Educational impact of COVID‐19 on foundation doctors and the decision to take a break from structured approved training programmes in the United Kingdom

The COVID‐19 pandemic impacted the Foundation Programme for doctors in the United Kingdom. Foundation doctors were working under increased pressure and significant changes were made to their training.

their broad medical education. 3Another purpose of the Foundation Programme is to provide new doctors with their first professional role, and as such, they are expected to provide a service to the National Health Service (NHS). 1 Even before the COVID-19 pandemic, there were times when these two components overlapped resulting in conflict. 4storically, some doctors have felt that the Foundation Programme has failed to meet their educational needs.This is often as a result of factors such as staffing issues and reduced teaching leading to a poor quality of training. 4This coincides with an increase in doctors choosing to take time out of training after completing the Foundation Programme.This time out of training has colloquially become known as an 'F3 year'.This was also noted in 'The F3 Phenomenon' Report which focused on furthering the understanding of why doctors are choosing to take time away from training after competition of the Foundation Programme.One reason why doctors may be choosing to take time away from training is to widen their experience enabling them to enhance their own career development.Other doctors may choose to work abroad or take up a career outside of medicine. 5In this report doctors also raised concerns that they felt the Foundation Programme had very little focus on their educational development and that there was a greater focus on providing service provision. 5r doctors who completed the Foundation Programme during the COVID-19 pandemic, they had to contend with an additional challenge during their training.As a result, foundation doctors were expected to move to unfamiliar departments, work altered rota patterns and cover any gaps that occurred due to illness. 6Emergency on-call rotas were frequently introduced, often including more oncall shifts with less rest in between. 7Often, these emergency rotas were in breach of the 2016 UK Junior Doctor Contract but considered essential due to the pandemic. 7It is likely that the demands placed upon foundation doctors resulted in a significant shift in the balance towards service provision rather than education. 8This issue was compounded when teaching sessions and career development opportunities were cancelled. 8,9This led to some doctors taking an F3 year to make up for lost clinical opportunities and career development. 9r doctors who completed the Foundation Programme during the COVID-19 pandemic, they had to contend with an additional challenge during their training.

| AIMS
This study sought to understand the impact of the COVID-19 pandemic on foundation doctors by seeking to: 1. explore how the COVID-19 pandemic impacted the educational opportunities of foundation doctors? 2. explore if the COVID-19 pandemic influenced doctors decisions to take an 'F3 year' and if so, why?

| Study design
A hermeneutic phenomenological approach was taken to understand the educational experiences of foundation doctors.This approach was chosen because hermeneutic phenomenology seeks to understand individuals' accounts of their own experiences in their daily lives. 10ctors were asked to reflect upon their own experiences of working during the pandemic.These were unique experiences that no previous foundation doctors had ever gone through.As such, it was important to acknowledge that these educational experiences had taken place during a time when sudden changes were being made to the Foundation Programme, the NHS was under significant pressure due to COVID-19 and foundation doctors were being asked to work more hours than they had previously done. 6,7To develop this deeper understanding of the educational experiences of foundation doctors during the pandemic, semi-structured interviews were carried out.A constructivist paradigm was used due to the subjective nature of the experiences of the foundation doctors.This enabled qualitative data to be gathered from doctors in detail while also taking into account their unique clinical environment during the pandemic and their wider role within the health care setting. 10,11Ethical approval was granted by the Hull York Medical School in February 2022 (reference 21/22 18).

| Data collection
Information about the project was posted on Facebook groups aimed at doctors who were taking time out of training.These Facebook groups were setup and run by doctors to provide information for doctors considering taking an F3 year.The groups included doctors who had continued working within the United Kingdom as well as those who had decided to work abroad.Through posting in these groups, this enabled doctors working in a wide range of locations to participate in this study.
These posts contained a brief summary of the project and asked doctors who were interested in taking part to contact the email address provided.Doctors who replied were provided with a participant information sheet and a consent form.To be included in the study, doctors must have completed the Foundation Programme in either 2020 or 2021, to ensure that they were part of the Foundation Programme during the pandemic.Once consented, an interview time was arranged.Semi-structured interviews took place over Zoom.Broad questions were preprepared for the interviews with more specific follow-up questions asked depending upon the participants answers.These interviews were recorded and transcribed verbatim by the researcher.The interviews lasted between 20 and 30 min.

