A presentation about this survey, made by Dr Jayanta Chatterjee, chair of RCOG Trainees Committee is available as a pdf. Regional breakdons of the data will be available shortly.
The European Working Time Regulation (EWTR) RCOG Trainees Survey was launched early this year in an attempt to study the perceived impact of working a reduced 48 hour a week by trainees. This regulation came into effect from 1st of August 2009, thus giving about six months for trainees to get accustomed to this new pattern of working and training by the time the survey was undertaken.
This was the fifth survey carried out by the RCOG Trainees’ Committee. The survey was run online through a link on the RCOG website. The survey was launched on the 5th of January and remained open for 6 weeks. There were 964 responses from trainees who had at least partly filled out the structured questionnaire. This accounted for approximately 50% of trainees in Obstetrics and Gynaecology (according to the latest RCOG census data). The whole of the survey was completed by 80.8% of the trainees who responded. 49.2% were UK graduates, 45.5% were non-UK, non-EU graduates and 5.3% were from the EU. There has been a slight increase in UK graduates responding when compared with the last survey in 2008. At the same time there has been a drop in IMGs (by almost 7%) due to recent immigration restrictions.
Demographics
There was uniform representation from all grades of trainees from ST1 to ST7 with the largest number of responses from ST3 trainees. The gender ratio was 73% females to 27% males. In 1995, the percentage of male trainees in the specialty was 56%. The gender proportion has been gradually changing in line with medical school entry and in the last survey in December 2008 there were 31% male trainees. London had the highest response rate followed by Wessex and Northern Ireland although these are not geographically the largest deaneries in the country. 91% of the trainees responding to the survey had a training number. 16% of respondents mentioned that their rotas were not EWTD compliant (i.e. 48hours/week). The main reason for non-compliance in the majority of cases (90%) was because there was not enough staff.
The majority of the trainees worked in a unit with between 2500-5000 deliveries (54.1%); 34.7% worked in a unit with more than 5000 deliveries and 11.2% worked in units with less than 2500 deliveries. Our survey also revealed that about 10% of trainees were Out of Programme/Training (OOP/T) at any one given time for reasons like maternity leave, OOPE and OOPR (out of programme experience and research).
Working Patterns
Less than Full-time Training (LTFTT) is becoming more popular with each passing years. In our survey, 11% of the trainees who responded were LTFTT as compared to 6% in the last survey. 64% are working 60% full-time. In the future this needs to be carefully monitored as there is evidence that some LTFTT trainees want to increase their training hours in the present EWTR climate. RCOG has recently produced guidance on the minimum requirement for trainees undertaking LTFTT.
Looking at pay banding and hours worked, Band 1A was the most common pay banding (40%). 88% of responders worked an average 48hr a week. However, there were still 9% of trainees who worked 56hr a week. This is in stark contrast to the derogation figures obtained from the Department of Health.
80% worked a full shift work pattern with 90% of respondents doing split weeks of nights with a 4/3 pattern of on-calls. However, worryingly 10% of trainees still work partial shifts and the same percentage of trainees work a hybrid shift pattern of work. 10% of trainees have continued to do 7 continuous nights on-call. The most popular rota pattern was 1:8.
The majority of trainees thought that EWTR has made no real difference in patient safety, work/life balance and job satisfaction.
Rota Gaps
This survey showed the profound impact Rota gaps were having on day to day training. 90% of trainees had to cover rota gaps during the day. 30% trainees thought that this had lead to a decrease in day time training opportunities while 50% of trainees were unsure if this had lead to an overall reduction in training sessions.
49% of trainees said that Trusts expected them to cover rota-gaps during evening and weekends and only 72% of these trainees were financially remunerated while the others were given time off in lieu. 36% of trainees answered that their trusts expected them to cover rota gaps at night and 78% of them were paid as Locum while the remaining had time off in lieu. The RCOG Trainees Committee strongly feels that this has had a further negative impact on training opportunities and has compounded the problem of EWTR.
15% of trainees who responded had officially opted out of EWTR by signing the personal opt-out declaration. The common reasons for this were to gain more experience and to also be able to do Locum work due to a drop in salaries because of re-banding.
74% of trainees said that they voluntarily attended work during their “off” time in order to take advantage of training opportunities. 23% of trainees felt that they had been put under pressure by seniors to attend duties during their “off” time.
Training progression
Looking at progression in training from ST2 to ST3, 82% of ST2 trainees did not feel competent to take on ST3/2nd on-call duties, at the end of their training year. However, it must be kept in mind, that this survey was completed by ST2 trainees who were only 5 months into their training year. When the same cohort of trainees were asked if there was resident on-call support for ST3 trainees where they worked, 38% said they had no cover, 10% had Consultant cover and 52% were supported by senior trainees.
