Out of Programme for Research - Clinical Research Fellow at St Michaels Hospital 2009-2011

I am an ST5 in the Severn Deanery and I am currently taking 2 years out of programme to work as a Clinical Research Fellow at St Michaels Hospital, Bristol.

Overview of the Post

This post comprises 50% of dedicated research time and 50% clinical (middle grade on-call rota for Obstetrics and Gynaecology and some antenatal clinics). I applied for prospective approval from PMETB (now GMC) for 6 months of the 2 years to count towards my CCT.

The salary for this post is funded by the UHB Trust (full banded ST scale), however a grant or funding is needed to cover the expenses of the research project (eg lab time/materials/consumables). Grants can be difficult to obtain and if you are interested in applying for this post it is wise to meet with your prospective supervisor, develop a project and apply for funding prior to the start of the post.

This post gives you the opportunity of getting involved in research projects, with anticipation of obtaining a MSc or MD thesis and first author publications. Currently there are 3 areas of research interest at St Michaels Hospital:

  1. Mechanisms of Pre-Term Labour (with an emphasis on developing potential bio-markers to predict pre-term labour). The project is supervised by Miss Jo Trinder in collaboration with Prof. A Lopez Bernal, University of Bristol.
  2. Development and Evaluation of training in instrumental delivery, supervised by Miss Bryony Strachan.
  3. Investigation of Natural History of the cervical transformation zone, supervised by Miss Susan Glew.

My Project

I have developed and I am currently evaluating an e-learning and simulation training programme for instrumental delivery.

I have learnt a huge amount about research during this post. At the start I attended a 5 day traininng course 'Good practice in Clinical Research which covers everything you need to know to run a research study. After formulating a plan with my supervisor, I wrote a protocol and applied for ethical approval. Concurrently I started to develop the e-learning and simulation training programme. Having completed these elements, I recruited trainees to the study, performed initial assessments and started the training programme. The participants will be reassessed post training.

I hope to write up my finidings to submit for an MD and some first author publications and would love to see my training course made available to trainees nationally. I am hoping to complete my TLHP (Teaching and Learning for Health Professionals) certificate. I have also learnt to use skills very different from those we use daily in clinical medicine - critical thinking, critiquing papers, writing and self discipline.

Clinically, I love my labour ward sessions and antenatal clinics so I feel this post has given me the best of both worlds (for me it was important to have the clinical element to this job - for stimulation/job variety and to maintain my skills). I have also been involved in teaching (obstetric emergency days and Friday afternoon trainee teaching).

I've learnt that to succeed in research you need to be dedicated and willing to persevere when things get difficult or go wrong. It involves a lot of self-directed learning/work, decision making and motivation. You need to have regular meetings with your supervisor, make 'to do' lists and start writing up early. On the plus side, the work is more flexible and you can decide what you do when. I have really enjoyed this post and felt it was a really good balance between research and clinical duties.

If any trainees are interested in doing this post or any research post in the future please contact me for further discussion.

Charlotte Sullivan - March 2011

Out of Programme Research - 'A Smashing experience' 2009-2011

I am a Specialist registrar in the Severn Deanery, currently completing 2 years of Out Of Programme Research (OOPR). It has been an extremely rewarding experience, despite the occasional frustration.

The specific job, Clinical Research Fellow at Southmead Hospital, has several important advantages. The Trust is very ambitious and supportive of research. Several people in key positions will do their best to support good projects. On some occasions I had applications signed by executive staff on a Sunday night so I could collect early on Monday morning; requests for extra research infrastructure have been dealt with effectively and efficiently. This level of support, combined with an excellent multi-professional environment within the maternity unit, imaginative supervision and excellent mentorship, as well as personal hard work, enabled me to submit my thesis by publications and to advance my academic skills and experience significantly.

