Clinical Teaching Fellows, the new norm?-Experiences of fellows and education faculty.

BACKGROUND: In the United Kingdom, there is an increasing tendency for doctors in the first 2 years after graduation, to step off the training pathway and take up Clinical Teaching Fellow (CTF) positions. We aimed to explore stakeholder experiences of CTF positions to inform future planning and support.
METHODS: Individual semi-structured interviews with 10 stakeholders (five CTFs and five education faculty members) from one institution in England were conducted. Interviews explored the participants' views of the CTF position, its benefits and challenges. Inductive thematic analysis was performed.
RESULTS: CTFs and education faculty views strongly aligned and three themes were identified. These were (1) developing a career, (2) developing confidence and competence as a clinical teacher and (3) developing a position that works for all. Participants reported that the CTF position allowed time for specialty decision making and curriculum-vitae strengthening and provide CTFs with the opportunity to work autonomously and to establish a better work-life balance by stepping away from training pressures and focusing on other aspects of life. There were differing thoughts on how the position should be structured, although retaining a clinical role with boundaries to constrain competing responsibilities was important.
CONCLUSION: A brief hiatus in clinical training, where individuals feel supported to progress personally and professionally and to renew their energy for the next steps of clinical training, seems important. The ideologies of providing the CTFs with autonomy, time to explore options, recharge and form connections with colleagues should be considered when structuring the posts.

BACKGROUND

In the United Kingdom, clinical training requires individuals to complete an undergraduate degree that takes 4, 5 or 6 years depending on whether a graduate entry, standard entry or entry with intercalation route is taken. This is followed by 2 years of Foundation training, usually involving a rotation around six clinical specialties. After this point, trainees embark upon specialist training, taking between 3 and 8 years depending upon specialty. This pipeline is designed to deliver the appropriate number of senior doctors, general practitioners or consultant grade specialists, to meet the health care needs of the UK population.

There has been a growing trend for UK trainees to take a break following Foundation training. The number of doctors not proceeding directly into training now exceeds those that do (65.1% in 2019), with strong indications that doctors are pausing so that they can recharge, gain skills and consider their career options. , , , Most continue to practice clinically, but not in training posts. Although there are obvious implications for workforce planning, it is important to support the significant number of doctors who take this route, especially as there is evidence that taking this option can lower risk of burnout later in their career. Some trainees feel that when they step out of training, the information about the different options and the support to return to a training programme is limited.

One established route that UK trainees take is to become a Clinical Teaching Fellow (CTF), with those taking this route citing that they do so for the same reasons as mentioned above. , , , Typically, these 1‐year posts combine delivering undergraduate medical education and providing clinical care, although there are varying contractual arrangements. The employer may either be the clinical service provider or the educational institution, and the role may span one clinical or educational department or several. Although there are surveys , and personal accounts , of doctors taking the CTF route, there are few studies that offer deeper insights, and an absence of reports from the education faculty, who work alongside CTFs.

Given the lack of in‐depth research into this topic, and the increasing tendency of junior doctors to take on posts of this nature, a greater understanding of the experiences of CTFs and the faculty members, that they work alongside, could better inform how to structure these CTF positions. This will ensure that CTFs have a supported and valuable experience, whilst contributing meaningfully to the clinical and education workforce needs. It may also provide insights into how a short hiatus in clinical training may contribute to the reduction in burnout rates later in a clinical career.

The aim of this study was to explore stakeholder experiences of CTF positions to inform future planning and support. In particular, we are interested in whether there are benefits associated with the CTF position to both the CTFs and the educational faculty.

METHODS

Study design

We approached this study from a phenomenological perspective, employing an interpretive approach. To explore the experience of CTF positions from the perspectives of CTFs and educational faculty, we used one‐to‐one interviews. The study design recognises that the research team, who were, or had been, CTFs and academic faculty, would bring their own perspectives to the research, from the positions that they held.

