Research article
Open Access

Perceptions of Study Leave amongst Neurosurgical Trainees

Gráinne McKenna[1], Alexander Alamri[1], Peter Whitfield[2]

Institution: 1. Barts Health NHS Trust, 2. South West Neurosurgical Centre
Corresponding Author: Mr Alexander Alamri ([email protected])
Categories: Education Management and Leadership, Students/Trainees, Postgraduate (including Speciality Training)
Published Date: 06/06/2018

Abstract

Background

There is a paucity of studies in medical education literature addressing the educational value of study leave to doctors in training. The aims of this study were to establish the utilisation of study leave by neurosurgical trainees, to explore the perceived benefits and barriers to taking study leave, and to evaluate to what extent trainees support a more standardised approach to study leave allocation.

Methods

Individual interviews were conducted with 10 neurosurgical trainees, selected from each stage of training – Early (ST1-3), Intermediate (ST4-6) and Final (ST7-8). Qualitative data were coded and an inductive approach was used for thematic analysis.

Results

Neurosurgical trainees at all stages of training perceive study leave offers a wealth of opportunities for learning and professional development. However, there is a striking mismatch between the utility of study leave and the practical uptake, which is partly due to the reported opportunity cost of sacrificing clinical training.

There was consensus that combining standardised courses with flexible opportunities for trainees to pursue individual interests and educational needs could enhance the potential educational value of study leave.

Conclusions

The findings demonstrate the critical value of study leave and support the role of standardised national training programme "boot camps", mapped to the curriculum. These can deliver knowledge and technical skills using high fidelity simulation models, thereby increasing educational yield from study leave.

Keywords: Continuing medical education; Neurosurgery; Study leave;

Main Body

INTRODUCTION

Study leave, as defined by UK national training guidelines, is “leave that allows time, inside or outside of the workplace, for formal learning that meets the requirements of the curriculum and personalised training objectives.”(NHS England 2016)

Specialty trainees in the UK are allocated 30 study leave days per annum, which can be used for a variety of purposes including practical courses, professional skills courses, teaching days, academic conferences, and private study for examinations. Although some of these activities are mandatory requirements for certification of completion of training, trainees usually have flexibility to choose when to undertake them.

Since the introduction of the European Working Time Directive (EWTD) and changes in shift patterns secondary to the new Junior Doctor Contract in 2016, surgical training has been impacted upon greatly (Maxwell et al. 2010; Kirkman et al. 2013). With this in mind, it is particularly important to investigate trainee perceptions concerning the  utility and value of study leave. With limited capacity for taking time out of clinical training, training programme leads should be exploring strategies to enhance the educational value of this time.

Some have argued that study leave is an unnecessary ‘burden’ to doctors in training, describing it as “non-evidence based, poorly coordinated non-clinical initiatives laid on top of a [training] system that could otherwise work better”- specifically referring to the consequent reduction clinical training time (England 2015). It is true that there is scarcely any evidence in the literature addressing the educational value of study leave. Some have tried to measure the ‘value for money’ of consultants’ study leave (Bennett 1997), but there has been no study investigating the relative ‘value for time’, which is particularly relevant in a finite training programme.

William Osler, eminent 19th century physician famously said “Medicine is learned by the bedside and not in the classroom.” Echoing this sentiment, Dr Adrian England, in his 2015 paper addressing the conflict between clinical and non-clinical learning opportunities in anaesthetic training, boldly questions the utility of study leave. He concludes that “Whilst currently there is little clear evidence of harm to training from the recent expansion in non-clinical initiatives, there is little evidence of any benefit either” (England 2015). He argues that to learn a vocational skill requires time spent undertaking that activity, and he draws comparisons with other elite practical vocations, “A concert pianist spent hours practicing playing the piano. A professional footballer spent hours practicing kicking a ball. To become a practicing consultant anaesthetist you need to spend hours pushing propofol. And you cannot learn that sitting in a classroom.” One could argue this is even truer of surgical specialty training, but it does not take into account all the non-technical skills that surgeons are expected to become proficient at, yet are not explicitly taught as part of their post-graduate curriculum.

In tackling the time constraints on training doctors, England suggests a need for “better organisation of the non-clinical aspects of training”. He blames “poor co-ordination” of non-clinical training time and suggests the implementation of “a nationally agreed curriculum with courses completed in set years of training” (England 2015).

