‘Just a year out’? – Challenges of the clinical teaching fellow

The number of clinical teaching fellows (CTF) has increased significantly over the past decade and have become a key stakeholder in medical education, bringing unique benefits and perspectives. There is, however, little in the literature examining the challenges of this role. This study explores the challenges of the CTF role using a phenomenological methodology, reporting on the findings of a workshop held at The Association for the Study of Medical Education’s Annual Scientific Meeting in July 2018. Workshop attendees comprised of CTFs, educational administrative staff and consultants with a senior educational role. Attendees’ perspectives were recorded on the day and subsequently underwent pattern analysis. Seven key areas of concern were revealed: poorly defined role identity, tension between different aspects of the role, rapid turnover and limited continuity, occasionally inappropriate pastoral role, limited career support, stigma towards the role, and being used as ‘rota fodder’. Potential solutions to these challenges were also identified, centring on clear, structured job roles at a local level and a network of past and present CTFs at a national level. This is the first study examining the challenges facing this growing body of educators, and suggests further research is needed to deeper understand and address these issues.


Introduction
The number of clinical teaching fellows (CTFs) has risen exponentially, perhaps reflected by the increasing numbers of doctors taking time away from traditional training roles post foundation (General Medical Council, 2017). In 2008 there were around 77 posts reported nationally (Wilson, Denison and McKenzie, 2008), which likely now only represents a fraction of the present number as 101 teaching fellow posts currently exist in the North East of England Ker R, Guckian J, Bowey A MedEdPublish https://doi.org/10. 15694/mep.2018.0000239.1 Page | 2 alone. These roles feature significant variation, usually revolving around delivering teaching within the undergraduate curriculum. While some posts embed significant clinical time into the job plan, others are dedicated to education delivery in their entirety. CTFs have been recognised as a valuable and unique resource for students, both in near-peer educational delivery and the provision of pastoral support (Woodfield and O'Sullivan, 2014). These doctors may represent the future of medical education academia, with many institutions now offering formal education theory qualifications in the form of Certificates, Diplomas or Masters in Medical Education.
However, the role is not without its difficulties. As doctors who have recently completed two years of CTF posts, and as a CTF lead for a hospital trust which currently employs 26 teaching fellows, we had experienced numerous challenges. We therefore sought to explore whether these challenges were reflected nationwide at a 'Pop-up Event' workshop at the ASME (The Association for the Study of Medical Education) Annual Scientific Meeting in July 2018, which is a major medical education conference. This is the first documented close examination of the CTF role featuring input from fellows themselves, and aimed to identify core domains of concern.
The aim of this study was to identify common challenges facing clinical teaching fellows nationally and subsequently consider potential solutions to these shared challenges.

Methods
This study followed an interpretivist stance, and used followed a phenomenological approach. The workshop was 45 minutes long and was attended over 30 delegates, representing a mixture of key stakeholders, which included past & present teaching fellows, educational administrative staff and consultants with a senior educational role, from various UK regions. These delegates formed a focus group from which the results of the study were drawn. Whilst this was an unusually large number for a focus group, it did provide a unique opportunity to gather data on a national scale, and to represent the views of the variety of stakeholders involved. The workshop had been advertised to all delegates at the conference, but was specifically and explicitly aimed at current and previous CTFs as well as those closely working in undergraduate education. Therefore, the focus group was created via a combination of self-selection and convenience sampling.
The focus of the workshop was to identify common challenges facing CTFs and potential solutions to these challenges. Initial ideas to provoke debate were gathered from a recent discussion on the role of the CDF, hosted by TASME (The Trainee Association for the Study of Medical Education), on Twitter as part of TASME's #MedEdForum series. The workshop was facilitated by one of the authors, who at the time was working as a CTF.
Workshop attendees were asked to document their thoughts onto post-it notes, which were then displayed on the walls of the room. Recurrent themes identified at this stage were then opened up for discussion amongst the group as a whole. Contemporaneous notes were recorded on the content of these discussions, and notes written by stakeholders were collected for further analysis after the workshop. Attendees were aware that their input would be analysed as part of a research project, and that all responses would be kept anonymous.
The post-it notes were subsequently analysed via pattern analysis to identify key themes expressed by attendees. These themes were then triangulated against the contemporaneous notes of the discussed themes during the workshop.
Ethical approval for the analysis of the workshop was gained from Newcastle University's Ethics Committee prior to

