Trainees’ tales of less than full time trainingBMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e5295 (Published 22 August 2012) Cite this as: BMJ 2012;345:e5295
- Rosa Topley, GP registrar1,
- Gemma Ashwell, GP registrar1,
- Jessica Webb, specialist registrar in cardiology2,
- Alexandra Brightwell, medical education fellow3,
- Ros Roden, associate dean for careers and personal development4,
- Oliver J Corrado, director5
- 1Leeds, UK
- 2St George’s Hospital, London, UK
- 3London School of Paediatrics
- 4Yorkshire and the Humber Postgraduate Deanery, UK
- 5West Yorkshire Foundation School
- Correspondence to: or
Rosa Topley and colleagues look at how less than full time training can help doctors deal with changes in their lives at the same time as progressing their medical careers
What happens to your medical training if something unexpected occurs? How can you train if you become unwell, a family member needs you, or your circumstances change? What if you want to start a family and raise young children?
Working flexibly, or less than full time (LTFT), can help trainees in any of these situations. LTFT training can also help doctors who want to do voluntary work—for example, with refugees or disadvantaged groups—and those who wish to follow opportunities for medical or non-medical personal or professional development.
Working LTFT has many benefits. For doctors, part time working can reduce exhaustion and allow more enthusiasm for work and a better work-life balance, and it will help to retain doctors in training who might otherwise have been lost from the workforce.
Formal flexible training first became possible in 1969, with the introduction of part time training.12 After the Calman reforms and the introduction of the specialist registrar grade, appointment of flexible trainees was integrated with the appointment system for full time trainees. In 2007 part time training and flexible training became known as LTFT training.
The most common reason to work LTFT is to care for children, and thus the number of flexible trainees tends to reflect the number of women doctors in a specialty. Paediatrics and general practice have the largest number of LTFT trainees,3 whereas specialties such as cardiology have few. Given that roughly 60% of entrants to medical school now are women,4 it is likely that specialties that have been traditionally less popular with women will attract more female trainees who may wish to work flexibly at some point in their career.
Here four junior doctors in different specialties and at different stages of their careers explain why they opted to train LTFT.
Gemma Ashwell is a GP registrar and has been training LTFT to look after her mother
I vividly recall when I first realised my mother was developing dementia. It was during my first year in medical school and we were discussing a case of Alzheimer’s disease, when it occurred to me that the history seemed too familiar for comfort. I think that initially I buried my head in the sand, seeing my parents often but trying not to worry about the increasingly frequent “incidents” such as forgetting appointments and forgetting names. Then late one night in my third year I received a call from my father saying Mum had gone missing. She was subsequently found by the police at 4 am, driving around completely lost.
My mother was only 57 years old, but we obviously couldn’t ignore the situation any more. My father and I took her to our general practitioner, who referred her to a psychiatrist, and she was then diagnosed with early onset frontotemporal dementia. For two years my father undertook the role of principal carer, but he died suddenly and unexpectedly about a year later when I was in my fourth year at medical school. My brothers and I then organised a rota to ensure that one of us would be at home with Mum most of the time, and through an agency we found a carer to cover any gaps.
It was extremely hard studying for my exams and looking after Mum. I often felt guilty trying to get her to occupy herself while I concentrated on revision. I passed my exams but then had to consider how I could balance work as a foundation year 1 doctor and being a carer.
My foundation year 1 was a blur of hospital shift work and weekends caring for Mum; however, I don’t think I was able to do either job to the best of my ability. I was struggling to juggle my different roles as a new doctor, a daughter, a carer, a sister, a girlfriend, and a friend. I discussed my situation and the different options available to me with my foundation training programme director, foundation school director, and the Yorkshire Deanery careers adviser (who also coordinates LTFT trainees). After considering the various possible work patterns we felt it best to alternate work in hospital with caring for Mum at weekly intervals. This was an unusual request, but the deanery and foundation school took into account my particular situation and the travel that being a carer necessitated and agreed to it.
