Out of Programme Opportunities [Re-release] (29 May 2024)

SPEAKER_03 0:00

If you enjoy listening to career conversations, why not become a member of the Royal College of Physicians of Edinburgh? Our membership provides you with access to the RCPE educational portal, the live evening medical updates, and you have options to view the symposia both in person or online. If you would like to learn more about this, please go to the Royal College of Physicians of Edinburgh website. My name is Marilena Gianudi, and I am a TMC member. Today I am delighted to be joined by Dr. Jivendra Gosai and Dr. Louise Mundy. Dr. Jivendra Gosai is the Deputy Training Programme Director of Cardiology in the Yorkshire and Humber region. He specialises in devices and heart failure and works at Bradford Royal Infirmary. He has also dedicated a lot of time to medical education and has undertaken an MD looking at simulation training within medical education with the University of Sheffield.

unknown 1:13

Dr.

SPEAKER_03 1:14

Louise Mundy is an acute medicine registrar based in Yorkshire and Humber. Her speciality skill is palliative care, and she is the only acute medic in the region with this special skill. She has therefore needed to create her own training path to facilitate this. She's currently in ST7, working on an out-of-programme year to undertake quality improvement within same-day emergency care at Bradford Royal Infirmary. So thank you both for taking the time to join me today.

SPEAKER_00 1:42

Thank you, Marilena, for asking us to speak.

SPEAKER_03 1:44

Thanks for having me along. So I guess I just wanted to start, Dr. Gasai, if it's okay with yourself, if you can briefly explain to us of the different types of out-of-program training opportunities that are available.

SPEAKER_00 1:59

Absolutely. So broadly speaking, I suppose you can divide out-of-program opportunities into those which are spent pursuing research and academic activities primarily, so usually research and some teaching type activities, and some which are more clinically focused. And of course, as well, in addition to that, there are out-of-program times where people are outside the practice of medicine altogether. They have breaks for pauses in training for reasons unrelated to work. And I was going to say that the most commonly used, I think, are out-of-program research. So OOPAR.

SPEAKER_03 2:40

So Jiv, would it be okay if you can just start us off by maybe going through the different types of out-of-program training opportunities that are available?

SPEAKER_00 2:49

Absolutely. So there are a number. There's OOP T or Out of Program Training Time. So that is where you are out of the core programme, the core training program, but obtaining usually clinical competencies, which are usually relevant to your CCT or usually relevant to your intended career. And that may or may not, some of those Oop T sessions may or may not count towards training, so it may or may not extend CCT. There's Oop E, so out-of-program experience, that's getting skills again, which are outside of the core curriculum, and they can be done in things like medical leadership, medical education, and various other things which may not necessarily be clinical, could also potentially cover work done overseas or perhaps work done in different specialties which are related to your intended career path. There's OOP R, so in the out-of-program research, which in the majority of cases will be out-of-program time, which is intended to lead to the award of either an MD or a PhD. There's Oop C, an out-of-program career break. So that's where trainees have a usually a pre-agreed period of time away from the training programme, which may be to allow for domestic opportunities or cover domestic responsibilities, including parental leave. It may be that there are other caring responsibilities that a trainee needs to take time out of. Or it may be that there's something altogether different. So, for example, some high-level athletes have had OOP Cs to pursue their sporting achievements and then have returned to programme once they're in a position to do so. And there's OOP P, which is the out-of-program pause, which is a pilot scheme, which I believe Louise knows a lot more about than I do. So I'd ask her to describe that.

SPEAKER_03 4:55

Okay, so this is probably a good time then if we do that now. So Louise, would it be okay if you just tell us about your experience with the out-of-program pause?

