the sub-consultant grade (a commonly cited potential longer-term criticism of such posts, discussed later).

What are the potential drawbacks? Possible pitfalls highlighted by other professional bodies, might include:

• timing in the job market, ie the post-CCT fellowship postholder completing that post only to compete with yet more post-CCT trainees in the ‘bulge’ (although proponents of such posts would argue that if the fellowship post has been carefully selected and a success then the applicant should be better placed to compete in this situation)

• loss of national terms and conditions on a junior doctor pay scale and contract (absence of the quality assurance safeguards of postgraduate medical education or an educational contract, ie not overseen by the Postgraduate Medical Education and Training Board (PMETB) or the deanery) in a non-standard job subject to local implementation with no formal recognition of the service provision demands that are received via the consultant contract

• the lack of a clearly defined training outcome or learning objectives and the potential just to be treated as another trainee rather than an accredited (post-CCT) specialist

• potential adverse effects on existing pre-CCT trainees’ training

• the lack of an obvious workforce need for such posts

• the fear of shifting closer towards the development of a sub-consultant grade.³

Finally, it has been suggested that a locum consultant post could deliver the extra subspecialist training with appropriate remuneration for experience and maintain service delivery in one negating the need for such posts.

Releasing further NTNs in specialties which are oversubscribed may compound the problem. A more important caveat is that post-CCT fellowships should not put into question the standard or validity of a CCT in that given specialty, ie they are an optional extra but the training curricula vetted by PMETB are of the required standard. In some specialties, there has been a requirement for an English NTN (as opposed to other parts of the UK) to apply for such posts leading to inequality in access. Rumours of a diploma on completion of these posts have yet to be realised so worries of creating a two-tier system at the point of consultant entry can be put on hold.

• © 2009 Royal College of Physicians