Study setting

This study was conducted in a single UK medical school in South West England that have utilised CTFs to deliver anatomy, biomedical sciences and clinical skills education to pre‐clinical medical students since 2013. The CTFs had completed their Foundation training across different geographical locations in the United Kingdom.

Data collection

Between January and September 2019, any CTF who had worked at the medical school (n = 7) and any faculty member who had worked closely alongside them (n = 20) were approached by e‐mail to participate in this study. Individual semi‐structured qualitative interviews were conducted either face to face or by telephone, to explore the participants' perceptions of the CTF position (topic guide in Table 1). The interviews were conducted by a non‐medical undergraduate student (JS) and a clinician researcher (DC) who had previously worked as a CTF at the same institution. Interviews were audio recorded and transcribed through an independent transcription service.

TABLE 1

Topic guide for the semi‐structured interviews

CTFs

Education faculty

Why did you decide to take up a position a CTF? Were you looking for a post like this (prompt: at what point did you make this decision)? What do you think are the advantages and disadvantages of taking a year out to teach as opposed to continuing straight into speciality training? (Prompt: what were your reasons for not continuing straight onto specialty training)? What were the advantages and challenges of the CTF position? What are your career ambitions/how do you perceive the CTF position helps on that journey? In your opinion, what are the advantages and disadvantages of using CTFs to teach medical students? How would you describe the way that you are viewed by your colleagues at the medical school and at the hospital? What are your thoughts about the role being a shared post between the medical school and the hospital? Can you explain your views on the way that you were contracted to this position? What were the benefits and challenges of a shared position? Were you happy with the decision you made to take the Clinical Teaching Fellow position? Can you suggest ways that could improve your experience in that role?

What has been your interaction with the CTFs? In your opinion what are the advantages and challenges of using CTFs to teach medical students? What do you think their unique contribution is to the teaching/how do they differ from other educators teaching medical students? Do CTFs affect your practice and if so how? Why do you think CTFs are choosing to take up this position rather than going straight into the next stage of their clinical training? Can you explain your views on how the CTFs are contracted to this position? Would you change the employment model (prompt: explain?) Can you suggest ways of improving your experience of working alongside the CTFs?

Abbreviation: CTFs, Clinical Teaching Fellows.

Data analysis

Thematic analysis was conducted through the steps of data familiarisation, coding and creation of themes. The interviewer (DC) and another member of the research team (SB) independently coded the CTF and faculty transcripts. The analysis was inductive, although one researcher (SB) was alert to the relevance of the theories of social cognitive career choice and multidimensional burnout. Themes and subthemes were created from the CTF interviews initially and applied back to the dataset. Particular care was taken to look for agreement and dissonance between the CTFs and the faculty member interviews. Discussion, expansion and collapsing of themes occurred throughout the process (DC, JT and SB). A reflexive approach was taken, whereby the study team questioned and challenged each other's viewpoints throughout.

Member checking

Study themes were also shared at a UK National Clinical Fellow conference in 2019 (https://www.esht.nhs.uk/medical-education/wp-content/uploads/2019/05/Cornwall-Fellow-Conference-2019-2.pdf) with attendees invited to comment anonymously whether the findings resonated with them.

Ethical approval was granted by the participating university (28 January 2019—Jan19/B/188Δ1). Attention was paid to the power dynamics between researcher(s) and participants, and role‐play training was used to promote ‐ researcher confidence. This included practising clear explanations of how the boundaries of confidentiality would be upheld and how researchers can control the conversation through careful questioning.

RESULTS

Five CTFs and five faculty members were interviewed (interview length between 15 and 45 minutes). Thematic analysis led to the identification of three themes, each with subthemes, and captured both the CTF and the faculty members' experiences of the CTF position (Table 2 for descriptors and quotes; Figure 1 for a summary).

