The F3 phenomenon: Early- career training breaks in medical training. A scoping review

Background: Since 2017, more than 50% of UK doctors have undertaken a ‘Foundation 3 (F3) Year’ training break after completing their foundation programme (the first two years following graduation), rather than immediately enter specialty training. The reasons for, and consequences of, the growing F3 trend are largely unknown. This scoping review presents the current evidence and identifies future research in this field. Methods: Following Arksey and O’Malley's guidelines, 12 databases and three UK-based national postgraduate organisation websites were searched for articles published in English (final searches January 2020). Multiple search terms were used to capture articles relating to the ‘F3’ time- period, including ‘post- foundation’ or ‘pre-specialty’ training. Title, abstract and full- paper screening selected articles reporting any aspect of F3, including within a wider context (eg postgraduate training breaks), and then underwent mixed- methods analysis. Results: Of 4766 articles identified, 45 were included. All articles were published after 2009; 14/45 (31.1%) were published in 2019. 27 articles reported research, and the remainder were opinion/commentaries. Specific personal (including demo-graphic),


| INTRODUC TI ON
programmes (should the doctor wish to change specialty). These recommendations were widely supported by the medical education community. 5,6 Since the introduction of MMC doctors, perhaps aligned with Tooke's criticisms, appear to have explored less streamlined career pathways. Over the past 10 years, the unwavering increase in the proportion of doctors taking time out between foundation and specialty training have seen it become the most popular postgraduate training break. 7 The annual UK Foundation Programme Office (UKFPO) reports between 2017 and 2019 reflect that over 50% of doctors undertake an 'F3 year', thereby making this the new norm. 8 The MMC mandated to 'address the uncertain career prospects of the 'lost tribe' of Senior House Officers' 1 who were perceived to be undecided and reluctant to enter into STPs, but the F3 phenomenon has arguably created a new 'lost tribe'. However, given that approximately 90% of post-foundation doctors enter into an STP within 3 years, 9 perhaps F3s should be considered 'temporarily misplaced' rather than 'lost'. So why is the F3 phenomenon a problem?
Firstly, there is little known about why doctors undertake an F3 year and why the trend has increased so rapidly over the past decade; is F3 a choice or a necessity very early in a doctor's career pathway? 9,10 Secondly, what activities are undertaken during an F3 year? Are doctors taking a clinical break, or compensating for an FTP that does not fulfil their preparedness for STPs? Thirdly, does the magnitude of the trend challenge workforce, and consequential financial, planning locally and nationally? In the long term, it reduces, or at least delays, the number of consultants and GPs produced at the end of training.
Finally, the label of the F3 'year' is slightly reductive since 'F4' and 'F5' years (and beyond) are not unusual 8,9 and hence in this review will be referred to as 'F3' as an umbrella term for all immediate postfoundation training breaks, regardless of their length.
Prior to this review, the authors became aware of one other review which included aspects of the F3 year. The Royal College of Physicians' narrative review 11 outlined their Student and Foundation Doctor Network workstreams and referenced the F3 year as a 'growing workforce challenge'. They acknowledged the increasing popularity of F3 but stated there was 'little research-based evidence to explain the underlying reasons for this'. The review suggested some theorised motivations for F3 and suggested better support for, and utilisation of, doctors outside of training posts to support the overall workforce. By contrast, our review aims to present the current evidence surrounding the F3 phenomenon more comprehensively to better equip doctors considering an F3 post, training programme leads and those with medical career advice responsibilities. The objectives of the review are to summarise what is currently known regarding the 'who, what, where, when and why' of the F3 training break and to identify gaps for future empirical research. The methodology chosen to achieve these aims and objectives is a scoping review.

| ME THODS
The authors anticipated that this review would yield a heterogeneous collection of articles and, rather than addressing preconceived questions, these articles would identify knowledge gaps using a broad, flexible and more inductive approach. Scoping reviews are considered an appropriate methodology for this purpose, whereby article content is included regardless of characteristics such as article type or quality 12 but instead is presented accurately and avoids the limitations of absolute systematicity. 13 That being said, scoping reviews should adopt a systematic methodology by including transparent, reproducible and comprehensive search strategies, take steps to reduce error and increase reliability, and extract and present results using a structured approach. 14 To that end, this scoping review adhered to the Arksey and O'Malley 15 guidelines.

