Dr Hugh Roberts / Anaesthetics Trainee / North East
Dr Hugh Roberts is an anaesthetic trainee currently working in the North East. He has worked as an expedition medic for the last 5 years. This started whilst taking time out of training to work as an emergency medicine and expedition medicine clinical fellow in Bristol. Now that he is back in training he has successfully continued to integrate his expedition work into his life as an anaesthetic trainee. In this article he uses his experience to explore the issues and options surrounding combining work as an expedition medic and specialty trainee.
Years out of training after the Foundation Programme are often some of the most enjoyable of a doctor’s career, and stepping back into training can feel like the end of the adventurous lifestyle of those F3+ years. However, being a specialty trainee does not have to mean your expedition medicine career is put on hold. This article describes how you can balance a career in expedition medicine with specialty training, with specific focus on anaesthetics, emergency medicine and general practice.
We will begin by reviewing the current state of UK specialty training and examining the benefits that expedition medicine can bring to both trainees and training schemes. We will then consider the options available for taking leave from training, and finish with some case examples of doctors who have managed to successfully balance expedition medicine with their specialty training.
The State of UK Specialty Training
There is a retention crisis across UK specialty training. In 2020, the Royal College of Emergency Medicine (RCEM) published the document Retain, Recruit, Recover – our call to action to improve the urgent & emergency care system.1 It reported that 36% of emergency medicine doctors in training were considering working abroad and 25% were considering changing specialty. In the same vein, in 2021 the Royal College of Anaesthetists (RCoA) released the document Respected, Valued, Retained – working together to improve retention in anaesthesia.2 It reported that 25% of anaesthetists in training were planning to leave the NHS within five years. It is a similar picture in general practice, with the Royal College of General Practice (RCGP) reporting that 22,000 GPs and GP trainees plan to leave the specialty in the next five years, citing exhaustion and burnout as key causes.3
These figures are stark and it is clear that training schemes need to make changes to improve retention. Although it is early days, it is encouraging that the Royal Colleges are acknowledging these problems and recognise that change is required. RCoA responded to the findings of its report by committing itself to improving work-life balance for trainees, increasing flexibility and supporting portfolio careers.2 These changes would certainly make it easier to balance expedition medicine with specialty training, but exactly how these will be implemented remains to be seen.
The Benefits that Expedition Medicine can Bring to Training
The benefits to training schemes of making it easier to balance expedition medicine with training go beyond improved retention. Expedition medicine training and experiences can also bring many other benefits that increase a trainee’s value to the NHS:
- Working without access to investigations can enhance a doctors’ clinical acumen and problem solving.
- Working independently in remote settings can increase self-reliance and clinical confidence.
- Experience of medical screening and working in challenging environments can enhance understanding of risk and ability to conduct dynamic risk assessments.
- Exposure to other healthcare systems and pre-hospital practice can inspire quality improvement projects and research on return to the NHS.
RCEM considers expedition and wilderness medicine to be a branch of pre-hospital emergency medicine (PHEM), and in this article they describe many benefits that training emergency medicine doctors in PHEM can bring.4
How to Take Leave from Training for Expedition Medicine
General Principles for Taking Leave
There are some general principles that are important to be mindful of when taking leave during your training. You should be up to date or ahead with your competencies and portfolio, otherwise you stand little chance of having leave approved. Make sure you give plenty of notice for leave requests; in most cases, several months advanced notice is required to facilitate the approval processes and prevent clashes with on-call commitments. When you do make it away on expedition, always keep your General Medical Council (GMC) registration, or you will lose your training number.
Options Available for Taking Leave
Option 1: Out of Programme (OOP)
The Gold Guide (also known as The Reference Guide for Postgraduate Specialty Training) details how to take time Out Of Programme.5 The GMC also has a useful guide on OOP.6 There are several types:
- OOPE (Experience)
- OOPC (Career break)
- OOPT (Training)
- OOPR (Research)
Information on OOP from RCoA can be found here, and from RCEM here. There should also be guidance available from your local deanery. There is no specific guide from RCGP, so you should refer to the GMC guide and your local deanery guidance.