TABLE 2

Thematic map and illustrative quotes from the interviews of CTFs and education faculty

Theme	Subtheme	Quotes from Clinical Teaching Fellow	Quotes from members of faculty
1. Developing a career ‐ by exploring career options and enhancing their curriculum vitae	1.1. Exploring career options ‐ by gaining further experience and time to make informed career choices	[The job] helped just to give me some time to kind of make sure that I was going in the right direction if you like, and I think that was helpful. (CTF 1) I think most people do take a year out now. I think it is becoming more of a norm to take a break from after F2. I think it is good to … I think it is hard to know what you want to do in F2. (CTF 3)	Taking that stop gap has either informed them of the training that they wanted to do in the future or given them the chance to up their experience to be able to go on to do that training. (Fac 5) If you look ahead to a career which is 40 years long, you want to have as many options as you can. So, you want to have a new chapter that you are opening every 6 to 8 years. Teaching is definitely one of those. (Fac 1)
	1.2 Enhancing their curriculum vitae ‐ by gaining qualifications and experience	I am doing the [post graduate] certificate in clinical education, so that looks good on my CV. (CTF 3) A lot of people put on their applications that they love giving bedside tutorials, or it is just like a buzzword that people say, but actually having a job with some kind of hard evidence that you have given tutorials on this for six months is quite unique. (CTF 2)	And the other thing was the PG cert, that … because we put that in there. I was quite keen that we put it in there, so that you guys [CTFs] got something tangible out of your time, it wasn't just turn up and teach. (Fac 3) Several have gone on to do more educational projects, present at conferences, gain publications. It's bolstering their CVs and potential careers in education if that is something they want to pursue after this role. (Fac 5)
2. Developing confidence and competence as a clinical teacher ‐ by recognising the near‐peer and clinical experience that they bring, improving their subject knowledge and teaching skills, and through autonomous working	2.1 Identifying a niche ‐ by recognising that CTFs are bringing near‐peer, clinical experience to the team	Junior doctors are closer to the students that they are teaching in terms of understanding how the information can be presented in the best and understandable way. I think the further away you get from the people you are teaching, the more you forget what you did know and what you didn't know. (CTF 4) I think it is less intimidating for them [students] as well, as I was able to say, ‘oh my goodness, I felt exactly the same, I had no idea how to do this, this is how I remembered it’. (CTF 5) I think is that you can keep it grounded to why it is important that these people need to understand the anatomy and the physiology and how that relates to life as a doctor. (CTF 1)	They have been F1s and F2s much more recently than I have and that is a huge advantage in terms of clinical links. (Fac 1) We are stripping the syllabus away from what colleagues had been teaching for years. It would be perceived as top heavy with a consultant deciding what to teach, but if a junior doctor is saying this is what you need to learn [it is more easily accepted]. (Fac 4) I think that can be helpful, because again we {specialist scientists} get so bogged down in detail, because that is our area of research. But again, hopefully a clinician can look at it, ‘Well actually, yes, although this is the basis of it, what you need to remember, because it is aligned with … these clinical outcomes.’ (Fac 2)
	2.2 Developing subject knowledge ‐ by revisiting content that they will teach	Doing this job has actually made me revisit a lot of the stuff in first and second year, my kind of foundation knowledge which I wouldn't have otherwise done. (CTF 2) I don't think lacking specialist knowledge is a problem, as long as you take the time to understand the basics fully before you try and teach it then I don't think it matters if you are a specialist or not. (CTF 4)	I don't think it's a bad thing if they're given subjects that they are potentially less comfortable with or have less knowledge of, because that gives them the opportunity to refresh and revise their knowledge of that content. I see it as win‐win as they get to revise knowledge which can then be applied for any future work or exams. (Fac 5) Everybody thinks they can teach communication skills but in our experience they can't. If you follow the study guide you can pick it up pretty quickly. It is just when people don't want to follow the study guide. They might be right, but for students it causes total confusion. (Fac 3)
