Rotational
training: time
for a rethink?
Rotational training is not new or unique
for postgraduate doctors, but now more
than ever its value is being questioned.
Postgraduate training programmes
in anaesthesia feature rotations every
three to 12 months to maximise skills
and experience and to fulfil training
requirements, especially in some
Special Interest Areas of the 2021 RCoA
curriculum that can only be delivered in
tertiary centres [1]. Rotations also help
Training Programme Directors provide
training opportunities in an equitable
manner, and attempt to maintain work/
life balance by fairly distributing longer
commutes and more distant rotations.
Rotating between departments is no small undertaking for a
trainee, though. There is a significant bureaucratic burden: outside
of the small number of deaneries with a lead employer model,
each rotation will require HR paperwork, ID checks, occupational
health clearance and changeover of payroll department, often
leading to trainees being placed on emergency tax codes, not
being paid correctly, or even not paid at all. Each hospital may
have different study leave policies, adding challenges to claiming
back fees or securing leave. For more distant rotations, there is
also a significant cost – both financial, in travel costs and fees to
rent second homes or move house – but also in time, with trainees
spending several hours a day commuting, leaving little time for
basic self-care, let alone studying for postgraduate exams or
spending time with loved ones. Provision of rest facilities within
hospitals can be variable. Long commutes pose significant
safety risks through fatigue; in a 2019 survey, 45% of consultant
anaesthetists admitted having had a car accident or near miss, and
72% of these incidents occurred during their time as a trainee [2].
In an era of improving sustainability and the environment in
anaesthesia, can we justify multiple cross-deanery rotations for
trainees on an environmental level? Congratulating oneself on
using TIVA and a reusable cup for coffee feels somewhat ludicrous
when producing an excessive and unnecessary amount of carbon
emissions merely to get to work, especially if the rotation is more
to supply trainees to a distant Trust than to fulfil a particular training
requirement.
Beyond the practicalities, trainees frequently report finding
the cognitive effort to get to know a new department to be
extremely demanding; they never truly feel as if they belong,
leading to disengagement. Forming meaningful and supportive
relationships with colleagues in such a short timeframe is difficult
and can be isolating for trainees, especially when living at a
distance from their support network. Portfolio requirements,
especially for multi-source feedback, can be difficult to meet,
especially when staff are only given a short time to get to know a
trainee; it can feel at times as if no ‘off days’ are allowed, because
that might risk biased or negative feedback. Negative comments
on social media indicate that some rotating trainees feel that
short rotations give departments a ready supply of trainees to
fill rotas, but do not encourage them to engage meaningfully in
their training and development – “What’s the point when they
rotate so soon anyway?”
Dr Marsden’s experience highlights many of the challenges
faced by rotating trainees:
I feel quite strongly about rotational training, having
recently undertaken a six-month rotation at one of
the furthest trusts in my Deanery. My door-to-door
commute was 70 miles that took around 90 minutes
at best, and often significantly longer in heavy
traffic. After a significant investment of my time in
highlighting the unsafe nature of the commute, I
was allowed funding for some accommodation in
the week, but had to arrange this myself and pay
out the money before claiming it back, where I was
heavily (and incorrectly) taxed on the repayments
during a cost-of-living crisis when both petrol and
utility bills were hugely increased. The significant
commuting burden and difficulty of living away from
my home and support network left me exhausted,
anxious and struggling, but this was often met with
a shrug and the attitude that rotating “just needs to
happen”; despite the fact I was commuting past a
tertiary centre 62 miles closer to home that could
deliver the required training experience. I was
studying for my written Final FRCA examination
at the time and found this very difficult under the
circumstances. As a single trainee with no caring
responsibilities, I can only imagine how much more
difficult this would have been if I had additional
demands on my time; it was already impossible to
maintain a healthy social life alongside basic self-care
of eating well, exercising and sleeping enough
to feel good in myself. The staff at the distant Trust
were very helpful and tried their best to give a
good training experience, but it was very difficult
not to feel resentful that I could have had similar
opportunities without such excessive travel. I highly
doubt I am alone in my experiences.
So what is the answer? It is not possible to place trainees in
one Trust for the duration of their training, given the range of
training experience required by the curriculum, and nor is it
necessarily desirable – many proponents of rotational training
express concern over the experience if sent to a Trust with
a poor working culture. However, longer and less frequent
rotations for trainees could bring many positives. Less rotating
might bring back some of the advantages of the ‘firm’ system of
days past where trainees could settle into a department more,
building relationships with both medical and non-medical staff,
and have more opportunity to get involved in some of the
activities needed for the seven generic professional domains
of the curriculum that include teaching, quality improvement
and leadership and management. Less bureaucratic burden
and cognitive effort in getting to know a new department
would allow trainees to focus on learning and meeting their
training requirements. The opportunity to have a stable home
life, without excessively long commutes or frequent home
moves, would also potentially reduce the feelings of social
isolation described in a Canadian study relating to rural location
rotations [3], and allow trainees more chance to ensure that they
are meeting their basic self-care needs in order to work well.
Adopting a lead employer model nationally would reduce the
bureaucracy and frustration associated with rotating. This has
already been adopted successfully in some deaneries meaning
fewer hours spent filling in repetitive new starter forms, travelling
for ID checks, an increased chance of being paid and taxed
correctly, and increased ease of claiming back the study budget
to cover courses.
It is time to re-examine rotational training and balance the risks,
benefits, and impact on trainees. A more secure working life
could begin well before CCT. Putting trainees’ basic needs first
could make a huge difference to the experience of being a
trainee, and happier trainees might make for a better experience
for all.
Sarah Marsden
ST4 Anaesthetics, Harrogate District Hospital
Sethina Watson
ST6 Anaesthetics, North Bristol NHS Trust
Kathryn Singh
ST4 Anaesthetics, Chelsea and Westminster Hospital
Twitter: @GaslingSarah; @morefluids; @AnaesthetistKat
References
- Royal College of Anaesthetists. 2021 Curriculum for
CCT in Anaesthetics, 2022. https://www.rcoa.ac.uk/
documents/2021-curriculum-cct-anaesthetics/introduction
(accessed 19/7/2023).
- McClelland L, Plunkett E, McCrossan R, et al. A national
survey of out-of-hours working and fatigue in consultants
in anaesthesia and paediatric intensive care in the UK and
Ireland. Anaesthesia 2019; 72: 1509-23.
- Dubé T, Schinke R, Strasser R. It takes a community to train
a future physician: social support experienced by medical
students during a community-engaged longitudinal
integrated clerkship. Canadian Medical Education Journal
2019; 10: e5-16.