Challenges and solutions: The experiences of geriatric medicine doctors in training
This report summarises findings from a BGS survey of training programme directors (TPDs) about recruitment, retention and support initiatives, as well as challenges they face and solutions they have found regarding their trainee workforce.
Introduction
It is irrefutable that the workforce required to care for the ageing population must be strengthened. Older people’s healthcare is a multidisciplinary endeavour and each discipline requires expansion in their own right. In 2023 BGS published The case for more geriatricians which outlined some of the barriers to recruiting and training more geriatricians. In order to ensure retention, we must consider both how to attract more people into the specialty and what can be done support those already on the path to becoming a geriatrician.
In 2023, the BGS surveyed training programme directors (TPDs) in order to better understand the experiences of those already in the training programme and to inform recruitment, retention and support initiatives through sharing good practice. The TPDs have been surveyed in the past by the BGS but not since 2019 (unpublished data). These surveys have mainly focused on trainee numbers, less than full time (LTFT) working and out of programme (OOP) time. The 2023 survey sought to collect this data but also gather the expertise of the TPDs by asking for qualitative answers about the challenges they face and solutions they have found regarding their trainee workforce. Using insights from this community of practice, the aim is that the BGS workforce committee will be better informed to target interventions for supporting trainees before, during and after their training to become geriatricians of the future.
The results of this survey were presented at the BGS Spring Meeting in 2024. Although there has been a delay in publishing this report, we felt it was important to add to the series following publication of a baseline report in 2019 and to ensure there is not a gap in the data when we publish the next report.
About
The TPDs were contacted directly by the then BGS Vice President for Workforce at the geriatric medicine specialty advisory committee (SAC) and invited to complete an electronic survey. The survey had been designed by the BGS workforce committee in line with the BGS strategic priority to strengthen the workforce for older people. The survey was open for six weeks in Autumn 2023 and TPDs were asked to share their trainee circumstances at that time to align with the start of the academic training year across all deaneries.*
The response rate was 87% although the data provided was incomplete from some regions. Most were able to give reliable data relating to their trainees but not relating to other questions including number of doctors on the flexible portfolio pathway (formerly known as Certificate of Eligibility for Specialty Registration or CESR) and retiring consultants in their region. Therefore, this report will only focus on data relating to trainees.
Results
NTNs and Vacancies
Of the estimated 614 national training numbers (NTNs) in geriatric medicine across the UK, 42 posts were reported to be unfilled. This suggests a vacancy rate of 6.8%; a figure similar to the vacancy rates collected from previous TPD surveys over the last few years (7.6% in 2019 and 6.9% in 2016). Table 1 shows a breakdown across the four nations, highlighting the significantly higher vacancy rate in Wales of 24.5%.
Table 1: National Training Numbers and Vacancy rates across the four nations
| Nation | NTN | Vacancies | Vacancy rate |
| England | 502 | 24 | 4.8% |
| Northern Ireland | 16 | 1 | 6.2% |
| Scotland | 43 | 4 | 9.3% |
| Wales | 53 | 13 | 24.5% |
| Total | 614 | 42 | 6.8% |
Within England, our data shows that regions with higher vacancy rates include Peninsula and Kent, Surrey, and Sussex, as shown in table 2. This corresponds with the data from Health Education England† (HEE) on geriatric ST4 recruitment fill rates in 2023 - the lowest being Peninsula (29%) and Kent, Surrey and Sussex (38%) for round 1 recruitment in 2023.
Table 2: National Training Numbers and Vacancy rates across the English regions‡
| Region | NTN | Vacancies | Vacancy rate |
| Peninsula | 18 | 6 | 33% |
| Severn | 36 | 0 | 0% |
| Kent, Surrey and Sussex | 44 | 11 | 25% |
| Wessex | 30 | 0 | 0% |
| West Midlands | 55 | 3 | 5% |
| Mersey | 32 | 0 | 0% |
| East of England | 54 | 2 | 4% |
| West Yorkshire | 26 | 0 | 0% |
| East Yorkshire | 12 | 1 | 8% |
| Northern | 35 | 0 | 0% |
| North West | 51 | 0 | 0% |
| East Midlands | 25 | Data not provided | |
| South East London | 32 | 1 | 3% |
| East Midlands South | 16 | 0 | 0% |
| South Yorkshire | 15 | 0 | 0% |
Less Than Full Time Training
Of those doctors currently working in the training programme, about 46% work less than full time (LTFT). This figure has increased from 22% in 2019 and 15.8% in 2017.
