academic colleagues, despite often working at comparable national and international level. 4.2.4 Difficulties in providing flexibility in particular disciplines and for particular trainees Some disciplines require persistent patient contact: Many of the most demanding clinical disciplines (not solely the surgical specialties but increasingly medical specialties such as cardiology) require trainees to acquire and maintain a high level of practical skill in clinical procedures. Maintenance of such skill requires its frequent and repeated use and this may limit the flexibility available for trainees to undertake ‘blocks’ of full-time research. Indeed, trainees returning from research may be faced with a need for intensive ‘re-entry programmes’ before they are viewed as having retrieved the clinical skills necessary to continue their training towards a still more distant CCST. Similar inflexibility exists in general practice, which is defined by continuity and accessibility of care. Trainees with domestic commitments: Trainees (usually women) who have to take additional time-out or periods of part-time work to fulfil domestic responsibilities may also face particular problems. Given that the proportion of doctors who are women is steadily increasing, opportunities for flexible training are essential if sufficient doctors are to be trained and retained in clinical academic medicine. Already, 96% of female and 51% of male medical students questioned in a 1996 survey have said that they would consider undertaking flexible training in the future . Unfortunately, this enquiry has revealed concerns that the established mechanisms for flexible training are ill suited to combining clinical and research training. Changing clinical activity after entry to the specialist register: A third problem that may limit the freedom to develop an academic career in some specialties relates to the current mechanism of entry to the specialist register. This does not allow the option of extension of training after a consultant position has been achieved. For example, there is currently no means for a doctor, accredited in 18 Report of the Academy of Medical Sciences
rheumatology, but not general internal medicine, to gain additional accreditation after appointment to a consultant post. In the past it was possible, and indeed commonplace, for a doctor to extend his or her areas of clinical practice after appointment as a consultant, frequently led by his or her research interests. Furthermore, NHS trusts, conscious of their proper responsibilities in risk management and clinical governance, may feel reluctant to allow consultants to extend their clinical practice, even if proper training could be obtained in the new area of clinical practice. Such problems may be particularly burdensome for the very small number of academic trainees who seek to enter the specialist registrar through the academic and research route. The trainee is put forward by a royal college to the Specialist Training Authority, which, after assessment of the relevant paperwork, may agree that the trainee is fully trained to practise in a particular sub-area of clinical activity. This offers the opportunity for an academic trainee to tailor a clinical training programme in line with his or her research skills. However, this route offers considerable risks to trainees as it tightly constrains the subsequent area of clinical practice as a consultant.