Since 2014 the UK Neurosurgery Specialty Advisory Committee (SAC), with financial support from the Society of British Neurological Surgeons has developed national simulation ‘boot camps’ for specialty trainee year 1 (ST1) and year 3 (ST3) trainees, under the umbrella of The National Neurosurgical Simulation Training Programme (NNSTB). There has been an expectation that all nationally appointed run-through trainees attend to meet the requirements in the curriculum for simulation training.  The aim of the programme is to teach clinical, surgical and professional skills appropriate for the stage of training, using high-fidelity simulation. These developments are in line with recommendations that simulation training should be integrated into healthcare (Donaldson 2008) to mitigate the detrimental effects of the European Working Time Directive (EWTD) on surgical training (Temple 2010). Neurosurgical trainees use five days of their annual study leave allowance to attend these boot camps, which have received excellent feedback from participants (Zhang et al. 2016).

What is the true educational value to neurosurgeons in training of time spent away from clinical practice for learning? Could it be used more effectively and efficiently to enhance individual learning and professional development, whilst minimising the opportunity cost of sacrificing precious on-the-job training? This study aimed to (1) establish how study leave is currently used by neurosurgical trainees, (2) explore the perceived benefits and barriers to taking leave, (3) evaluate how these perceptions vary according to stage of training and (4) ascertain the extent to which trainees support structured allocation of study leave.

 

METHODS

Semi-structured interviews were conducted with 10 individual neurosurgical trainees from the same deanery, selected by convenience from each of the three stages of training – Early (ST1-3), Intermediate (ST4-6) and Final (ST7-8) in July 2017.

Interviews were recorded using an audio recorder on a smartphone and transcribed for analysis. All participants were provided with an information sheet about the study and written consent for recording the interviews was obtained from all participants in advance.

The work was carried out in accordance with the Declaration of Helsinki, including, but not limited to the anonymity of participants being guaranteed and the informed consent of participants being obtained. In accordance with UCL Research Ethics Committee criteria for exemption from ethical approval this study proposal was assessed in January 2017 and deemed to be exempt from the requirement for ethical approval from the UCL Research Ethics Committee. Transcripts were anonymised; no sensitive or personal information was sought, and the study had no direct impact on patient care.

The following questions were asked:

How have you spent your study leave allowance in this academic year?

What benefits do you think there are to taking study leave?

Does anything put you off or prevent you applying for study leave?

Why don’t you use all your study leave?

Do you think study leave should be more prescribed for each stage of training, or do you prefer complete flexibility?

 

Quantitative data on the number of study days taken by each participant were recorded.  The transcribed data were coded and analysed qualitatively to identify common themes in respect of the questions asked. The interviews were designed to generate responses through both deductive and inductive reasoning, and thus a mixed approach was used for the data analysis.

 

RESULTS

Ten interviews were conducted with neurosurgical trainees ranging from ST1 to ST7. There were four participants from the early years’ stage of training (ST1-3), three from the intermediate stage (ST4-6) and three final stage trainees (ST7-8).

None of the participants was certain of their study leave allowance and whether regional teaching days were included. All believed the allowance was between 9-15 days per year which was significantly less than the official allowance of 30 days per year. The number of study leave days taken by participants ranged from 3 to 15 days in the current academic year.

 

What were the perceived advantages of taking study leave?

A strong positive theme of ‘gaining perspective’ emerged from participants at all stages of training, and consensus that a break from routine allows ‘time for reflection’ on clinical practice.  One senior trainee commented, “When you go on a course you enjoy, it really gets your brain thinking again, rather than just - clinic, operation, ward round…” (Appendix 2).

Many of the participants commented on the ‘social aspects’ of study leave, which included the themes of ‘collaborative learning’, ‘keeping up-to-date’, and ‘comparisons with peers’. As one junior participant described, “you get to speak to other trainees, you get perspective on where you are, what other people are doing… and it can be quite motivational...” (Appendix 1).

 

What were the perceived barriers to taking study leave?

