Recruitment

Medical student experience is very important when choosing a specialty.3 The child health placement is an ideal opportunity to capture student enthusiasm and promote paediatrics as an appealing specialty choice.4 Many medical schools have moved to vertically integrated courses which focus on longer clerkships, giving the chance to follow patients for several months. This promotes earlier definitive career choices and increases preparedness for specialty training.5 Programmes such as these increase exposure to child health early in the medical course, which may encourage students to undertake paediatric special study modules or electives, thereby encouraging them to select paediatrics as a career.6

Students need support during their early encounters with children and families as this can be daunting and may deter interested students from pursuing a career in child health.7 It is imperative that students are encouraged to give meaningful feedback on their placements and that changes are implemented in response. In some countries, students interested in paediatrics are encouraged to select additional courses which may nurture this interest.8

Box 1 offers some suggestions for engaging medical students in child health.

Configuration of specialty training programmes

The configuration of paediatric specialty training programmes varies considerably worldwide. Most schemes involve time spent in different institutions, often shared between community and acute healthcare facilities and sometimes across considerable geographical distances. A consistent message from paediatric trainees is a desire to know well in advance where they will be placed and to have some input into this decision. Different trainees will value different locations based on personal and professional circumstances but a location they consider desirable is valued highly by trainees when considering a training post. Being notified well in advance also allows trainees to plan accommodation, employment for a partner and childcare.11 Knowledge of their work schedule more than 1 month in advance was found to be associated with increased satisfaction with life overall in one cohort study of early career paediatricians.12 Health Education England now mandates that trusts are notified of which trainees have been placed with them at least 3 months in advance.13 It is imperative that this placement information is also shared with trainees.

The structure of paediatric training in the UK, for example, presents both problems and opportunities. For most trainees, it consists of a run-through training programme lasting around 8 years, which offers job stability and the possibility of remaining in one geographical location for a long period of time (figure 1). This is often noted by trainees to be a major draw of the specialty. In addition, a competency-based training such as the UK allows trainees to progress at different paces depending on the experience they have gained rather than based solely on time within the programme.14

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Figure 1

Representation showing the paediatric specialty training (ST) in the UK.

However, as trainee circumstances change or as career aspirations alter, trainees may wish to change where and how they train. Ideally, a trainee's needs should be considered annually when determining placements and certainly towards the end of each training level. A flexible approach is required from training programme directors and the ability to use a nuanced method of placing trainees, often involving individualised career discussions with them. Such flexibility should be considered for all trainees and not just those who are well known to teaching staff. This can be challenging, especially in large training programmes, but can be facilitated by engaging educational supervisors locally who proactively address these issues as part of the support they offer trainees. In addition, those involved in running training programmes need to be adequately remunerated for undertaking this challenging role and given adequate time within their work schedule to do so. Some countries with difficulty recruiting to rural placement have compiled specialised programmes to support trainees working in these challenging areas.15 A consistent finding is that satisfaction of the doctor's partner and children with the area improves overall satisfaction and increases the chances of them remaining in post.16

Personalised career advice

Doctors at all stages of training find personalised career advice useful.17 Such robust guidance gives trainees confidence in their chosen path and may prevent those considering leaving paediatric training from doing so. For example, those training in general practice (family medicine) in the UK usually have the same educational supervisor throughout their training. This senior clinician maintains an overview of a trainee's strengths and areas for improvement. If there is a change in supervisor, the Royal College of General Practitioners mandates that the regional training board oversee a managed handover.18 The longevity of this partnership offers the opportunity to build a meaningful relationship and may increase the chance of the trainee seeking counsel from this person in times of difficulty. Unlike many paediatric programmes where a senior clinician working with the trainee also provides the educational supervision, the general practice scheme allows a degree of detachment from the day-to-day clinical activity which may further nurture the relationship.

Changes in the gender balance in medicine mean that in many countries, women now comprise the majority of medical graduates and entrants to paediatric specialty training. This makes the value of role models and robust career advice ever more important. The variable nature of career advice, especially for women, has been shown to result in missed opportunities to cultivate talents and develop interests, for example, in academic medicine.19 This can include misinformation or discouragement of trainees wishing to pursue a particular path.

One challenge can be variations in the confidence of individual senior clinicians to provide support to trainees, particularly around a change of career or divergence from the standard training pathway. Those involved in providing career support for trainees need sufficient time allocated to undertake it properly and to access high-quality supervisor training as well as opportunities to be kept up-to-date with the changing medical career landscape.20 This has been found to be important in obtaining buy-in from senior clinicians in low resource settings.21 Career surgeries run by experienced training programme directors can ensure equity of access to clinicians skilled and motivated to provide career counselling, though trainees may be reticent to access support from senior regional faculty if they are contemplating a career change. Other programmes, such as the Royal College of Paediatrics and Child Health Effective Educational Supervision course, have sought to upskill local training representatives to better equip them to provide guidance to trainees.22 Certainly, all trainees should have access to excellent career counselling throughout their training with high-quality local support associated with job satisfaction and an increased likelihood of continuing to practise medicine.23

Flexibility

A key issue for trainees leaving paediatric training is the lack of flexibility within programmes. This includes work patterns as well as access to training in subspecialties and allied specialties such as child mental health.