While only 38% of women working in the training programme work LTFT, women account for 88% of trainees working LTFT. Table 3 shows the breakdown of the reasons trainees applied for LTFT training. Perhaps unsurprisingly, the most common reason given is ‘category 1’ – health reasons or responsibility towards dependents.
Table 3: Reasons for LTFT training across the four nations
| Nation | LTFT | Cat 1 (%) | Cat 2 (%) | Cat 3 (%) | LTFT rate |
| England | 219 | 81 | 8 | 11 | 48% |
| Northern Ireland | 3 | 100 | 0 | 0 | 20% |
| Scotland | 16 | 81 | 13 | 6 | 41% |
| Wales | 16 | 69 | 6 | 25 | 40% |
Cat 1: Health reasons or responsibility towards dependents
Cat 2: Unique opportunities for personal professional development, religious commitments or non-medical development
Cat 3: Personal choice
According to the GMC national training survey in 2022, 17.1% of trainee doctors are working LTFT. Although LTFT working is becoming increasingly popular across all medical specialties, it appears that geriatric medicine has a particularly high number of people working LTFT. This means that systems must adapt to accommodate this change to support trainee wellbeing and retention while ensuring that the required workforce is available. Vacancies for recruitment can be difficult to predict and the rotational nature of the programme at different sites brings additional complexity. One solution to producing a well-staffed rota is job-sharing, where more than one trainee is appointed per post. From the survey, there appears to be variability across the deaneries in facilitating job-sharing. A few TPDs have commented that job-sharing is not common in their deaneries for trainees in 0.8 whole time equivalents (WTE) and is only facilitated for those in 0.6 WTE. These arrangements require adequate funding and thorough logistical planning as well as an adequate number of NTNs being available to the deanery.
Time out of Programme (OOP)
TPDs reported that 32 trainees were on an out of programme experience (OOPE) at the time of the survey. The majority of the OOPEs appear to be taken to fulfil curriculum competencies (15 in stroke), as shown in table 4, rather than trainees taking additional opportunities for personal development such as leadership and research roles. A few TPDs have also highlighted trainees with an integrated work schedule (i.e. one day per week in a specialist tertiary service).
Table 4: Reasons for OOPE across the four nations
| Nation | Stroke | Leadership | Research | Community | Other* | Total |
| England | 10 | 3 | 7 | 1 | 5 | 26 |
| Northern Ireland | 2 | - | 1 | - | - | 3 |
| Scotland | 2 | - | - | - | - | 2 |
| Wales | 1 | - | - | - | - | 1 |
| 15 | 3 | 8 | 1 | 5 | 32 |
*Other includes perioperative medicine, orthogeriatrics, oncogeriatrics and movement disorders
Academic training
Only nine academic training numbers were reported in this survey, two of which were unfilled. This excludes those taking OOPEs in research or those in the flexible portfolio training scheme where protected time for research can be integrated into their work schedule. We recognise that this figure is not representative due to missing data from London and Thames Valley (both of which are regions with strong links to academic institutions). However, this small number does still suggest that only 1.5% of the NTNs are currently in academic training posts.
Dual-accreditation
Following the introduction of the new curriculum in 2022, all trainees in geriatric medicine are required to complete training in Internal Medicine (IM) stage 2. Only two trainees have been reported to not be pursuing General Internal Medicine (GIM) Certificate of Completion of Training (CCT). However, there appear to be downsides with accounts of trainees having to come off the on-call GIM rota for several months due to stress. Most of these people with a plan for a phased return.
Completion of training
About 12% of the NTNs were expected to gain CCT by September 2024. Current numbers suggest a trainee takes about an average of eight years to complete training.
Attrition
Six trainees were reported to have left the training programme before gaining CCT. Four trainees left for alternative medical specialties with ongoing on-call commitments, one left due to personal circumstances (international medical graduate returning home) and another left due to the rotational nature of the training programme and pursued the portfolio pathway (formally known as CESR).