However, for anyone wishing to undertake a similar period out-of-programme, there are some important decisions to be made:

  1. Whether to continue out of hours cover, my vote is for a strong yes. It is good for the mortgage payments, it is also necessary for maintenance of obstetric skills and useful to do the occasional laparoscopy.
  2. Whether to pursue counting some daytime work towards CCT; this is a difficult decision and I am afraid I do not have the gold answer. It is not too rare to find oneself faced with the responsibilities or pressures of two full-time jobs, one clinical, one academic. This issue is not local or limited to the specific unit, region or specialty. You may find this article amusing and enlightening.

If you do decide to count time towards CCT, it is crucial to apply for prospective recognition to the GMC, RCOG and Deanery, in advance of your OOPR, as the criterica are strict. Do not feel overwhelmed though, as the local support for such applications is outstanding. However, it is interesting the National Institute for Health Research recommends for all 'trainees who are out of programme in research or working for a higher degree' not just NIHR posts, joint academic and clinical ARCPs where both academic and clinical achievements should be discussed and not just the latter.  See The Academy of Medical Sciences: Supplementary Guidelines for the Annual Review of Competence Progression (ARCP) for Speciality Registrars undertaking joint clinical and academic training programmes.

On balance, were the frustrations significant? Not really and if you are oversensitive to expert advice by seniors, an acute surgical specialty like O&G might have been a bad idea for you.

  • Was it a positive experience? Extremely.
  • Do I have any regrets for taking this time out of programme? None.
  • Would I recommend this post to others? Undoubtedly, in the strongest terms: not just future academics but anyone interested in critical thinking and clinical excellennce.

Please do feel free to contact me with any questions if you are interested in OOPR.

Dimitrios Siassakos

Out of Programme Experience - Clinical Teaching - Fellow Bath Academy August 2009 - August 2010

I was the first to do the teaching job at Bath and this meant I had the freedom to set it up as I wished. My supervisor at the time was Rob Slack, who is an ENT Surgeon and at the time was the Head of Undergraduate Training at the Academy in Bath. My other supervisor was Miss DIana Dunlop, who is a Consultant in O&G with a special interest in maternal medicine at the RUH and in charge of fthe 4th year medical students doing the RHCN attachment at the RUH. I took most of her role over in my job and both she and Rob left me free to devise new teaching sessions and methods.

In this job, I was responsible for creating the clinical and teaching timetables for the 4th year medical students doing the RHCN (Reproductive Health and Care of the Newborn) attachment in Bath. I also gave the bulk of the teaching sessions, though I also delegated some of the tutorials and case presentation workshops to other O&G registrars and most were keen to help with this.

I as encouraged to do educational research and started up a simulation project with Nickie Jakeman. Nickie is one of the Emergency Medicine Consultants and spends a lot of her job teaching undergraduates with simulation. We started a project comparing teaching using simulation with traditional tutorials. This was a challenge to set up but was great fun to deliver.

I also helped the other 2 teaching fellows in the academy. They were responsible for the teaching of the 2nd, 3rd and 5th year students and worked full-time in the academy. I helped out by doing mock OSLERS, assisting at OSCE's and with teaching 2nd year students basic examination skills.

The job provides 4 teaching sessions per week which comes down to 4 half day sessions per week. These are spent teaching, doing admin work and working towards the Postgraduate Certificate in Medical Education by doing the THLP (Teaching and Learning for Health Professionals) course, which Bath Academy pays for. I found doing the TLHP very educational and useful but found writing the assignments tedious.

The admin took up more time than I had expected. I have to liaise with and chase up all the others involved in teaching the RHCN students including paediatricians, Sexual Health consultants, community midwives and family planning specialist nurses.

The remainder of the week was spent doing clinical sessions. The RUH is a fantastic place to do O&G training. It is a very friendly department and there are plenty of special interest clinics and theatre sessions to attend. I spent very little time in theatre though, because it was felt O&G trainees should attend them and I was not in a training post. I ended up filling in the gaps in the rota, so did a bit of everything. I did manage to do a lot of maternal medicine clinics and started my ATSM in this. It also meant I could touch base with Miss Dunlop once or twice a week.

