A qualitative study of the perspectives of key stakeholders on the delivery of clinical academic training in the East Midlands

Trainee survey

A bespoke online survey was designed to assess trainees’ views of the quality, barriers and enablers of all aspects of their training. The survey questions were agreed and piloted by a small group of trainers and trainees to confirm the survey feasibility. Trainees of all grades, enrolled in a National Institute for Health Research or locally funded Integrated Clinical Academic Training, were invited to participate anonymously via a link to the online survey. The survey was repeated one year later with modification of some questions in light of previous responses (Appendix 1).

Focus groups

Systems and processes

The process is problematic at all stages – very difficult to understand and priorities are unclear. (Academic Supervisor)

There was concern among both trainees and trainers that the processes involved in recruiting to and delivering National Institute for Health Research Integrated Clinical Academic training programmes were complex, rigid and poorly understood. It was generally felt that having academic posts was desirable since they came with their own funding and had the potential to attract high-calibre trainees from outside of the region. However some trainers, particularly academic supervisors and university representatives, expressed the view that opportunities to recruit to posts were not always transparent or consistent which lead to a sense of frustration and injustice. It was also felt that opportunities to recruit to Academic Clinical Fellow and Academic Clinical Lecturer posts did not always align to local priorities, either academic or clinical. It was recognised that tensions between the priorities of university departments, clinical academics and National Health Service employed supervisors could influence the allocation of academic training opportunities. Trainees reported frustration that their roles were not always understood or valued either by university departments or by clinical teams. Better communication between hospital trusts and universities and between clinical and academic teams was described as a key priority.

Career pathways

There should be rigorous assessments to facilitate flexible exits – we need to think about honourable escape routes for those not suited to continue an academic career and recognise that the skills they have acquired are useful in their own right. (Academic Supervisor)

Trainee survey responses and information collected at all the focus groups raised considerable anxieties about career pathways for future clinical academics in the face of a changing health service and reconfiguration of postgraduate medical training. Educators believed that it was crucial to recruit potential academics very early on in their careers, even at undergraduate level, and to focus on long-term planning, both for individual trainees and for the management of both the academic and clinical programme. One striking difficulty mentioned by several participants was an apparent disconnect between academic foundation programmes and the rest of the academic training pathway. This was described as a major threat to the retention of potentially excellent local academic trainees. Indeed some respondents to the online trainee survey stated that lack of support and integration into the wider academic community during academic foundation placements had led them to look elsewhere for subsequent training.

Trainees worried that academic career pathways were inflexible, with bottlenecks at various stages hindering their progression, a concern that was shared by many of the educators. There was a general perception that trainees who experience delays in progression through the pathway or reverted to purely clinical training (e.g. on completion of an academic clinical fellowship programme) had failed to realise their potential. Given the difficulties in obtaining personal fellowships to complete a higher degree (an entry requirement to an Academic Clinical Lecturer post) this was a significant source of stress for academic trainees who were generally considered to be ‘high fliers’ with no previous experience of ‘failure’. Furthermore, some educators felt that this may even prevent some talented candidates from considering an academic career, since failure to progress through an academic pathway may be seen more negatively than not having embarked on it in the first place. Increased investment at the key transition points, particularly improved funding for fellowships to bridge the gap between Academic Clinical Fellow and Academic Clinical Lecturer posts, was felt to be crucial to overcome these concerns.

The rigid structure of Academic Clinical Lecturer (ACL) posts was raised as a particular issue. Strict entry requirements (unlikely to be achieved until the latter stages of clinical training) combined with a requirement to relinquish the post on completion of clinical training led to the belief that Academic Clinical Lecturer posts often provided insufficient time to maximise the chances of obtaining a Clinician Scientist Fellowship. This was felt to be particularly unfortunate given the competitive nature of these awards and the lack of alternative opportunities for transition to a senior academic position. Some educators including clinical and academic supervisors and training programme directors expressed a lack of confidence in their ability to provide accurate careers advice due to limited understanding of the options and insufficient information regarding alternative ‘exit points’. This was reflected by trainees’ responses with several identifying careers advice as an area for improvement.

