Returning to Work in Anaesthesia Back on the Circuit

Visit the link below to download the full version of this book:

https://medipdf.com/product/returning-to-work-in-anaesthesia-back-on-the-circuit
/

Click Download Now

 University Printing House, Cambridge CB2 8BS, United Kingdom

Cambridge University Press is part of the University of Cambridge.

It furthers the University’s mission by disseminating knowledge in the pursuit of
education, learning and research at the highest international levels of excellence.

www.cambridge.org
Information on this title: www.cambridge.org/9781107514690

C Cambridge University Press 2016

This publication is in copyright. Subject to statutory exception

and to the provisions of relevant collective licensing agreements,
no reproduction of any part may take place without the written
permission of Cambridge University Press.
First published 2016
Printed in the United Kingdom by Clays, St Ives plc
A catalogue record for this publication is available from the British Library
Library of Congress Cataloguing in Publication data
Names: Plunkett, Emma V. E., editor. | Johnson, Emily, 1977– , editor. |
Pierson, Anna, 1980– , editor.
Title: Returning to work in anaesthesia : back on the circuit / edited by
Emma Plunkett, Emily Johnson, Anna Pierson.
Description: Cambridge, United Kingdom ; New York : Cambridge University
Press, 2016. | Includes bibliographical references and index.
Identifiers: LCCN 2016006109 | ISBN 9781107514690 (pbk.)
Subjects: | MESH: Anesthesiology – manpower | Return to Work
Classification: LCC RD81 | NLM WO 221 | DDC 617.9/6 – dc23
LC record available at http://lccn.loc.gov/2016006109
ISBN 978-1-107-51469-0 Paperback
Additional resources for this publication at www.cambridge.org/returningtowork
Cambridge University Press has no responsibility for the persistence or accuracy
of URLs for external or third-party internet websites referred to in this publication,
and does not guarantee that any content on such websites is, or will remain,
accurate or appropriate.

...........................................................................
Every effort has been made in preparing this book to provide accurate and
up-to-date information which is in accord with accepted standards and practice at
the time of publication. Although case histories are drawn from actual cases, every
effort has been made to disguise the identities of the individuals involved.
Nevertheless, the authors, editors and publishers can make no warranties that the
information contained herein is totally free from error, not least because clinical
standards are constantly changing through research and regulation. The authors,
editors and publishers therefore disclaim all liability for direct or consequential
damages resulting from the use of material contained in this book. Readers are
strongly advised to pay careful attention to information provided by the
manufacturer of any drugs or equipment that they plan to use.

06 Jun 2017 at 17:02:42, subject to the Cambridge Core

terms of use, available at https:/www.cambridge.org/core/terms. https://doi.org/10.1017/CBO9781316227633
 For my husband Adrian and our children; Aubrey,
Penelope and Arthur. Three lovely reasons to have
had time away from anaesthesia.
EP

Dedicated to my son Euan and nephew Alexander.

EJ

For the three boys in my life; my husband, Richard,

and our sons, George and Henry. Your love and
support have made this possible.
AP

27 May 2017 at 20:06:07, subject to the Cambridge Core

terms of use, available at https:/www.cambridge.org/core/terms. https://doi.org/10.1017/CBO9781316227633
 27 May 2017 at 20:06:07, subject to the Cambridge Core
terms of use, available at https:/www.cambridge.org/core/terms. https://doi.org/10.1017/CBO9781316227633
 Contents
List of contributors page ix
Foreword by Dr Annie
Hunningher xi
Preface xiii
Acknowledgements xiv