OOPE
The purpose of OOPE is to gain professional skills that would enhance your future practice. It may benefit you (e.g. working in a different health environment/country) or may help support the health needs of other countries (e.g. with Médecins Sans Frontières, Voluntary Service Overseas, global health partnerships). GP training deaneries are offering opportunities for international OOPEs to locations such as South Africa, Zambia and India. There is also the National Global Health Fellowships Volunteer Programme, open to GP, paediatrics and ACCS trainees, offering posts in a number of African countries.
OOPC
OOPC allows you to step out of the training programme for a designated and agreed period of time to pursue other interests (e.g. domestic responsibilities, work in industry, developing talents in other areas or entrepreneurship). Dr Tamal Ray, a finalist from the sixth series of The Great British Bake Off, used an OOPC to join the show from anaesthetics training. An OOPC could also be used to pursue expedition interests.
OOPT
OOPT is clinical training, taken out of programme, that can count as time towards CCT provided certain conditions are met. For anaesthetics trainees, you need to be a higher or advanced level trainee to take an OOPT, which can count for up to one year towards CCT.7 RCEM do not specify at what stage of training you can take an OOPT.8 Specifically to support trainees wanting to undertake OOPT in a low-middle income country, RCoA has developed a unit of training Annex D – anaesthesia in developing countries to enable this to count for up to six months towards your general duties requirements. The criteria for this are quite rigorous, so you are probably better off joining an established project, such as those advertised here.
OOPR
OOPR is research taken out of programme. If an expedition involves research, this may be an opportunity to take OOPR. Both RCoA and RCEM state that some OOPR time may count towards CCT, provided certain criteria are met.7,8
How to Apply for OOP
You should refer to the relevant guidance described above. Unlike OOPT and OOPR, OOPE and OOPC cannot count towards your CCT and are approved at the level of the Local Education and Training Board (LETB), meaning you do not need Royal College or GMC approval.6 Your LETB will have its own OOP application process that you will need to follow. It is recommended that you discuss your OOP with your Educational Supervisor (ES) and Training Programme Director (TPD) at least six months in advance, so it is unlikely that these are going to be useful for last minute expeditions. Ultimately, approval for OOPE or OOPC is at the discretion of your TPD and Postgraduate Dean. This can work for or against you, depending on where you are training. Although it may seem unfair, that is the current system. It is important to note that for anaesthetics trainees, you are allowed up to a maximum of two years total in any mixture of Out Of Programmes.
Option 2: Study Leave
This is another option that requires a sympathetic ES, although it is easy to justify why study leave for expeditions or expedition medicine courses/certificates/diplomas/MSc programmes is reasonable:
- Expedition medicine teaches lots of ‘soft skills’ that are often specific learning outcomes for specialty training, such as: communication, leadership, teamwork, organisation/planning and situational awareness.
- Research and critical appraisal are usually components of specialty training curriculums and may be components of expedition medicine postgraduate certificates, diplomas or MSc programmes.
- Expedition medicine experience is useful for higher specialty training applications. ST4 anaesthetics self-assessment criteria include Domain 10: activities demonstrating leadership and/ or management inside or outside of work, with high scores for ‘commitment to leadership or management inside or outside of medicine such as expedition leadership’. A postgraduate certificate, diploma or MSc will also score points, and expedition medicine is a great topic to talk about at an interview!
Set expectations early by discussing your interest in expedition medicine with your ES at your initial meeting. Having a Personal Development Plan (PDP) that links your interests in expedition medicine with your chosen specialty is likely to help too. It is generally easier to get study leave for courses, diplomas or MSc programmes than it is for expeditions, although study leave for expeditions is not unheard of and so it is always worth asking. You should not expect to get any study leave funding, and shorter periods of study leave are more likely to be approved.
