Intended for healthcare professionals


What happens to the foundation trainees who don’t move straight into specialty training?

BMJ 2013; 347 doi: (Published 31 October 2013) Cite this as: BMJ 2013;347:f6425
  1. Eleanor Checkley, North Western Foundation School careers lead1,
  2. Hannah Williams, specialty registrar in histopathology2,
  3. Paul Baker, Foundation School director3
  1. 1Health Education North West, Manchester, UK
  2. 2Mersey Deanery, Liverpool, UK
  3. 3North Western Deanery, Manchester, UK
  1. Ella.checkley{at}


North Western Foundation School has surveyed foundation trainees who do not go straight into specialty training. Eleanor Checkley, careers lead at the school, Hannah Williams, and Paul Baker look at why these trainees choose to take time out of training, at the support they need, and consider the potential impact on their careers

For several years the North Western Deanery has been collecting data on career plans for all doctors leaving the two year foundation programme. At the end of foundation training, about 30% of doctors do not go straight into specialty training, and we wondered what happened to these people. We wanted to know why they had made their decision, and what career support we might be able to offer anyone planning to take time out after foundation training in the future.

We surveyed two groups of trainees: those leaving in 2013 and those who had left in either 2011 or 2012. Demographic data on each trainee leaving the school, as well as individual career plans, are collected as part of the e-portfolio sign off process in July, and this information is also used by the UK Foundation Programme Office for their national survey.1

We identified the 169 trainees (32% of the 532 leaving in 2013) who did not plan to enter specialty training and emailed a request to complete a survey on their plans. We also emailed all doctors who completed foundation training in the school in 2011 and 2012 with a link to a similar survey, asking them to complete it if they had not moved straight into specialty training.

We asked trainees to tell us about their plans on exit from foundation training (table 1), and to choose the reason that most explained their choice (table 2). In total, 59 doctors from the group leaving in 2013 completed the survey, giving a response rate of 35%, and 23 of those who left in 2011 or 2012 replied. However, not all respondents answered all questions.

Table 1

Plans at time of exit from foundation training*

View this table:
Table 2

Reasons for not moving straight to specialty training

View this table:

Reasons given

The most common reasons for not moving straight into specialty training were uncertainty about future career choice and desire to work abroad. Few gave the reason as not being able to obtain a training job in the location of their choice, but several in the most recent cohort said their choice was a result of not obtaining a training post in their chosen specialty.

We gave trainees the opportunity to explain further, and their comments show the varied reasons for not moving into specialty training straight after foundation training. Some had made their decision after successful specialty training application. One said that the possibility was “always in the back of my head but [I] still applied [to specialty training] for the experience, then decided after getting an offer that I wanted a change of pace.” Another respondent said, “[I] successfully obtained a core surgical training post, but tracks on offer included no paediatric surgery so I withdrew my application.”

Others simply wanted a break. One respondent wanted a “natural break in career,” saying it was “important to know I’ll get home for Christmas for the first time in three years.” Another group said working conditions or their experience of training in the United Kingdom were factors in their decision. One respondent had made the decision for “multiple reasons: wanted to experience time abroad; unsure about long-term career plans; dislike of UK working conditions and remuneration.” Another said, “I just felt I needed a break—had had a few foundation jobs which were particularly trying.”

Trainees who planned to work abroad for a while were asked whether they eventually planned to return to medicine in the UK. In total, 75% of respondents who left in previous years planned to return, whereas only 43% of 2013’s leavers were certain they would return.

In total, 15% of trainees who left in 2013 said they had received career support that covered areas other than specialty application. Programmes seem to be providing support, perhaps because they notice the trend for more and more of their trainees to make this career choice.

These trainees would have liked more information on alternative career pathways during their foundation programme, particularly around locum work and financial considerations as well as help with making career decisions.

Many believed, however, that a lot of the preparation work must be done as an individual. “It’s too much of an individual thing to be able to give wide ranging advice,” one trainee said. “I got the information elsewhere fairly easily so this is not crucial,” another said.

Trainees also commented on the need for help to plan specialty application when they left foundation training and on planning to maintain medical skills during a career break. None of them mentioned planning for revalidation or maintaining a licence to practise.