Continuing professional
Introduction xv development (CPD) 21
Emma Plunkett, Emily Johnson and Anna Pierson
Anna Pierson
5. Improving your return to work 23
Should I find a mentor? 23
Section 1: The Practicalities of Kathryn Bell and Nancy Redfern
Returning to Work Using technology to your
advantage 26
1. A break from practice: the Stephen Phillips and Fran Haigh
current state of play 1
Communication and team
Carolyn Evans
working 29
2. Returning to work guidance 4 Emily Johnson
Emma Plunkett Limitations and sources of help 34
3. Returning to work experiences 7 Emma Plunkett
Emily Johnson Avoiding adverse outcomes and
what to do if one occurs 36
4. Preparing to return to work 11 Emily Johnson
RTW programmes 11 Fatigue and burnout 38
Anna Pierson Emma Plunkett
Good medical practice and
revalidation 16 6. Supporting a colleague’s return
Emma Plunkett to work 41
Statutory and mandatory Supporting a trainee: working with
training 17 Educational Supervisors and
Emma Plunkett College Tutors 41
Jill Horn
Returning from sick leave 18
Emma Plunkett Supporting a consultant’s return to
work 44
Keeping in touch (KIT) days 19
Emma Plunkett
Emma Plunkett
Changing to less than full time
(LTFT) working 20
Anna Pierson

vii
27 May 2017 at 20:06:59, subject to the Cambridge Core
terms of use, available at https:/www.cambridge.org/core/terms. https://doi.org/10.1017/CBO9781316227633
 viii Contents

Section 2: Refreshing Your 23. Preoperative assessment and

anaesthetic planning 229
Knowledge Katy Miller, Anna Costello and Emma
Nicholas Cowley, Kerry Cullis, Anna Plunkett
Dennis, Hozefa Ebrahim, Ruth
24. Consent and documentation 250
Francis, Maria Garside, Sarah Gibb,
Anna Costello
Emily Johnson, Surrah Leifer, Randeep
Mullhi, James Nickells, Anna 25. AAGBI guidelines 256
Nutbeam, Anna Pierson, Jane Pilsbury, Maria Garside
Emma Plunkett, Louise Savic,
Charlotte Small, Alifia Tameem, 26. WHO Safer Surgery Checklist 271
Caroline Thomas and Benjamin Emma Plunkett
Walton 27. Drug doses 273
Introduction 47 Anna Pierson and Emma Plunkett

7. Scientific principles 49 28. Paediatric physiology and

equipment 279
8. Emergency management and Emma Plunkett
resuscitation 66
29. Practical procedures 282
9. Airway management 79 Laura Tulloch, Laura Fulton and Emily
10. General principles 85 Johnson

11. Obstetrics 107 30. Resuscitation algorithms 297

Emily Johnson and Anna Pierson
12. Intensive care medicine 121
31. Intensive care guidelines 306
13. Paediatrics 137 Laura Tulloch and Emily Johnson
14. Pain medicine 151 32. Analgesic ladders 315
Alifia Tameem
15. Regional anaesthesia 157
33. Difficult Airway Society (DAS)
16. Neuroanaesthesia 164
guidelines 318
17. General, urological and Emily Johnson and Emma Plunkett
gynaecological surgery 172
34. National Audit Project (NAP)
18. Day surgery 181 summaries 329
Fran Haigh and Anna Pierson
19. Trauma and orthopaedics 185
35. National Institute for Health
20. Subspecialty anaesthesia 193
and Care Excellence (NICE)
21. Patient safety 211 guidance 338
Laura Fulton
22. Ethical and legal issues 220

Section 3: Guidelines, Updates

and Checklists Index 342

Introduction 227

27 May 2017 at 20:06:59, subject to the Cambridge Core

terms of use, available at https:/www.cambridge.org/core/terms. https://doi.org/10.1017/CBO9781316227633
 Contributors