SPEAKER_01 5:04

Yeah, so the out-of-program pause is a relatively new idea and it's currently being piloted in Yorkshire and Humber, which is how I've managed to benefit from that. So this is an out-of-program time that you can take really for sort of well-being reasons or because you'd like to try something different. So the process for it was that you have a discussion with your educational supervisor and agree that this is something that you'd like to do. And there aren't too many conditions on it, actually. You have to have a satisfactory ARCP at your last ARCP, and you have to have a job in the NHS that you can go to. But other than that, it's really quite flexible, and that's what it's been designed for to give trainees that flexibility because sometimes the training programs don't leave room for that kind of thing.

SPEAKER_03 5:51

And I gather for the different types of out-of-program opportunities that we have, some of those can count towards training and some of those can't. What kind of additional skills can a doctor think about doing during their out-of-program time to allow for that to count towards training? I guess, Jiv, this is probably a question more for you.

SPEAKER_00 6:15

Yeah, it's a it's an individual discussion really, and it depends very much on every individual opportunity that's that's happening. So, for example, during some OOPR time, sometimes people may develop a clinical skill as part of their out-of-program research, and they may be able to consider adding some of that time which they spent in research, or they may, for example, do some clinical sessions during their research. They may have a day or two a week where they do clinical sessions. And there could be a discussion about using some of that or counting some of that time towards their CCT. And it will vary slightly between specialties, but I suppose I'm most familiar with the cardiology curriculum. So it's a 60-month full-time equivalent from ST3 to the end of ST7, which of course traditionally is done over five training years, but you may count some months towards those 60 months. If to give just an example, if you were going off to do a research project in a specialized imaging technique, and as part of that, you gained accreditation to do that specialized imaging technique, which would count towards your CCT and would count towards your intended career. There are some which are more obvious, particularly oop T or OOP, where you're gaining particularly clinical skills which count towards your CCT. For those areas where you are Oop and doing things which are less clinical. So to use my own example, I suppose my research being in medical education primarily, there wasn't a lot in there which was particularly relevant to day-to-day clinical cardiology. So there wasn't any of that time that I would have or could potentially have counted. And as I said, it is very much on an individual level. I think you have to be very careful about it as well and make a decision as to whether or not you do want to count some of that training time or whether you want it all to be completely separate to the 60-month equivalent full training programme. And of course, some trainees very much benefit from having the additional time in training and some extra clinical experience which isn't counted.

SPEAKER_03 8:28

And can I ask just touching briefly on the out-of-program research opportunities? Is that something that you can only apply for if you have either PhD funding, MD funding, a master's setup? Does it need to be specifically for having a degree at the end of it, or could you simply apply because you were interested in research into a particular area, for example, as a research fellow?

SPEAKER_00 8:54

Um it's my understanding that as a trainee, then the majority of cases, then it will the expectation is that it's research done with a goal towards working towards a formal research degree.

SPEAKER_03 9:06

Okay.

SPEAKER_00 9:07

An MD or a PhD in most circumstances.

SPEAKER_03 9:10

Thank you. And Louise, if it's okay, could you maybe talk us through your first out-of-programme experience and how you went about organising that? Because I'm sure there are lots of trainees that maybe want to take out-of-programme opportunities but haven't quite found the one that suits them.

SPEAKER_01 9:28

Yes, so my first out-of-programme time, which was two years ago now, doesn't feel that long ago, was I spent six months out of programme as an out-of-programme experience working at my local hospice. And the reason why I did that was because, as you've already mentioned, my special skill within acute medicine is palliative care. So acute medicine, as some people will know, has a variety of different special skills that you can pursue. Palliative care has always been listed for a long time as one of the special skills, but the way to achieve it was through postgraduate study. And I felt that actually I'd like to do something a bit more practical. So quite early on in my register of my training, I started talking to people about how I could potentially pursue that. And eventually I ended up submitting a proposal that went through the local training committee and to the further higher committees within acute medicine, and a new route to obtaining palliative care as a special skill was developed in which there was a clinical component. However, what there wasn't a clear path to was how you'd actually achieve it. So, as many people will know, a lot of palliative care is delivered in hospices and they are not generally part of NHS trusts, they're charities and independent. And so when I wanted to go out of programme and spend some time working in a hospice, one of the things that I came up against was how am I actually going to achieve that in terms of the trust isn't going to pay me to go and work in a hospice for six months because why would they? There's no benefit to them. So I had to start thinking about alternative ways to go and do it. And I managed to make links with a lot of the palliative care registrars and some consultants in the region and got talking to people. And it seemed that the way that it was going to be possible to pursue that was to apply for a job in hospice and then take time out of programme in order to do that. So that's how I came to be doing an out-of-program experience working in hospice. And I have to say it was absolutely brilliant. So I loved the six months and I gained a fantastic ranger experience while I was there.