| Data analysis
Braun and Clarke's six-step approach was used to carry out a thematic analysis of the data collected from the participants. 11,12Transcripts were checked and re-read to ensure accuracy and to familiarise the researcher with the data.The transcribed interviews were then uploaded to NVivo 12 (QSR International).Using NVivo 12 (QSR International), the data were preliminarily coded.As the research was addressing specific research questions, a thematic analysis was used.[13] Codes that were related were collated together to form themes which again related back to the research question. 12,13Themes were then revised and redefined to ensure all coding within was unified.These themes were then summarised using participants quotes. 13

| Reflexivity
Due to the constructivist, qualitative nature of this research, it is the researchers' responsibility to construct meaning from the data collected.As part of this process, we have acknowledged our own views on the research and how this can influence the data. 14,15Reflexivity enables us as researchers to acknowledge that our professional roles, such as working as a clinician during the pandemic, may influence how we interpret the data collected.CK worked as a foundation doctor when the pandemic began.Through discussion with peers, CK was aware of how his own education had been impacted by the COVID-19 pandemic and was aware that many colleagues were choosing to take time away from training upon competition of the Foundation Programme.JB and WL both work as senior academic clinicians, researchers and educators but were more removed from the direct educational impact on foundation doctors.Our differing backgrounds have enabled us to collaborate on the reflexivity process.This has provided the opportunity for our assumptions to be challenged and to discuss differing interpretations of the results. 15| FINDINGS

| Education versus service provision
Due to the pandemic, it became clear that formalised teaching would not be prioritised.All of the participants explained that their formalised foundation teaching had been cancelled: 'All our teaching was completely like stopped'.Due to the pandemic, it became clear that formalised teaching would not be prioritised.Most participants acknowledged that their interdepartmental teaching, within each specific speciality, had been cancelled as well: 'Like even teaching on there, sort of doing ward rounds and things that just didn't exist.'Dr 3.
Even when hospitals began to transition from focussing on COVID-19 as an acute issue to a long-term problem teaching has continued to be impacted:

| Redeployment and rotating specialities
There was a great deal of variation regarding whether foundation doctors were rotated, as originally planned, or redeployed.This was because this decision was made at a local NHS Trust level:

| Challenges with career progression
As all the participants were at the stage where they were considering For some of the participants taking time out of training has also provided them with the opportunity to gain more experience than they were able to get in the Foundation Programme.This has led to doctors being able to focus on gaining experiences which they felt were specifically beneficial to them: Taking time out of training has also provided them with the opportunity to gain more experience than they were able to get in the Foundation Programme.

| DISCUSSION
Changes were made to education within the Foundation Programme as a result of the COVID-19 pandemic.Many participants were negatively impacted due to cancelled teaching and reduced educational experiences.This then had a knock-on effect as some doctors then took time out of training to make up for this 'lost education'.Few studies have focussed on obtaining in-depth qualitative data from post-foundation doctors. 8,9This study provides a unique opportunity to discuss the lived experiences of foundation doctors during the pandemic and an insight into how this impacted their education.

| Education versus service provision
Prior to the COVID-19 pandemic, there were concerns that at times the service provision aspect of the Foundation Programme limited the educational opportunities of foundation doctors. 5Due to the unique nature of the pandemic, this significantly worsened as all participants felt that their role as a foundation doctor was about service provision and just getting through each day working on the wards. 7,16This point was highlighted when all of their formalised teaching was cancelled. 2is issue was compounded by the unknown nature of the pandemic.
No one knew how long these changes would last for. 17ile all participants highlighted that their formalised foundation teaching was initially cancelled, some participants noted that there was an increase in non-formalised ad hoc teaching.Doctors who had this opportunity felt that it was beneficial for their learning, but it was not able to make up for the teaching which was lost.
When teaching restarted, some doctors were made to feel guilty for attending teaching.As teaching began to be reintroduced, some participants felt as if a precedent had been set and that service provision was now considered more important than education.This led to situations where doctors were told they were not allowed to attend mandatory teaching.This is despite the General Medical Council (2020) stating that they will 'work with other bodies to make sure trainees are able to catch up on missed competencies'. 18This echoes previous research carried out during the pandemic which showed that doctors had difficulty attending teaching, even when it was organised as a virtual session. 9This was because doctors 'attended' from their respective wards, and this led to the loss of the 'protected' nature of the teaching session. 9erall, while the pandemic did provide opportunities for innovation with regards to how teaching is provided to foundation doctors, it is clear that COVID-19 had an overall negative impact on teaching as part of the Foundation Programme.It was understandable that priorities changed at the beginning of the pandemic. 16However, the increased working pressures on hospital staff have remained since the beginning of the pandemic. 19Therefore, foundation doctors remain at risk of not being able to attend teaching as a result of working pressures.In order to overcome this, more needs to be done to ensure that all doctors are able to attend their mandatory teaching.Otherwise, foundation doctors will remain at risk of missed learning opportunities while also putting their career progression at threat through not being able to meet their ARCP requirements. 2