Kathryn Bell Sarah Gibb

Consultant Anaesthetist, The Newcastle Locum Consultant Anaesthetist, The
upon Tyne Hospitals NHS Foundation Newcastle upon Tyne Hospitals NHS
Trust, UK; Training Programme Director, Foundation Trust, UK
Northern School of Anaesthesia, UK
Fran Haigh
Anna Costello Consultant Anaesthetist, Poole Hospital
Specialty Registrar, Oxford School of NHS Foundation Trust, UK
Anaesthesia, UK
Jill Horn
Nicholas Cowley Consultant Anaesthetist, Bradford
Consultant in Anaesthesia and Intensive Teaching Hospitals NHS Foundation Trust,
Care Medicine, Worcester Acute Hospitals UK; Training Programme Director,
NHS Trust, UK Leeds/Bradford School of Anaesthesia, UK
Kerry Cullis Emily Johnson
Consultant Anaesthetist, University Consultant Anaesthetist, Worcester Acute
Hospitals Birmingham NHS Trust, UK Hospitals NHS Trust, UK
Anna Dennis
Surrah Leifer
Consultant in Anaesthesia and Intensive
Specialty Registrar, North West School of
Care Medicine, Heart of England NHS
Anaesthesia, UK
Foundation Trust, UK
Katy Miller
Hozefa Ebrahim
Specialty Registrar, Birmingham School of
Consultant in Anaesthesia and Intensive
Anaesthesia, UK
Care Medicine, Heart of England NHS
Foundation Trust, UK Randeep Mullhi
Carolyn Evans Consultant in Anaesthesia and Intensive
Bernard Johnson Advisor LTFT, Royal Care Medicine, University Hospitals
College of Anaesthetists, UK Birmingham NHS Trust, UK

Ruth Francis James Nickells

Consultant Anaesthetist, University Consultant Anaesthetist, North Bristol
Hospitals Birmingham NHS Trust, UK NHS Trust, UK

Laura Fulton Anna Nutbeam

Specialist Registrar, Barts and the London Specialty Registrar, South West School of
School of Anaesthesia, UK Anaesthesia, UK

Maria Garside Stephen Phillips

Associate Specialist, Bradford Teaching Specialty Registrar, Wessex School of
Hospitals NHS Foundation Trust, UK Anaesthesia, UK
ix
27 May 2017 at 20:07:33, subject to the Cambridge Core
terms of use, available at https:/www.cambridge.org/core/terms. https://doi.org/10.1017/CBO9781316227633
 x List of contributors

Anna Pierson Charlotte Small

Specialty Registrar, Birmingham School of Specialty Registrar, Birmingham School of
Anaesthesia, UK Anaesthesia, UK

Jane Pilsbury Alifia Tameem

Specialty Registrar, Birmingham School of Consultant in Anaesthesia and Pain
Anaesthesia, UK Management, The Dudley Group NHS
Foundation Trust, UK
Emma Plunkett
Specialist Registrar, Birmingham School of Caroline Thomas
Anaesthesia, UK Specialty Registrar, Leeds/Bradford School
of Anaesthesia, UK
Nancy Redfern
Consultant Anaesthetist, The Newcastle Laura Tulloch
upon Tyne Hospitals NHS Foundation Consultant in Anaesthesia and Intensive
Trust, UK; Honorary Membership Care Medicine, Worcester Acute Hospitals
Secretary, Association of Anaesthetists of NHS Trust, UK
Great Britain and Ireland, UK
Benjamin Walton
Louise Savic Consultant in Intensive Care Medicine
Consultant Anaesthetist, The Leeds and Anaesthesia, North Bristol NHS Trust,
Teaching Hospitals NHS Trust, UK UK

27 May 2017 at 20:07:33, subject to the Cambridge Core

terms of use, available at https:/www.cambridge.org/core/terms. https://doi.org/10.1017/CBO9781316227633
 Foreword
This is a ‘must-have’ handbook for any anaesthetist returning to work. It binds the practical-
ities, essential knowledge and latest guidance into a friend, companion and guide.
I remember when I first returned to work (I’ve done it three times- once for sickness and
twice for parenthood), there was no clear process; I could not remember which switch was
which, or doses for drugs. I was worried and anxious about my performance and patient
safety. Since this time, return to work guidance and collaboration from the AAGBI and
RCOA, have brought great advances in our safer and phased return to work practice.
And now, at last, Back on the Circuit, an anaesthesia return to work book! Written by a
highly credible team, who know how we feel as they have returned to work and might again.
Emma Plunkett, Emily Johnson and Anna Pierson have worked with drive and dedication,
to bring together this unique book, an important milestone for us as a profession and an
essential resource for those returning to work.

