02 Mar 2020

Supporting orthopaedic trainees returning to training after taking time out of programme

By Tricia Campbell

The orthopaedic training pathway is competitive. More trainees are seeking time out of programme to pursue interests, such as leadership, research or education. They may also have caring responsibilities or take parental or sickness leave. In order to fulfil these roles and pursue extra-curricular interests, trainees need flexibility and a certain degree of control over their working lives. This flexibility has the potential to also ultimately benefit patients and create a diverse workforce of well-rounded individuals to serve our diverse patient population. Allowing trainees the flexibility to take time out of training will enable formation of a diverse workforce1.

To facilitate such time out of training, we need to also consider the issue of safe transition back to the clinical workplace. It can be a daunting experience for many trainees, regardless of their training level, to return to an unsupervised trauma list or a night shift in a busy major trauma centre after a period of absence. A recent survey of all General Surgery Higher Speciality trainees in the Kent, Surrey and Sussex (KSS) region identified key concerns regarding their return to training around their operative skills, confidence, work-life balance, clinical knowledge and perceptions of colleagues2. These findings are consistent with the results of a survey conducted by the AoMRC in 2016, which found the following specific concerns:

  • Attrition of clinical knowledge and practical skills.
  • Expectation of immediately being able to function at pre-level when resuming work.
  • Working out of hours without supervision from the outset.
  • Worries about missed new developments and changes in local and national guidelines3.

To support sustainable careers and wellbeing, we need to normalise time taken out of programme and ensure that surgical career progression accommodates for trainees who wish to do so. In essence, we need to ensure that trainees wishing to take time out of training are not disadvantaged by their decision. As part of the ACAS agreement in May 2016, Enhancing Junior Doctor’s Working Lives group reported the importance of providing equity to those who have had a period of absence4. In response to this commitment, Health Education England (HEE) have developed a programme to support trainees returning to the work place following a period of absence over three months (opt in available for those less than three months).

Trauma and Orthopaedic trainees that take up the programme are low in numbers, despite having a lot to gain from the Supported Return to Training (SuppoRTT) programme. The aim of this article is to raise awareness of the challenges that trainees face when they return to training and to highlight the support available.

The areas of concern

Orthopaedics is a craft-based specialty requiring hands on learning to gain experience and allow for training progression. The concern is that time away from the operating theatre will lead to a diminution in operative skills.

In 2014, the GMC published the ‘skills fade’ review. This review of the evidence found that clinical and professional skills fade. They found “substantial evidence that time out of practice does impact on skills retention. Skills have been shown to decline over periods ranging from 6 to 18 months, according to a curve, with a steeper decline at the outset and a more gradual decline as time passes”5.

An example within the orthopaedic practice is measurement of knee and shoulder aspiration skills retention learned by simulation in medical residents between 6 to 30 months post teaching event. They found that proficiency declined over time. It was also demonstrated that an opportunity to practice similar skills in the interim can positively influence retention of a learned skill6.

The support available

The Supported Return to Training Programme (SuppoRTT) was developed to enhance the experience of doctors returning to clinical practice.  It enables them to regain their confidence and previously required skills quickly and safely. This in turn significantly benefits patient safety and quality of care. It has been designed to be flexible and takes into account the length of absence as well as the speciality and experience of the trainee. The programme is designed to ensure that the individual can safely and confidently return to practice3,7.

Figure 1

Support star.png


The SuppoRTT star (Figure 1) illustrates the HEE offering: peer-to-peer mentoring, coaching, return to training activities, testimonials or case studies, guidance documents and signposting of useful resources.

SuppoRTT uptake and funding co-ordinated regionally with national HEE oversight

The delivery of the programme has regional differences but should include a series of meetings with your supervisor prior to, during and after your period of absence. The purpose of these meetings is to establish your individual needs and plan your return. This plan may include a period of enhanced supervision, supernumerary period, supervised on-calls, clinical immersion, a phased return (with or without occupational health input), work-based assessments in addition to generic return to training and specialty specific refresher courses.