On this issue, there was a notable divergence in the perspectives of junior trainees (ST1-3) versus more senior trainees (ST4+). Junior trainees reported common positive themes of ‘feeling supported’ to take study leave, and being ‘more dispensable’ in terms of service provision. The one barrier cited consistently by junior trainees was ‘financial cost’. One comment summarised this dilemma in a nutshell, “Courses can cost upwards of £300 per day, and annual study budgets are in the region of £800”, (Appendix 4).

Senior trainees reported more numerous barriers to taking study leave: ‘rota constraints’, the ‘opportunity cost’ of missing out on elective operating experience; ‘competition’ from other trainees; ‘NHS culture’; ‘bureaucracy’ of the application process as well as ‘funding’ barriers. The conflict with service provision and in particular, on-call commitments, was illustrated by one participant who described her attempt to take study leave for a subspecialist course: “I was desperate not to miss this, but I was on a night shift, and there’s no scope for education and taking time off” (Appendix 2). In describing NHS culture and the lack of time for reflection in clinical training, she went on to say, “You see doctors from other countries and they are thinking about what they’re doing in their operations and how they can improve them…  we’re so busy we don’t have time to read, think or innovate” (Appendix 2). Emphasising the opportunity cost of sacrificing on-the-job training, one trainee pointed out that if he took all his study leave, “it would definitely affect [his] logbook numbers”, and thus his capacity to achieve clinical competencies within the time limits of the training programme (Appendix 4).

 

Did trainees prefer a structured or flexible approach to study leave?

There was a strong consensus amongst trainees at all stages of training that the best system for allocating study leave would involve a ‘combination’ of prescribed courses/educational programmes, whilst maintaining flexibility for individuals to choose how to spend some of their allowance.

Three positive themes were identified for a structured approach to study leave: ‘uniformity of learning opportunities’; ‘guidance on appropriate training courses’, and ‘opportunities for comparison with peers’. Junior trainees were strongly positive about the new national ‘bootcamps’, concluding that it was a good idea to “make sure you’re all at the same level” (Appendix 3).

Similarly, positive themes emerged for maintaining flexibility and allowing trainees to choose how to spend their study leave. These were; ‘flexibility to pursue individual interests’ and ‘individual developmental needs’. For example, one participant expressed a need to present at academic conferences, “because I’m interested in research” and because “presenting is something [she is] not very good at” (Appendix 3).

 

DISCUSSION

The findings from this study establish that neurosurgical trainees at all stages of training perceive study leave offers a wealth of benefits for their personal and professional development.

The positive themes which emerged are in line with a number of key learning paradigms, supporting a theoretical basis for these perceived educational benefits. For example: responses emphasising the advantages of ‘time for reflection’, demonstrate the perceived value of Kolb’s Learning cycle (Kolb 1984). One trainee commented, “I remember things better” (Appendix 3), when she learned in different contexts, reflecting the advantages of multimodal learning described by Gardner’s ‘Theory of Multiple intelligences’ (Brink 1985). Other positive themes of ‘collaborative learning’ and ‘comparisons with peers’ suggest a key role for a social aspect to learning and development. Reflecting the learning paradigm of social constructivism,(von Glasersfeld 1989) our standardised national boot camps provide a unique opportunity for direct peer-peer learning, collaboration and comparison in a niche surgical speciality with small numbers of trainees based in training units scattered across the UK.

Despite the perceived benefits of taking study leave, it was striking that none of the participants knew their annual study leave allowance and that none planned to take more than half the annual allowance during the academic year in question. This finding contravenes General Medical Council guidance (General Medical Council 2011) and demonstrates a mismatch between the perceived utility of study leave and the practical uptake.

We attempted to discover the reasons for this mismatch by exploring why trainees applied to take only a fraction of their allocated study leave. It was perhaps unsurprising that for junior trainees the main barrier to taking more study leave was ‘financial cost’, given the expensive nature of hands-on surgical skills courses. This finding highlights another key role of nationalised bootcamps in subsidising the cost of expensive high fidelity simulation training through Society of British Neurological Surgeons (SBNS) funding and commercial/industrial sponsorship. It was, however, reassuring that in general junior trainees felt encouraged and supported to take time away from clinical work to focus on their individual professional development.