Dr Annie Hunningher
Consultant in Anaesthesia, GASagain course co-lead

xi
27 May 2017 at 20:08:44, subject to the Cambridge Core
terms of use, available at https:/www.cambridge.org/core/terms. https://doi.org/10.1017/CBO9781316227633
 27 May 2017 at 20:08:44, subject to the Cambridge Core
terms of use, available at https:/www.cambridge.org/core/terms. https://doi.org/10.1017/CBO9781316227633
 Preface
Doing anything that you’ve not done for a while can be daunting. People often say, ‘It’s just
like riding a bike’, although even for previously experienced cyclists the first time back on
the saddle can be uncomfortable and unsteady! For more complex tasks of an unpredictable
nature, this ‘unsteadiness’ is magnified and things that one might have previously done auto-
matically need more deliberate thought. Returning to work in anaesthesia is no different.
Anaesthesia is a multifaceted specialty with many different requirements: specialist knowl-
edge, complex clinical skills and timely and effective communication particularly in stressful
situations, to name a few. As anaesthetists we are highly trained individuals. Trained in the
areas mentioned, but also trained to be aware of our limitations and when we should ask for
help.
In anaesthesia, indeed through all the medical specialties, patient safety comes first. We
have a duty as doctors to ensure that we are capable and competent. It is therefore important
that we acknowledge times when we are a bit ‘unsteady’ and seek appropriate support. In the
past this has not always been easy to do, as extra support when returning from a break has not
always been perceived to be required. The service needs of running departments might also
at times put pressure on individuals to work outside their comfort zone. In combination this
might lead to doctors returning to work being expected to be back up to speed the moment
they set foot in the workplace. Anyone who has experienced a significant break will know
that this is usually far from how they feel.
Everyone involved in this project has had time away from anaesthesia, for numerous rea-
sons. Many of them also teach on returning to work courses or are responsible for supervising
and supporting those returning to work. We have worked together to produce what we hope
will be a valuable resource for those preparing to return to anaesthesia after a break. There
is a lot of useful information already available; however, it is in many different places and it
can feel rather overwhelming working out where to begin.
This book is your starting point. We have thought hard about what we needed when we
were in your position. We have a section which gives practical advice, one to help you refresh
your knowledge and one that provides all the guidelines and checklists that you might want
to look at before you come back or in your first few weeks back.
A commonly quoted problem returning to work is a lack of confidence. We cannot resolve
this directly in a book. However, we can help you to feel well prepared for your return and
hopefully that will help your confidence to come flooding back. We want this book to be your
friend and have worked hard with this goal in mind. We wish it had been available for our
returns to work in anaesthesia and hope it is useful for you.
Good luck and please get in touch to let us know how you get on.

xiii
Downloaded from https:/www.cambridge.org/core. University of Alberta Libraries, on 27 May 2017 at 20:09:34, subject to the Cambridge Core
terms of use, available at https:/www.cambridge.org/core/terms. https://doi.org/10.1017/CBO9781316227633
 Acknowledgements
This book is the product of hard work from a fantastic team of authors. They have all given
their precious time to the project and we appreciate their support and commitment to our
shared vision. We think that the strength of the project comes from this collaboration and
hope we have created a really useful resource.
As well as this team of authors, we have some other people to thank. Thank you to James
Nickells and Ben Walton, lead editors from FRCAQ. They supported the project from the
outset and have shared some of their bank of Final FRCA Single Best Answer questions that
covered topics in our refresher section. We are incredibly grateful for their contribution.
Thank you to Sara Ormorod for writing the question on the definition of capacity. As
a consultant liaison psychiatrist, her expertise is much appreciated. Thank you to Hannah
Church, Hari Krovvidi, Nancy Redfern and Amy Walker who have each reviewed chapters
for us and provided their wisdom and advice on their areas of expertise.
Thanks to all those individuals and organizations who have granted permission for us to
reproduce their images, figures, tables or guideline summaries in this book. Thanks to Sam
Salib who took the photo of the epidural set up trolley.
Thanks to Nisha, Jade and Ross from Cambridge University Press. Nisha has been a
fantastic support from the inception of the project and throughout the preparation of the
manuscript and beyond.
Finally, and most importantly of all, the biggest thank you has to be to our families for
their encouragement, patience, understanding and help with childcare. This book really is a
team effort and we are so very grateful to have had such a great team.