I have been working less than full time for nearly four years now, and despite some challenges my experience has been tremendously positive overall. The main advantage has been the ability to get a much better work-life balance. I am incredibly grateful that I have been able to have the time to care for my mother, to keep her happy and comfortable and in her own home.
Rosa Topley is a GP registrar and trained LTFT because of health problems
I became unwell a few weeks into my foundation year 1. I assumed I had developed migraine, even though I had never had it previously. Even when I noticed that my vision was blurred I still didn’t associate this with anything too untoward and went to an optician. After examining me the optician urgently referred me, and I soon found myself on a neurosurgery ward awaiting surgery for a cerebral tumour.
After time off and discussions with the foundation school and occupational health I had a “phased return” to my foundation year 1 post in medicine, working for part of the day and not participating in the out of hours rota. The foundation school had liaised with the trust to ensure that it appointed a locum doctor to cover my duties, enabling me to work as a supernumerary member of staff.
During foundation training it is permissible to miss only one month of training owing to ill health before it becomes necessary to make up any lost time. I was disappointed to have to repeat the year as I was very keen to continue training alongside my peers and friends.
Because of my health problems I was classified by the foundation school as having “special circumstances” and I was able to choose my repeat programme. I chose a city centre post that was easily accessible, as there are driving restrictions after a craniotomy. I maintained good health during my extra year and felt more experienced than my peers. This enabled me to develop additional professional skills and attributes such as teaching and to broaden my knowledge and experience.
Unfortunately, during my first foundation year 2 attachment I received news that my tumour had recurred and, after advice, opted for further surgery. After the operation I was again phased back to work on a supernumerary basis and was extremely well supported by the school and my educational supervisor throughout.
I applied to train in general practice during this time and was pleased to secure a place, deferring my start on the general practice training programme until I had completed my foundation year.
Soon after this I took a further break from my training for a six week course of radiotherapy. I found that I worried far more about my work and training than I did about my health. As doctors we are used to success and it is a shock when plans don’t go as smoothly as we have planned or expected.
After 10 different training posts, three craniotomies, six weeks of radiotherapy, my driving licence removed and reinstated twice, I was determined to complete my foundation training, and with support I was able to do so. There is room for flexibility in foundation training providing you too are willing to be flexible.
Jessica Webb is a specialist registrar in cardiology and trained LTFT to start a family
I never considered how training might affect family life when I was choosing a medical specialty and chose cardiology purely because it was the specialty that interested me the most. I started as a cardiology registrar in 2006 and was aware that there weren’t many female cardiology consultants. However, it didn’t bother me that I had never personally worked for a female cardiologist, either registrar or consultant, as I just imagined I would make the job work for me.
I subsequently had three children in three years and am now working in a tertiary centre as an LTFT specialist registrar trainee. As there were no other registrars training LTFT, there was no option to job share, so I am in a supernumerary post. The advantages of being supernumerary are that I can direct my own training, have more autonomy, and have more opportunities to take on other projects and challenges. I have achieved more general registrar training than I suspect I would have had I continued full time, as I am working towards a teaching qualification (postgraduate certificate in healthcare and biomedical education) and participated in the NHS London Prepare to Lead programme.
Working LTFT in a specialty such as cardiology initially seemed quite daunting, but it has been the best thing I could have done. I have thoroughly enjoyed returning to work after my third child and feel lucky to have been able to take such a long time off to be with my children during my spells of maternity leave and to combine work with family life. I love the balance of spending days at home with my children and also enjoy working: interacting with adults, seeing patients, and spending time in the catheter lab and the echocardiography department. I have had to learn to be more efficient with my time and certainly find myself working on the days I am at home with my children.
There have been moments when I’ve found LTFT training difficult. When I first started in 2008 I felt I had to apologise for not being at work on my days off, and I have been told in the past that as I’m supernumerary my training needs are less important than those of full time trainees. I am currently not on the formal on-call rota and so carry the bleep during the day. This has the advantage of more regular hours, which makes my childcare easier, and consultant help is at hand if needed.
