Perceptions of Study Leave amongst Neurosurgical Trainees

Background There is a paucity of studies in medical education literature addressing the educational value of study leave to doctors in training. The aims of this study were to establish the utilisation of study leave by neurosurgical trainees, to explore the perceived benefits and barriers to taking study leave, and to evaluate to what extent trainees support a more standardised approach to study leave allocation. Methods Individual interviews were conducted with 10 neurosurgical trainees, selected from each stage of training – Early (ST1-3), Intermediate (ST4-6) and Final (ST7-8). Qualitative data were coded and an inductive approach was used for thematic analysis. Results Neurosurgical trainees at all stages of training perceive study leave offers a wealth of opportunities for learning and professional development. However, there is a striking mismatch between the utility of study leave and the practical uptake, which is partly due to the reported opportunity cost of sacrificing clinical training. There was consensus that combining standardised courses with flexible opportunities for trainees to pursue individual interests and educational needs could enhance the potential educational value of study leave. Conclusions The findings demonstrate the critical value of study leave and support the role of standardised national training programme "boot camps", mapped to the curriculum. These can deliver knowledge and technical skills using high fidelity simulation models, thereby increasing educational yield from study leave. McKenna G, Alamri A, Whitfield P MedEdPublish https://doi.org/10.15694/mep.2018.0000118.1 Page | 2


INTRODUCTION
Study leave, as defined by UK national training guidelines, is "leave that allows time, inside or outside of the workplace, for formal learning that meets the requirements of the curriculum and personalised training objectives." (NHS England 2016) Specialty trainees in the UK are allocated 30 study leave days per annum, which can be used for a variety of purposes including practical courses, professional skills courses, teaching days, academic conferences, and private study for examinations. Although some of these activities are mandatory requirements for certification of completion of training, trainees usually have flexibility to choose when to undertake them.
Since the introduction of the European Working Time Directive (EWTD) and changes in shift patterns secondary to the new Junior Doctor Contract in 2016, surgical training has been impacted upon greatly (Maxwell et al. 2010;Kirkman et al. 2013). With this in mind, it is particularly important to investigate trainee perceptions concerning the utility and value of study leave. With limited capacity for taking time out of clinical training, training programme leads should be exploring strategies to enhance the educational value of this time.
Some have argued that study leave is an unnecessary 'burden' to doctors in training, describing it as "non-evidence based, poorly coordinated non-clinical initiatives laid on top of a [training] system that could otherwise work better"specifically referring to the consequent reduction clinical training time (England 2015). It is true that there is scarcely any evidence in the literature addressing the educational value of study leave. Some have tried to measure the 'value for money' of consultants' study leave (Bennett 1997), but there has been no study investigating the relative 'value for time', which is particularly relevant in a finite training programme.
William Osler, eminent 19 th century physician famously said "Medicine is learned by the bedside and not in the classroom." Echoing this sentiment, Dr Adrian England, in his 2015 paper addressing the conflict between clinical and non-clinical learning opportunities in anaesthetic training, boldly questions the utility of study leave. He concludes that "Whilst currently there is little clear evidence of harm to training from the recent expansion in nonclinical initiatives, there is little evidence of any benefit either" (England 2015). He argues that to learn a vocational skill requires time spent undertaking that activity, and he draws comparisons with other elite practical vocations, "A concert pianist spent hours practicing playing the piano. A professional footballer spent hours practicing kicking a ball. To become a practicing consultant anaesthetist you need to spend hours pushing propofol. And you cannot learn that sitting in a classroom." One could argue this is even truer of surgical specialty training, but it does not take into account all the non-technical skills that surgeons are expected to become proficient at, yet are not explicitly taught as part of their post-graduate curriculum.
In tackling the time constraints on training doctors, England suggests a need for "better organisation of the nonclinical aspects of training". He blames "poor co-ordination" of non-clinical training time and suggests the implementation of "a nationally agreed curriculum with courses completed in set years of training" (England 2015 (NNSTB). There has been an expectation that all nationally appointed run-through trainees attend to meet the requirements in the curriculum for simulation training. The aim of the programme is to teach clinical, surgical and professional skills appropriate for the stage of training, using high-fidelity simulation. These developments are in line with recommendations that simulation training should be integrated into healthcare (Donaldson 2008) to mitigate the detrimental effects of the European Working Time Directive (EWTD) on surgical training (Temple 2010). Neurosurgical trainees use five days of their annual study leave allowance to attend these boot camps, which have received excellent feedback from participants (Zhang et al. 2016).
What is the true educational value to neurosurgeons in training of time spent away from clinical practice for learning? Could it be used more effectively and efficiently to enhance individual learning and professional development, whilst minimising the opportunity cost of sacrificing precious on-the-job training? This study aimed to (1) establish how study leave is currently used by neurosurgical trainees, (2) explore the perceived benefits and barriers to taking leave, (3) evaluate how these perceptions vary according to stage of training and (4) ascertain the extent to which trainees support structured allocation of study leave.