SPEAKER_03 11:38

That's really good to hear. And I guess really exciting for other doctors that may want to do something that doesn't have a clear-cut pathway, knowing that actually there is always a way around it. So in terms of your first out of programme experience, were you at ST5 level at that point?

SPEAKER_01 11:56

So from leaving medical school, I'd gone right through training without any gaps. And the point at which I went out for that experience was halfway through my ST5. So I'd done six months of ST5 at the point when I went out.

SPEAKER_03 12:08

Okay. And do you think that kind of leaving it until ST5 to take your first out of programme experience was a good thing with regards to your training? If you could almost turn back the time, would you have done it earlier? Or do you think maybe it would have been better to be done later?

SPEAKER_01 12:24

I don't think I'd have wanted to do it any later because if I hadn't been able to organise it, I needed to have time to be able to obtain my specialist skill in another way. But in terms of whether I'd have done it earlier, I don't think it would really have mattered, to be honest. A lot of it for me in terms of the timing was about when the hospice job became available. So for a few months, I was sort of waiting for hospice jobs to be advertised and apply to them. My training programme director knew that that was what I wanted to do. But because these were specialty doctor jobs, they were often advertised at short notice. And so I had to work with my training programme director. And he spoke to some people higher up in the deanery to get permission for me to have a slightly shorter notice period on the out-of-program experience than other people might have. So there are all these different factors that need to be taken into consideration.

SPEAKER_03 13:16

Yeah, definitely. And I guess it also makes a difference on what your specialty is, really, because with a cumidon, you need to make sure you get your special skill in place. I guess from a cardiology route, things are slightly different because you need to make sure your practical competencies are also where they need to be. So from a, I guess, TPD point of view, do you think there's a there's a better time for trainees in practical specialties to be doing out-of-program experiences?

SPEAKER_00 13:46

I think in many curricula there are natural points during the curricula where there is a, I suppose, an inflection point. And again, using cardiology as the example, at the end of ST5 is the end of what's considered to be general cardiology training with ST6 and ST7 being subspecialty skill acquisition. You know, as we know, life rarely works like that, and it's it's rarely that neat and tidy that trainees can choose to, for example, do ST3, 4, and 5, acquire all of the skills of general cardiology and then take time out of training. And we all know that for various opportunities, as Louise says, these opportunities often come up at relatively short notice, and in order to take them up, then the trainee is often at the mercy somewhat of funding, whether it's research funding or a job being available, or whether it's personal circumstances, they're often at the mercy of those things happening in order to do it. The key from a TPD point of view, we absolutely try and be as as flexible as we can to support as many opportunities which add real value to people's training. But the key, uh sadly, as with all of these things, is making sure that there are enough boots on the ground, as it were, there are enough people left on rotors to cover the clinical service requirements and to make sure there are enough people populating a rotor. And we have had opportunities where, for example, people have had research funding and the research funders want them to be in place and starting to begin their research within a very short space of time. But because of the number of people currently on that rotor, then we haven't been able to approve that at the exact time specified, and we've had to work with the trainee and help them work with the research funders, and this applies equally to providers of all other foop opportunities to negotiate a time when the trainee can be released from the rotor and it is a reasonable time for the trainee to go out of programme. I suppose there are fairly natural points where it may be less desirable to do so, and that particularly comes around the time where there are mandatory exams, for example, during training. And different training programs have got exams at different stages during their curriculum. So it would be, I suppose, ideal not to take an out-of-program break immediately before an exam, because often the exams are relatively clinically focused, and trainees do better if they are in and immersed in clinical training at the time that they're sitting these exams. So it would be less ideal to immediately return from an out-of-program period, particularly if towards the end of your out-of-program period you're furiously writing up your MD or PhD and don't have much time to focus on anything else, and then have to sit an exam immediately that you return into programme.

