The art of medicine was to be properly learned only from its practice and its exercise.
Thomas Sydenham 

So after managing to prolong my training to its maximal extent, with two separate years in Perth, Australia and a PhD, tomorrow my medical ‘training’ in one sense comes to its end as I start work as a consultant. I’ve had a chance to reflect on what I have actually learnt since starting on the wards as a wet-behind-the-ears junior doctor back in 2001. Its funny, I don’t feel I am in any way, shape or form an expert now, even though I have probably done my obligatory 10000 hours. I certainly don’t feel as wise as the paediatric consultants I remember when I was a house officer. This might reflect an element of an impostor syndrome – or perhaps I have actually become unconsciously competent.

I’m not really sure how this all happened. I struggle to remember more than a handful of occasions when I specifically learnt anything from anyone, although there are some notable exceptions.

“Don’t listen for the murmur, listen for the absence of noise”

This brilliant advice has always stuck with me, especially as someone who has always struggled with the complexity of paediatric cardiology.

I remember being shown during my first neonatal attachment that babies often open their eyes when put over their mother’s shoulder (which makes identifying the red reflex much quicker).

One of my most powerful experiences occurred in Australia as I watched an Emergency Department Consultant at the resuscitation of an infant from an out-of-hospital cardiac arrest. After several of rounds of CPR it was clear the outcome was going to be devastating. I saw the mother realise this; she was inconsolable. And then the consultant handed leadership of the resuscitation to someone else and went over to her, putting his arm around her and bringing her to her child’s side. He spoke to her about loss and how no more could be done. I don’t remember exact words but I vividly emember him crying with her as we all took a step back. It was one of the most incredible things I have seen a consultant do.

Clearly I was taught things – lectures, seminars, ward rounds must have had an impact – but nothing tangible remains and many of the times I know I learnt the most were situations when I was on my own, sometimes inappropriately so.

I have no idea how I learnt to cannulate the septic ex-prem with tiny hands already scarred, little knowledge of when I gained the confidence to lead a group of people I have never met to deliver emergency care to an injured child, and certainly not a clue when I began to appreciate the subtle difference in the reaction of a parent who has not deliberately injured their child compared to one who has when asked how that bruise happened.

But what is more incredible is what I still have to learn. I am a mere ’13 years old’ – health permitting, I may be practicing medicine for double that time yet. It is inconceivable that I will not learn exponentially in that time. And it will be an exciting time, I think. I hope I continue to reflect on those learning experiences, painful or not, in this next phase of my life.

My training begins again  – it’s just that now I have a different title.

This was first writen in 2010 and never published – I was prompted by a recent article in Archives of Disease of Childhood Education and Practice to put it into a blog form.

“Ability is of little account without opportunity”.  ~Napoleon

Prior to the introduction of the Modernising Medical Careers Programme (MMC) it had been recognized that academic medicine was in decline in the UK and there were perceived deterrents to entry into this specialist field. Dr. Mark Walport, the director of the Welcome trust, brought together a number of stakeholders with an aim to use MMC to find solutions to the traditional barriers to an academic career. What emerged from these meetings was the Walport report and the development of an integrated academic training path (table one).

Table One – The Integrated Academic Training path as proposed by the Walport report [1]

(please click on to expand – picture via Imperial College)

So although many doctors were unsettled by the experience of implementing the MMC programme, and even more disaffected by the initial failure of its recruitment method (MTAS), there was one group of trainees who potentially stood to benefit. Those interested in an academic career found themselves able to gain academic experience and competencies without having to go out of programme or at detriment to their careers. Introduced in 2006 the initial recruitment of the Academic Clinical Fellow (ACF) was slow. However as knowledge of these positions has increased they have become increasingly popular and for the 2009 year 260 posts were available.  The concept of the Post is novel and a summary of the role from the Walport report [1] quoted below:

“Each trainee will have the opportunity to develop a flexible training programme to achieve his / her academic and clinical goals, through the provision of an ad personam training programme and mentoring. Delivery of these programmes should be trainee-centred as far as possible, with a single point of contact for the trainee.”

Essentially an ACF is designed to give enthusiastic clinicians protected time (25% over three years) to develop a thesis proposal. When they embark on a PhD or MD their fellowship ends to return afterwards either to a clinical lectureship or back into clinical medicine. Their run through training pathway is protected and, subject to clinical competencies, they would be able to return with minimal disadvantage if their academic career was not successful or didn’t suit them.

So what’s it like to be an ACF and why would you want to be one? There are many popular misconceptions about academic medicine. You do not have to be the cleverest of your peers, have a photographic memory or be a social recluse. I know that because I was an ACF and received no distinctions or awards at medical school (you’ll just have to take my word for it that I have friends.)

Although originally designed for entry at ST1-3 I entered an ACF in paediatric emergency medicine in March 2008 at the level of a year three registrar (ST6). I already had some research experience from a fellowship I undertook in Australia so had a few imprecise academic competencies. Examples of some of these are listed in table two. They are much less specific than clinical ones and some may be interpreted in an open-ended manner. Therefore you need to go out and find the information required; it will certainly not present itself to you fortuitously while you are on call.

The aim was, given a protected day a week, to develop a research proposal which would enable funding to be obtained for a higher degree. I had an office, a desk in a blood taking room with painfully bright lights and a buzzing ultra-low temperature fridge, but away from a nurses’ station and a bleep.

