Maintaining training progression in remote-working junior doctors

Practical preparations

To protect training for junior doctors, specific practicalities must be addressed to facilitate effective remote working.

Clearly, a junior doctor needs an appropriate computer system and broadband at home. It is also important to consider, in advance, which programmes and applications will be necessary, including software for virtual meeting attendance. The remote worker will need access to the hospital's electronic documentation, imaging and results systems.

Many hospital departments have introduced online clinical and educational meetings with success.⁴ In our department, a daily MS Teams meeting has been set up with the stroke service so that the on-site and remote teams can review all the patients on the ward, their notes and imaging together. This gives both teams an invaluable update on the plan for each patient as well as providing an opportunity for consultant teaching either on the clinical cases or facets of the radiology.

Online educational sessions are particularly helpful for remote workers. They can plan their day around these, attempting to clear tasks and allow time for learning. Our experience is that education sessions have been better attended when held virtually than when in person.

Tasks that are appropriate for remote workers included the following:

• telephone clinics with consultant discussion and review of each case

• preparing electronic note entries in advance of the morning ward round

• preparing electronic discharge summaries

• making referrals to other hospitals or specialties

• requesting clinical communications from a general practitioner or other hospital

• obtaining results or arranging image transfers from other hospitals

• chasing results internally

• ordering and arranging investigations and tests.⁵

The overriding aim is to ensure that education is maintained alongside service delivery.

Remote workers should complete workplace-based assessments in a similar manner to their on-site colleagues. After completing several tasks remotely for a single patient, a junior doctor is well placed to complete a workplace-based assessment via telephone or email with their supervising consultant.

While that is specific to enabling trainee doctors to work remotely, many online resources have been developed to provide advice and support to healthcare professionals beginning remote working.^1,6–8

Working hours

Within the experience of the authors, remote-working junior doctors have been restricted to in-hours working. However, it may be feasible for a remote-working doctor to support an on-site team out of hours with appropriate tasks in circumstances of exceptional need, or to support routine ward tasks at weekends, such as checking results. Out-of-hours work, however, has lower staffing and less consultant supervision and is, therefore, higher risk than in-hours remote working.

Keeping to rostered working hours is important. It is often assumed that remote working will decrease workload and decrease working hours. Indeed, remote working healthcare professionals commonly report a sense of guilt for not working on-site, or of having to justify their contribution.⁵ As a result, some describe drifting into a cycle of working longer hours than they would do on site.

Morale, momentum and mental health

Increased risk to wellbeing has been described in those working from home across all careers.⁹ Some juniors may move from a busy, enjoyable work environment to being at home alone doing a job that feels alien to their old role. Many doctors working remotely felt their contribution was not valued or were uncertain if their work had been acknowledged by their colleagues.⁵ Because of this, regular voice or video interactions with colleagues may boost wellbeing.

When working remotely, proactively maintaining human contact can help sustain morale, by opting for an occasional phone or video call rather than solely using electronic messaging to communicate. Consultants should recognise that additional supervision time may be required, as a junior doctor is not receiving the daily informal direction customary during on-site work.

Creating structure and momentum while working remotely can be challenging. This presents challenges not only in times of COVID-19, but also to doctors leaving clinical environments to pursue research and academic roles. Self-directed organisational and motivational skills will differ between junior doctors, and it is important to be aware that some may require more help than others to build a successful job plan and daily work structure, especially if they are new to the department. A friendly supervisor arranging a meeting to help them organise their work schedule at the start of a period of remote working may be invaluable.

Some junior doctors have a readily available, spacious, quiet environment at home. Others have partners, family, children and pets at home; limited space; or slow computer and internet facilities. Supervisors should proactively explore the challenges that a junior doctor's home environment may present. This conversation could also provide an opportunity to discuss a junior doctor's ideas, concerns and expectations around working remotely and any implications to their own mental health.

Positive impacts

In our experience, off-site IT access allowed remote-working junior doctors to provide highly flexible support to several on-site teams at the same time. They could adapt their focus each day to target the clinical areas most in need of assistance. Of course, remote working suits some specialties more naturally than others, but identifying what can be done within a junior's role, rather than focusing on what cannot, is crucial.