I participated in the on call O&G registrar rota which is 1:8 and EWTD compliant. Nights are divided into 4 weekday nights and 3 weekend nights. I did not do any educational sessions in the weeks I did weekday nights but there were other weeks when I had more than 4 educational sessions to make up for this.

All in all I would recommend this job to anyone who has an interest in teaching and wants to spend more time doing this, without doing it full-time. I think a real perk of this job is that 50% of the time is spent doing clinical work, which keeps your hand in and gives much needed extra clinical experience. You can count part (max 50%) of the year towards your CCT training. You need prospective GMC approval for this. I enjoyed working at the RUH so much that I requested to stay on as an ST6 and I am now doing alot of operating.

I am happy for people to get in touch with me if they want any further information or have any questions about this job.

Maud van de Venne

Out of Programme Experience - Clinical Fellow in Medical Education Aug 2008 - July 2009

"I am an StR4 in the Peninsular Deanery and am curently spending a year as a Clinical Fellow in Medical Education at Southmead Hospital (Bristol). Broadly, this post has 2 roles, the provision of teaching to Undergraduate Students and a service element, which is working on the middle grade on call rota in Obstetrics and Gynaecology.

In terms of the Education element, I spend the most time with fourth year Obstetric and Gynaecology students as well as doing 1-2 days a week with final year and second year students. The amount of non-obstetric and gynaecology teaching varies throughout the year.

My Consultant Supervisor and I have been keen to create a varied and interesting teaching programme for the O&G students and move away from the didactic powerpoint lecture. We have used role play, clinical case studies and problem based learning. We have also introduced a teaching caesarean list and a teaching gynae clinic. With hard work and alot of luck we have got the programme pretty much right first time and have been able to improve the sessions steadily, rather than rewriting the course for every new intake.

There is a lot of contact with medical students in other years and anyone applying for the job should be aware of this. I was asked to undertake 2 sessions a week teaching surgery to final year students and understandably this was a fairly daunting prospect as it has been a little while since I have done any general surgery myself! I felt I was able to help most in the field of clinical skills and did mock long cases with the final years at the Southmead Academy (approximately 40). This was very time consuming and difficult to fit in around other commitments however the feedback was hugely favourable and very rewarding. I also do 4 fortnights spread over the year teaching basic clinical skills to second years and I will confess I find this element of the job challenging. Going to respiratory and cardiac wards to find patients to teach on felt very awkward as well as feeling uncomfortable teaching subjects which have probably changed somewhat since I qualified seven years ago.

A real perk of the job is that the Academy pays for you to do the Teaching and Learning for Health Professionals Course (TLHP) which gives you a Postgraduate Certificate in Medical Education from the University of Bristol. This requires the writing of several assignments about teaching and associated theory which whilst takes up time is very useful".

Would I recommend the job to others?

"A guarded yes. Most elements of the job I have loved, I enjoyed interacting with the students & being able to explain difficult concepts to them. I enjoyed setting up the course & writing the seminars. Teaching other years on other subjects however is actually a big part of the job & this should not be underestimated".

Jon Ash

Out of Programme Experience - A Year with VSO - August 2007 - August 2008

"VSO is an Internal Development Charity that works through volunteers. The volunteeers aim to pass on their expertise to local people so when they return home their skills remain. My main role was to act as an O&G trainer as well as providing an O&G service, as there are very few specialists in developing countries.

I went at the start of my Year 4 SpR, as part of the RCOG/VSO fellowship. This is a perfect time to go as you need to be an independent practitioner as usually you will be working alone.

My first posting was to Western Kenya in a Catholic mission hospital but I also visited 5 health centres (travelling via the dusty roads in my old Suzuki jeep) to hold Gynaecology clinics and educational sessions. My role as a volunteer was to assist in the running of the maternity department, to train staff in Obstetric Emergency Care, to provide a regular gynaecological service in the diocese and to work within the 5th millennium development goal in reducing maternal mortality.