Reflections
Less than full time working
Geriatric medicine has a large number of doctors working LTFT, both during training as reflected by this survey and this continues into consultant posts as shown by the RCP census. In both cases more women work less than full time than men. This survey shows that the overall number of trainees choosing to work less than full time continues to grow year on year from previous similar surveys, mostly for caring responsibilities (category 1) but increasingly trainees are choosing to train less than full time as a personal choice (category 3).
LTFT working has clear advantages for individuals as it allows people a better work/life balance and can enable them to take on caring responsibilities or pursue interests outside of medicine. There are also system benefits associated with working LTFT, especially once trainees are placed into ‘job shares’. Job shares can enable gaps to be filled and reduce the sense of guilt about vacancies that trainees can experience. In addition, by working LTFT but rotating annually, trainees have an opportunity to rotate through more placements and therefore gain additional experience. If trainees are paired and more NTNs can therefore be advertised then ultimately it is likely that more geriatricians will be trained from a training programme.
Despite the positives for individuals, TPDs report that having more LTFT trainees does come with challenges, including vulnerability to rota gaps or entirely empty training posts, especially at undesirable locations, and difficulty pairing trainees to work together to make one full time role. When job shares are successfully implemented, there are nevertheless implications for individuals, including being disadvantaged both financially and in training hours if only doing 50% of out of hours GIM work. There can also be reduced flexibility to return to full time work or to move to longer hours for example from 60% to 80%. In reality though, TPDs tell us that the majority of those working LTFT remain so and do not choose to return to working full time.
Job sharing does have local and regional financial implications and support must be sought from Trusts and the deanery. TPDs tell us that a job share including, for example, two 80% trainees in one full time slot is feasible as a solution. However, this is not a standardised process and it has been reported to be difficult and complex to navigate.
Looking to the future, this pattern of LTFT working can be carried forward into consultant roles with flexible working and job shares. There is an anticipated pilot project in which candidates can be directly recruited into LTFT posts for higher specialty training which may alleviate some of the burdens discussed here.
BGS has published a position statement about flexible and LTFT training in geriatric medicine and is currently in the process of updating this guidance to make it relevant to our multidisciplinary membership.
Time spent out of programme
Time can be spent out of programme for a number of reasons, both personal and professional, and this was reflected in our survey. In this survey, we enquired about details into how that OOP time was being spent. The rationale behind this was to see if trainees are opting for time OOP to complete competencies associated with the new curriculum “theme for service” or perhaps, to catch up on opportunities missed by training during the Covid-19 pandemic.
The survey showed that all trainees who took time OOP for experience or research did so to comply with curriculum competencies, with the most popular being stroke competencies. It is likely that this is due to the requirements for a fellowship year in stroke in order to practise as a stroke consultant in the future.
A small number of trainees were gaining additional experience in peri-operative medicine or oncogeriatrics, both of which now have a place on the 2022 curriculum. This not yet as a specific “theme for service” although both are growing subspecialties of geriatric medicine. Our prediction would be that these numbers grow over the next decade.
It was encouraging to hear that at the time of the survey only a few trainees were reported as taking extended leave requiring time out of programme for personal or health circumstances. This is something we will continue to enquire about as we are mindful of the physical and emotional burden upon trainees.
Incoming and outgoing trainees
Firstly we will discuss the trainees that have left the training programme. There was a significant geographic variation regarding those anticipated to complete training. This ranged between 4 and 25%, with the largest number of ST7s in southeast London. At the time of the survey, trainees were still straddling two curricula as they approached CCT depending on their training time. As such, interpreting these results presents a challenge. In theory, it could be expected that 25% of trainees will complete the four-year training programme each year, but with so many opting to train less than full time and taking time out for various reasons, this translates to a lower output.
Looking to the future we hope there will be more geriatricians, and this requires more training numbers and the candidates to fill them. The training numbers available to geriatric medicine have been gradually increased over the past few years with plans for additional NTNs over the next two years. However, the counterargument to increasing these further is that the fill rate remains modest and the specialty is undersubscribed, especially in certain geographic locations (as highlighted in the results section). Geriatrics was one of the few specialties where the number of applications dwindled this year compared to the previous year. In 2023, the number of applications for geriatric medicine ST4 training posts dropped to 266 from 343. In 2024 however applications increased slightly to 281 applications for 161 posts.