Some educators were concerned about the rates of attrition, which were considered higher at earlier stages in the pathway, and raised the possibility that this was due to inappropriate selection and recruitment of Academic Clinical Fellows.

Comments were raised about the difficulty in completing both clinical and academic training for doctors with caring responsibilities. It was suggested that the School should be closely linked to the Athena Swan programme to facilitate improvement.

Supervision and support

The quality and commitment of supervisors is crucial as is the need for well thought out projects – finding the right project can be quite a skill. (Educator)

It was recognised by both educators and trainees that academic supervision can be challenging and requires different skills than those required by clinical supervisors. The identification of suitable projects which are both relevant and feasible for clinical academic trainees was said to require particular expertise which was not always evident.

Considerable variation in the availability and quality of academic supervision was raised during the focus group and highlighted by a few trainees completing the survey. One potential explanation for this was a lack of clear guidelines of the roles and responsibilities for the various levels of supervision necessitated by these integrated programmes. The particular challenges faced by integrated clinical academic trainees sometimes meant they felt isolated and they were keen to explore options for mentoring, peer and pastoral support. There was some frustration that fellow academics did not offer guidance unless they shared common research interests. Educators also recognised variation in the experience and commitment of academic supervisors and suggested that sharing areas of best practice in academic supervision may help to drive up standards. Likewise it was recognised that clinical supervisors were not always positive about academic training which sometimes caused tension.

Assessment procedures

Clinical supervisors would recommend clarification from academic supervisors and vice versa. I feel involving clinical and academic supervisors/TPDs in both ARCPs for academic trainees would benefit us immensely. (Academic Clinical Lecturer)

The one area that raised much more concern for trainees than for their supervisors and educators was the assessment process. Trainers did comment on the need for rigorous process of assessment, particularly to ensure that clinical competences were maintained during periods of reduced clinical exposure and to ensure that trainees knew what was expected of them at each stage: ‘Some trainees appear clueless’ (Training Programme Director). Trainees also raised the issue that they were not always given clear expectations and they found this stressful.

The other major area of concern over the assessment process for trainees was the lack of understanding of Annual Review of Competence Progression panels and the lack of communication between clinical and academic supervisors about their progress. Trainees recognised that they could take the initiative by maintaining regular contact with their TPDs and helping to facilitate communication between supervisors.

The Annual Review of Competence Progression panels have often failed to understand what I am trying to do however the program directors have been able to direct the panels. I would suggest that all academic trainees are encouraged to develop a good working relationship with their program directors and not just leave this to a yearly Annual Review of Competence Progression feedback session.

The balance between clinical and academic training

I am simultaneously disappointed and impressed with myself. (Academic Clinical Fellow commenting on how they manage the demands of the role)

In parallel with the strategic tensions between clinical and academic departments, there was universal recognition that achieving a working balance between the competing yet equally important demands of clinical and academic training was particularly difficult. It was acknowledged that the various supervisors did not always appreciate this. It was suggested that this may be a particular issue where trainers had not previously been exposed to integrated academic training programmes and therefore may not understand them. Trainees felt that they had to be highly motivated to reach their potential given the heavy workload. There were very practical concerns about the delivery of clinical duties from the staffing of on-call rotas to the tension of being called away from research labs to acute clinical emergencies. It was felt by educators that academic trainees, particularly early in their career, often felt embarrassed or guilty if they were not always seen to be ‘on the shop floor’. This worry was further exacerbated by a shortage of clinical staff; very many trainees reported that failures to recruit to clinical posts leaving gaps on rotas made a significant impact on what was expected from them. Trainees commented that they were just about able to manage the challenges of their dual role until they experienced difficulties that were out of their control such as covering for colleagues’ absences.

Trainees also reported their perceptions of an academic culture where failure to respond to email messages immediately may be seen negatively as a neglect of duty, making some feel as though they were ‘on duty’ 24 hours a day.

It was suggested that a shift in opinion was needed to improve the credibility of these posts among clinical supervisors and peers. A limited understanding of the roles and responsibilities of academic trainees among administrative staff was also highlighted. Some educators questioned whether it was possible to successfully achieve all the required clinical competences without an extension to training; this was considered a particular issue for craft specialities.