Option 3: Less than Full Time (LTFT)
73% of UK anaesthetists in training state that being able to work flexibly or work LTFT is important to encourage them to stay in the NHS, and 57% of emergency medicine doctors in training are considering reducing their working hours.1,2 All doctors in training can apply for LTFT, either at the point of application for entry into training or at any point during training. It is important to note that when applying for LTFT at the point of application, it will not affect your chances of being appointed. Although you have to give a ‘well-founded individual reason’ to apply for LTFT, expedition medicine should certainly fall within this scope.5 LTFT is a great option if you want to complete a postgraduate certificate, diploma or MSc, or need time to be involved with a regular commitment such as mountain rescue. Information about LTFT can also be found in The Gold Guide.
Option 4: Weekends
We now move onto the first of two options that require you to give up your free time. The disadvantages of using weekends are obvious: you risk burnout, and lose time that you could be spending with friends and family, or pursuing your own adventurous interests! However, there are some advantages: it will not extend the duration of your training and you are not required to justify your weekend activities to your training programme. Charity challenge companies are always looking for volunteer medics for their weekend UK events, and these are a great way to foster your relationship with companies whilst continuing to gain expedition medicine experience and bolster your CV.
Option 5: Annual Leave
This is arguably the least attractive option. As specialty trainees, we deserve our time off; we work long and unsociable hours whilst balancing many other work commitments, such as audits, exams revision and portfolio management. RCoA agrees with this sentiment, advising that individuals should ‘take annual leave and time they need to look after themselves and recuperate’.2 The advantage of this option is that your annual leave is yours to do with what you will, so there is no need for justification and approval from your training programme. Where possible, give your rota coordinator plenty of advanced notice to avoid clashes with on-call commitments. Make sure you include time for recharging on a sunny beach or ski slope as well!
Examples of Doctors Who Have Made It Work
In case you need proof of what you have read so far, here are some examples of doctors who have managed to strike the balance with specialty training and expedition medicine. Hopefully their stories will provide you with encouragement and inspiration, as well as some tips on how to make it work for you.
Dr Nikki Cox / Consultant Anaesthetist / Queen Alexandra Hospital, Portsmouth
What have you done during training?
I finally CCT’d in summer 2021, but I had plenty of gaps in my training! After completing core training, I took some time out and worked with a charity challenge company on UK events, an Everest Base Camp expedition and a London to Paris cycle ride. I also volunteered with Mercy Ships in the Congo and Madagascar. Once I started specialty training, I managed to continue with both of these companies, using annual leave for charity challenge events and taking a combination of study leave and an OOPE to teach in Senegal with Mercy Ships. I also took an OOPC to spend 6 months in Provence and improve my French language skills, ready for Senegal.
What was your experience of getting leave?
My TPD was very supportive. I think in anaesthetics, you tend to be recognised as a whole person rather than just as an anaesthetist. They are not trying to make us all into identical doctors.
Any advice?
Once you have got your final exams, the training programme is very keen to keep you and that can help. On expeditions, you are pushed out of your comfort zone and often have to deal with the unexpected, so there is a lot you can learn that is relevant to work as an anaesthetist. Whilst you are in-programme, it helps to save money so you then have the flexibility to take six months off and be free to do what you want, rather than having to locum.
Do you think anaesthetics and expedition medicine complement each other well, and why?
Anaesthetics is a sessional specialty, and that makes it easier to take time off. Since CCT, I have been away again for a month to teach in Senegal. Just do not expect to get leave during the school holidays when everyone else wants time off!
Dr Ellie Debenham / CT2 Anaesthetics / Cumberland Infirmary, Carlisle
What have you done during training?
I went LTFT when I began ACCS. My reason for going LTFT was to do the Diploma in Mountain Medicine (DiMM) and to have more time to get out in the mountains. I have done the first three DiMM modules now and just have the alpine module left. I also planned to get involved with mountain rescue, but I am yet to join as I am enjoying my climbing too much!
What was your experience of getting leave?