| Stage 1: Identifying the research question
The research question of this scoping review was 'What information has already been published about F3 phenomenon?'. This encouraged a broad search strategy, with no restrictions on article type (empirical research articles, editorials, reports and opinion pieces) or year of publication.

| Stage 2: Identifying relevant studies
To find relevant articles, nine literature databases were searched specialising in medicine, psychology and social science (MEDLINE, PubMed, EMBASE, CINAHL, PsycINFO, ERIC, ASSIA, Scopus, Web of Science). Grey literature, including conference proceedings and research dissertations/theses, was identified by searching ETHOS and OpenGrey databases. Google Scholar was also searched to capture any additional articles not identified by the more formal search tools.
All of the above databases/resources were guided by our institution's library advice on literature reviews. Searches were completed across all databases between January 09, 2020 and January 17, 2020.
The authors were also aware that reports concerning the F3 phenomenon had been published by the British Medical Association (BMA), General Medical Council (GMC) and the UK Foundation Programme Office (UKFPO), and therefore, their official websites were also searched.
The search terms were applied as consistently as possible across databases, but allowed for minor formatting differences to optimise search results. The only inclusion criterion was that articles had to report one/more aspect of F3; hence, search terms included phrases describing 'post-foundation' or 'pre-specialty' training breaks as well as 'F3' synonyms. Appendix S1 contains the search terms used for each database and BMA website. The GMC and UKFPO websites were title-searched manually.
The only exclusion criterion was articles not written in English (to avoid translation error). Articles were not excluded based on article type or quality.

| Stage 3: Study selection
Each article identified from primary search was subjected to sequential title, abstract and full-paper screening to achieve final inclusion to the review. Initially, this was performed by HC.
Uncertainty about inclusion of an article was discussed between the two authors and inclusivity favoured. Figure 1 demonstrates how articles were processed using an adapted PRISMA flow diagram. 16 Appendix S2 contains the raw dataset for the included 45 studies.

| Stage 4: Charting the data
All included articles were logged into a spreadsheet for analysis. Each article was examined initially against predetermined items including year of publication/article type/methodology HC undertook initial data extraction for each paper, which was subsequently independently checked and verified by SA.
Uncertainties were discussed until agreement was reached.
F I G U R E 1 PRISMA diagram for the scoping review 2.5 | Stage 5: Collating, summarising and reporting the results In contrast to a systematic review, a scoping study presents an overview of all included material and does not seek to 'synthesise' or assess the quality of the evidence. 15 A consistent approach to reporting the findings allowed comparisons across article types, and a mixed-methods approach, incorporating both content 17 and thematic 18 analyses, was adopted to analyse both quantitative and qualitative data. The content within a single article often contributed to more than one theme. For example, 'why' doctors undertake an F3 and 'what' they do during that time were often addressed within the same article. However, to avoid over-interpretation, making spurious links between themes or adopting a reductive stance, this review will present each theme individually and will include all content which contributed to that theme. This approach might lead to some repetition across themes, but is in keeping with scoping review methodology. 13,14

| RE SULTS
Forty-five studies were included in this scoping review. The full data extraction table can be found in Appendix S1.

| Article characteristics
As demonstrated in Table 1, the majority of the 45 included articles were research papers (13 articles, 28.8%). Editorials/commentaries (10, 22.2%), reports (8,17.8%) and personal opinion pieces (7,15.6%) were also common. When categorised methodologically, the majority of articles were considered personal opinion (18,40.0%), rather than incorporating research output from cross-sectional (14,31.1%), qualitative (6, 13.3%) or cohort studies (2, 4.4%). Four articles reported or commented upon secondary data from other sources (8.8%). Only one review was found, which was narrative in methodology. 11 Over half of the included articles were written from a national perspective (27, 60.0%). The remainder were written from regional (5,11.1%), local (3, 6.7%) or personal (10, 22.2%) perspectives. Only 3 articles (4.4%) cited one/more specific career theory. [19][20][21] Thirty-three (73.3%) articles reported research data, with just over two-thirds (23 of 33, 69.7%) reporting their own empirical (primary) research findings and the remainder reporting secondary data from other sources. Of those reporting empirical data, the number of study participants ranged from 13 22 to 38 905. 23 FY2 doctors were the most common cohort to be enrolled across all primary empirical data articles (8 of 23, 34.8%). No studies recruited medical students. Table 2 contains the results of the thematic analysis, displaying the six major themes, the nested sub-themes and the citation numbers of the articles which contributed to each. Figure 2 provides a visual overview of the spread of evidence within the review. Within each of the thematic segments of the star, a single dot represents an individual article which contributed to that theme. Most articles provided evidence for more than one theme. Within each theme, the articles are further differentiated by their focus on F3 topics. The innermost section contains articles which specifically report aspects pertaining to the F3 phenomenon ('About F3'), whereas in the outermost section articles discuss aspects of F3 within a more generalised context ('Around F3'). Examples of the latter include articles focusing on general career or training breaks, or issues linked to the medical workforce, and whilst both of these provide some insight, they do not relate exclusively to F3.

