Interview manuscripts were analysed using a coding framework and three broad themes emerged which centred around the aim of exploring reasons why foundation doctors are not directly entering training. In addition, a fourth theme emerged from the data, related to participants perceptions of the FY3 year, including both issues that concerned them and suggestions for improvement generated.
Participants were prospectively interviewed and therefore often did not have set plans for their FY3 year. Table 1 above shows that most participants had plans which included several options; travel and locum work being the most popular options amongst their plans.
The three central themes which emerged from the data had interlinking data and significant overlap and are presented in Fig. 1.
Theme one: feeling undervalued – ‘you feel like you are doing two people’s job’
Foundation doctors expressed strong feelings of feeling undervalued, often citing lack of flexibility within their roles and rotas. Participants talked about feeling that they were only valued for service provision, using examples of being unable to secure annual leave to attend significant family events or take holiday. The view that they were the ‘cheapest option’ to fill rota holes left doctors feeling that they felt undervalued as ‘you are doing two peoples jobs and also kind of undervalued because of that’. The suggestion amongst those interviewed was clearly that the balance has moved away from being trained for a future career and more towards being responsible for mundane jobs which held little benefit for personal development.
“especially in my FY1 a lot of the tasks I did almost felt administrative and I wasn’t learning or using what I’d learnt throughout medical school.”
The facilities for doctors within the trusts was a strong sub-theme within the data, with doctors commenting that poor rest facilities, limited access to catering facilities and expensive, limited parking impacted on their feelings of being unappreciated. This negatively impacted on doctor’s feelings of self-worth. Doctors felt that the pressure put on them in the workplace from workload, pressure to cover rota gaps and poor facilities increased their frustration at work and negatively impacted on their feelings of being appreciated.
“that’s just a completely crap atmosphere to be working in never mind training”.
Participants raised issues with poor workplace administration, saying ‘you know nothing is going to be straight forward, you are going to have to chase people around’ in relation to getting timetables, rotas and difficulties with requesting annual leave, being paid correctly and claiming expenses. This meant that even those who felt motivated to request study leave or try to work towards outside goals were frustrated by the administration processes required for these and sometimes unable to achieve these goals because of this:
“the hope of having flexibility in a locum year is that I could take a couple of weeks of to get you know, some revision done”.
Theme two: career uncertainty – ‘you’ve got to make sure you go for what you actually want to do’
The majority of those interviewed expressed some uncertainty about their career choices. The common theme was that it was ‘too early’ to decide on a specific career path, magnified by the lack of flexibility within training schemes and the difficulties faced if you want to change between speciality.
“You’ve done half an F2 job when you have to apply, I think if there was more support and signposting through F1 then I think that would be better”.
Those who had not had experience of the careers they were applying to mentioned that the lack of flexibility within foundation training and difficulty securing ‘taster weeks’ where you can experience a week within the specialty you are considering impacted on their ability to commit to a pathway of training.
“I’m committing myself to another eight years of training and you don’t want to get that wrong”.
A strong theme within the data was the feeling that if you did not want to take time out of training you would be disadvantaged when compared to those who did, and specifically those who had used that time to experience specialties they were considering and had improved their CV with reference to specialty training. This also crosses over significantly with the third theme, a new culture within training.
“So I had also considered applying now but deferring for a year. But I just felt overall partly because of time constraint like I just didn’t, by the time I’d had those conversations you know it was a few weeks until applications were due and I just didn’t feel like I had enough time with my rota”.
Theme three: the cultural norm – ‘there is a culture change there, for better or for worse’
The majority of doctors now take time out of training after FY2, so many interviewed felt that if they did not, they would be missing out on positive experiences they had seen others take advantage of. This included the opportunity to travel, without risk of losing a training number, with the end of foundation training being seen as a natural point to take a break. ‘You finish one discreet period of training before you start another one, it’s a good time to work abroad or travel’. As part of this participants mentioned the opportunity to increase their income through working locum shifts, though they also mentioned that as a foundation doctor they found it unfair that locum doctors earned more for covering ‘the same job’. Some felt that this would be a good opportunity to locum and save money for their life goals, such as house deposits or paying for travel.
“I think financially as well, obviously there’s a lot more earning potential. We want to try to ideally save for a deposit for a house and I feel like it’s a lot more feasible with a few months of a good locum rate than foundation rate”.
After speaking to colleagues and friends, participants mentioned that positive recommendations from those who had experienced an FY3 year was an important influence on their choices. As the majority of trainees now take an FY3 year, the fact that many around them are also considering taking time out is a strong driving force to many:
“I think it used to be the done thing [going into speciality training] whereas now I think it’s the done thing to not go on and to do something else for a bit”.
The ability to take control of their time, to use this time to improve their CV in order to be competitive whilst also improving both their work/life balance and their bank balance was seen by many as an opportunity to good to miss:
“at the end of the day what’s another few years in the grand scheme of life, I’ll be a consultant for forty years at this rate”.
Theme four: supporting trainees with the practicalities of their FY3 year – ‘I have absolutely no idea how it works?’
The doctors asked were unsure of governing body and academic requirements that might need to be maintained if they are to take an FY3 year and they felt that there was a lack of support from their foundation programmes with regard to the options available to them. This was combined with worries about returning to training and what the extra requirements might be. They had reservations about how to actually go about taking a year out and how to return successfully.
“Yeah well I have no idea how that works, I don’t know if I need to get someone re-validate me or if I just can apply come October, I have absolutely no idea how it works”.
Some of those asked also felt uncertain about the security of their choices with worries about becoming ‘unemployed’ or having no confirmed role within the year, and reservations about negative impact on their pensions or future pay. The general feeling was that the difficulties within the practicalities of securing their FY3 year were outweighed by the ability to ‘get off the treadmill’ and looking after their own resilience and recharging.
It was clear that the foundation doctors asked had strong opinions about their training and were keen to offer suggestions for improvement within FY1 and FY2 as well as supporting FY3s. These are shown in the figure below.
Participants suggested that the support for FY3 doctors should start within foundation training, supporting those applying to specialty training while not neglecting the fact that a majority will be taking a year or more out. This could include support from those who have experience of the positives that have been mentioned but also academic and administrative support to cover common issues such as ‘how to return to training’. Structured FY3 posts are offered within some trusts, including teaching fellow posts, which have strong administrative drive towards supporting doctors achieve their future goals and it may be worth considering using these posts to help model necessary competencies and experiences for those forging their own path.
Participants also suggested that FY3 ‘champions’ might also allow hospitals to structure FY3 programmes which support both the hospital and trainees, having mutual benefit for those involved. This might assist those who feel the uncertainty of locuming is too concerning for them. To allow those doctors to have structured weeks of experience within specialties, particularly those specialties struggling to recruit would also be of mutual benefit for training programmes and doctors taking an FY3 year. Participants also suggested that specialty training could be more flexible in their interview and start dates, allowing some to join throughout the year, and some feeling that flexibility and transparency about time out of training would help.