Conversely, most of the barriers cited by senior trainees were related to the theme of ‘time’; specifically, the ‘opportunity cost’ of missing operating lists and ‘service commitments’, which included ‘competition’ from other trainees. A ‘culture’ of not taking study leave was identified, possibly as a long-term consequence of these other barriers. These findings are in keeping with studies demonstrating the detrimental impact of working time restrictions on neurosurgical training (Maxwell et al. 2010; Kirkman et al. 2013). It is anticipated that recent changes to shift patterns as a consequence of the new junior doctors’ contract in England may further compound this conflict (Ahmed et al. 2015).

Participants from all stages of training presented evidence in support of both ‘prescribed’ and ‘flexible’ systems, suggesting a combination/ hybrid model of study leave allocation may maximise the educational yield. These findings add weight to the concept of employing standardised study leave programmes through national simulation training programmes, “bootcamps” for trainees at the same stage of training. To date, national neurosurgical bootcamps for ST1 and ST3 level trainees have been implemented in the UK. On the back of the success of these educational programmes, development of an ST8 level bootcamp, preparing senior trainees for consultant practice is also underway.

Despite the advantages of structured or standardised study leave allocation, our findings highlighted trainees’ additional desire to have opportunities to pursue their individual learning needs and professional interests. The theoretical advantages of maintaining flexibility for trainees to choose how to spend their study leave are rooted in Mezirow’s concept of ‘transformative learning’ which emphasises the central role of self-directed learning in adult education (Mezirow 1985).

This study represents only a snapshot of the experience of neurosurgical trainees in a specific region of the UK. However, the sampling strategy enabled us to explore the perspectives of trainees at each stage of training and provided ample data to represent a broad range of opinion across the whole cohort of neurosurgeons in training. We chose to conduct in-depth semi-structured individual interviews, rather than a questionnaire, with the aim of acquiring richer qualitative data to address the objectives of the study. Although a focus group may have provided even richer data, bias from the influence of other participants may be prevail.  Methodologically it was practical and convenient to interview individuals on a one-to-one basis with a semi-structured qualitative approach.

Since the interviewers (GM and AA) were neurosurgical trainees and colleagues of the participants, personal views had the potential to bias the interview process, both in terms of how the questions were asked and the responses received. Despite these potential confounding influences, the strong thematic outcomes generated from the study suggests meaningful conclusions can be drawn about the factors influencing trainees’ decisions when applying for study leave and their views on the how study leave should be organised to maximise the educational impact.

We consider that a hybrid approach supporting compulsory attendance at national simulation training bootcamps and allowing flexible attendance at other educational meetings provides the optimal approach to support individual learning.

 

CONCLUSION

Neurosurgical trainees at all stages of training perceive study leave offers invaluable opportunities for deep learning and individual professional development. Despite these perceived benefits, there was a striking mismatch between the perceived utility of study leave and the practical uptake, which is in part due to the perceived opportunity cost of sacrificing clinical training. This is particularly relevant in the craft speciality of neurosurgery, and in the era of working time regulations and recent changes to shift patterns with the implementation of the new junior doctors’ contract in 2017.

The findings from this study support the role of standardised ‘bootcamps’ for trainees at the same level, and suggest they may reduce financial burdens and enhance the educational yield of study leave. Trainees value highly the social learning aspects of bootcamps, which provide a unique opportunity for interaction and collaboration between small numbers of peers who are training in disparate parts of the UK. There is consensus that trainees want a balance between standardised courses/bootcamps and opportunities to engage in self-directed study leave activities which allow them to fulfil their individual educational needs and explore their professional interests.

Take Home Messages

  1. Neurosurgical trainees at all stages of training perceive study leave offers a wealth of individualised learning opportunities outside of the clinical environment.
  2. Despite this, there is a mismatch between the perceived utility of study leave and the practical uptake, partly due to the perceived opportunity cost of sacrificing clinical training in the era of working time regulations and changes in shift patterns.
  3. Standardised, subsidised national training ‘bootcamps’ can relieve financial barriers and can enhance the educational yield of study leave.

Notes On Contributors

Gráinne McKenna MA(Cantab) MB BChir FRCS(SN) is an ST8 neurosurgical trainee in North Thames who was recruited through the national selection process in 2009. She is the national trainee representative for the Neurosurgery SAC and is currently undertaking an MSc in Medical Education with UCL and The Royal College of Physicians.

Alexander Alamri is a North Thames neurosurgical trainee. He was previously an anatomy demonstrator at King’s College, University of London where he also gained the postgraduate certificate in medical education. He is currently the North Thames neurosurgery trainees representative.