When I started ACCS, work-life balance was not considered a valid reason for going LTFT, so I had to sell it as doing the DiMM. That is definitely not the case anymore. Some people are very supportive and might say: “I am slightly jealous of your lifestyle, I wish I had made different decisions!”; others might say: “you are not committed, why are you even a trainee, why are you even a doctor?”. You have to stay true to what is giving you the lifestyle you want. Sometimes I have been able to get study leave for the DiMM modules, and sometimes I have had to take annual leave, it is variable.
Any advice?
One of the nice things about doing a postgraduate qualification like the DiMM is that suddenly, you have a network of channels that you can contact as you are in a room of like-minded people who want to have a career but also want to go on adventures! Once you have got the diploma, you have got it, and you do not know what opportunities it might open up in the future. I would like to go work at the Sherpa outpost hospitals. It is also helpful for higher specialty training applications – a diploma is another tick in the box, so why not do it in something really fun rather than something dull?
Do you think anaesthetics and expedition medicine complement each other well, and why?
I think that anaesthetics is the best career you can do in medicine, why would you want to do anything else?! It is the most fun and practical. With anaesthetics, you learn the ability to deal with horrendous situations and look after critically ill people. I also think having A&E experience is useful, for example for trauma management, and GP is useful for managing comorbidities or problems that might present to primary care.
Dr Alex Taylor / ST3 ACCS Emergency Medicine / Bristol Royal Infirmary, Bristol
What have you done during training?
During ST1, I worked on an event with Children in Need. Covid had cancelled another trip I was supposed to be on to Nepal and luckily the leave I had taken lined up with this UK challenge! In ST2, I spent two and a half weeks on a polar expedition in Greenland with a youth development charity. Most recently I worked in a rural hospital in South Africa for four months as part of a six month OOPE offered by Health Education England. I have also taken leave to teach on a variety of expedition and wilderness medicine courses.
What was your experience of getting leave?
The Children in Need event was annual leave. Greenland was a mix of annual leave, study leave and Educational Development Time (EDT). South Africa was an OOPE, and the role included reimbursed costs (up to a limit per month), funded accommodation and annual leave. For teaching on courses, I was granted study leave. In my experience, I have found it is definitely easier to get study leave for teaching than it is for going on expeditions.
Any advice?
Be prepared! Tell your ES about your interest in expedition medicine from the outset. It helps to write a PDP before your initial meeting which demonstrates a long-term interest, and support it with evidence. Your ES may not have any personal experience of expedition medicine, so having a discussion about what is involved (screening participants, preparing medical kits, leadership and teamworking, risk assessments, working in a resource poor environment) helps them understand that you are not asking for extra holiday leave! I also like to use Workplace Based Assessments (WBAs) as evidence of my clinical work on expeditions. You could arrange a Case Based Discussion (CBD) with your ES after your expedition, or with a senior medic on your expedition if there is one – it is all helpful for your portfolio.
Do you think emergency medicine and expedition medicine complement each other well, and why?
The cases you are likely to encounter on expedition are either problems that might present to GP, or emergencies, and the emergencies are the ones that people tend to worry about. Emergency medicine also teaches you a lot of ‘soft’ skills that are useful on expedition, like dynamic risk assessment, resource management, flexibility and leadership. Looking after an unwell patient on expedition usually requires the whole expedition team, so it is a lot like managing a busy emergency department!
Dr Jack Watson / GP / Cheltenham / @outdoormedics
What have you done during training?
I was interested in expedition medicine during foundation training, but did not feel I was cut out for it – looking after sick patients alone in a remote setting seemed like a lot of responsibility, and I was never the one fighting to the front at crash calls! I started GP training and after ST2, took a global health fellowship to rural South Africa. This was a huge change for me – I was caring for really sick patients and the buck stopped with me, so it gave me the confidence to manage prehospital cases on my own. When I returned to finish GP training, I felt inspired to gear everything towards expedition medicine. I started working events with a charity challenge company and built on my prehospital experience, including a case that summer when a spectator fell and broke her arm. I also enrolled on a BASICS course near the end of ST3. The events were a ‘foot in the door’ for me to get on my first international expedition to Kili in January 2019, a few months after I finished GP training. I have also spent time working as a rural GP in Shetland and the Outer Hebrides. There was lots of overlap with expedition medicine in that role, and having BASICS was really useful.
