Returning to Medicine

A Vital Signs guide

One doctor’s journey

Dr Rachel Rummery is Health Education England National Fellow at Supported Return to Training and Specialist Registrar in Paediatric and Perinatal Pathology. She returned to medicine after a 12-year break to raise a family.

Everyone was very supportive when Rachel Rummery said she wanted to return to medical work after 12 years out. But no one really knew how to go about it and there was no clear and obvious path. Numerous telephone calls produced encouraging responses but no information. Eventually it became apparent she needed ‘foundation competences’ – which she had never heard of – and was unable to apply to the formal Foundation programme on account of her previous experience.

This issue seemed insoluble, but she applied for a locum in histopathology and, to her surprise, got it.

I commuted to London from Derbyshire for a year. Returning was very scary though the post was well supported. I felt I had a giant beacon on my head which said: ‘I am old and I am weird’. Things got better and I started to really enjoy the feeling of confidence I got from doing something ‘as me, not as mum’. Unable to overcome the foundation competencies issue I applied as a locum to the Foundation programme.

This was a very hard year, but she worked on updating her clinical knowledge and gaining competencies such as Advanced Life Support.

I did feel competence and confidence return with greater empathy and kindness from the life experience I had gained on my years out.

Returning to work

Although a break may feel as though you have left medicine, it could be viewed as bringing something else to medicine.

People take breaks from medicine for a number of reasons. For example, to start a family, do research, travel, because they are sick, to try a different career path, or just take a career break. Whatever the reason, many people find that on returning they face similar issues – both practical and emotional.

Practically, there are different procedures for medical students (which may vary between medical schools), doctors in training, general practitioners, and established hospital clinicians.

It is easy to see a break as ‘missing medical training, or losing your skills and knowledge’. It is just as valid to see it as enhancing you – as a doctor, as a person and as the vehicle for all the knowledge and expertise you will acquire. Gaining new insights and having new experiences can be positive things.

Some people do not fall into any clear category and may have particular difficulty getting information about how to return.

Emotional responses

Not everyone will experience the feelings discussed here, but they are frequently seen in many doctors returning after breaks of three months or more – irrespective of the reason for the break.

Confidence can be sapped by a number of things including:

  • Anxiety that they will have “forgotten everything”
  • Anxiety that they will have lost all their practical skills
  • Guilt and shame – for being off sick, for being part-time, for having to leave at a certain time, for having been away while others worked
  • Imposter syndrome
  • Their peer group having moved on, and perhaps being their seniors now

If you recognise anything in the above list, remember, these are normal responses, and you are not alone.

Fear of having forgotten

Most returning doctors will have studied and trained for several years before their break. It is true that there may be new clinical knowledge, guidelines and procedures, and all the stored learning may take longer to access at first. But it will still be there and soon become automatic.

Initially it is important to be aware of your limitations while you get up to speed but this will happen. You need to continue to believe that there is no reason that you will not be the doctor you were in a short time.

You will learn the new stuff the same way those who did not take a break did – by study and using it regularly.

Doctors in craft-based specialties may lose some of their practical skills after a break. People talk of “loss of feel” and being a “novice again”. This is to be expected, and motor skills will return faster than the first time they were learned. Again, you need to be aware of your level of competence and practice.

‘Muscle memory’ will return faster for having been there once.

Less easy quantifiable may be the loss of the ‘medical mind’ – the feel, approach and mindset that comes with being a doctor.

Remember:

  • It will come back with practice and patience
  • Simulation sessions may be available – just ask
  • You are not alone.

I have had imposter syndrome for as long as I can remember. It may be something of a defence mechanism; if my expectations for myself are low then any failures are mitigated, and successes happy surprises. Imposter syndrome doesn’t necessarily stop me from achieving my goals and I have the confidence to apply for jobs and exams that I want. However, what I find difficult is the mental struggle it creates that causes me to doubt whether I am good enough or capable of attaining these goals. It’s impossible for me to imagine what my life would look like without imposter syndrome, as it is so ingrained in my mental processes.

Guilt, shame and imposter syndrome

Doctors are renowned for being high-achieving perfectionists. Medical culture may be improving but some teams still exhibit a tribal, macho approach. Sickness is for patients not for ‘members of the tribe’ where illness, especially mental illness, can be seen as weakness. Even if this approach is not present, returning doctors can be wary of it and project guilt onto themselves.

Part-time working can be a sensitive issue. The part-time worker may feel guilty for leaving the rest of the team to carry on. The part-time doctor may be their own harshest critic in this regard.

But it may also be true that envy plays a part too. The full-timers see someone leading a life they would want to lead. Little wonder deep feelings of resentment are stirred up.

For returning doctors, having to leave at a set time (to pick up a child for example) and leaving outstanding work to others can throw up difficult feelings of guilt, shame and inadequacy.

Imposter syndrome, that ‘psychological pattern in which an individual doubts their accomplishments or talents and has a persistent internalized fear of being exposed as a fraud’ is often just below the surface in many doctors. All the other factors in play for the returning doctor can cause it to rear its head.