| Redeployment and rotating specialities
There was great deal of variation in how much COVID-19 impacted the trainees and their rotations.The decision to redeploy foundation doctors was left to each individual hospital. 20This resulted in some foundation doctors remaining on their second rotation for an extended 4 months, whereas other doctors were taken out of their current rotation and redeployed to another department.
Some participants found that remaining on their second rotation for an extended 4 months to be beneficial.Findings from this research suggest that some of the trainees found it easier to integrate themselves within their respective speciality teams simply because they were within the department longer.They also felt that they learned more about the speciality, and this allowed them to take on a greater level of responsibility in their role.This is in keeping with previous research which suggests that longer rotations lead to an increase in trainee productivity as they became more integrated within their respective departments. 21However, attaining more specialist knowledge is not in keeping with one of the main purposes of the Foundation Programme which focuses on doctors obtaining a breadth of experience. 22Therefore, while foundation doctors found the longer rotations to be educationally beneficial, this is not in keeping with the overall educational aims of the programme.wildly different experiences.There was no consistency when deciding which doctors were redeployed as each NHS trust made the decision based on their own unique set of circumstances. 20Further research is needed on supporting doctors who were redeployed, and questions need to be asked as to whether trainee doctors should have an increased say in redeployment should the need for this arise in the future. 24Doctors' previous rotations and experience should also be considered when deciding whether to redeploy them.This would at least help to identify those doctors who are at risk of having a narrow range of experiences and allows deaneries to offer targeted support for these doctors.

| Challenges with career progression
Many of the doctors who took part in this research felt that their own portfolios were not competitive enough to apply for speciality This aligns with other studies which have highlighted the negative impact of cancellations of exams and courses. 8,17This was again because the focus of health care workers was shifted solely to dealing with the COVID-19 pandemic. 26 a result of COVID- However, one issue participants had was they had great difficulty attending speciality specific courses.For example, Advanced Trauma Life Support.This was because these courses were originally cancelled during the pandemic and then there was a backlog when they restarted.The course organisers then started to prioritise those doctors who were already in a training post leaving those outside of training with little chance of successfully attending. 28though these courses are not mandatory for applicants to apply for speciality training, it does give a clear advantage to those doctors who had the opportunity to attend courses.Essentially, it disadvantages those doctors who completed their foundation training during the pandemic.
It is clear that some doctors have utilised time out of training to try and make up for opportunities which were lost during the pandemic.It has also highlighted that the pandemic has made it more challenging for some doctors to apply for speciality training and may be at a disadvantage to their counterparts who completed the Foundation Programme prior to the pandemic.

| Recommendations Finding Recommendation
Foundation doctors struggled to attend mandatory teaching sessions often due to increased working pressures.This puts them at risk of not meeting the requirements to progress in their training.