Table Two – Selected Academic Competencies

There is always the potential for resentment from your colleagues when you are given time away from the shop floor. You sense they feel you will be sitting in front of a computer playing solitaire and looking up friends on face book. It is interesting that I am more tired at the end of an academic day than a clinical shift! When you start it is virtually impossible to sit there doing nothing as you have a range of meetings to organise, courses to book and journals to read. You feel guilty (not least because of your colleague’s unseen glares) if you don’t do anything. This is spur enough to wade through a soporific statistical book trying to explain the difference between sensitivity and specificity, something you thought you learnt in medical school but actually never understood.

“Everyone who’s ever taken a shower has an idea.  It’s the person who gets out of the shower, dries off and does something about it who makes a difference”.  ~Nolan Bushnell

The purpose of the ACF programme is to steer you towards obtaining funding for a thesis (MD or PhD). Although the academic department you are based in will have its own research themes this application will not have been written yet. Ownership and development of an idea by the ACF is considered good practice. It is both enjoyable and frustrating to develop a project. The learning process involves being able to formulate a question (very different from an ‘idea’) which is practical, achievable but most importantly fundable. Many of the suggestions you have will be placed on a back burner as, although good, they are just not achievable in time scale available. In order to develop your ideas experienced advice is needed and developing that advice is a useful first lesson. In my first year as an ACF I had 42 distinct meetings with various individuals and groups and many more ad hoc encounters with my research supervisor. While trying to formulate a research question I first approached those who had any potential connection with my planned topic. Those initial discussions spawn many ideas and lead to a cascade of meetings both within and without the university, hospital and even region. You quickly learn it is vital to have a plan or strategy prior to any meeting. All health care professionals whether doctors, academics, research nurses or representatives of funding organisations are busy people. An initial question of “what can you do to help me?” can be easily be perceived as wasting their time. Explaining your background, interests and aims focuses your direction of travel and it is a lot easier for appropriate advice to be given.  Directly associated with this is need to record information effectively. It was three months before one senior lecturer asked me why I was writing everything she said on a small scrap of paper; “how on earth was that going to be useful in the future?” The next day I brought an A4 ring binder and now have an organised log of all meetings and most importantly outcomes. This is not only necessary for project development it was also a vital piece of evidence for my academic ARCP.

“Librarian is a service occupation.  Gas station attendant of the mind”. ~Richard Powers

In conjunction with developing your question it is important to understand the background research which already exists in your area of interest. Libraries are familiar places to doctors from the late nights spent trying to cram, now long forgotten, knowledge into your brain prior to finals. Librarians at this stage were of little practical use especially as they never seemed to find riotous laughter as much of an adjunct to revision with friends as you did. However the clinical librarian is a mine field of information and is extremely useful in being able to locate a recent article of the “Journal of Amytrophic Lateral Sclerosis” or a 1974 response to an editorial in “Augmentative and Alternative Communication” (both real journals). They are also extremely skilled in designing literature searches and an hour spent with one reaps many hours saved in the future.

Having reviewed the relevant journals and spoken to various authorities on the subject I began putting together an initial research proposal. This document was subsequently revised 13 times before an acceptable version was submitted for a NIHR Research Doctoral Fellowship. Although the theme, questions and method of the final version was very different from the initial draft it was not unrecognisable. With each draft came an increased focus to the question, a better idea of the projects limits and perhaps most importantly an increased understanding of the style of language needed to write applications. Aside from the draft of the proposal the final application took nearly three months to complete. In applying for grants all monies have to be accounted for, which includes your salary, pension and national insurance contributions. The costs of expenses as simple as paper and pens need to be included and statistical help is unfortunately not free. In hindsight trying to bring a whole application together on a day a week (and I certainly did a lot of work in the evening and weekends) added to the stress of the process. With advance agreement and co-ordination the time taken for research over the three years can be taken in any form up to 25 % of the total clinical time. Some centres provide a six month academic block which is especially useful for laboratory studies and allows the ACF to gain experience to inform the thesis application. Others allow a mix of time dependant on the clinical demands (some attachments require a greater clinical commitment to achieve competencies – neonatology during paediatric training is a good example). It is expected the ACF will progress at a faster rate than their peers enabling the academic time to be taken without prolonging the training programme.

Effective forward thinking is important as decisions on major grant applications may take up to six months. Following submission it may take a month to decide whether to send the proposal for peer review and even then a final decision, based on interview, may not be made for another 4-5 months. In that time there will be other grant applications to write and additional research to be performed. It may be during these periods that a return to full time clinical medicine occurs to obtain competencies and exams.

“Failure is only the opportunity to begin again more intelligently”. ~Henry Ford

My initial NIHR Doctoral Research Fellowship application was unsuccessful. The detailed feedback indicated that although I was a suitable candidate the thesis project and support was not of sufficient quality. It is important for grants that you show that you are a committed potential candidate with a robust project detailing measurable outcomes in the planned time frame. You must also demonstrate your supervisors have sufficient experience to supervise you and a training programme is in place for you to obtain the skills necessary to complete the work. It is easy to forget the latter two points in applications. I had presented a couple of abstracts at national meetings based on reviews and audits performed while an ACF. This improved my academic curriculum vitae however we had not thought carefully enough about some of the research techniques needed for the qualitative components of the project. During the next year we refined the question and developed a project group consisting of my research supervisor but also containing academics with specialists interests which were not present in my academic department. I have subsequently obtained funding for a revised project via a fellowship opportunity which has become available at my trust. This certainly would not have been a possibility without the time available from an ACF position.

I have thoroughly enjoyed my time as an ACF despite the pressures of applications deadlines, hours in front of a keyboard and a buzzing fridge.

Regardless of how my academic career develops the experience has been extremely stimulating and rewarding and will be of benefit to me whatever the future holds.

References

1. Medically- and dentally-qualified academic staff: recommendations for training the researchers and educators of the future (the ‘Walport report’). The Academy of Medical Sciences. 2005.