From specialist registrar to consultant: permission to land?

After many years of hard work and training, the transition fromtrainee to consultant is potentially challenging. Having successfullynegotiated the hurdles of pre-registration training, the MRCPsychexamination and the specialist registrar (SpR) interview, traineeshave to pass one final signpost to mark the end of their formaltraining – securing their first substantive consultantpsychiatrist post. Despite overall vacancy rates of about 12%for consultant psychiatrists in the UK (Royal College of Psychiatrists, 2002),competition can be intense for some posts.

This paper aims to guide trainees in the transition from SpRto consultant, via RITA (record of in-training assessment)reviews, CCT (certificate of completion of specialist training)awards, specialist registers and the consultant interview.

Higher specialist training

TOP

Higher specialist training

The setting of educational objectives at the outset of eachSpR post can ensure that trainees develop the relevant competencyrequired during higher specialist training (HST). Such objectivesshould be set jointly by the trainee and trainer, and adhereto the acronym ‘SMART’ (i.e. be specific, measurable,achievable, realistic and time limited). They should relateto the College’s ‘core’ and ‘additional’ competencies required for HST, and be appropriate to the stageof SpR training. It can be convenient to group such objectivesinto four broad categories: research, clinical, teaching andmanagement.

Good planning can ensure that trainees make constructive useof their research day sessions. Involvement in research projectscan help trainees to develop an understanding of the principlesof research methodology and audit, and refine their organisational,time management and leadership skills (Strydom & Higgins, 2004).It also provides experience in writing protocols andpapers for peer review and obtaining ethical approval for projects.Publications can improve a trainee’s competitivenessat consultant selection (Guthrie & Black, 1991).

Although most SpRs believe research to be important (Allsopp et al, 2002),there are concerns about the effectiveness ofthe current research day (Vassilas et al, 2002). Only halfof the SpRs in psychiatry have ever managed to secure a publication(Smart & Cottrell, 2000). Recent surveys have suggestedthat problems with lack of experience, resources and supervisionmay be a reason for this (Petrie et al, 2003).

Recommendation 1. Box 1 outlines our advice on how SpRs canmake more effective use of their research day.

Many of our suggestions in Box 1 parallel the recent recommendationsmade by the Collegiate Trainees’ Committee, that thereshould be greater flexibility in the use of the research day (Ramchandani et al, 2001). Securing a publication by writingup how you modified an existing practice guideline will lookmore impressive than a half-completed randomised controlledtrial that failed to get published.

Box 1. How can the SpR research day be used more effectively?

Aimto do collaborative work, either with other SpRs or with consultants who have an established record of publications

Attend localuniversity courses on literature searching, writing protocols, research methodology, statistics, etc. before starting anyprojects

Be realistic about the time-span of a project (e.g.literature searching and obtaining ethical approval may takeup to18 months)

Think innovatively – are there questionnairesurveys/audits that can be performed to help develop a newintervention or can modifications be made to existing practiceguidelines?

Consider spending some sessions with your trust’sclinical governance department, assisting them with any regionalaudits required by the Department of Health

Consider whatcould be written as a paper at every stage in the research process,rather than leaving it to the end (e.g. a review paper afteryour literature search?)

Target and select appropriate journalsfor submission of any papers, rather than attempt a blanket‘top-down’ approach.

SpR, specialist registrar.

Special interest sessions should be organised in advance ofeach SpR post. Careful planning can ensure that they are linkedto your intended career plans. Therefore, a trainee interestedin organic aspects of psychiatry may organise their sessionsin an epilepsy clinic and a liaison psychiatric service, overa 1- to 2-year period.

Recommendation 2. Utilise the‘bank’ of suitablespecial interest placements which the College encourages HSTprogramme directors to keep, based upon feedback of previoustrainees. Use some of the sessions to fill in training opportunitiesnot readily available elsewhere, e.g. family therapy.

SpRs should aim to develop good teaching skills, including experiencein examining (and giving constructive feedback to) senior houseofficers (SHOs) preparing for the MRCPsych examination andmedical students. It is also important to gain experience ineffective communication, negotiation (including resource andconflict management) and managing meetings (Heard et al, 2001). Regional and national courses provide good opportunities fortraining in these areas.