METHODS
Semi-structured interviews were conducted with 10 individual neurosurgical trainees from the same deanery, selected by convenience from each of the three stages of training -Early (ST1-3), Intermediate (ST4-6) and Final (ST7-8) in July 2017.
Interviews were recorded using an audio recorder on a smartphone and transcribed for analysis. All participants were provided with an information sheet about the study and written consent for recording the interviews was obtained from all participants in advance.
The work was carried out in accordance with the Declaration of Helsinki, including, but not limited to the anonymity of participants being guaranteed and the informed consent of participants being obtained. In accordance with UCL Research Ethics Committee criteria for exemption from ethical approval this study proposal was assessed in January 2017 and deemed to be exempt from the requirement for ethical approval from the UCL Research Ethics Committee. Transcripts were anonymised; no sensitive or personal information was sought, and the study had no direct impact on patient care.
The following questions were asked: How have you spent your study leave allowance in this academic year?
What benefits do you think there are to taking study leave?
Does anything put you off or prevent you applying for study leave?
Why don't you use all your study leave?
Do you think study leave should be more prescribed for each stage of training, or do you prefer complete flexibility?
Quantitative data on the number of study days taken by each participant were recorded. The transcribed data were McKenna G, Alamri A, Whitfield P MedEdPublish https://doi.org/10.15694/mep.2018.0000118.1 Page | 4 coded and analysed qualitatively to identify common themes in respect of the questions asked. The interviews were designed to generate responses through both deductive and inductive reasoning, and thus a mixed approach was used for the data analysis.

RESULTS
Ten interviews were conducted with neurosurgical trainees ranging from ST1 to ST7. There were four participants from the early years' stage of training (ST1-3), three from the intermediate stage (ST4-6) and three final stage trainees (ST7-8).
None of the participants was certain of their study leave allowance and whether regional teaching days were included. All believed the allowance was between 9-15 days per year which was significantly less than the official allowance of 30 days per year. The number of study leave days taken by participants ranged from 3 to 15 days in the current academic year.

What were the perceived advantages of taking study leave?
A strong positive theme of 'gaining perspective' emerged from participants at all stages of training, and consensus that a break from routine allows 'time for reflection' on clinical practice. One senior trainee commented, "When you go on a course you enjoy, it really gets your brain thinking again, rather than just -clinic, operation, ward round…" (Appendix 2).
Many of the participants commented on the 'social aspects' of study leave, which included the themes of 'collaborative learning', 'keeping up-to-date', and 'comparisons with peers'. As one junior participant described, "you get to speak to other trainees, you get perspective on where you are, what other people are doing… and it can be quite motivational..." (Appendix 1).

What were the perceived barriers to taking study leave?
On this issue, there was a notable divergence in the perspectives of junior trainees (ST1-3) versus more senior trainees (ST4+). Junior trainees reported common positive themes of 'feeling supported' to take study leave, and being 'more dispensable' in terms of service provision. The one barrier cited consistently by junior trainees was 'financial cost'. One comment summarised this dilemma in a nutshell, "Courses can cost upwards of £300 per day, and annual study budgets are in the region of £800", (Appendix 4).
Senior trainees reported more numerous barriers to taking study leave: 'rota constraints', the 'opportunity cost' of missing out on elective operating experience; 'competition' from other trainees; 'NHS culture'; 'bureaucracy' of the application process as well as 'funding' barriers. The conflict with service provision and in particular, on-call commitments, was illustrated by one participant who described her attempt to take study leave for a subspecialist course: "I was desperate not to miss this, but I was on a night shift, and there's no scope for education and taking time off" (Appendix 2). In describing NHS culture and the lack of time for reflection in clinical training, she went on to say, "You see doctors from other countries and they are thinking about what they're doing in their operations and how they can improve them… we're so busy we don't have time to read, think or innovate" (Appendix 2).
Emphasising the opportunity cost of sacrificing on-the-job training, one trainee pointed out that if he took all his study leave, "it would definitely affect [his] logbook numbers", and thus his capacity to achieve clinical competencies within the time limits of the training programme (Appendix 4).

