British cardiology training assessed

The British Junior Cardiologists’ Association Starter committee (BJCA Starter) promotes cardiology as a career choice to pre-speciality doctors within the UK. Our members range from foundation doctors to core medical trainees (including those out of formal training). Pre-speciality training in the UK takes place in an increasingly pressurized National Health Service (NHS) environment. Previous surveys have shown that a quarter of junior doctors feel ‘burnt out’ due to work commitments and a third feel that training opportunities are lost due to gaps in staffing rotas.1 Within medical specialties, 50% of trainees described their daily workload as ‘heavy’ or ‘very heavy’ compared to 19% of trainees within anaesthetics.2 UK Cardiology training is considerably longer than most other European countries (9–11 years after leaving medical school).3 Forthcoming training reforms mean most cardiology trainees will have general internal medicine commitments throughout their 5-year cardiology residency.4 The potential impact of these changes on the appeal of Cardiology as a medical speciality remains unexplored. This study aimed to assess members’ attitudes towards cardiology speciality training in the UK and the main barriers they perceive towards attaining a place on this training programme. Further, we aimed to determine the level of satisfaction with pre-speciality training and exposure to educational opportunities within cardiology for pre-speciality doctors. A consensus methodology survey, comprised of best match (45), Likert scale (21), and open questions (10) probed six key domains (see below), and was disseminated May–July 2018 to pre-speciality trainees via the BJCA starter member email database, social media, and post-graduate education deaneries across England, Scotland, Wales, and Northern Ireland. Fellowship was defined as a period of clinical or research work prior to commencing speciality training. Microsoft® Excel (2018) was used for statistical analysis. Each item is reported as a percentage of the total respondents to the question. Ninety-three unique responses were received. The median age of respondents was 28 years [interquartile range (IQR) 27--29] with 66% (n = 61) being male. Thirty-one percent (n = 29) of respondents were foundation trainees, 45% (n = 42) core medical trainees (Table 1). Seventy-one respondents (76%) completed their undergraduate training in the UK. Respondent demographics EEA, European Economic Area. Respondent demographics EEA, European Economic Area. Of respondents, 72 (78%) indicated that they would definitely/likely pursue a career in cardiology while 14 (16%) were unlikely/certainly not considering cardiology. Figure 1 illustrates the key influencing factors on choosing a career in cardiology. Factors influencing choice of a cardiology career. The majority of respondents (55%, n = 45) disagreed or strongly disagreed that they felt prepared for starting as a cardiology trainee including managing outpatients (58%, n = 49) and procedural aspects (62%, n = 52). Pre-speciality trainees report more exposure to coronary and heart failure emergencies compared to arrhythmic presentations. Figure 2 describes trainees’ exposure to core practical skills. Only a quarter (28%, n = 26) described some echocardiography experience. Pre-speciality trainees’ exposure to core clinical skills in cardiology. The vast majority of trainees (97%) completing the survey work full time. Sixteen (17%) would consider less than full time (LTFT) training in the future. ‘Family commitments’ was cited as the main reason for considering LTFT training. Most trainees (n = 66, 71%) felt that pursuing LTFT training would be detrimental to their career, agreeing with the statement: ‘It is harder to progress in cardiology as a LTFT trainee’. Thirty-eight percent (n = 35) felt they did not have a role model within cardiology who maintained a work life balance which mirrored their own aspirations. Trainees’ responses to questions about Shape of Training (SoT) are summarized in Figure 3. Overall trainees felt that the changes would make specialization more difficult and reduce the quality of training. There was little enthusiasm for compulsory general internal medical training. However, trainees agreed that SoT would improve the care of general medical patients and improve their physician skills. Trainees’ opinions regarding the ‘Shape of Training’ changes. Twenty-two trainees (24%) felt they had been bullied at least once during their cardiology placement. For some, this had occurred more than once (10% n = 9) and in a minority (n = 3, 3%) on a weekly or daily basis. Thirty-two percent (n = 30) had witnessed a colleague being bullied or harassed in the workplace. We demonstrate that Cardiology remains an extremely popular speciality amongst early career doctors, with 78% of respondents determined to pursue a career in this speciality and 54% not considering any other speciality. Despite this, our survey highlights a concern felt by the majority towards a lack of exposure to practical procedures. In particular, echocardiography is a key skill that pre-cardiology trainees lack despite the vast majority completing jobs in cardiology. One solution would be to establish safeguards within the curriculum that ensures trainees in cardiology rotations are allocated time to attend clinics, echocardiography, catheterization laboratory as well as appropriate funding to attend echocardiography courses. The survey raised interesting views towards LTFT. Less than full time remains more popular amongst female trainees (88%), however, only a minority would consider it in the future (17%), citing family reasons as their main motivation. Our results demonstrate stigma still exists towards LTFT training, as trainees consider it a barrier to career progression. The widely held belief that LTFT will hinder trainees is concerning and may indicate that cardiology is less inclusive than other specialties that have adopted a more supportive stance.5 The BJCA Starter intends to work alongside national and local training stakeholders such as the Royal College of Physicians and the British Cardiovascular Society to further probe attitudes of trainees towards, and promote, LTFT. Unacceptably, nearly a quarter of trainees described feeling bullied or undermined on at least one occasion during their cardiology placements, while 32% witnessed a colleague being harassed in the workplace. These results are alarmingly high and raise cause for concern when compared to the national average of 5.1%.2 Previous studies in the UK have shown that a trainee who is a victim of bullying in the workplace is 10% more likely to drop out of training.6 The majority of trainees were familiar with the ‘Shape of Training’ report,4,7 and the impact this may have on their future careers. Overall, respondents reacted negatively to the proposed changes, concerned they will reduce the quality of clinical training and allow less time to develop specialist cardiology skills. Despite concerns regarding the quality of cardiology training, the majority of respondents acknowledged that shape of training may make them ‘a better general physician’ with 70% stating that the changes should improve the care of general medical patients. The BJCA Starter intends to work in collaboration with the British Cardiovascular Society and the Joint Royal Colleges of Physicians Training Board to ensure cardiology is not negatively affected as a speciality and safeguard the importance of developing speciality skills while supporting the utmost care quality for patients. The findings of our survey are particularly alarming in light of the recently published results of the foundation year exit survey. In 2018, only 37.7% of foundation trainees chose to progress directly into training, compared to 71.3% in 2011.8 Junior doctors are increasingly opting to practice medicine outside of the UK or take a career break from medicine altogether.7 This sharp reduction in the retention of UK doctors has potential significant impact on the calibre and rate of recruitment to cardiology training. However, our survey has identified the key factors that cardiology as a speciality must build upon in order to continue to attract the best candidates and maintain its competitive status. The BJCA pre-speciality training survey is the first to draw attention to pre-speciality trainees’ concerns towards increased provision of general internal medicine in cardiology training and highlights the limitations in practical experience in the current system. The survey has identified the key factors that cardiology as a speciality must build upon in order to continue to attract the best candidates. The authors would like to acknowledge the help of Mr Azeem Ahmad [Affiliates Coordinator, British Cardiovascular Society (BCS)] and Mr Richard Guy (Member & Affiliates Societies Manager, BCS) for uploading and disseminating the survey. Conflict of interest: none declared. References are available as supplementary material at European Heart Journal online.