Results/Analysis
The most widely-accepted reflection from the attendees considered that of role variation. Even within the same hospital, teaching fellows had very different responsibilities. This led to uncertainty from both CTFs & wider faculty about how they should operate and what exactly their areas of responsibility should be. This feeling was compounded by how new these posts were, with little prior experience or formal guidance to work from. However, this variety led to flexibility: upon applying for posts, doctors felt able to select a CTF role that suited their particular development needs, which was felt to be a great strength.
Attendees reflected that at times there was significant tension between the educational and clinical components of their posts. This would become particularly apparent when time was needed for administrative tasks such as lesson planning. There was a perceived pressure, and occasionally 'guilt', that if teaching fellows were not physically educating students, they should be in the clinical environment.
One area highlighted as both an important role of a CTF, and potential challenge, was that of providing pastoral care to students. As near peers, it was felt that CTFs may represent an attractive initial point of contact for students, who are able to provide informal support. However, there were significant concerns that teaching fellows had little training in dealing with students facing potentially sensitive challenges around finance or mental health, and that there could be a risk of blurring professional boundaries in these settings.
Attendees reported that CTFs held their post for 1 to 2 years. This turnover period was felt too short in some cases to develop, refresh and refine learning opportunities in a specific roles or department. This may have limited the continuity and sustainability of the role. Some felt that each year CTFs had to 'start from scratch' with little feedback or information on previous years. However, attendees felt that CTFs were keen to be able to individualise their own sessions and were identified as being vital to educational innovation. A note of caution regarding the proliferation of CTF roles lies in the lack of professionalisation or national governance surrounding the role. This bled into reflections from the attendees as CTFs struggled to access relevant training portfolios, supervisors or appraisers, identify mentors to help them develop as an educator and overall felt uncertain how to pursue and develop a career in medical education once the post had ended. Furthermore, a perceived stigma existed towards the CTF role: attendees described accusations of being 'less dedicated' to clinical specialities and encountering pressures to return to traditional training programmes.
There was concern from delegates that some CTF posts had being created as 'cannon fodder' for difficult-to-fill clinical rotas, or as a 'sticking plaster' to relieve consultants from educational obligations. Many felt disempowered to challenge this situation, and there were reports of teaching fellows simply resigning from posts in light of this.
These seven main challenges are summarised in Figure 1. To combat uncertainty about the role of the CTF it was felt the employing department in conjunction with the education team should devise a clear and explicit job role, which was available at the point of advertising the job. Within this job role there should be dedicated session for administrative work, which should be as protected as teaching time. There should be a clear communication to all senior staff members that administrative time, teaching time and clinical time are equally important in this job role.
One solution to some of these issues that had been noted by stakeholders from social media platforms prior to the event, was the creation of a 'governing body' to help regulate teaching fellow roles, challenge stigma surrounding the role, and help guide teaching fellows towards mentors and a future career in medical education. However, this was met with significant apprehension by delegates. It was agreed that a formal teaching fellow network would bring significant benefits, but a governing body was felt to be a step too far. There was concern that this would remove the variety of the role and lack of mandatory portfolios which were readily identified as some of the key benefits of the role. The teaching fellow role was felt to be a sanctuary away from the tiresome bureaucracy of many training roles -and this should be protected where possible.
This national network could also allow for previous CTFs to review their posts and give feedback. This information could be shared with prospective CTFs to highlight areas of excellence, but also uncover inappropriate placements. This could also allow a method for a more structured handover process between each successive cohort of CTFs within a hospital or trust. Attendees to the workshop agreed that handover between successive CTFs should be Ker R, Guckian J, Bowey A MedEdPublish https://doi.org/10.15694/mep.2018.0000239.1 Page | 5 improved and formalised, but whether this was done best face to face or electronically was unclear. It was agreed that senior teaching and administrative staff should be involved within the handover process to aid continuity and transparency.
The suggested solution for the issue of a potentially inappropriate pastoral role was for clear departmental process of where to direct students to when they were facing significant or sensitive challenges, and also to make formal training in pastoral support available to CTFs in the induction to the role. Table 1 summarises these suggested solutions.