Did trainees prefer a structured or flexible approach to study leave?
There was a strong consensus amongst trainees at all stages of training that the best system for allocating study leave would involve a 'combination' of prescribed courses/educational programmes, whilst maintaining flexibility for individuals to choose how to spend some of their allowance.
Three positive themes were identified for a structured approach to study leave: 'uniformity of learning opportunities'; 'guidance on appropriate training courses', and 'opportunities for comparison with peers'. Junior trainees were strongly positive about the new national 'bootcamps', concluding that it was a good idea to "make sure you're all at the same level" (Appendix 3).
Similarly, positive themes emerged for maintaining flexibility and allowing trainees to choose how to spend their study leave. These were; 'flexibility to pursue individual interests' and 'individual developmental needs'. For example, one participant expressed a need to present at academic conferences, "because I'm interested in research" and because "presenting is something [she is] not very good at" (Appendix 3).

DISCUSSION
The findings from this study establish that neurosurgical trainees at all stages of training perceive study leave offers a wealth of benefits for their personal and professional development.
The positive themes which emerged are in line with a number of key learning paradigms, supporting a theoretical basis for these perceived educational benefits. For example: responses emphasising the advantages of 'time for reflection', demonstrate the perceived value of Kolb's Learning cycle (Kolb 1984). One trainee commented, "I remember things better" (Appendix 3), when she learned in different contexts, reflecting the advantages of multimodal learning described by Gardner's 'Theory of Multiple intelligences' (Brink 1985). Other positive themes of 'collaborative learning' and 'comparisons with peers' suggest a key role for a social aspect to learning and development. Reflecting the learning paradigm of social constructivism,(von Glasersfeld 1989) our standardised national boot camps provide a unique opportunity for direct peer-peer learning, collaboration and comparison in a niche surgical speciality with small numbers of trainees based in training units scattered across the UK.
Despite the perceived benefits of taking study leave, it was striking that none of the participants knew their annual study leave allowance and that none planned to take more than half the annual allowance during the academic year in question. This finding contravenes General Medical Council guidance (General Medical Council 2011) and demonstrates a mismatch between the perceived utility of study leave and the practical uptake.
We attempted to discover the reasons for this mismatch by exploring why trainees applied to take only a fraction of their allocated study leave. It was perhaps unsurprising that for junior trainees the main barrier to taking more study leave was 'financial cost', given the expensive nature of hands-on surgical skills courses. This finding highlights another key role of nationalised bootcamps in subsidising the cost of expensive high fidelity simulation training through Society of British Neurological Surgeons (SBNS) funding and commercial/industrial sponsorship. It was, McKenna G, Alamri A, Whitfield P MedEdPublish https://doi.org/10.15694/mep.2018.0000118.1 Page | 6 however, reassuring that in general junior trainees felt encouraged and supported to take time away from clinical work to focus on their individual professional development.
Conversely, most of the barriers cited by senior trainees were related to the theme of 'time'; specifically, the 'opportunity cost' of missing operating lists and 'service commitments', which included 'competition' from other trainees. A 'culture' of not taking study leave was identified, possibly as a long-term consequence of these other barriers. These findings are in keeping with studies demonstrating the detrimental impact of working time restrictions on neurosurgical training (Maxwell et al. 2010;Kirkman et al. 2013). It is anticipated that recent changes to shift patterns as a consequence of the new junior doctors' contract in England may further compound this conflict (Ahmed et al. 2015).
Participants from all stages of training presented evidence in support of both 'prescribed' and 'flexible' systems, suggesting a combination/ hybrid model of study leave allocation may maximise the educational yield. These findings add weight to the concept of employing standardised study leave programmes through national simulation training programmes, "bootcamps" for trainees at the same stage of training. To date, national neurosurgical bootcamps for ST1 and ST3 level trainees have been implemented in the UK. On the back of the success of these educational programmes, development of an ST8 level bootcamp, preparing senior trainees for consultant practice is also underway.
Despite the advantages of structured or standardised study leave allocation, our findings highlighted trainees' additional desire to have opportunities to pursue their individual learning needs and professional interests. The theoretical advantages of maintaining flexibility for trainees to choose how to spend their study leave are rooted in Mezirow's concept of 'transformative learning' which emphasises the central role of self-directed learning in adult education (Mezirow 1985).
This study represents only a snapshot of the experience of neurosurgical trainees in a specific region of the UK. However, the sampling strategy enabled us to explore the perspectives of trainees at each stage of training and provided ample data to represent a broad range of opinion across the whole cohort of neurosurgeons in training. We chose to conduct in-depth semi-structured individual interviews, rather than a questionnaire, with the aim of acquiring richer qualitative data to address the objectives of the study. Although a focus group may have provided even richer data, bias from the influence of other participants may be prevail. Methodologically it was practical and convenient to interview individuals on a one-to-one basis with a semi-structured qualitative approach.
Since the interviewers (GM and AA) were neurosurgical trainees and colleagues of the participants, personal views had the potential to bias the interview process, both in terms of how the questions were asked and the responses received. Despite these potential confounding influences, the strong thematic outcomes generated from the study suggests meaningful conclusions can be drawn about the factors influencing trainees' decisions when applying for study leave and their views on the how study leave should be organised to maximise the educational impact.
We consider that a hybrid approach supporting compulsory attendance at national simulation training bootcamps and allowing flexible attendance at other educational meetings provides the optimal approach to support individual learning.