What was your experience of getting leave?
The South Africa global health fellowships are run by Health Education England, so it was easy to get study leave for the preparatory courses for that. The fellowship itself was an OOPE. There was no pay progression during the fellowship year, which was quite frustrating. I got study leave for the BASICS course and received funding of about £1500 to cover the course fees. My ES was very supportive, but was surprised that I got the funding approved! I sold it mainly as being useful for rural GP rather than expedition work, and I think that it also helped that by that time I had completed my Clinical Skills Assessment (CSA) and Applied Knowledge Test (AKT). I also did ALS during ST3, as I wanted to do some work in A&E, but the training programme would not fund that as GP training only requires ILS.
Any advice?
You have to fight your corner and be savvy. Show that what you are doing brings transferable skills and relate it to the GP training curriculum. Unfortunately there is big variability geographically, and what you get approval for depends on what region you train in.
Do you think GP and expedition medicine complement each other well, and why?
I am a big believer that GP is the best specialty to balance with expedition medicine as it is a short training scheme and then you can be your own boss. There is a big overlap in skills and 90% of problems you encounter on expedition are GP presentations.
Conclusion
There is no doubt that finding time for expedition medicine is harder as a trainee on a rota than it is with the complete freedom of working as a locum. However, hopefully this article has helped to show that there are ways that you can make it work. The Royal Colleges recognise the need to prevent trainee burnout and drop out, and want to work with trainees to fit their goals around their training and keep them in the programme. Use the options that are available to you, plan well in advance, engage with your ES and TPD, and expect that shorter expeditions, weekend events and postgraduate qualifications will be easier to fit in around your training than longer expeditions. Do these things, and the adventure does not have to end at CT1/ST1!
References
- The Royal College of Emergency Medicine. Retain, Recruit, Recover – A Call for Action [Internet]. 2021 [cited 2023 Mar 1]. Available from: https://rcem.ac.uk/retain-recruit-recover-a-call-for-action/
- The Royal College of Anaesthetists. Improving retention in anaesthesia [Internet]. [cited 2023 Jan 25]. Available from: https://www.rcoa.ac.uk/policy-communications/policy-public-affairs/anaesthesia-fit-future/improving-retention-anaesthesia
- The Royal College of General Practice. Retention as vital as recruitment in addressing GP workforce crisis – College calls for urgent action to keep GPs in the profession [Internet]. [cited 2023 Mar 4]. Available from: https://www.rcgp.org.uk/News/Workforce-Retention-Statement
- The Royal College of Emergency Medicine. What do RCEM committees do? Introducing the RCEM PHEM Professional Advisory Group [Internet]. 2021 [cited 2023 Mar 4]. Available from: http://president.rcem.ac.uk/index.php/2021/01/18/what-do-rcem-committees-do-introducing-the-rcem-phem-professional-advisory-group/
- Conference of Postgraduate Medical Deans of the United Kingdom. A Reference Guide for Postgraduate Specialty Training in the UK – The Gold Guide 9th Edition [Internet]. 2022 [cited 2023 Jan 11]. Available from: https://www.copmed.org.uk/gold-guide/
- General Medical Council. Out of programme guidance for doctors in training [Internet]. [cited 2023 Jan 11]. Available from: https://www.gmc-uk.org/education/standards-guidance-and-curricula/guidance/out-of-programme/out-of-programme-guidance-for-doctors-in-training
- The Royal College of Anaesthetists. Out of programme [Internet]. [cited 2023 Jan 11]. Available from: https://www.rcoa.ac.uk/documents/12-out-programme
- The Royal College of Emergency Medicine. All UK Training Programmes [Internet]. [cited 2023 Mar 4]. Available from: https://rcem.ac.uk/emergency-medicine-training-programmes/