	2.3 Developing confidence in teaching ‐ through exposure and practice	It helps develop all your social skills and being able to stand in front of a lecture theatre full of people and give a lecture. Yeah, because I struggle with public speaking, so I have grown in confidence with that. (CTF 2) I wasn't [confident teaching medical students] in the beginning, but I have definitely grown in confidence since doing this job. (CTF 3)	I found them to have really good ideas and really high‐quality work [writing OSCE stations]. (Fac 3) Their experience will be limited … but what I would say is they are very quick learners, and that is such an important aspect. (Fac 1)
	2.4 Working autonomously ‐ by planning their own work and being individually accountable for the teaching sessions	It is quite a lot of responsibility, because no one really check, because you can't just turn up and say, ‘Oh, I haven't done this teaching session. I am not ready for it’, because you have got 50 students there waiting for you. You have to be organised, you have to be on it, so it is kind of a grown‐up job. (CTF 3) I do have a vague memory of turning up on my first day and being told you are teaching communication skills tomorrow. However, if we can swap our sessions so that I can I observe somebody first, everybody's very happy to do that. It just takes a bit more organisation and sort of saying I don't feel comfortable, can somebody help me out. (CTF 5)	Part of the job description is that ‘you will be involved in initiating, leading and producing new content and new core material’ and it is difficult when you start as a CTF because you have never had instruction on how to do that. (Fac 4) I think having the access to senior colleagues that were there to support has obviously been really important, but I think it just depends on the character in terms of whether you are holding their hands all the way through or whether actually you give them a task … I think that is probably key, because you don't necessarily want people to come in and go, ‘Right, we are holding your hand all the way through.’ For junior doctors, it is a development thing for you as well. (Fac 2)
3. Developing a position that works for all ‐ by considering the terms of employment and the perspective of different stakeholders	3.1 Terms of employment ‐ proportion of time spent carrying out clinical versus teaching and the type of contract	The variety is far more interesting. It was nice to have a mix of things to do that year. (CTF 1) I had some hassle in my first pay cheque because they only paid me 20 percent of what I was owed because they didn't understand the contract. The main benefit of having a NHS contract is that you maintain your increments for the NHS pay scale. (CTF 4)	If you have teaching fellows coming in for only two months at a time, they actually need to learn how to do it and by the time they have learnt how to do it they've moved on, so the staff were finding they were doing a lot of training with them. (Fac 3) We are floating the idea that you split the year in two, six monthly blocks, six months purely teaching and then six months clinical commitment. (Fac 4) The surgical directorate who have indicated that it would be better to have a 25:75 split [25% education]. (Fac 5)
	3.2 Balancing the dual roles ‐ by managing competing responsibilities and integrating into both teams	The hospital wants you to be quite flexible, and then the teaching side is you need to [deliver at this time]. There is a risk that they encroach on each other. (CTF 1) It's been really easy to slot into teaching and the team, they've all been really receptive to having a Clinical Teaching Fellow …. In the hospital I have just been perceived as a Trust grade, rather than anything different. (CTF 5)	The problem comes where the CTF becomes the ping pong ball and their time isn't their own. They get a call [from the hospital] saying ‘somebody is off sick can you do that’ and they say ‘well I was going to work on my teaching commitments’ and they are told ‘No we want you in the NHS.’ (Fac 4) There are certain individuals that are not willing to get involved, but others have really just fitted into the department and are one of the team. (Fac 2)
	3.3 Taking time to recharge and establish work–life balance	F1 and F2 can be really stressful, and I think taking a year out where you don't have the responsibility of your portfolio. I think it is good to have a break. (CTF 3) My wife was a year behind me so we wanted to join up years and I didn't feel ready to apply for a particular training post in F2. (CTF 4) This [job] is the first time in my working life that I haven't done four months and left. So, it has been nice having some continuity, and you get to know people. (CTF 2)	Most use it as a stop gap to get specialty training that they want or to catch up with a partner if they are doing something else. (Fac 5)