Remote working may positively affect some aspects of training. A remote-working junior doctor may find they have more time to focus on management, remote clinics and academic writing. Focusing on non-clinical aspects of a trainee curriculum, such as quality improvement or teaching and reflection, may allow trainee doctors to be comparatively ahead in these areas on their return to on-site working.

Remote working may also provide a rare opportunity for a better quality of life, replacing commuting time with family time or the pursuit of personal interests. In contrast to noisy, cramped ward offices and workspaces, with innumerable distractions and insufficient computers, remote working may provide a more efficient, spacious and pleasant working environment. Anecdotally, some remote-working doctors have reported improved wellbeing. Certainly, studies across a variety of industries have reflected a broad range of outcomes, with some remote workers reporting lower stress levels and improved physical health.¹⁰

In our experience, telephone clinics increased clinic time for remote-working trainees above that of on-site trainees. For trainees, learning to consult patients and give clinical advice remotely, rather than in person, is an important skill to develop prior to becoming consultants.

Remote working gives on-site colleagues opportunities to hone their delegation skills. Within hospital-based teams, coordination of workload for remote-working staff must come from the on-site team, by direct delegation. The alternative, namely that remote-working staff self-initiating jobs from reading documentation alone, can lead to confusion, duplication of workload and clinical error. Delegation of computer or telephone-based tasks may seem like an additional task for a busy on-site doctor, but ultimately it decreases workload and frees up time for patient-facing tasks.

In our experience, delegation from on-site to off-site colleagues was most effective and most time-efficient using mobile group messaging platforms, such as WhatsApp. Where the benefits outweigh the risks and where there is no practical alternative, using commercial applications (such as WhatsApp) to share anonymised information with colleagues is acceptable.¹¹ Using these groups, on-site doctors could delegate suitable tasks to those working off-site immediately as the task arises.

In addition to using mobile messaging platforms, remote-working trainees can join meetings that generate large numbers of tasks (such as board rounds) via telephone or online platforms to allow the on-site team to delegate tasks directly during the meeting itself. Joining board rounds remotely also allows remote-working trainees the opportunity to interact with any nursing staff or allied health professionals who may be present.

When delegating work to off-site colleagues, using closed-loop communication is crucial, with a named person confirming responsibility for each task and feeding back when it is completed. Closed-loop communication gives an opportunity for clarification that happens less naturally in virtual communication than in face-to-face communication.¹²

Training progression

To explore whether a period of remote working will affect training completion dates, a trainee and supervisor should list any outstanding curriculum requirements and identify which of these can and cannot be completed while working remotely. Creating an action plan for any outstanding curriculum requirements that cannot be met will inform decision making as to whether extra training time is required.

To minimise delay to training progression, the trainee could consider:

• focusing initially on completing all curriculum requirements suited to remote working to free up time to concentrate on a smaller handful of outstanding requirements after returning to on-site working

• using simulated or online resources relevant to a specific outstanding curriculum item to prepare for completing the curriculum item upon return to on-site working

• exploring whether an alternative approach, more suited to remote working, is acceptable for completion of the curriculum item.

For some trainees, loss of patient-facing skills is a concern, and Supported Return to Training (SuppoRTT) options may need to be considered when coming back to on-site working.¹³

Summary

Optimising a junior doctor's training progression while working remotely requires careful planning and support. Remote working can also provide new learning experiences.

We would recommend that a junior doctor beginning remote working should consider the following practical points with their supervisor.

• Identify suitable and unsuitable tasks and communicate these to the on-site team.

• Agree working hours and draft a daily and weekly work structure.

• Plan remote IT access requirements.

• Consider what challenges a junior doctor's home environment may present.

• List outstanding curriculum requirements and identify which can and cannot be completed while working remotely. Create an action plan for any that cannot be completed remotely.

• Consider management, teaching and academic opportunities available.

• Plan the frequency of scheduled contact with supervisors while reinforcing a low threshold for unscheduled contact for support when required.

• Discuss a junior doctor's ideas, concerns and expectations around remote working, and possible mental health implications.

• Consider whether a change to training completion dates is necessary.

• Discuss SuppoRTT for returning to on-site working.