Table 1) Suggested solutions of each domain of concern
Area of concern Possible solutions Role identity Clear and explicit description of role, responsibilities and expectations from trust at point of advertising job Tension between different aspects of role Sessions for administrative work built into job plan Clear communication to senior staff on CTF role identity Rapid turnover and limited continuity Handover process from each CTF cohort to the next -either face to face or electronic, with senior teaching staff and admin staff involved to encourage continuity Inappropriate pastoral role Formal training on pastoral support. Clear departmental processes and structures to direct students with challenging needs to Limited career support Development of a national network of CTFs to share experiences and advice, allow for networking of enthusiastic educators and encourage mentor mentee relationships to develop Stigma towards role Greater advertising of benefits of the role and sharing 'success stories' and examples of excellence Use as 'rota fodder' Encourage previous CTFs to feedback and review posts which can be then shared -poor practice, and inappropriate placements can be exposed and avoided by prospective trainees

Discussion
This paper intended to identify common challenges to CTFs and provide potential solutions. There have been seven key areas of challenge identified and despite the wide range of these challenges, each may be resolved by a practical solution. There were also several unintended findings; notably that the flexible and sometimes unstructured nature of the CTF role can be seen as a real strength of the role, and there was resistance to reducing this with the introduction of further governance and formal structure to the role. It was clear from CTFs themselves, and those who work closely with them, that the role is provides unique educational experiences for students and is key to further educational developments and innovations.
This paper is the first in the published literature looking the challenges facing CTFs, particularly from the CTFs' perspectives themselves. The direct, straight forward approach of the workshop has generated clear responses with little subsequent data manipulation required to extract the common themes and messages. The majority of participants' views were recorded with minimal input or interference from the facilitator, and the subsequent data recorded on the post it notes in participants own words. That views of multiple key stake holders, including CTFs themselves, were taken into account is also a strength. The study investigators have had direct experience of being, and working with, CTFs which may have encouraged more open discussion in the workshop itself, allowing easier interpretation and contextualisation of the data gathered. In terms of limitations, the workshop itself was relatively short, which will have limited the breadth and depth of views gathered. The thirty participants is only a fraction of CTFs, educational administrators and consultants with an interest in education. This combined with the incredible variation in CTF role nationally, may mean that only this paper does not fully explore that challenges facing CTFs at a national level. It is possible that the participants were primarily from the North East of England, as the workshop was held at ASME 2018 Annual Scientific Meeting in Newcastle upon Tyne, which again may make the results of the study less generalisable at a national level. Whilst having the views of multiple key stakeholders is a strength, the different groups were not separated in analysis, so it is not clear whether CTFs have different perceptions of challenges to educational administrative staff, for instance. There were no student opinions gathered in the focus group, who may offer an added dimension of insights from their perspectives. While the fact that the investigators were CTFs or worked directly with CTFs may be a strength, it may also have also brought the authors pre-conceptions and personal experiences into the discussion which will have influenced the data.

Conclusion
Given the rise in importance of CTFs in the undergraduate domain, further critical analysis of the role is essential. Our findings suggest there are issues of professional identity, inappropriate use of the role, stigmatisation and, a significant lack of long-term career pathways. Our workshop identified the passion that CTFs have for medical education, with this generation of CTFs representing a bright future. The suggested solutions (Table 1) are not novel, indeed teaching fellow networks and communities of practice have previously been described in the literature with varying success. However, if the medical education community fails to harness CTF enthusiasm, address challenges and build manageable educational career pathways, we are missing an exciting opportunity to shape our future.

Take Home Messages
There has been a rapid proliferation in the number of documented CTF positions over the past 10 years The role of the CTF is significantly varied between post to post which allows for CTFs to meet their own individual development needs There are multiple, significant, challenges facing CTFs at present -particularly around professional identity, inappropriate use of the role, stigmatisation and long-term career pathways Several potential solutions to these challenges have been identified, but further critical analysis is needed into the role of the CTF and how best to recruit, inspire and retain this enthusiastic and skilled cohort.