I had some experiences in Kenya I will never forget like doing a post mortem caesarean section on a mortuary floor (not refrigerated) surrounded by other bodies and monkeys hovering by the door. I had to divide conjoined twins so they could be buried separately and we also had 5 maternal deaths in as many months. I also learnt many new skills like operating without diathermy, an anaesthetist, an assistant or consultant on call!

Living conditions were basic, I had no running water but usually had electricity although I was careful to keep my laptop charged at all times, as there was very little to do once the electricity went off! There was very little to do socially in both Kenya and Indonesia, probably the highlight of my week was going to the local market, however every 2-3 weeks I took a trip to the big city where I was able to have a sneaky beer, a pizza and stock up on supermarket goodies (like processed cheese or a tin of tuna!).

Due to the political violence over the Christmas period, VSO were forced to evacuate all volunteers from Kenya, I was very impressed with the support we had from VSO and felt perfectly safe during this time. It was with mixed feelings I left Kenya as I felt I had not achieved what I set out to do and felt guilty leaving the hospital with no Obstetric care. However it gave me the opportunity to experience another country and another culture - West Timor, Indonesia. This posed a new challenge - learning Indonesian, as very few Timorese spoke English! However the language school was based in Bali - so it wasn't all bad!

I felt much more prepared for my time in Indonesia as I knew what to expect, again I had no running water but a continuous supply of electricity. As well as looking after the O&G service I felt my role was much more than that as I was only going to be in the hospital for 4 months and there was no Obstetrician to replace me, it was important for me to teach the doctors and midwives working in the hospital how to manage Obstetric problems as well as putting structures into place including guidelines, teaching materials, data collection, checklists & even risk management meetings! Needless to say Clinical Governance had not reached Kenya or Indonesia.

If I was to sum up my year, of what I gained, it would be independence in decision making, a great deal of teaching experience (I rang twice weekly teaching sessions, an added difficulty was it had to be done in Indonesidan, so it took me a little more preparation!), management experience, for example introducing weekly meetings, helping staff to organise the unit and empowering them to make changes.

There were obviously many frustrations as well. Most patients have very little money and they live day to day, it is very frustrating to see a patient, order investigations or prescribe them medication only to be told they have no money and they often leave the clinic with no treatment. Many patients attended the clinic with sub fertility & although I could offer them investigations - sending them to the nearby city for an HSG and semen analysis, there was very little treatment which could be offered. One patient attended after having been on Clomiphene for 3 years (prescribed by private Doctor) without any investigation and after an HSG her tubes were found to be blocked. She was heartbroken that I would not prescribe anymore Clomiphene.

Midwives are not considered a separate profession here although all nurses receive training in basic midwifery skills, this means however we often had nurses working in maternity who are not interested in midwifery as well as having few midwifery skills, making it difficult to motivate staff to change things for the better. Staff turnover was high, wages poor and morale low, many staff just want to do their job & not think about continued professional development or improving health services.

I would recommend VSO to anyone with a sense of adventure. I feel I learn many skills during my year which are easily transferable to the NHS!

Further details on the RCOG/VSO Fellowship can be found on the RCOG and VSO website.

Sonia Barnfield

Out of Programme Experience - "The South Pole Race" - September 2008 - March 2009

Ronald Amundsen finally defeated the South Pole in December 1911. Close on his heels was Robert Falcon Scott and his British team of men who arrived 3 weeks later and perished in the snow on their return leg from the South Pole. This was billed as one of the most hazardous journeys of all time. In 2009 a race was permitted for the first time to cross Antarctica and race to the role in an effort to re-create the fierce British and Norwegian rivalry.

I am an ST2 O&G Trainee in the Severn Deanery. In July 2008 I won a National competition to race across Antarctica and take part in the first ever South Pole Race. This opportunity arose when I was approaching the end of my ST1 year at St Michael's Hospital in Bristol. After careful consideration I felt I needed to take a 6 months 'Out of Programme Experience (OOPE) and essentially a 6 month career break to train for the race. It would not have been possible to do this without the support of the Head of the Deanery.

