It became clear to us very quickly that these individuals are a well of information and introspection. With the new benefit of objectivity, they provided high quality analyses of their time in anaesthetic training, and how it could have potentially been adjusted for them to stay. Some themes became particularly clear.
An individual’s ability to have an impact on the environment around them, and to make decisions that determine their own path is a key pillar of wellbeing.
A significant number of our interviewees came up with the concept of loss of agency as a prohibitive factor in training. Doctors in training lose agency in many forms: the work they do, its location, work pattern, and leave are but a few. We expect a significant sacrifice from this group, especially at the beginning of training. One interviewee described it as “increasing responsibility without any increasing influence’ in their work environment. Another compared their feeling of ‘being treated as a number’ in comparison to their new work where they felt valued for their skill and expertise.
The concept of burnout has been part of the conversation surrounding retention of healthcare staff for many years now. The formal training pathway involves a significant collection of challenges in a short space of time, all while an anaesthetist in training feels the need to ‘prove themselves’ in their clinical practice. Quick succession of high stakes exams, intense specialty recruitment, and necessary extra-curricular achievements add to this burden. One interviewee described this sense of burnout when they left training, in a way that meant they were no longer the best version of themselves. After time, they reflected on the nature of ‘institutional burnout’ within the NHS. This was the concept that ‘if you weren’t exhausted, it was almost like you weren’t working hard enough’. This culture is something that can become second nature to many who enter into it, and fail to realise it in themselves and those around them.
Not all anaesthetists in training are the same. The structure of training and its hierarchy are based on a template from many decades ago. Luckily, our workforce is now more diverse in terms of sex, gender, socioeconomic background, sexuality, and disability status. In addition to this, many doctors in training will have significant life events throughout their training that mean their focus on clinical work and progress may shift. Our training pathways need to reflect this.
It became clear throughout these interviews that a number of people left the formal training pathway due to its perceived rigidity and what felt like an exceptional sacrifice required for those who didn’t fit a ‘standard template’ of a trainee. Particular challenges included working patterns in combination with exams and recruitment rounds for those who were parents to young children, or those who experienced significant illness or disability. These challenges meant that many sought out careers that had more certainty and personal influence around working patterns, including a career as a SAS anaesthetist.
It is clear that any career will have its sacrifices and challenges. Medicine has always been this way. However, it is clear that the lived experience of training now has a balance tipped towards sacrifice. This means that those who thrive within it are those who can inherently afford to make such a sacrifice, and have the inherent infrastructures to support them through it.
Anaesthetic specialty training in the UK is amongst some of the longest and most challenging in the world. Many of the obstacles a trainee must pass through during this pathway are seen as markers of merit and skill. However, given the striking evidence of differential attainment in many specialty postgraduate exams, the MSRA, and specialty interviews, is it simply that we are filtering out those who aren’t able to thrive in our current system? If so, does the very construct of our working pattern, rotations, and curriculum do something similar?
The purpose of this project was not to focus on our specialty’s shortcomings. Instead, much of the feedback we gained was that the clinical practice of anaesthesia is incredibly rewarding, enjoyable, and fulfilling. The personal support offered to those individuals who left training was strong and impactful. However, to celebrate our specialty means also to reflect on it. If we can lead the way in this regard, and hope to adapt our training pathway to improve retention and equity, then this is something we can truly be proud of.
Dr Stuart Edwardson
Chair, Trainee Committee