Recommendation 3. Use some of your special interest sessions to‘shadow’ the consultant representative on localcommittees for drugs and therapeutics, risk management andclinical governance. Be proactive in gaining other ‘hands-on’local management experience, e.g. does your region need a newlaptop computer/projector for their academic programme (findout what can facilitate funding, who provides the budget andwho authorises it)?

Up to 12 months work in an ‘out-of-programme’ experience (Stratford, 2003), either abroad or in a related sub-specialty,can be of benefit to trainees. This should be planned in advance,and approval is needed from your programme director, regionaladvisor and the postgraduate dean. Such posts can count towardsCCT approval with agreement of the College.

Log books provide an excellent means of recording the experienceand competencies gained during SpR training (Paice & Ginsburg, 2003),and should be filled in prospectively.

RITA reviews

TOP

RITA reviews

The annual review process should ideally be a positive and supportive experience but still be able to highlight additional or furthertraining needs (Pidd, 2003). Recent research analysing theoutcome of RITAs for UK psychiatric SpRs showed that about 98% were assessed as satisfactory (RITA grade C) (Tunbridge etal, 2004). SpRs should use the RITA process to help identifytheir own preferred methods of systematically recording theiryearly training experiences (e.g. log books, feedback letters,attendance certificates). Consider making use of ‘360-degreefeedback’, by obtaining information on your performancefrom multi-professional colleagues. Many of these processescould be applied to your career as a consultant, aiding the mandatory appraisal process. They can also help to identifyany deficits in the experiences available within your trainingscheme.

Recommendation 4. Get used to incorporating your yearly educational objectives (see Table 1) into the RITA process, as they closelyresemble the format of personal development plans, which willbe a central element of the consultant appraisal process (Newby, 2003).

View this table:
[in this window]
[in a new window]
Table 1. A sample educational objective that could be reviewed as part of the record of in-training assessment process

Acting up

TOP

Acting up

During the final year of HST, up to 3 months spent in a locumconsultant post (in the appropriate specialty) may count towardsthe CCT award. This provides a realistic ‘taster’for consultant life (attending directorate meetings, runningclinics, being team leader and deciding priorities) in a semi-protectedenvironment (Pickersgill et al, 2003).

Recommendation 5. In acting up, ensure that you have adequate supervision arrangements and litigation cover.

Specialist registers

TOP

Specialist registers

Although SpRs can be interviewed for a substantive consultantpost during the last 3 months of their training, they can onlymove into such a post once their details appear on the GeneralMedical Council’s (GMC) specialist register. Upon successfulcompletion of the final appraisal (RITA G), the postgraduatedean notifies the College, who will recommend to the Postgraduate Medical Education and Training Board that a CCT award is granted.Once the SpR has completed a CCT application form and sentoff the application fee, a CCT certificate is issued (around2-4 weeks before the CCT completion date). An accompanyingform, sent with the CCT certificate, must be completed and forwardedto the GMC before entry onto the specialist register can be completed.

Recommendation 6. Consider using your 6 months ‘periodof grace’ by remaining on the training programme andcompleting any research publications while actively lookingfor a substantive consultant post.

The new consultant entry scheme

TOP

The new consultant entry...

SpRs who have completed their HST may opt to enter the new consultantentry scheme prior to applying for their first substantiveconsultant post. Placement on the scheme (in a locum consultantpost) is usually limited to 6 months and is organised via NationalHealth Service (NHS) Professionals (http://www.nhsprofessionals.nhs.uk/). Such placements have the advantage of having two protectedsessions a week for professional development, a personal developmentplan and a mentor.

Selecting a consultant post

TOP

Selecting a consultant post

Available consultant posts are advertised in the weekly BMJ Careers. The website http://www.bmjcareers.com allows identificationof advertised posts in particular regions. ‘Adplus’has helped to simplify the application process for some postsby providing job profiles, local trust information and applicationpacks online. Regional advisors in psychiatry approve consultantjob descriptions, and can be a useful source of informationregarding the post itself.

Recommendation 7. Beware of large job adverts in glorious technicolour,showing beautiful, rural scenery! It could imply that the trust is awash with money (uncommon in the NHS), is led by enthusiasticclinical managers or is in the middle of a recruitment crisis.