The race was filmed as part of a TV series on BBC, which aired in the summer of 2009. In our team were two other guys from the world of television and sport. The first is double Olympic Gold medalist 'James Cracknell' and the second was 'Ben Fogle' a well known day-time TV presenter. These two individuals have a long history of adventure and so joining their established team was like arriving for your first day on the wards as a junior doctor. I was in awe of their achievements gut had to grow to feel part of this team. Usually strong in character it doesn't take me long to join a team. The old adage 'two is company, three's a crowd' was going to be put to the test.

We left the UK in mid December 2008 and after 18 days racing on the ice we finally made it to the South Pole at 3.30pm on 22nd January 2009. This has to be one of the most physically and mentally challenging episodes of my life. Antarctica is a magical place with which provokes and evokes human emotion. We spent 42 days on the ice in total in temperatures as low as -58 degrees, we lost on average 2-3 stones in weight and suffered frost bite. I now know what real hardship is and haven't even come close to experiencing the difficulties Scott and his men experienced almost 100 years ago.

I have learnt a huge amount about effective teamworking, focusing on a goal and how to inspire and motivate myself and others. I found returning to O&G has been an interesting time to reflect on those experiences and try to translate them into my daily work. I would encourage all trainees to consider OOPE as a way to broaden yourselves outside a very generic linear system.

Ed Coats

 

Out of Program Experience in New Zealand & Zambia

Hawke’s Bay, NZ

I travelled to New Zealand after completing ST2 training in Bristol, to start my first registrar job in the relatively isolated and largely rural area of Hawke’s Bay. I did have reservations about leaving a training program which was so carefully designed to facilitate a smooth transition from ST2 to ST3 but I needn’t have worried. The excellent foundation that two years in Bristol had provided stood me in good stead. Bar the usual ‘frissons’ of the early days as a registrar on the labour ward, the transition was a smooth one.

New Zealand is an obvious choice if one’s looking for a 1st world overseas experience. Its heritage means that the health system resembles the NHS closely, and you cannot underestimate the value of working in a place that shares your first language. That said there were enough differences to make the experience worthwhile. Covering a large, sparsely populated area presented unfamiliar challenges in terms of antenatal management. Caring for women living in remote communities, many hours from the nearest health facility, required planning on a scale that is rarely necessary within the NHS. It was a welcome novelty to board a 4-seater aircraft to reach peripheral clinics, and to race out of them early to get home before a storm grounded the plane for who knew how long!

A large Maori and South Pacific Islander population also brought welcome differences. The down side was high rates of obesity and gestational diabetes – in Auckland GDM affects 25% of mothers in some districts. With women weighing up to 200kg, surgery and the post-op period could be extremely challenging. Rheumatic heart disease was also not uncommon. The up side was the social aspects of working amid a Maori population, and these were fascinating. Given the outward appearance of New Zealand’s hospitals it can be easy to forget you’re outside the UK, but working in a delivery room amid 15 bare-footed family members was a stark reminder. I will never forget the wall of collective grief I met on ITU when a young pregnant woman who had sustained a catastrophic subarachnoid haemorrhage had her care withdrawn, having been kept on life-support for 5 weeks in the hope of saving her fetus. Whatever one’s opinion on this management (and opinion was strongly divided) you could not fail to be moved by the music, wailing and keening of 40 relatives as it echoed through the hospital, and permeated every member of staff. Maori funerals last for days and absorb everybody within that person’s orbit. The young brothers and sisters of a dead baby will cradle and speak to it, accepting death as an inevitable part of life. To be invited to a Maori gathering, as I was lucky enough to be, is an experience that leaves you subtly changed, and questioning some of our western values.

 

Monze, Zambia

Leaving the first snows of New Zealand winter it was something of a culture shock to arrive in hot and bustling Lusaka. Unsure what to expect, I found myself in the enviable position of working with an Irish-trained consultant, Dr Michael Breen, who had amassed a positive wealth of experience after 20 years working in Africa. Monze is a medium-sized rural hospital in Zambia, staffed by 5 doctors and a number of medical officers and licentiates.

