Continuing professional development whilst shielding

Dear Sir,

On 23 March 2020, at the start of the first UK COVID-19 lockdown, clinically vulnerable individuals were instructed by the government to shield.¹ This applied to vulnerable doctors including 1343 doctors in training² and has resulted in 216 days of shielding away from clinical duties, patients and supervisors.

The impact on staffing and patient care from those suddenly required to shield was substantial. The UK government body, Health Education England (HEE), who are responsible for training, noted trainees were not “sick” and recommended they continue to engage in clinical work. Despite this unprecedented situation, there was no uniform formula for such a large proportion of the workforce to suddenly start to work from home (WFH).

Trainees shielding reported feelings of guilt, frustration, anxiety and loneliness,³ along with concerns about delays to training and career progression. There are a number of opportunities to ensure training continues. We present our experience from a large UK plastic surgery department with personal perspective from a shielding trainee and a local lead for training. We offer recommendations that we hope may be useful for trainees faced with situations where they are unable to undertake face-to-face clinical work, but where there is the opportunity for remote working.

Enablers & pre-requisites

The key to successful WFH is summarised in Table 1 . This revolves around the IT infrastructure, remote access passes to hospital systems and help from non-clinical and clinical staff. Supervisors should ensure they have access to and are familiar with the latest trust software for remote consultations to allow participation of WFH trainees.

Table 1.

Enablers and pre-requisites for working from home staff.

Theme	Detail
Trainee's IT	• Availability of a fast and reliable broadband connection at home
Trust IT	• Access to hospital systems through a Virtual Private Network or other access gateway • Availability on the hospital systems of referral letters, clinic letters, results of investigations, radiology and other ancillary documentation
Management support	• Adequate NHS hardware in clinics, including webcams and computers of sufficient speed to run modern video programmes, preferably with dual-monitor setups • Support from departmental management to navigate the approvals and adjustments that are required to equip the trainee with all that they need to work from home
Supervision	• Consultants’ and trainees’ familiarity with remote video systems, including those designed for remote video clinics (such as Attend Anywhere) and those used for MDTs/other departmental meetings (such as Zoom, Microsoft Teams or Google Meet) • Clear supervisory arrangements with nominated and agreed consultant ownership of “registrar remote clinics” • Flatter hierarchies: consultants happy to discuss clinical work, for example ad hoc case discussions, clinic debriefs etc

Opportunities for continue professional development during shielding

There are a number of activities that those shielding can be involved with depending on local provision. These are summarised in Table 2 . Opportunities for professional development may seem difficult to achieve, but each allows the individual to guide their learning to personal development objectives. Cumulatively this allows for greater self-directed learning, but does not compensate for face-to-face clinics or time in theatre.

Table 2.

Opportunities for delivering clinical care and for continued professional development.

Theme	Recommendation for engagement
Outpatient activity Training rating: good	• Clinic participation must be tailored to the patient groups and the trainee's level of experience / independence • Participation at consultant-led video clinics can be either observational or through actively leading the consultation
Multidisciplinary team meetings Training rating: excellent	• Attendance is possible as an observer • Ideally those shielding should be encouraged to take an active role by preparing patients’ notes, imaging and histology where appropriate • These opportunities can also be recorded on the trainee's e-portfolio for review at progression meetings
Triaging referrals Training rating: average	• Involvement in this process offers those shielding the opportunity to understand referral pathways, to develop skills in clinical prioritisation and to identify cases to see in clinic
Discharge letters Training rating: average	• In centres that have electronic case notes and prescribing, those who are shielding may be able to write discharge letters and take-home prescriptions. We would not recommend this as this work is vulnerable to omission of relevant details and we would advocate the team physically seeing the patient each day doing this task
Audit, quality improvement & research Training rating: excellent	• Shielding can give protected time to complete audit, quality improvement and research tasks • The particular project should be considered in detail as there are limitations in the information that is available remotely • These opportunities contribute to completion of training requirements • Given the restrictions in face-to-face meeting sizes, audit and research meetings, are now often via an online platform, allowing an assessment of audit to be completed
Organising & delivering teaching Training rating: excellent	• During the pandemic, the virtual webinar has become more popular4 and involvement in teaching in this format can be on a local, regional or national level both in the trust, for external groups or even for local Universities • The latter also provides further opportunities for further development including interviewing applicants, writing exams or examining clinical skills • Contacting your departmental/ hospital lead for teaching, local university or even national trainee group will guide you towards medical education opportunities
Webinars & conferences Training rating: excellent	• There are a number of webinars, both in and outside of working hours run through national (eg JPRAS journal club, PLASTA) and international groups (Eg ICOPLAST) • A number of national and international meetings have moved to an online format, often at a reduced price to the traditional meeting • Study leave and budget can be utilised for these opportunities