Areas of further research required
Further research is needed into the best methods for supporting doctors who were redeployed.
Further research is needed to identify if COVID-19 resulted in more doctors taking time away from training and how this will affect workforce planning within the NHS.
Further research is required to establish if the Foundation Programme is meeting the educational needs of its doctors.

| LIMITATIONS
We recognise that only a relatively small cohort of doctors were interviewed.However, this is in keeping with other phenomenological research which typically has a smaller number of participants. 10,29This allowed for in-depth interviews which obtained a greater level of detail of participants experiences. 29Although there was variation in the locations of the doctors who were interviewed, due to the smaller scale of the project, it was not possible to cover all of the NHS trusts who each took a unique approach to the role their foundation doctors had during the pandemic.
We acknowledge that when some of the participants took part in the interviews, it had been over a year since they were a foundation doctor, possibly introducing some recall bias.Furthermore, this study is limited to one health care system, the NHS.Transferability to other countries may be limited, although mobilisation of the medical workforce to cover COVID-19 duties was of course required in many health systems across the world.

| Future work
As noted in the 'Areas of Further Research table', this research has highlighted that foundation doctors missed out on educational experiences as a result of the pandemic.Further research is required to identify the long-term impact of this 'lost education'.Questions also need to be asked as to whether the Foundation Programme is providing educational value to trainees.Further research is needed because it is apparent that COVID-19 has worsened concerns from foundation doctors that service provision is being prioritised over education.

4. 1
| Participants Twelve post-foundation doctors who had chosen not to apply for speciality training after completion of the Foundation Programme were interviewed.Interviews took place between April 2022 and July 2022.These doctors had undertaken their foundation training across nine different deaneries across the UK.Participant characteristics can be seen in Table 1 .

4. 2 |
OverviewThree themes were identified from the data.Two focussed on foundation doctors educational experience during the pandemic: Education Versus Service Provision and Redeployment and Rotating Specialities.The other theme focussed on doctors experiences since they completed the Foundation Programme: Challenges with Career Progression.
COVID started during my F1.So, I didn't have three rotations in F1.' Dr 8. Some doctors found that remaining on a rotation was beneficial as it provided them with opportunities that they otherwise would not have been afforded: '[The] continuity probably ironically in general surgery meant that I probably learned quite a lot more because I was on the job more so that was almost positive.'Dr 5.While doctors themselves were also able to gain more experience in a speciality, they were also able to use this prolonged time to develop new speciality specific skills and integrate within the speciality team: 'Um, and actually then developed way more skills in that specialty [and] found that I enjoyed getting to know the staff more.[I felt] like part of the team and things.'Dr 4. Whereas other doctors felt that most of their clinical experience was COVID-19 related: 'I just felt like I literally, I could, I could tell the consultant how to manage a COVID patient.' Dr 3.
applying to various speciality training programmes, they were all familiar with the training programme requirements for the speciality they were interested in.Many of the participants had found it challenging to meet these requirements.This was because COVID-19 had led to the cancellation of courses, exams, and conferences: 'Obviously, I was planning to go to quite a few conferences, which were points on your portfolio.Um, I think near enough, all of them were cancelled.'Dr 7. Attending courses in particular had become more challenging as priority was being given to doctors who were already on training programmes: 'They've explicitly said that they prioritise a training post trainee.' Dr 12.Many of the doctors have been able to make up for some of these missed opportunities through taking time out of training and focussing on what is specifically required for them to progress in their careers: 'And I would say I've probably got probably 10 or 12 additional points from doing my F3 job.' Dr 10.

'[
Taking an F3 year] enabled me to do essentially sort of like a non-official sort of CT1 year by doing six months of general surgery, six months urology.So, I definitely would feel more prepared when it comes to doing core training in the future.'Dr 7.
Other participants felt that due to the COVID-19 pandemic, they had essentially become 'COVID doctors'.They were repeatedly treating patients who had been admitted with COVID-19.Some participants in the study had spent a whole year working specifically on COVID-19 wards.This had resulted in them attaining a great deal of knowledge about COVID related illness but little experience in other specialities or managing other medical conditions.While the COVID-19 pandemic created a unique set of circumstances, the doctors who completed their foundation training during the pandemic have had a narrower range of experiences as part of their training.This directly contrasts Health Education England's view that rotations should include a broad range of specialities and include at least one community placement. 23Due to individual NHS trusts deciding what to do with foundation doctors at the start of the pandemic, this resulted in doctors having training.For example, speciality training programmes such as the Core Surgical Training programme are ranked on a points-based system.Doctors acquire extra points for taking part in research, sitting speciality exams, attending courses and attending conferences.25Participants noted that many of the extra components which are required to attain entry to speciality training were cancelled as a result of the pandemic.This was particularly noticeable at the beginning of the pandemic as research, exams and conferences were cancelled.