ST3 trainees were asked if they had commenced 2nd on-call duties as expected at the beginning of their training year. 72% said yes while 28% said that they had required further support before they performed independent 2nd on-call duties. Of these 28% ST3 trainees, 45% had no senior resident support during out of hours.
ST5 trainees were asked if they felt competent to take on senior trainee (including possible 3rd on-call) duties at the end of their training year. 62% said yes while 38% answered no. The main reasons for this were a large proportion of ST5 trainees did not feel competent to independently manage acute complex gynaecological emergencies like ovarian torsion, ruptured ectopic pregnancy etc.
The RCOG is keeping a close eye on progression at various levels of training, especially from ST2 to ST3. Apart from our survey, data is also being collected on ARCP outcomes to consider the need for extending the length of training in the future.
Clinical Training Experience
When trainees were asked about General Training, majority of them felt that Labour Ward experience, Labour Ward supervision and supervision in theatre were very good or good. In contrast the majority of trainees answered that ward round supervision and operative teaching continued to be very poor or poor.
The majority of trainees have continued to perform on average 8-11 minor procedures a month with some doing at least 4-7 minor procedures per month in gynaecological theatres. The majority of trainees perform only 1-3 or no major gynaecological procedure in a month. This could be partly explained by the decrease in the number of major operations being performed for benign general gynaecological problems with the increase in alternative treatments. These figures are similar to the 2008 survey.
When specifically asked about Laparoscopic Ectopic management, 46% of all trainees answered that they had not done any such procedures and were not being trained to manage ectopic pregnancies laparoscopically. When the same question was targeted to ST4/ST5 trainees, 62% said that they managed 1-3 ectopic pregnancies Laparoscopically in a year, 25% did 4-7 and 2.5% did more than 8 such procedures in a year.
When trainees were asked about their obstetric experience, 50% of trainees had performed 1-3 vaginal breech deliveries in the last year. 6% had performed 4-7 such procedures in the last year and 40% had done none. These figures are slightly lower than the 2008 survey probably as a result of the increase in Caesarean Section for breech presentation. Similarly when asked about managing an Occipito-posterior position at full dilatation with vertex being 1-2cm below the ischial spines, the majority (~55%) of the trainees said they would attempt a ventouse delivery, while 30% of trainees answered that they would attempt at manual rotation. The number of trainees who would perform a caesarean section under these circumstances was lower (~5% compared to ~8%) in this survey compared to the findings in 2008.
Basic Ultrasound training is now compulsory as part of core and intermediate training and in order to deliver this the College has recently appointed a senior clinician to take on the role of the Ultrasound Officer. In our survey, 69% of trainees said that they had not completed the basic ultrasound modules; however, 89% of these trainees were thought to be progressing towards completion.
In our survey, the most popular ATSMs were the Advanced LW module followed by Acute Gynaecology, Colposcopy, Maternal Medicine, Benign Hysteroscopic surgery module, Labour Ward Lead and Benign Laparoscopic surgery.
When looking at Advanced Training, 50% of senior trainees thought that the present on-call rota and time off in lieu was having a negative impact on their training. 70% of them were on track to achieve their ATSM competencies while 30% thought they will not be able to achieve this in their allocated training time.
90% of present Sub-specialist trainees are covering Obstetric on-calls and 52% of them thought that this had a negative impact on their sub-specialty training.
There has been a huge improvement in the ability of trainees to complete workplace- based assessments (WPBAs). Almost 50% of trainees complete their WPBAs more than 50% of the time (compared to 10% in 2008). OSATS were the most frequently completed, while Mini-CEXs were the most least.
Conclusion
The salient findings of the survey highlight that rota compliance is an important issue that needs urgent attention and rota gaps are having a significant negative impact on training. Becoming competent and/ or getting the confidence to do independent 2nd On-call may be an issue at ST2/3 level. At ST5 level, trainees felt less confident about providing senior independent cover for gynaecological emergencies due to less exposure to such cases during intermediate training. The present on-call rotas used to achieve EWTR compliance are detrimental for both Advanced and Sub-specialty training.
The effect of EWTR is very much a work in progress and its impact needs to be carefully monitored by repeating such surveys in the next few years.
I would like to take this opportunity to acknowledge the support and help of all the members of the RCOG Trainees Committee for ensuring such a good response to the survey. A special word of gratitude to Dr Andrea Pilkington, who helped me in designing the survey and also to Mr Simon Kemp and Miss Kay Weir at the RCOG for all their help.
I would like to express my sincere thanks to Dr Maggie Blott, Mr Kim Hinshaw and Dr Clare McKenzie for all their helpful suggestions and advice
Dr Jayanta Chatterjee, MRCOG
Chair, RCOG Trainees Committee