Return to training

In practical terms returning to training can be straightforward. You have a job to go to, you may have kept in touch during your absence, you will have an educator supervisor, you will not need to arrange an appraisal. You may even have had a discussion about returning before you went off.

Health Education England (HEE) has Supported Return to Training (SuppoRTT) programmes in each deanery. They can organise ‘keep in touch days’ and simulation sessions while you are away. Some areas also offer coaching and other services.

All the confidence sapping emotional responses may be present despite the structures in place. Doctors in training have to cope with numerous specific stresses that can make returning after an absence difficult; exams, ePortfolios, job moves and a high degree of scrutiny.

Why does medical training have to be a sausage factory? Why can’t it be an artisan bakery?

Return to general practice

If you once practised as a GP and are returning to practice after a break, HEE has an established Induction and Return to Practice Programme (I&R). It offers “a safe and supported route for qualified GPs to return to NHS general practice”. The devolved nations have similar schemes. Under these programmes, practical and financial support is offered, as well as assessments, placements and mentorship.

In some cases the returning doctor will have a job to go back to as a partner or salaried doctor. There will be a framework to fit into, though there may have to be some re-negotiating of roles and responsibilities.

General practice has traditionally expected a high degree of self-reliance and can be a lonely place. There will be all the practical issues to deal with (appraisal, performers list, indemnity) and all the emotional aspects as well.

I felt I could just as well have been the locum. They wanted me to start working with minimal introduction.

Return to hospital work

In an ideal world, returning to clinical work in a hospital would involve an interview with the clinical director, a graded return to full duties, the offer of a mentor, and Occupational Health involvement if appropriate. The Academy of Medical Royal Colleges has guidance on the ideal return. Sometimes though it can feel a little rushed, with the clinical imperatives of full clinics, busy wards and rota gaps dominating.

Some doctors are just pleased to be back, but others have some of the doubts and uncertainties that come with returning. If you experienced these you are not alone.

We are expected to just step through the door and carry on.

The NHS scours the globe looking for doctors so why is it so difficult for us to return?

Shortly after returning to work my consultant asked me to do a procedure with him watching. It was the sort of thing I was doing routinely and independently before I went off, but this panicked me. ‘It’s a trap’ I thought, ‘he wants to see me mess up’. I realise now that he was trying to build my confidence, but it freaked me out. I was a lot more anxious than I let on.

For managers, trainers, supervisors, colleagues and HR

It is estimated to cost up to half a million pounds to train a doctor. If a machine costing this much was being put back to work, possibly after a breakdown, repair or period of not functioning, it would have an inspection and service. It would be monitored and cherished.

In a perfect world, all the structures listed in the Academy of Medical Royal Colleges’ Return to Practice Guidance would be in place for all clinicians returning to practice. Sometimes clinical imperatives and being overwhelmed by the workload make this not practical. At the very least it is helpful to understand the mindset and uncertainties of the returning doctor. A small amount of understanding and empathy will pay dividends in the future.

A break from medicine can enrich you

No one can be untouched by a life experience and this includes taking a break from medicine. Whatever the reason for the break you will have had a different set of experiences and bring a new perspective to your clinical practice.

The break might be life-changing in its own right – parenthood or serious illness for example – but even a career break, failed start-up or holiday will add to what you can give in medicine.

Michael Balint, a psychoanalyst who works with doctors, said “the most powerful drug is the doctor themselves”. Applying all our knowledge, training and experience can make people better. Doing it with wisdom and empathy can make people feel better too.

Medical training and practice can be rigid in its expectations. Taking a break may feel like a violation of the boundaries. We will all be better doctors if we think about the life we want to lead. Taking a break may be part of this.

What is the life you want to lead?


Useful sources of information

Academy of Medical Royal Colleges – Return to Practice Guidance (.pdf)

GP Return to Practice Programme

General Medical Council – Induction and support for doctors returning to work

GP Induction and Refresher Scheme (.pdf)

Health Education England – Return to practice

Royal College of Obstetricians and Gynaecologists – Return to work toolkit

British Medical Association – Covid-19: your wellbeing

Health Education England – Career Refresh for Medicine Programme

Acknowledgements

Thanks for the insights and ideas given by Kate Bresler-Jones, Steve Crone, Naomi Elton, Liz Gagiano, Ann Heath, Claire Horndern, Dominic Johson, Aimee Manicon, Joe Meredith, John Phillips, Rachel Rummery, Chris Smith, Emma Stewart, Haido Vlachos and numerous Anonymous contributors.

Written by Richard Stevens FRCGP, Associate Director and Coach at the Thames Valley Professional Support Unit and Trustee of the Royal Medical Benevolent Fund.

This publication was produced with support from BMA Giving.

Download this guide

Returning to Medicine: a Vital Signs guide (.pdf)

More guides in this series

The Vital Signs: a guide for doctors seeking help and advice

The Vital Signs in Primary Care

The Vital Signs for Medical Students

Vital Signs in Anaesthesia