SPEAKER_03 16:40

So, in terms of logistics, then I think you need to let your deanery know: is it six months before that you're hoping to do an out-of-program experience? Give them a six-month window?

SPEAKER_00 16:52

Um, the earlier the better, really. The more notice, and it stands as with anything, really, the more notice that people have to work with, the better. So as soon as you think that you've identified an opportunity which you may wish to pursue, that's probably the time to start talking either to your educational supervisor or TPD or both and say that this opportunity has arisen. And you'll get a couple of things from that. You'll you'll hopefully get an answer about what the training rotation looks like in terms of numbers, because the TPD will obviously have an idea of how many trainees are where what recruitment numbers look like. It may be that we're able to consider recruiting people into programme on the expectation that someone would be out of or would be going out of programme. And it might be that if we forecast that someone's going off for a three-year PhD and it's before we have to submit numbers for recruitment, that we're able to generate another training number and get someone into the program to cover part of that. But again, the earlier the better. The other thing, of course, is that if you're thinking about an opportunity, discussing it with your ES and your TPD will perhaps help get a bit of perspective on what they perceive the value to your training to be.

SPEAKER_03 18:02

Yes, of course. And Louise, you mentioned that obviously one of your out-of-program experiences was six months, and I think the one that you're doing now is for a year. Is there a either minimal or maximal duration that you can have for each out of programme experience?

SPEAKER_01 18:18

So actually, that's something that came up when I was looking at the planning for a second out-of-program experience, because at one point somebody did actually tell me that because I'd been out of programme already, I wouldn't be allowed to go out of programme again. That's incorrect. You are allowed to take more than one out-of-programme experience, as the fact that I'm now taking a second one demonstrates. And there's a lot of information about that in something that's called the gold guide for training. So, one of the things I'd say for anyone who's thinking about taking some time out of programme is to just familiarise yourself with what the rules are, because occasionally it happened to me, somebody will tell you something that turns out to be incorrect. And actually, if you're able to say to them, Well, I'm not sure that's correct. This is what my understanding of the rules are, then you're not just going to give up on your idea at the first time that somebody suggests that you might not be able to do it.

SPEAKER_03 19:11

Okay, that's definitely good to know. I know I hadn't heard of that. And is there obviously most people will be out if they're going to do a PhD for three years? Can that time be extended if needed? I guess this question may be more for Jiv.

SPEAKER_00 19:27

The answer again is that the usual maximum amount of programme is three years during any given training programme. And as Louise says, it doesn't necessarily need to be taken all at once, but the usual maximum is three years. But again, if there are individual circumstances, I don't think anything which was intended from the outset to be greater than three years would ordinarily be considered. But what you may well find is that if there are extenuating circumstances, and of course we've had quite a lot of that recently with trainees that were out of program in research posts particularly, and all of their recruitments had to stop for an extended period of time because of COVID, and their recruitment targets, and it was clear that some of them just weren't going to be able to achieve their MD or PhD in the intended time. So some of them have had extensions to their out-of-program time. And again, as I said, it's something which can be considered on an individual basis, and if needs be, can go all the way up to the head of school for further discussion if it's a more challenging case. But as Louise said, the gold guide for training and the deaneries themselves do publish detailed guidance on out-of-program and the rules and the sort of guidance that goes around out-of-program applications. So it's well worth, if you're thinking about it, familiarising yourself with those documents. They should be fairly straightforward to find, to find out what rather than, as as Louise said, relying on someone like my my memory. But if you're armed with the actual facts and what it says in the guidance, that often makes things a lot smoother.