Peter Whitfield, Consultant Neurosurgeon and Personal and Professional Development lead at Plymouth University Peninsula Schools of Medicine and Dentistry is also Chairman of the SAC in Neurosurgery and Chairman of the Board of Examiners for the Fellowship of the European Board of Neurological Surgery.  He is former Secretary to the Neurosurgery National Selection Board. 

Acknowledgements

Bibliography/References

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Appendices

Appendix 1.

ST1 Trainee Interview Transcript (Participant 1)

How do you plan to spend your study leave in this year of your training?

I didn't actually apply for any study leave funding this year. Doing PG Cert Med Ed but wasn't sure if it would be considered an essential course for ST1. I'm hoping to do ATLS because it's a requirement for CCT, but I'm not sure I'll get a place on the course, so may not use my study budget at all this year. So far used 15 days for PG Certificate. Regional teaching days once a month on average, but that's not taken out of study leave. Other courses clashed with PG Cert so I couldn’t take them.

Will you take all of your study leave?

I doubt I will take all my study leave. Maximum of 18 days if I do ATLS, but I don’t actually know how many we’re entitled to.

What do you think are the advantages of taking study leave?

It’s educational. Keeps you up-to-date. Going to courses and conferences is really useful when you have time and rotas permit.

There’s also the motivational element of taking study leave. When you're at work all the time, a lot of it is service provision. When you step out, for any reason, you get to speak to other trainees, you get perspective on where you are, what other people are doing, and it's actually very pleasant to step out of that 'treadmill' and it can be quite motivational for your development.

Do you encounter any barriers when applying for study leave?

Although people on the whole are supportive of taking study leave, there is a lot of bureaucracy; downloading forms from internet, getting them submitted and signed by various people, then to secretary and waiting for approval. I directly contacted TPD and got informal OK. Not even a consistent process. Speaking to peers and colleagues, it’s widely known - just get your rota sorted out and you can take the time out.

As an SHO slightly easier as you are a little more dispensable. Normally swap on-calls. As a 'trainee' I feel well protected; I get taken seriously in terms of my training needs.

Do you think study leave should be more prescribed for each stage of training, or do you prefer flexibility? Why?

Definitely flexibility. I think we should cultivate trainees who can explore their own interests. We are always being asked to reflect on strengths and weaknesses and we all know where we need to develop or need extra support. Glad it's not prescribed at the moment, I like the flexibility to choose.

Have you noticed any significant changes in how you have used your study leave over time? (Or do you anticipate changes?)

Early on I expect I'll be doing more courses. Approaching CCT to use SL to study for FRCS. Intermediate term I’ll probably use it for attending more conferences because I'll probably be more established in my role, have more projects/something to present and have more reason to keep up to date with recent evidence, because at registrar level you are more of a decision maker, a doer. You need to know the intricacies of what you're supposed to be doing, and know current guidelines etc.

 

Appendix 2.

ST5 Trainee Interview Transcript (Participant 5)

How do you plan to spend your study leave in this year of your training?

So, I haven’t taken much because I’ve been declined several times. It can be quite hard to get SL. I’m still waiting to hear if I’ll get a 3 day SL request for a compulsory leadership and management course. I’ve been declined twice before because of the rota. The problem is when you have ST slots on rotas, and people are coming up to exams they get priority. They often decline requests, and I think that’s something which needs addressed. It’s difficult when you only have so many opportunities to do a course in a year and you get declined. And night shifts as well. An example - someone gave me the opportunity to attend a white matter dissection course, and I was desperate not to miss this, but I was on a night shift, and there’s no scope for education and taking time off. The rota coordinators don’t care about that sort of thing. It’s a real problem. It’s symptomatic of an attitude. I think we need to be smarter about training. In neurosurgical training we have a few years to learn to be a surgeon, as a registrar, and I think we’re being swamped with clinical commitments. There needs to be a change in thinking in the way we spend our time. I think SL is hugely representative of the problem with the culture. You should be allocated much more time for personal study around your clinical commitments. There needs to be rethink about the whole SL concept.

Will you take all of your study leave?