As such, the bottleneck may be occurring at entry to internal medicine training, where the competition ratio at application is 2.64, ie, 2.64 applications were received for every available post. It could be presumed that if a candidate has been unsuccessful at IMT application they will follow an alternative training path such as general practice and potential geriatric medicine consultants are therefore lost at this stage of application. It may also be that once trainees reach the stage of training for ST4 applications, they have also reached a stage in their personal life where the rotational aspect of training is less achievable or appealing. Therefore, potential candidates are choosing to achieve an alternative CCT such as the portfolio pathway or take a sidestep into other roles including education or research. It is proving difficult to fully understand this potential bottleneck as it occurs at a stage of transition between training programmes.
Making geriatric medicine more attractive to trainees
We asked TPDs in this survey to give their insights into how medical students and doctors could be encouraged to consider geriatric medicine as a future specialty.
Multiple themes regarding barriers to applications were discussed including the burden of out of hours work and general medicine commitment, alongside the rotational nature of the training programme. It should be noted that neither of these are exclusive to geriatric medicine but are also encountered in other medicine programmes.
Solutions for making geriatric medicine more attractive to trainees included providing a positive experience during their geriatric medicine training including showcasing sub-specialties and getting trainees involved in audits and research.
There was also a suggestion to raise the profile of geriatric medicine as a specialty on both local and national levels. The barriers perceived by medical students when considering a career in geriatric medicine have recently been analysed in Fisher and True’s 2024 literature review. This summarises recurring themes in multiple literature sources that medical students perceive as barriers to pursuing a career in geriatric medicine, including high emotional burden and preconceptions of non-clinical factors such as prestige and salary. It is noted some of these themes persist as barriers to early career doctors when they also come to choosing their specialty. An effort to improve the experiences of undergraduate students is being made by the recently formed Geriatric Medicine Educators’ Collaborative.
Another consideration is how geriatric medicine is portrayed worldwide. Whilst we are a well-established speciality in the UK, the place of geriatrics within the overall scope of medical care varies greatly between countries and across continents. A significant proportion of NHS doctors are international medical graduates who choose to pursue their specialty training in the UK. We hear stories of those dissuaded from applying for geriatrics because of the lack of prestige of geriatrics as a speciality and underdeveloped organisation of older people’s care in their home country.
Conclusions
Training in geriatric medicine has been evolving substantially, not only with the introduction of the new curriculum in 2022 but also in the working patterns of trainees. Less than full time working and out of programme experiences are becoming increasingly popular. Whilst this helps with recruitment and retention in geriatrics, with trainees reporting better work life balance and job satisfaction, it comes with challenges, particularly with regards to rota planning. Innovative solutions are being recognised and shared. The survey opened up further discussion including an analysis on the current recruitment process and identification of bottlenecks which prevent an increase in the geriatrician workforce. There is a growing group of doctors choosing to progress into geriatrics via the portfolio pathway instead of the more traditional national training specialty route - more work is required to explore this further.
This study was limited by incomplete data, and a mixture of non and partial responses. However, it was able to provide insight into the paths to becoming a geriatrician and solutions TPDs have found to supporting individual needs. These solutions can now be shared to help our members counter the workforce crisis by successfully recruiting, training and retaining the geriatricians of the future.
Next steps
In our next survey, we would like to explore the ease and accessibility for trainees to undertake an OOPE. We plan to look into whether trainees could find these fellowships within their own deanery or if they were required to go out of the area for a year in order to complete additional experience. An increasingly popular OOPE involves gaining leadership experience, commonly within the Royal College Physicians “chief registrar” programme.
What we do not know is how the number of trainees out of programme in geriatric medicine compares to other specialties. We also do not know much about why trainees choose to spend time out of programme and their experiences when they do so. Some TPDs reported that as an alternative to their trainees spending a fixed term out of programme, they had elected to pursue an integrated work schedule or fellowship such as flexible portfolio training. This may be more appealing for both trainees and trainers depending on individual development needs and the constraints of the training programme. It is hoped that a future project driven by the BGS Trainees Council may give us more insights.
We intend to repeat this survey every two years to build a cumulative picture over time of the issues affecting the progression of trainees in geriatric medicine.