ABOUT F3
Individual ArƟcle includes this theme from negative training experiences, an unsuccessful STP application or career uncertainty.

| Theme 4. Why are doctors choosing to take an F3?
This was the most heavily populated theme of the review, with factors coded into 'push', 'pull' and 'neutral factors'. The latter focused on the opportunity for a training break given the natural division between completing the FTP and applying for an STP. 32,36 'Push' factors included doctors wanting to step off the training programme 'treadmill'. 20 Burnout was reported as a significant contributor to needing time out of training, 10,31 which was especially pertinent here given that 'burnout seems also to peak at FY2'. 32 Other push factors included low morale, feeling unappreciated 20 or unsupported, 19 feelings of isolation due to lack of interaction with peers and little support from seniors which impacted enjoyment at work. 20 Doctors reported a lack of preparedness for entering, and even applying for, STPs 44,47 due lack of specialty exposure and clinical experience during their FTP. Wakeling et al. 43 presented the conflict within the FTP where consultants acknowledged the need for 'variety' to ensure different specialty exposure but simultaneously 'perceived four-month rotations to be too short' and 'wondered whether trainees spent long enough in a specialty to help with career decisions'. STP application competition was also recognised as encouraging doctors to undertake F3s to enhance their curriculum vitae and gain more specialty-specific clinical experience. Likewise, improving leadership, professional and clinical skills 10 were other common motivators, especially for those aspiring to apply to highly competitive and/or clinical skill-dependent specialties, for example surgery. 44 Finally, the perceived STP rigidity contributes to the rising F3 popularity; 'to have flexibility before committing to specialty training' 36 is appealing, especially having established the prevalence of doctors who reported feeling 'forced to choose [a specialty career] too soon after graduation'. 21 The 'pull' factors for F3 jobs countered the 'push' factors above, with F3 roles appearing to be more personalised and flexible, 37,40,42 offering more location 10 and specialty choice, 33,42 and enable doctors to regain work-life balance 9 with 'greater control over working hours', 40 than STPs. F3 Career progression opportunities include both increased clinical experience and 'incentives that are not available as part of the formal training programme, such as medical education, subspecialty training or additional qualifications'. 53 For example, completing clinical courses during F3 deemed inappropriate/unnecessary for foundation training but are credited at STP interview, for example Advanced Trauma Life Support (ATLS), would strengthen subsequent STP applications. 44 Finally, peer influence was also highlighted as a 'pull factor', 'seeing others take a training break is encouraging them [other doctors] to do the same', especially given that trainees often 'consulted friends and more senior trainees, rather than their supervisors'. 10

| Theme 5. What is the relationship between F3 and career decision making?
The majority of articles in this theme highlighted positive perceptions of, and reiterated some of the aforementioned reasons for taking, an F3.
From a mental health perspective, specialty trainees who had undertaken an F3 were less likely to burnout than those who entered into an STP immediately post-FTP. 35 Doctors who spent their post-FTP break outside of the UK reported 'increased motivation, a greater sense of perspective, increased confidence, improved clinical skills and a better-informed decision on which specialty they wished to pursue'. 53 Other countries' health care systems, such as Australia, were considered to provide better working environments, training conditions and pay. 20 In a similar mechanism to peer influence, the increasing popularity of the F3 makes it more 'socially acceptable' 32 as an alternative to entering an STP immediately post-foundation training. 35 Doctors' negative perceptions of F3 commonly related to its potential impact on subsequent career progression and the lack of structure/support during F3 posts. These concerns included 'falling behind' peers, taking longer to achieve Completion of Certificate of Training (CCT), receiving less support than an equivalent-level doctor enrolled in an STP, change of STP contract terms/conditions prior to applying to that training programme and how F3 is perceived on future job applications given that some senior doctors 'couldn't understand the appeal because they thought I was putting my career on hold'. 36 Consultants echoed concerns that locum-style F3 posts do not provide the necessary supervision that junior doctors require. 10,36 Supporting doctors to take a career break may support their long-term retention in health care, 50 'letting junior doctors step off the training conveyor belt does not mean that they will all leavesome, like me, will return with a fresh outlook on their career'. 37 Two articles called for more guidance for doctors considering an F3, particularly planning time abroad, working in UK non-training posts, revalidation and maintaining a licence to practise. 34 Although arguably outside of the remit of the FTP, 'the input of trainees who have experience of time out of training' 34 perhaps through a 'peer to-peer framework and a well-established mentoring scheme' 11 could be useful to those planning a training break.