SPEAKER_03 21:00

I guess looking forward, because we're all in it training programs to hopefully get to the end and work within a consultant role. Is out of program experience something that is favoured upon when you're applying for those consultant roles? Is it something that we should all be not hoping to do, but I guess something that we should all at least consider during our training? And that question could be to both of you if you could maybe tell us your thoughts on that.

SPEAKER_01 21:29

Is it all right if I go first?

SPEAKER_00 21:31

Please do, yeah.

SPEAKER_01 21:32

Yeah, so one of my main motivations for going out of programme this second time this year was actually the fact that during my training, I've never stayed in one job for more than six months, because I've always rotated through different posts, even if I've stayed in the same hospital for a year. So one of the things that I really wanted to get out of this year that I've only just started on, I've been doing this job for four weeks, is the opportunity to get involved in some really meaningful projects and service to. Development because I felt that actually that was something that was lacking from my experience with having been on shorter rotations, that I've generally only been involved in smaller quality improvement projects. So I definitely think that if I can get involved in some projects that are bigger this year and make some real substantial, meaningful changes, then that'll definitely be something that I can bring to consultant interviews and say, well, this is what I've done. And so I really hope that this will be something which is beneficial for me.

SPEAKER_00 22:29

I have to say, I couldn't agree more. I think it adds an extra dimension to you, which often you can't, or it's it's much more difficult to get in the relatively rigid framework of training. I think as well, it's it's important to recognise that you are often a consultant for a very long time. Consultant jobs are complex, and consultant jobs have got a lot of flexibility in terms of how you shape and how you mould both the job you start doing and also how you build your consultant job. So there may be skills which you can acquire during your out-of-program time, which you wouldn't be able to get in ordinary clinical time, which may either be attractive to your employer. So if you, for example, acquire specialist skills in something like leadership or management, that may well be something which discriminates you from other candidates when it comes to consultant interviews, for example. You've got these additional skills, it may be something that you approach a department and they look to develop. And Louise's very innovative out-of-program and training path illustrates that. Absolutely no doubt that having that special skill will make you very desirable to a department that would want and would welcome the development of that kind of service, which may not be available or may be much more difficult for them to implement without having an individual that's got that. The other thing is that I, having been a consultant now for about, or coming up, just coming up for five years, when I uh started my consultant job, like Louise, you you move around a fair amount in training, and I started my consultant job, and I realized that if I worked until my state pension age, it would be pretty much 30 years in the same job. And whilst when you're a trainee, I remember quite often thinking, I wish it would end, I wish the night shifts would end, I can't wait to become a consultant. The closer you get to the end of training, often the more you think that adding extra bits on to your training or adding additional skills onto your training can be very valuable and out of program is a really useful mechanism and opportunity for trainees to add additional skills on, which are much more difficult to acquire once you are a consultant. There's a middle ground, of course, there are post-CCT opportunities, and once you CCT, it doesn't necessarily mean that you need to immediately take up a consultant post, but doing it during training certainly is a very valuable opportunity. And if you've picked up special skills, which not everyone has, then that can look very attractive to an employer.

SPEAKER_03 25:06

Yeah. So I guess I can say with a lot of confidence that you both really enjoyed your out-of-programme time and it's something that you would encourage other doctors in training to think about doing?

SPEAKER_01 25:19

Absolutely, yes. My first six months where I spent time at the hospice was brilliant. It it wasn't quite what I expected because I found myself there as COVID kicked off in February, February 2020 was when I started that out-of-program. But nonetheless, it was absolutely fantastic. I've only been in my current post for four weeks, but so far I'd say I'm enjoying it and it seems to be going well. So I'm looking forward to the rest of the year. Excellent.