Again, despite my fears about my own inexperience I found a routine that was mutually beneficial for myself and the local staff and patients. Monday-Saturday, days began at 7.30 with formal consultant ward rounds of up to 80 antenatal, postnatal and gynae patients. There were 3 operating lists and a gynaecology clinic per week; emergency work fitted around these. With Michael Breen’s backing I ran a modified obstetric emergency course for midwives and medical officers in the afternoons. It was a useful experience to be forced to adapt UK practice to the local resources and skill sets. The absence of certain drugs, syringe-drivers, lab facilities, blood products and the average time taken to get a patient to theatre had implications for management strategies. I was struck by the lack of staff familiarity with basic life support measures, and the training identified a number of problem areas that we were able to address, a striking one being that none of the maternity staff knew of the existence or location of the hospital defibrillator! The concept of teamwork training and role play was entirely new, and having focussed repeatedly on directed communication, I was overjoyed to see this group of individuals transforming into a team, exchanging information clearly and demonstrating leadership and cooperation. The move from a reactive to an anticipatory management of common obstetric emergencies was very encouraging. That said, it is easy to revert to old habits and I think the impact of this training will be reliant on ongoing input from Michael Breen or visiting clinicians.

The trainee clinical officers were focussed upon learning to perform caesarean sections, so I was able to operate with Michael Breen without denying them training opportunities. I had originally contacted him due to his experience as a fistula surgeon. During my time in Zambia I had the privilege of seeing a number of young women, some just girls, pass through the hospital. Arriving, emaciated after the traumas of an obstructed labour, the loss of a first baby and the subsequent pain and degradation of developing a vesico-vaginal or recto-vaginal fistula, at Monze they met and were befriended by other young women who had suffered in a similar way. They were fed and sheltered until well-enough to undergo surgery, then looked after at the hospital until their catheters could be removed and the success of the their repair assessed. They were a cheerful group, braiding each other’s hair in the hospital quadrangle, singing and drumming from their rooms and twisting Michael Breen’s arm for cosmetics and other treats which he invariably supplied! It was wonderful to see their confidence rebuilt over the course of only a few weeks.

In terms of operating, the experience was unparalleled. With 18 hours a week in theatre assisting and performing the simpler cases, I saw bladder resections, formation of pouches, re-implantation of ureters, and many vaginal fistula repairs. The gynaecology clinic was a case series of tragically late presentations – choriocarcinoma, cervical and endometrial cancer, very large fibroid uteri and ovarian cysts. Often the women carried the tattoos of numerous visits to the local healers, before submitting themselves to western medicine. The hospital was a last resort for many. With minimal investigations at our disposal, we were thrown back upon clinical examination skills.

On labour ward vaginal twin and breech deliveries were a daily occurrence. I was able to support and teach the traineemedical officers by helping them to identify high risk women, develop a management plan and anticipate problems – a concept that seemed somewhat alien! We did a lot of caesarean sections together in the wee hours of the morning, and it was useful to take that duty away from a consultant who is on call all but 2 weeks per year. I was humbled by the medical licentiates’ breadth of knowledge and ability. Without a comprehensive range of specialists to plumb for advice, they managed neonatal problems, infectious disease and a range of other miscellaneous conditions adeptly. I was reminded again that by compartmentalising patients’ problems and delegating them to the relevant specialist in the quest for optimum clinical care, it is inevitable that we become deskilled in the UK as general clinicians.

I must extend my thanks to those at Severn Deanery who are responsible for overseeing our training and for having the flexibility and foresight to enable trainees to have this sort of experience. I come back with renewed enthusiasm for O&G. To anybody considering taking an OOPE I would whole-heartedly recommend it, and given the quality of our UK training I suggest that we have something valuable to offer host hospitals even in the early stages of our careers.