Abbreviation: CTFs, Clinical Teaching Fellows; Fac, member of faculty mem.

FIGURE 1

Themes and subthemes emerging from the interviews

Theme 1: Developing a career

Participants reported that the CTF position provided space to make informed career choices. They felt that this was particularly important given the length of time that they would spend in their future specialties (Subtheme 1.1). Participants also valued being able to build their curriculum vitae (CV), through evidencing teaching experience and gaining qualifications (Subtheme 1.2).

Participants reported that the CTF position provided space to make informed career choices.

Theme 2: Developing competence and confidence as a teacher

The unique niche carved out by the CTFs seemed to involve tailoring education content so that it was appropriately pitched, clinically relevant and delivered by an approachable role model (Subtheme 2.1). The CTFs reported being able to improve their subject knowledge (Subtheme 2.2) and develop their teaching ability (Subtheme 2.3). Whilst generally more critical of their abilities than faculty members, the CTFs reported growing in confidence throughout their employment. Faculty members perceived the CTFs as quick learners, with good ideas, with their only criticism being that they sometimes overestimated their ability to teach clinical and communication skills (Subtheme 2.2). CTFs were surprised about the level of responsibility provided to plan their own work and to be accountable for their teaching (Subtheme 2.4).

CTFs were surprised about the level of responsibility provided to plan their own work and be accountable for their teaching.

Theme 3: Developing a position that works for all

Participants considered it important that the CTFs position should include some clinical work and that the contract was held by the National Health Service (NHS). There were differing views on the division of time between the clinical and education roles (ranging from 2 months to a year) (Subtheme 3.1). The amount of time spent training and supporting CTFs was an important consideration for the education faculty when considering the length of the contract (Subtheme 3.1). Despite integrating well into both clinical and education teams, the CTFs found themselves navigating competing expectations. CTFs reported that hospital partners desired flexibility from them, whereas the education faculty wanted them to deliver to a fixed timetable (Subtheme 3.2). CTFs referred to the opportunity to step away from some of the pressures they had experienced in Foundation training. Several participants had life partners who were at a different stage of their professional training and pausing in this way had allowed their career stages to align. The education faculty spoke less about this theme, although they were aware of this as a motivation (Subtheme 3.3).

The amount of time spent training and supporting CTFs was an important consideration for the education faculty.

Ten comments were received from CTFs attending the conference, all aligning with the themes of this study (Table 3).

TABLE 3

Member checking activity performed at UK National Clinical Fellow conference in 2019

Response to the question ‘Do our themes map to your thoughts and experiences?’
1. Realistic and accurate
2. Agree wholeheartedly
3. The enlightenment
4. I feel like this research has hit the nail on the head
5. Enough with the NHS [National Health Service] conveyor belt
6. Agree
7. For me I would mainly like time to decide the direction of my career and get some things done outside of medicine
8. Really fits with my thinking ‐ needing the time to improve portfolio and have a break from training programmes
9. Fairly accurate
10. Yes. Accurate
11. 100% the experience I've had this year. Spot on

DISCUSSION

The findings of this work complement those existing in the literature but provide deeper insight about the benefits and challenges of the CTF position.

In accordance with other studies, the CTFs were found to be using the opportunity to decide upon their future careers, , , enhance their CV, , , develop skills as an educator , , and take some time for their lives outside of clinical practice. , , Given that 43% of trainees are uncertain about their specialty choice after Foundation training, pausing to consider career options is understandable. There also seems to be a growing acknowledgement, in this study, and others, that a wider portfolio of activities, including teaching, may be a way for doctors to sustain job satisfaction throughout their clinical career. Through the lens of social cognitive career theory, time to gain personal experience in a role will support the development of self‐efficacy beliefs, which promotes further interest in that career.

Although CTFs wanted to build their CVs, their professional development was far more than this. They described increased levels of responsibility within this position and the feeling of being valued and equal to other members of the teaching team. Control to make decisions and a positive sense of community are protective features of the multidimensional theory of burnout. They also resonate with self‐determination theory, whereby individuals, who feel competent, connected and autonomous, have improved motivation, performance and well‐being. Working autonomously as a CTF may also help trainees to prepare for the next level of clinical training, where the expected levels of responsibility will increase.