Among the extensive lists of senior managers in the trust andthe demographic details of the area, hidden within the jobdescription should be the essential details of the post:

is this a new post or an old one?
has the catchment area sizebeen changed – if so, why?
do the in-patient beds stillexist or are they being cut orstill developed?
are therevacancies (and plans to appoint) among the communitybased team?
is there an identified full-time, or equivalent, secretary?
does the post have a full-time staff grade or associate specialist doctor?
is the post approved for regional SHO training andis therean opportunity for you to be approved as a SpR trainer?
are there any local teaching/university commitments and/ortheopportunity to participate in research?
what are theon-call commitments – would you be on a sub-specialtyor generic psychiatry rota and is there middle-tier cover?

The importance of each of these details will vary for differentapplicants – for example, some doctors enjoy the continuedchallenge of training SHOs, while others prefer the long-termsupport of an effective staff-grade doctor.

Recommendation 8. While there is no such thing as a perfectjob, you may have scope for revising the proposed job plan,depending on your experience and specialist skills.

The consultant interview

TOP

The consultant interview

Before the interview
Preparation is essential and should include time spent makingvisits (preferably before making a formal application, to avoidcanvassing). Consider spending time in the service, by askingto attend team meetings and ward rounds. If relevant, try tofind out why the last consultant left. Speak to the key consultantsand follow up any suggested leads. The medical director willbe able to explain how last year’s cost improvements weredelivered and which aspects of the service will be reshapedin the coming year. You could also discuss issues relatingto the consultant contract (including the ‘programmedactivities’). Ask the chief executive about the trust’svision for the next 5 years. Ask the trust representatives what mentoring arrangements would be available if you were appointed– the College recommends that such arrangements are identifiedbefore the meeting of the appointments’ committee (Dean, 2003).Do not be afraid to discuss informally why you wantthe job; others may have come to the trust for the same reasons!

Recommendation 9. Gather information about national and localtrust policies, e.g. clinical governance plan, annual reports.Individual trust information can be accessed via http://www.nhs.uk/england/. Access other useful websites (e.g. http://www.healthcarecommission.org.uk, http://www.nice.org.uk/ and http://www.dh.gov.uk) and obtainpapers on topical developments (e.g. appraisal) from Advances in Psychiatric Treatment.

Practise interview techniques with your educational supervisoror any recently appointed consultants, videotaping the sessions.You need to sound confident and natural, but not rehearsed.

At the interview
The appointments’ committee usually consists of:

the chief executive of the trust
the medical director
aregional consultant
a College-approved member from the samespecialty but a differenttrust
a lay member (often a non-executiveboard member).

Additional members can include university representatives forteaching and research, a representative from the primary caretrust, a service manager and a carers’ representative.Good preparation can reduce anxiety levels, as you will havemet some of these people before. Each panel member will havean appropriate area to question. The College representativewill check HST issues, while the chief executive will be moreinterested in trust targets and clinical governance issues.The medical director will need to know what the successfulcandidate will offer to the trust (e.g. local service developments),whereas the local consultant will be interested in team-working skills. Be able to say what skills and experience you may bringto the trust, using objective evidence from your curriculumvitae. Be aware of your strengths and weaknesses and try todisplay a good understanding of current training and servicedevelopment terminology (e.g. clinical governance, appraisal,revalidation, personal development plans).

Recommendation 10. At the end of the interview, when asked whether you have any questions for the panel, it helps if you can commentthat you have met some of the panel members before and thatthey have already been helpful in answering your questions.Whywould an interview panel wish to appoint someone who had notcome to meet their possible future colleagues?

After the interview
If you are not successful, ask for a contact to obtain feedback.There may have been a better candidate on the day or you mayneed to improve your interview skills.

Conclusion

TOP

Conclusion

Despite the current vacancy rates of consultant psychiatristposts, the SpR to consultant transition can be challenging.By introducing a SpR ‘competency based curriculum’,the College has shown its commitment to ensuring that traineesdevelop the necessary skills needed to practise as a consultant.Offering new consultants a named mentor should also make thetransition a smoother one.

While many regard securing a consultant post as marking theend of a long training process that started at medical school,it is better viewed as marking the start of another ‘newbeginning’ – that of lifelong continuing professionaldevelopment. As Sir Winston Churchill wrote in 1942:

‘This is not the end. It is not even the beginning ofthe end. But it is, perhaps, the end of the beginning.’

References

TOP