We asked trainees how this career support would have been best delivered. The most common choice for both groups was talks from trainees who have returned from spending time outside of training. Formal lectures and group workshops were more popular than one to one sessions. Trainees said they thought that the best time for these sessions would be between February and August during foundation year 1, perhaps with some follow-up sessions early in foundation year 2. One trainee said doctors feel anxious about making non-conventional career choices and want “genuine opinions of colleges on people who take time out,” adding, “I heard lots of rumours that it would be detrimental to my chances of getting a job, but this appeared to be untrue.”

Consequences of time out of training

Trainees often worry about the consequences for their future career chances of taking time out working abroad or travelling. We therefore asked those who had already had time out to report on their experiences and assess the impact on their career.

Trainees who had left one or two years ago were asked how their time out of formal training had affected their personal and professional development. Most rated their time out as highly useful or useful for professional development, and 74% rated it as extremely useful for personal development.

Trainees also commented on the opportunities for professional development that time out can provide. “I developed new skills including leadership qualities due to multiple opportunities,” one said. “I got experience that I would never have gained in the UK, and I gained an additional qualification,” another said. “Fantastic experience, served me well at interview,” a further respondent said.

Although several respondents described the benefit of non-curriculum driven training (box), not all respondents had positive experiences. One said that, despite the benefits of the experience, “I wish I had not gone to work in Africa as I became ill there and this has impacted on returning to training in the UK.” Another said that a tough year had provided development opportunities but had led to a feeling that “it has left me a year behind rather than equal with my current colleagues.” A further respondent said, “I don’t feel my year out was as useful for my professional development, but it could have been if I’d tried harder to make it so.”

Box: Benefit of freedom

Several respondents commented on the benefit of non-curriculum driven training, and the freedom to develop their professional role at their own pace, saying:

  • “A brilliant year spent gaining experience with no pressure to tick boxes.”

  • “You no longer feel that you are on a conveyor belt.”

  • “I feel like a professional, I have control over my work life compared to hospital training roles where I felt very controlled.”

  • “I felt much more eager to return to full time training by the end of the year, and I think this made me a better doctor/trainee as a result.”

  • “Much needed for me personally. When I returned, I felt more sure about my career choice and I also felt older and more at ease saying that I was a doctor.”

  • “I met and interacted with others who had stepped away from the formal training route —seeing that there are options other than what we are used to seeing daily in the hospital.”

Foundation doctors who choose not to go straight into specialty training appear to fall into several groups:

  • Aspiring academics

  • Disillusioned with working conditions

  • Undecided on specialty or have missed out on a desired post

  • Planning a career break

  • Seeking to work in different healthcare settings

Most trainees who do not move straight into specialty medicine plan to come back to medicine in the UK, although some are disillusioned with working conditions and the rigid training pathway.

The overwhelmingly positive comments from people who have had time out of training reflect the beneficial effect this experience has had on their morale. It would be interesting to see how long this effect lasts and follow up these trainees as their careers progress.

Few of the respondents said they had made the choice because they had failed to obtain the job they wanted in specialty application. It would seem it is a positive career choice for many, not a default position for those who have not been successful.

Those who had left in previous years said that they had learnt from the experience. They appreciated the need for planning and ownership of personal development better than those who were about to embark on the same path.

It is clear, however, that some doctors and some of those responsible for specialty recruitment still see this as a risky choice in terms of future career chances. More research into this area is needed to explore in greater detail the educational benefit of taking time out, with reference to the wider leadership curriculum.2

Support for trainees

Career support is currently tailored to the 70% who enter specialty training, with sparse provision of information around other potential career pathways. Foundation trainees who do not plan to move straight into specialty training need more support. They need information on planning time abroad, on working in UK non-training posts, on less than full time training, on retainer schemes, on revalidation, and on maintaining a licence to practise. They would also benefit from information on finances and options outside medicine, as well as better information from the royal colleges on the impact of their choices on chances for specialty training posts in the future.

Not all of this is within the remit of the foundation programme, but more could be done. Trainees who do not go straight into specialty training are happy for information to be provided in groups as lectures or workshops, but would appreciate the input of trainees who have experience of time out of training. Those who have spent time out seem to appreciate that a lot of the planning and information seeking needs to be done on an individual basis.

Trainees who work as doctors after experience in other jobs, in different countries, and in other roles will enrich the profession. Time out of formal training need not be seen as a life on hold until the proper job comes along, but as a positive career choice made by an increasing number of doctors.