CTFs described being valued and equal to other members of the teaching team.

A novel element of this research was to take into account the experiences of the education faculty working alongside the CTFs. Faculty clearly understood the value of the education provision provided by the CTFs, the motivations of the doctors taking these positions and the need for there to be a clinical component to the role. What faculty found difficult to agree upon was the optimal length of contract and how the CTFs rotated between their education and clinical work. Balancing the benefits of appointing CTFs, who bring near‐peer, clinical contextualised and creative teaching approaches, with the costs of short contract lengths, high turnover and high training needs, seemed pivotal. Careful consideration of the type of educational roles that CTF fulfil may be useful. This study highlighted that there were a greater balance of benefits, when the CTFs were creating educational content, lecturing and delivering science seminars, compared with when they were delivering sessions with highly structured content, for example, clinical and communication skills.

The dual role between clinical practice and educational provision resulted in CTFs navigating competing expectations. CTFs reported that hospital partners desired flexibility from them, with emphasis on being able to cover sick leave, and education faculty had the expectation that work would be delivered according to a pre‐planned timetable. The differing nature of the roles may predicate the difference in expectations. However, it was important that clear boundaries between clinical and education work were set so that the CTF did not become overcommitted. A workshop for CTFs at The Association for the Study of Medical Education's Annual Scientific Meeting in 2018 recognised similar challenges around poor role definition and limited time in post. They recommended that developing communities of practice would be useful of sharing knowledge and this may also work to reduce the training burden for education faculty. We would recommend that this idea is promoted.

It was important that clear boundaries between clinical and education work were set so that the CTF did not become overcommitted.

The number of health care professionals reporting burnout within their careers is increasing worldwide. , Burnout has negative consequences, not just for the individual but also for recruitment and retention of clinicians, and ultimately the quality and safety of patient care. So, although this study provides a context‐bound understanding of the well‐being and development gains of junior doctors taking a short break in training in the United Kingdom, the findings may provoke thoughts about clinical training in other areas of the world. For example, are there opportunities to introduce greater flexibility into doctors training programmes? We accept that clinical service pressures and patient safety mean that flexibility cannot be carte blanche, but allowing some increase in flexibility in clinical training may support doctors to develop protective strategies (such as opportunities to follow their professional interests, learn how to self‐organise and build meaningful professional and personal relationships) that prevent burnout later on. Additionally, might the process for applying for roles outside of training be conducted within national recruitment rounds? This may both support doctors choosing to have a brief break in training and reduce the mental toll experienced by doctors who are unsuccessful in their first attempts applying for training posts/residency.

Flexibility in clinical training may support doctors to develop protective strategies that prevent burnout later on.

Strengths and limitations

This study does provide a rich insight into the lived experiences of CTFs, and the education faculty that work alongside them, in the United Kingdom, which to our knowledge is a new contribution to the field. The small number of participants constrained to one geographical locality limits this study. The research participants may have also felt unable to share fully their experiences, despite reassurances from the interviewer. It is reassuring, however that when the data were shared with wider members of the CTF community, that they related to the themes.

Future work

It would be valuable to expand the number of participants and range of institutions and to also explore the views of other members who work with the CTFs, in particular their clinical colleagues. Exploration of the experiences of newly qualified doctors training outside of the United Kingdom who are also choosing to take up teaching positions alongside clinical work would also enhance understanding and promote sharing of ideas.

CONCLUSIONS

Ultimately, the study provides insights into how CTFs can have a supported and valuable experience and how a short hiatus in clinical training may promote well‐being. This is particularly important when considering how to create a workforce that is both retained and enthusiastic to inspire the upcoming generations of medical students for whom they are a role model.

CONFLICT OF INTEREST

The authors have no conflict of interest to disclose.

ETHICS STATEMENT

Ethical approval was granted by the College Medicine and Health Research Ethics Committee, University of Exeter (28 January 2019—Approval Number: Jan19/B/188?1).