Overall, working LTFT has been a fantastic experience and one that I would wholeheartedly recommend to anyone, irrespective of their specialty. I feel more enthusiastic and motivated about my career having had my children, and I have benefited from being the only LTFT trainee in my department as I have been able to carve my own trajectory. Importantly, I have had supportive consultants who have been available to listen, support, and encourage me to ensure I get the best experiences possible to prepare me for being a consultant.
Alexandra Brightwell is a specialist registrar in paediatrics and trained LTFT because of family responsibilities
I always wanted a family, and when I became pregnant at the end of my second year as a specialist registrar I never doubted that I would return to paediatrics to train LTFT. Since my first job in paediatrics as a preregistration house officer I have been surrounded by positive role models of women and men who have made working part time a success. Many of my most inspiring role models in paediatrics have worked part time, and the difficulty of balancing work and family life is an open reality in my specialty, for full time and part time trainees.
I now have two children, a surgeon husband, a fantastic nanny who works three days a week, and a full and exciting working life. Training LTFT has given me the opportunity to participate fully in other areas of my working life that I would never have been able to tackle as a full time working mum. I am a member of the London School of Paediatrics Trainees Committee (along with many other flexible trainees) and part of the 2011 NHS London Prepare to Lead programme. I am undertaking a postgraduate certificate in medical education and am currently out of programme as a fellow in medical education at the London School of Paediatrics. I use my days off to do projects and write between my children’s naps and the nursery run. For me this extra time is an advantage of training flexibly, and it motivates and energises me to achieve more than I ever did in the days when I was full time.
Even in paediatrics, where LTFT trainees are an established group of the workforce, training part time is not without its challenges. Working in neonates when my slot share post was unfilled I was constantly asked if I’d found someone to do “my” on-calls on the days that I didn’t work, and the need for me to job share has meant that my rotation has changed three times in three years. However frustrating they are at the time, these challenges have ultimately improved my skills—for example, when I found that none of the specialist registrar training clinics fell during my working days I negotiated changes that brought benefits to all trainees in my department.
Ultimately, I love paediatrics, and working LTFT has enabled me to apply the family centred principles that I believe in so strongly to my own family life. I believe that my experiences of balancing work and home life can only give me increased insights to improve the quality of care I give to children and families, and I am grateful for the opportunity to do so.
How to go LTFT
To be considered for LTFT training, doctors must be in a substantive post (not a locum) in any grade from foundation year 1 onwards. LTFT training can be done in three ways: in a full time post, in a slot share, or as a supernumerary doctor. Most deaneries prefer LTFT trainees to take up slot share posts or to work part time in a full time slot, because these have no additional funding requirements and they can help hospitals or trusts to maintain rotas.
In supernumerary training the LTFT doctor is an addition to the current complement of doctors in a department and is often thought of as an extra pair of hands. Though supernumerary training involves no additional funding requirements for trusts and can help them maintain rotas, deaneries need to find additional funding for the extra LTFT post, and thus supernumerary training is not always possible. Supernumerary trainees sometimes struggle to feel part of the team and have reduced exposure to out of hours work, which may affect their training and experience.
LTFT training time is calculated pro rata with full time training. Many deaneries expect LTFT trainees to work at a rate of 50-60% of full time working, but some flexibility exists. Deaneries fund salary costs but do not cover on-call pay, which must be covered by trusts. Bear in mind the considerable financial implications of fewer working hours and therefore a lower salary.
If you are considering working LTFT, first talk to your training programme director and the associate postgraduate dean with responsibility for LTFT training at your deanery; it may be easier to arrange than you think. It is important that training programme directors are included in discussions to ensure that the structure of the proposed LTFT training meets curriculum requirements and training objectives. Make the most of your personal support network (friends, relatives, and colleagues) during this period. You are likely to need reassurance and practical and emotional support.
Once you start training LTFT, try not to worry about falling behind your peers in terms of career development. A medical career needn’t be a rush to a final end point; it is an important journey that may be as effective, perhaps more effective, if taken at a slower pace.
We acknowledge the outstanding level of support that the late Peter Templeton provided to trainees in Leeds as a foundation training programme director.
Competing interests: None declared.