In this year I might take 3. I’ve found it so hard to get time off, and that’s with rearranging all my on calls to get a day off here and there. That’s for compulsory leadership course and teaching course. I think I’m allowed 3x5 days, so 15 days. Is that right? In a year? I suspect there are some people who take lots and lots of study leave. I know there are – and miss lists. I would never miss a list if I could help it. I’ve never take the full whack of study leave, if that makes sense. (Interviewer: “The allowance is 30 days”) See that exemplifies what the expectation of study leave is. That’s probably what we should be doing. Using that time to read. If there’s a topic you need to read about or learn. It’s how you develop your understanding. You can’t do meaningful research without time. The SL think exemplified how stretched we are by clinical commitments in the NHS and how difficult it is to train because of that.

What do you think are the advantages of taking study leave?

When you go on a course you like, it really makes you think. It really gets your brain thinking again, rather than just clinic, operation, see patient, submit list. It’s a break from routine which allows your brain to think. The problem with the NHS is you don’t have time to think. You become a bit of a machine for productivity, and I don’t think that’s very good for development, for pushing back boundaries for surgery. You think about what you’re doing. It’s a breather. Maybe that sounds silly, but it gives you time to think. You see doctors form other countries and they are thinking about what they’re doing in their operations and how they can improve them. We just bash on, because we’re so bloody busy we don’t have time to think and innovate.

Do you encounter any barriers when applying for study leave?

I find it very hard to miss a list that will help me. Swapping makes it logistically difficult. Sometimes I just give up on getting funding, but it’s usually ok. It hasn’t kept up with inflation. I think it should be used for books and exams too. Ophthalmology get an afternoon a week for private study. They study more, they do exams earlier. I definitely think we should have time for private study leave.

Do you think study leave should be more prescribed for each stage of training, or do you prefer flexibility? Why?

Grass is always greener. We need the flexibility for personal study, to read journals, keep up to date.

Have you noticed any significant changes in how you have used your study leave over time? (Or do you anticipate changes?)

I am actually thinking about applying for SL for my own study, and just doing it myself, without going to a course. Maybe one day every couple of weeks.

 

Appendix 3.

ST3 Trainee Interview Transcript (Participant 8)

How do you plan to spend your study leave in this year of your training?

I have already spent my SL. I went to SBNS - that was 3 days. I took 3 days as well for my grant application interviews. At The Royal London you have to take study leave for regional teaching, so about once a month I take a day. I said to [rota coordinator] I think I’m coming close to using up my days now, but he said, he’s been quite flexible about it, because some days we come in to cover for people.

Will you take all of your study leave?

Yes, definitely. Monthly teaching, SBNS, conferences and something like the hydrocephalus conference which is a whole week off.

Oh I can’t remember now. Isn’t it 9 days per 6 months? I think it is 9 days. 30 days? Oh that’s really bad, I’m not sure. That might be why [rota coordinator] is so relaxed about it?

What do you think are the advantages of taking study leave?

Well, it means I don’t have to use annual leave, or do annoying swaps for courses or teaching.

The courses are great. The conferences… well... I find it really useful to do something other than... well, because I’m interested in research, and that’s why I go to the conferences. It’s helpful to do something that isn’t just completely clinical. It helps me remember them as well. I learn things better when I research them. Yeah, and it’s good for me. I like to go to present at conferences, because presenting is something I’m not very good at.

Do you encounter any barriers when applying for study leave?

Not at RLH. Historically yes, because of service provision issues. No particular issues. People are very supportive and understanding of the importance of teaching, courses and conferences.

Do you think study leave should be more prescribed for each stage of training, or do you prefer flexibility? Why?

I kind of like a mix. You know in our year we did that bootcamp thing. It’s really helpful actually, because you know there are some things you don’t get taught as much in different centres, so it sort of makes sure you’re all at the same level. So yes, that was really prescribed, and I liked that. And I like the monthly teaching and the mock exams are really helpful. But it’s nice to have some time that is flexible so you can choose what you want to do.

Have you noticed any significant changes in how you have used your study leave over time? (Or do you anticipate changes?)

Yes, In ST1 I used it for MRCS revision. Since then it’s been for regional teaching and conferences. But I suspect that soon it will be more courses and exam preparation.

 

Appendix 4.

ST7 Trainee Interview Transcript (Participant 10)

How do you plan to spend your study leave in this year of your training?