Most clinical opportunities are through outpatient clinics and these form the basis for workplace-based assessments. Before clinic, the role of the trainee should be discussed. In fully remote video clinics, the trainee may be better as an observer to avoid more than one clinician speaking. In consultant face to face clinic a multiscreen set up can allow the trainee to be more involved, for example by guiding examination. It is important that the consultant is familiar with the video systems available and complies with the trust's IT policy. Recommendations for online clinical engagement should be adhered to. Our patients have viewed the remote attendance of the trainee as positive, interesting and have had no concerns.

Proof of professional development & supervision

UK guidance from HEE advises that an appropriate professional development plan should be devised reflecting the opportunities available.^{1 , 5} A diary of opportunities missed and gained should be kept up to date whilst WFH and uploaded to the surgical portfolio for progression review as well as any learning events attended including the certificate of attendance.

HEE also recommends that supervisors need to be proactive whilst engaging with shielding trainees to stop the feeling of ‘out of sight, out of mind’. This is achieved by agreeing a set of goals early with regular check-ins, appraisal of progress and review of goals, and attention to the pastoral and emotional elements of shielding. These meetings should be documented on the surgical portfolio. Before return to work any outstanding training and personal issues should be addressed and whether any enhanced supervision should be implemented on return.

Across the UK, clinical supervision for trainees has been reported to be variable. Ideally for each clinical opportunity an appropriate supervisor should be sought, whether this is the trainees own clinic or attending a consultant's clinic virtually, this allows for contemporaneous discussion about cases and opportunity for assessment.

Through the e-learning for health care portal in the UK there is an e-learning programme for supervisors and shielding trainees as well as a module for when this cohort returns to work.⁵

Psychological impact

WFH creates a number of challenges psychologically as well as clinically. The lack of face-to-face contact with colleagues and patients resulted in feelings of unequal distribution of tasks, namely that while WFH I was not completing my equal share of the work. Through perseverance attending clinic remotely I found there were ways that I could contribute such as requesting scans and imaging ahead of time, chasing letters from other health care professionals and booking tests during the consultation through my remote log on. Maintaining motivation for self study and solo clinics was also difficult. Through open and frank discussions with trainers about patients, arranging ‘de-brief’ sessions for case-based discussions helped reduced feelings of isolation and gave drive to read around topics.

Conclusion

Shielding provides a number of unique challenges for trainees and supervisors. It requires the trainee to be organised and motivated to actively seek out a diverse range of learning opportunities. It also enables trainees to direct their own learning to areas they have a personal interest in or require development. With the increasing face to face component in clinics, this can reduce the role of the shielding trainee and adding to feelings of frustration and isolation. However, engagement of trainers and supervisors in the commitment to continued professional development can help improve this. Support is also crucial from the managerial team in the department to help prepare opportunities (such as clinics), identify supervisors and provide contacts to enable remote access to the hospital systems.

Currently there is no guidance from the UK Royal Colleges nor speciality groups about supporting this cohort of trainees. While there can feel like a plethora of challenges for all involved it is essential to remember that this cohort are still members of the team and must not be forgotten. The pandemic has created a number of challenges but WFH has also allowed trainees to develop skills, contribute to the team and continue to provide good patient care.

Funding

None.

Ethical approval

Not required.

Conflict of interest statement

None.