SPEAKER_00 25:46

I can only agree again. I think absolutely it gives you a fresh perspective as well, particularly if you go and do something which is very different to the day job, as it were. It gives you a completely different perspective. And often in training, it can feel a bit like you're on the treadmill towards CCT, particularly if you've not had periods out of training up until that point. So it just is an opportunity to have a completely different perspective, and it's one which may or may not ever arise again in your future. So if they are an opportunity that interests you, I would wholeheartedly encourage people to go for it.

SPEAKER_03 26:22

And I guess just starting to wrap up, obviously, you both made the absolute most of your out-of-programme experiences and did it to focus solely on training and on gaining further skills. If doctors are needing to take out-of-programme time as either a career break or sick leave, is that something that can be shortened if required? So if you know that they initially meet with their TPD and they're granted a year off, but actually in six months' time they feel that they can return back to training. Is that something that's possible? Or would they have to take that full time, the pre-allocated time out?

SPEAKER_00 26:59

Yeah, and I think it depends on the circumstances and what it is. If it's sick leave in the, I suppose, traditional sense of sick leave, then that would be handled in the same way as sick leave for any other employee would be handled. And it partly depends on the medical advice that the person gets, and there would be a period, and of course, it doesn't have to be an all or nothing thing. So for some people who've had periods of sick leave or time out of programme for other reasons because they're unable to complete the duties of their job at the time, then things like modified training or perhaps considering slightly different jobs or different hours or less than full-time return or a phased return or something could be applied. Again, I think it's something you often get into some relatively complex situations. And certainly there are trainees who have got complex situations and additional health needs that have got very tailored training. And some of them, for example, may need a period of time where they're supernumery, so they're not occupying a slot on the rotor, but their training can be much more individually modified as a result of that. It's something which I would hope in the majority of circumstances there will be enough flexibility to allow tailored responses to individual needs.

SPEAKER_03 28:20

And I guess if we finish off, if you could both maybe give one piece of advice to anybody thinking about doing an out-of-programme, maybe about how to go about it or why you did it and why someone should consider doing it. And Louise, if we start with you.

SPEAKER_01 28:36

Yeah, so I think piece of advice that I'd give is to pick something that you're enthusiastic about and be prepared to put in some legwork to get your out-of-program experience organised. It definitely took me a lot of time and enthusiasm to be able to get my out-of-program opportunities organized, to get them approved, to talk to all the right people. But because I knew that they were something I really wanted to do, I'm really pleased that I put that effort in and that I was able to get those experiences.

SPEAKER_03 29:07

Thank you. And Giv?

SPEAKER_00 29:09

Yeah, I agree. I think look carefully at what's on offer. Think about the opportunities or the kind of opportunities that you may want and start to look at opportunities that are available. Start talking to people. If, for example, you're interested in research, then start to talk to both other trainees, trainees that may have done something similar in your own specialty or in other specialties, and start to talk to the people that may be able to offer that sort of out-of-program session, whatever it might be. Think outside the box and don't necessarily think about opportunities which arise only within your immediate locality. If it's feasible, there may be out-of-programme opportunities that happen further afield. And also think very carefully when opportunities do arise. Well, what are the pros? What are the cons? Where am I in my training? Is it the right time for me to take a step out of training? Will there be the opportunity to consider continuing some clinical training during my out-of-program time? And what are the consequences of stepping out of programme now? But also what will be the consequences of passing up on this opportunity? Are there downsides? And certainly we've seen some trainees think about taking the first available opportunity, which may not necessarily have been right for them. So, as with any relatively major life decision, give it some very careful thought and seek advice from people you trust.

SPEAKER_03 30:33

Excellent. Okay. Well, thank you so much for your time and for joining me today. And thank you everyone for listening.

SPEAKER_02 30:51

We wish to recommend our Demystifying PACES podcast series on career conversations. As some of you may know, in late 2023, MRCP UK updated the PACES exam format, so we developed this new series to support PACES candidates. Episodes cover exam organization, calibration, every PACES station, including key changes and candidate perspectives.