Fifteen days for PG Cert Med Ed this year. Much more than I have taken historically.

Will you take all of your study leave?

No, I've never taken anywhere near my study leave allowance. Earlier in my training it was because neurosurgical courses can cost upwards of £300 per day, and annual study budgets are in the region of £800, and so I couldn't afford to go to more than one or two a year. In my registrar years it was because of the impact of taking time off on my clinical and operative training. Neurosurgery is a craft specialty, and you work closely with your consultant trainer, so being available for continuity of care and avoid missing theatre lists when possible, puts you off taking too much time away for any reason.

If I took all my study leave it would definitely affect my logbook numbers and I might struggle to get my competencies for ARCP.

What do you think are the advantages of taking study leave?

It’s great for stepping out of the clinical routine and allows time for reflection on what you do every day on a clinical basis.

It's often a great opportunity to meet other trainees at different stages of training and often in different deaneries, which is particularly helpful in such a small specialty. It's also an opportunity to keep up to date and find out about different clinical practices. You learn so much from interacting socially with other trainees and sometimes consultants, often that's as much of a learning opportunity as the course itself.

Do you encounter any barriers when applying for study leave?

Other barriers are the paperwork associated with applying for leave and funding, giving adequate notice. It's usually a really inefficient process. As a registrar, it's often difficult to get your on-calls swapped or to get cover for your clinical duties, particularly for popular courses or conferences if others on your rota are attending. Sometimes there is a lot of competition amongst trainees and some can only go to bits of a conference.

Do you think study leave should be more prescribed for each stage of training, or do you prefer flexibility? Why?

I think flexibility is essential, but I would appreciate a bit more guidance on how I should be spending my study leave and what courses would be useful at different stages.

Have you noticed any significant changes in how you have used your study leave over time?

Courses in the beginning, then I found my early clinical training as a registrar so all-encompassing and in a very busy unit, that I struggled to take any time off, struggled to produce anything to present at a conference and so took very little SL at all. More recently I did the Teaching the Teachers course, Management course, Advanced Communication Skills course which are compulsory for CCT. I will probably take some personal SL for FRCS exam preparation and related courses towards end of training.

Declarations

There are some conflicts of interest:
Mr. Peter Whitfield is currently Chairman of the SAC in neurosurgery. He has previously held the post of Secretary to the National Neurosurgery Selection Board.
Miss Gráinne McKenna is the national trainee representative for the Neurosurgery SAC.
This has been published under Creative Commons "CC BY-SA 4.0" (https://creativecommons.org/licenses/by-sa/4.0/)

Reviews

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Richard Hays - (14/03/2019) Panel Member Icon
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While it is difficult to challenge the idea that attendance at education sessions is an important component of any training program, this paper sits uncomfortably in an international journal because the setting is so context-bound to the UK, NHS and a single specialty program. The paper could be improved by seeking data from more training programs and attempting to draw out principles that may be relevant in other systems and nations. I also wonder why there is specific mention of a particular workshop category (why do we call some “boot camps”, a term I associate with suffering and pain)?
Possible Conflict of Interest:

I am Editor of MedEdPublish

Ken Masters - (28/01/2019) Panel Member Icon
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A reasonably well written paper, although the data reporting could be much stronger than it is..

The Introduction gives a comprehensive background to the problem, drawing on a range of relevant literature. The sample size, however, is rather small. In qualitative research, sample size is generally not as important as it is in quantitative research, but then other controls are built into the study, the most frequently-used is some sort of saturation determination. In this case, this was not done, so we are not sure about the extent to which the gathered data represents a comprehensive overview.

It also would have been better if the researchers had taken this into account in their results reporting, by giving more details: Firstly, they could have spread the sources more widely. For example, in answer to the question “Did trainees prefer a structured or flexible approach to study leave?”, the researchers have given multiple answers, but they are from the person. This (correctly or incorrectly) gives the impression that this was the view of one person only. This sense of limitation is reinforced by the fact that, overall, only 4 interviewees’ data were cited (40% of an already very small sample).

I would recommend that the authors cite a much wider range of the interviewers’ answers. Also, given that the interview transcripts are not very long, unless there are compelling reasons to do otherwise, it might be a good idea to publish all of them.
Laura Lippa - (07/06/2018)
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Really well done, interesting topic.