CONCLUSION
Neurosurgical trainees at all stages of training perceive study leave offers invaluable opportunities for deep learning McKenna G, Alamri A, Whitfield P MedEdPublish https://doi.org/10.15694/mep.2018.0000118.1 Page | 7 and individual professional development. Despite these perceived benefits, there was a striking mismatch between the perceived utility of study leave and the practical uptake, which is in part due to the perceived opportunity cost of sacrificing clinical training. This is particularly relevant in the craft speciality of neurosurgery, and in the era of working time regulations and recent changes to shift patterns with the implementation of the new junior doctors' contract in 2017.
The findings from this study support the role of standardised 'bootcamps' for trainees at the same level, and suggest they may reduce financial burdens and enhance the educational yield of study leave. Trainees value highly the social learning aspects of bootcamps, which provide a unique opportunity for interaction and collaboration between small numbers of peers who are training in disparate parts of the UK. There is consensus that trainees want a balance between standardised courses/bootcamps and opportunities to engage in self-directed study leave activities which allow them to fulfil their individual educational needs and explore their professional interests.

Take Home Messages
Neurosurgical trainees at all stages of training perceive study leave offers a wealth of individualised learning 1.
opportunities outside of the clinical environment. Despite this, there is a mismatch between the perceived utility of study leave and the practical uptake, partly 2.
due to the perceived opportunity cost of sacrificing clinical training in the era of working time regulations and changes in shift patterns. Standardised, subsidised national training 'bootcamps' can relieve financial barriers and can enhance the 3. educational yield of study leave.

What do you think are the advantages of taking study leave?
It's great for stepping out of the clinical routine and allows time for reflection on what you do every day on a clinical basis.
It's often a great opportunity to meet other trainees at different stages of training and often in different deaneries, which is particularly helpful in such a small specialty. It's also an opportunity to keep up to date and find out about different clinical practices. You learn so much from interacting socially with other trainees and sometimes consultants, often that's as much of a learning opportunity as the course itself.

Do you encounter any barriers when applying for study leave?
Other barriers are the paperwork associated with applying for leave and funding, giving adequate notice. It's usually a really inefficient process. As a registrar, it's often difficult to get your on-calls swapped or to get cover for your clinical duties, particularly for popular courses or conferences if others on your rota are attending. Sometimes there is a lot of competition amongst trainees and some can only go to bits of a conference.

Do you think study leave should be more prescribed for each stage of training, or do you prefer flexibility? Why?
I think flexibility is essential, but I would appreciate a bit more guidance on how I should be spending my study leave and what courses would be useful at different stages.

Have you noticed any significant changes in how you have used your study leave over time?
Courses in the beginning, then I found my early clinical training as a registrar so all-encompassing and in a very busy unit, that I struggled to take any time off, struggled to produce anything to present at a conference and so took very little SL at all. More recently I did the Teaching the Teachers course, Management course, Advanced Communication Skills course which are compulsory for CCT. I will probably take some personal SL for FRCS exam preparation and related courses towards end of training.

Declaration of Interest
The author has declared the conflicts of interest below.
Mr. Peter Whitfield is currently Chairman of the SAC in neurosurgery. He has previously held the post of Secretary to the National Neurosurgery Selection Board. Miss Gráinne McKenna is the national trainee representative for the Neurosurgery SAC.