Your individualised return to work requirements, as agreed with your educational supervisor or training programme director (region dependent), will be funded by the SuppoRTT Programme through the meetings via submission of forms signed by selected supervisors.


To be eligible for the funding, trainees must be on a training programme with a National Training Number (NTN) or accepted onto a training post due to start after their period of absence. Their absence should be over three months in duration (although those with shorter absences may opt-in) and less than two years. All eligible trainees are encouraged to engage with the SuppoRTT programme7.

Education and training

There is an abundance of courses covering the generic skills trainees across all specialities may require, (see Table 1). There are also a number of specialty specific courses available. These include, GASAgain (Anaesthetics), Springboard (Medicine), Return to Clinical Practice for General Surgery (Imperial College London) and Paediatric Return to Acute Clinical Practice (Paediatrics). Various learning modalities are being utilised including simulation, clinical updates, small group learning and scenario-based discussion. 

There are slight regional differences in the courses available. This often depends on local specialty focus on education and training.  All regions offer training for supervisors and helps upskill them in preparation for supervising trainees returning after an absence. It can also help them deal with potential challenges and introduce them to local support and guidance.

Table 1

Generic Skills Return to Training Courses

Work life balance and managing your time effectively

Communicating with confidence

Conflict resolution and assertiveness

Dealing effectively with change

Human factors training

Building resilience

Productivity in focus

Exam game plan

Coaching and virtual coaching

Return to training cross-specialty day

Clinical leadership courses

There is currently a lot of work being done to ensure T&O trainees can benefit from the SupoRTT programme. An orthopaedic specific return to training course is being piloted in May 2020. If you would like more information please contact the National HEE SuppoRTT Fellow (details below).


Increased awareness is paramount in shaping the culture around returning to training. The T&O community need to recognise the difficulties faced by trainees transitioning back into clinical practice after a period of time out of training. We need to help these trainees during their time of need and ensure that they are not disadvantaged as a result of their decision to take time out of training.

There is support available for any trainee taking time out training. Please ensure that you contact your local HEE office for further information.

Useful resources:




  1. General Medical Council (2017). Adapting for the future: a plan for improving the flexibility of UK postgraduate medical training. Available at: https://www.gmc-uk.org/-/media/documents/adapting-for-the-future-a-plan-to-improve-postgrad-med-training-flexibility_pdf-69842348.pdf. Accessed Feburary 2020.
  2. S Williams, VA Bowbrick, S Chan. Return to work for higher surgical trainees: a deanery perspective. Bulletin of the Royal College of Surgeons, 2020.
  3. Academy of Royal Colleges. Return to Practice Guidance (2012) and Return to Practice Guidance Revision (2017). Available at: https://www.aomrc.org.uk/wp-content/uploads/2016/04/Return_to_practice_0412.pdf and https://www.aomrc.org.uk/wp-content/uploads/2017/06/Return_to_Practice_guidance_2017_Revison_0617-2.pdf. Accessed February 2020.
  4. NHS Health Education England (2016). Enhancing Junior Doctor’s Working Lives - A progress report Available at: https://www.hee.nhs.uk/sites/default/files/documents/Enhancing%20junior%20doctors%20working%20lives%20-%20a%20progress%20report.pdf. Accessed February 2020.
  5. General Medical Council (2014). Skills fade literature review. Avaialble online at: https://www.gmc-uk.org/about/what-we-do-and-why/data-and-research/research-and-insight-archive/skills-fade-literature-review. Acessed February 2020.
  6. Preisner R, Jasti H, Elnicki M, Jeong K. Impact of web-based review on long-term retention of simulation-acquired knee and shoulder aspiration and injection skills. J Grad Med Educ. 2012;4(4):460-6.
  7. NHS Health Education England (2018). Supported Return to Training. Available at: https://www.hee.nhs.uk/sites/default/files/documents/Supported%20Return%20to%20Training.pdf.