| Theme 6. What is the relationship between F3, service delivery and training?
The articles in this theme established a supply/demand relationship between rota gaps and F3 posts: The increasing uptake of F3 posts contributes to STPs being underfilled 27 which causes rota gaps at Trusts which accommodate specialty trainees. 36 These rota gaps may be filled by short-term locum doctors who are unable to provide continuity of care and are expensive to employ. 36 Alternatively, employing F3 doctors on fixed-term contracts to fill rota gaps 57 may be more cost-effective 42,56 and establish a longitudinal working relationship with the department. 52,53 The F3 raises questions about the length and organisation of rotations within the FTP. Watts 47 suggests that 'although the foundation programme contains a variety of specialties, they are often grouped in a non-sensical fashion'. Watts also suggests that the FTP should be extended to three years, whereby doctors would obtain 'core competencies' during FY1, whereas FY2 and FY3 would include thematically arranged rotations to allow specialty exploration and support STP applications. Many other articles echo the sentiment that FTP organisation fails to support career decision making, 23,26,36,41,52,58 where taster sessions and careers advice are 'not an adequate replacement for actual experience'. 58 Hatley 36 reinforces this opinion with a quote from the deputy head of the Wessex Foundation School who said, 'The foundation programme was designed to give doctors a broad experience and to gain generic competencies not necessarily to set them up for a specialist career'. Finally, the FTP was also perceived as failing to support doctors to develop clinical skills beyond basic medical competencies, such as teaching, leadership and assessment, which are required both to enter and progress in STPs. 45 Specialty training programme organisation also appears to contribute to the F3 phenomenon. Firstly, regarding STP applications, more than a third of surgical trainees in a deanery-wide survey expressed that foundation training 'had not provided enough time to prepare for CST [core surgical training] application'. 48 More than half of these trainees would have 'welcomed an extra year, helping to improve their portfolio'. The second issue is the perceived difficulty of changing from one STP to another, should doctors wish to change clinical career, 23

which deters doctors
who are uncertain about their future career choice from applying.
One retired physician recalls that following the introduction of MMC 'the voices of experienced NHS physicians and surgeons' were ignored when they 'warned of the dangers of forcing young people into decisions that would determine the course of their careers for decades'. 51 The introduction of MMC was 'intended to give better training for what had been called the "lost tribe" of senior house officers'. 26 Although it could be argued that F3 doctors have replaced this cohort, Checkley and Remmington 26 suggest that 'they are not yet lost to the NHS'.

| What does the evidence tell us?
The evidence supporting this F3 scoping review includes a combination of research reports and personal commentary. Figure 2 demonstrates that several of the review themes are heavily populated with articles but given that many of these are personal perspectives rather than report large studies, and many of national perspective articles include secondary data rather than empirical research, the quantity of data known about F3 is relatively small. However, given that F3 is such a new and individualised career choice, personal commentary articles arguably offer valuable qualitative information. Doctors' dissatisfaction with the FTP and STPs appears to be a major contributory factor to the rise in F3 popularity. Many articles in this review implied that changes to these programmes would flatten the F3 curve and retain more trainees. 25,45 Given that the FTP appears not to support career decision making 21,43,47

| What remains unknown?
Many variables such as demographics, 23 working environment preferences 33 and chosen specialty 35 have been independently identified as contributing to the likelihood of a doctor undertaking an F3. However, are there confounding influences play? For example, trainees who enter general practice are less likely to have undertaken an F3, but this specialty also attracts higher numbers of mature, graduate-entry, 60 female doctors 7 and offers more career familiarity in terms of exposure to the specialty during under-and postgraduate training. 33 The exact opposite is true of specialties with high higher F3-rates, such as academia and anaesthesia/ intensive care. 35 The latter also have higher STP competition ratios, 61  The suggestion to extend the FTP to three years, aligning the latter two years with potential specialty interests, 47 is similar to recommendations made by Tooke 4 and would increase clinical experience, and support career decision making, prior to STP application. 63 Although this would be ideal for foundation doctors who had chosen a specific specialty/general area (eg surgery, medicine), would this not compound the pressure on those uncertain about their career to declare specialty interests at an even earlier stage in their training?