Training schemes must offer flexibility in work patterns given the high proportion of doctors in training who have young families and the need to retain them within the specialty.24 In the UK, paediatric training is largely supportive of part-time working and will actively facilitate those with caring responsibilities to work in a slot-share or part-time in a full-time slot.25 In addition, there has been a recent commitment from National Health Service (NHS) England to better support flexibility in training, including for those wanting to pursue other interests such as charity work.26 In the interests of fairness, such schemes should be accessible to all trainees, irrespective of subspecialty choice or location.27 In reality, however, those regions with more rota gaps, especially at middle-grade level, will often limit the length of time that a trainee can train part-time, for example, to the first 2 years after the birth of a child. In Sweden, both parents can share parental leave and recent changes in legislation have made this possible in the UK.28 It is prudent to embrace these changes and consider how changing working patterns can be facilitated within our programmes rather than risk a mass exodus of trainees frustrated by lack of flexibility.

There is also an issue of flexibility around access to subspecialty training within paediatrics as well as opportunities to train within, for example, primary care or child and adolescent mental health. There is a balance to be struck given the need to provide well-rounded training and adequate medical staff to run safe healthcare facilities. One successful scheme running within existing conventional training posts has involved clinics run jointly by paediatric and general practice trainees.29 Such innovations allow shared learning, promote integrated care and have been well received by trainees. Others have undertaken training posts in child and adolescent mental health or public health within their training programme.

Taster weeks can allow trainees to try out different subspecialties and have been highly successful where this practice is employed. This can be particularly useful for those considering applying for subspecialty training and is facilitated through approved study leave from their base site. Such practice should become the norm. In addition, trainees should be facilitated in taking time out of programme to undertake fellowships in, for example, teaching or leadership schemes.

Study days and courses

An important quality indicator for training programmes is the ability of trainees to gain release from their clinical responsibilities to attend training. One study exploring trainees' reasons for leaving a surgical residency programme found that trainees felt an informal contract had been breached when clinical duties were consistently prioritised over educational needs.30 Importantly, interviewees did not object to working long and often anti-social hours but felt that this sacrifice must be matched by educational and career-building opportunities.

Educational opportunities may include regional study days which seek to cover areas of the curriculum that are harder to achieve in day-to-day practice. Such educational symposia are well received by trainees but require careful planning and engagement by senior staff across a training region as senior clinicians may provide clinical cover during these training sessions. While this may be challenging, the provision of excellent healthcare for the long term relies on retaining high-quality trainees who rightly expect protected training time. Others have produced online case-based modules, though sufficient time must be allocated within working hours for trainees to complete such programmes.31

Pastoral support

Paediatrics can be harrowing and trainees must be supported, particularly at times of increased vulnerability such as transitioning to being the most senior clinician on site overnight. A study of paediatric and medical trainees found that they were often tired, worried and stressed, all of which adversely affect the quality of clinical care.32 Box 2 identifies key times when trainees may be particularly at risk of emotional distress.

It is important that trainees are given opportunities to talk through their experiences in order to reflect and develop.33 Psychiatry trainees typically have weekly one-to-one supervision with a senior colleague to discuss challenging cases and consider their personal impact. Such close supervision and the perceived availability of a supervisor is valued very highly by trainees.34

These discussions may be especially important around serious incidents, such as the unexpected death of a child. If well handled, this debrief can promote resilience and equip trainees with skills that they can use when they are senior clinicians themselves.35 Clinicians working in acute specialties often report feeling ill-prepared for the non-clinical aspects of senior roles such as supporting distressed trainees.36 There is a risk of serious psychological harm in the face of tragedy and a proportion of trainees who leave paediatric training report that a single event, often a child death, was the tipping point for them. This is true even when there was no blame apportioned. Box 3 offers some suggestions for providing pastoral support.

One mentoring scheme for those working in academic paediatrics found increased retention and overall satisfaction with their career for mentees.41 Importantly, this programme involved a mentor chosen from outside the mentee's area of work and someone to whom the mentee had been personally matched.

Reflections from those leaving paediatric training identify improved pastoral support, increased flexibility of training programmes and access to personalised career advice as key areas for change that might help retain trainees within paediatrics (Jacob H, Shanmugalingam S, Kingdon C. Why do trainees leave paediatric training? A qualitative study. Unpublished work, 2016). Importantly, those resigning their training numbers typically do not cite anti-social hours as their primary reason for leaving. Rather, they report that working patterns become an issue only when the training programme is lacking in these other key areas. Nevertheless, gaps in rotas remain an issue in many paediatric programmes around the world. In the UK, the Medical Training Initiative, overseen by the Academy of Medical Royal Colleges, is a successful scheme that recruits doctors from overseas to work in the NHS for up to 2 years. This helps staff UK rotas while gaining additional skills and training.42

Summary

Paediatrics continues to be a unique specialty in its variety, opportunities for innovation and its wealth of enthusiastic and highly skilled clinicians. It is imperative for the health of children and young people across the world that those already working in the specialty seek to embrace and nurture medical students and doctors in training. Those involved in paediatric training programmes must see the challenge of retaining trainee paediatricians as an opportunity. We have identified a number of low-cost interventions that could improve morale and the quality of the training experience for trainees. We believe these could go some considerable way to address and avert a serious workforce disaster.