| Areas for future research
Future F3 research could be guided by the least-populated themes shown in Figure 2 and also overlapping issues with other current topics of interest within medical education.
A larger-scale study could more comprehensively investigate retrospectively how long doctors take out of training following FTP completion, their objectives for the F3 and whether these were achieved. Although many articles assert that the F3 is used to explore career options, uncertainty is often not resolved at the end of an unstructured F3. 21 So, does F3 serve its purpose for doctors?
The synergistic workforce relationship between the F3 and STP posts invites further exploration. STPs are underfilled, in part due to the appeal of flexible and incentivised F3 posts, 29 Although burnout is the fastest growing reason for taking a break from training, 9 statistics on fatigue during F3 are also increasing. 36 The reasons for this are unclear, but may include lack of support/guidance surrounding the F3, 34

| Strengths and limitations of the review
This review was approached using a systematic, well-established methodology, 15 with associated reporting guidelines, 64  Although there is no specific guidance on an optimal number of reviewers for the 'Charting the data' phase, other published scoping reviews appear to favour two authors. [66][67][68] Furthermore, given that systematic reviews conform to much stricter methodological requirements to achieve their superior evidence status and also recommend two independent reviewers, 69 we consider our review in this context methodology rigorous. Both authors approached this topic with a good understanding, but different with different perspectives of, postgraduate medical training. HRC is a clinical academic currently in postgraduate medical training, whereas SA is an academic with an extensive background working in a postgraduate deanery. Neither author had completed an F3 post themselves and therefore did not bring that particular bias to the interpretation of the results.
This was not a systematic review, but given the contemporaneous nature of, and the lack of prior published literature reviews pertaining to, the F3 phenomenon a wider-reaching scoping review was considered more appropriate and useful to the readership. 13 Some relevant articles may have been overlooked by this review: Despite using a wide-reaching search strategy, it was not as comprehensive as a systematic review. Given the increasing interest in this topic, related articles are likely to have been published after the review data collection date (January 2020).
This review presents the literature specifically surrounding F3, a UK-centric phenomenon. As such, the literature search strategy did not aim to discover articles pertaining to other postgraduate training breaks in the UK nor in other countries. Therefore, the review does not provide generalisable outcomes, but does provide transferable considerations pertaining to postgraduate training breaks both in the UK and other countries, including 'what' activities doctors might undertake during a training break and 'why' they may do so (ie the personal, professional and organisational reasons underpinning the decision to take a training break).

| CON CLUS ION
There appear to be personal, professional and system-level influences on persons' decision to take an F3 training break, yet not all of these aspects have been fully explored. By collating and summarising the current F3 literature, this review offers practical information to doctors considering an F3, employers wishing to recruit F3s and STPs/royal colleges wishing to better understand current trends in medical career progression and workforce planning. There are few empirical studies into the F3 phenomenon, but the increasing number of personal commentaries in this area suggests there is growing interest within the medical education community.
This scoping review has established the increasing popularity of the F3, typical demographics for doctors undertaking F3, and has summarised some of the reasons for, and issues surrounding, the phenomenon. There are many questions which remain unanswered, such as how F3 impacts health care service workforce and finances, whether doctors make and meet their personal and professional objectives during their F3(s), and how the rising F3 phenomenon is impacting competition at specialty training level. We encourage the medical education research community to address these questions through further empirical research.

CO N FLI C T O F I NTE R E S T
No competing interests declared.

AUTH O R CO NTR I B UTI O N S
HRC planned the scoping review and collected the data. She undertook initial data extraction and analysed the data. She drafted the scoping review. SA provided guidance regarding search terms/ databases. SA checked data extraction independently. He critically revised the draft of the manuscript. Both authors agree on the final version.

E TH I C A L A PPROVA L
Ethical approval was not required for this scoping review. *Name of authors redacted for anonymous version of manuscript.