27 May 2017 at 20:10:19, subject to the Cambridge Core

terms of use, available at https:/www.cambridge.org/core/terms. https://doi.org/10.1017/CBO9781316227633
 Introduction
Emma Plunkett, Emily Johnson and Anna Pierson

If you are reading this book, you are likely to be on a break from working in anaesthesia
and may be starting to think about your return. Whatever the reason for your break, the
previously familiar beeps from the anaesthetic machine will have faded into a dim and distant
memory and you may feel as if you cannot remember how to take an anaesthetic history, let
alone give an anaesthetic. You are not alone. The feeling of trepidation returning to work after
a break is a common one, shared by many.
People feel apprehensive about different aspects of returning to work. Some agonize over
their perceived lack of knowledge, feeling that they have forgotten everything. Others worry
about their ability to perform practical procedures. Some may be concerned about human
factors: ability to communicate and situational awareness. Plus, there may be factors related
to the reason for your leave that cause anxiety, for example worries about health or about leav-
ing a small child or unwell relative. All of these are valid concerns and need to be addressed,
but the good news is that many of them can be remedied.
Welcome to your returning to work handbook! This book has been written to help you
prepare for your return to anaesthesia, whatever the reason for your break from practice, and
whatever your particular concerns are.

How to use the book

The book is divided into three sections, according to when you might want to use them.
Section 1 considers the more practical aspects of returning to work and so this might
be best used when planning a break (if this is possible) or once it is known that you will
be taking one. It starts by considering the current state of play regarding management of the
return to work process and the potential effects of a break from practice. Next we review the
available guidance from the Academy of Medical Royal Colleges (AoMRC), the Royal Col-
lege of Anaesthetists (RCoA) and Association of Anaesthetists of Great Britain and Ireland
(AAGBI), summarizing the important points. After this we discuss ways of preparing for
your return to work, with chapters covering topics such as keeping in touch days and phased
returns to work. Following the publication of the guidance mentioned above, many regions
in the UK have introduced Return to Work Programmes to support those returning to work
and guide those supervising them. We have therefore included an example of one such pro-
gramme, which we have experience of using, which you might want to adapt and use yourself
if there is not one already in your hospital or region.
Ways that you can help your return to work are considered next with an important
chapter describing how mentoring can help you in your return to work period. This is a
period of significant change for you and in the 2013 version of ‘Good medical practice’, the
General Medical Council (GMC) recommends that you ‘find and take part in structured
xv
26 May 2017 at 16:17:01, subject to the Cambridge Core
terms of use, available at https:/www.cambridge.org/core/terms. https://doi.org/10.1017/CBO9781316227633
 xvi Introduction

support opportunities . . . whenever your role changes significantly’. We demystify what men-
toring is and give an example situation. To accompany this we also give some anecdotes of
people’s experiences returning to work and their tips and suggestions. We also consider how
you can make technology work to your advantage.
The final chapter in Section 1 discusses how we can support colleagues returning to
work – both trainees and consultants.
Section 2 is the knowledge refresher section. In this section we have used the RCoA CPD
Matrix as a rough ‘syllabus’ of important subjects to cover. When considering how to struc-
ture this section we felt it was important for it to feel practical and interactive and to be
different from reading lists of facts. So we decided to cover each topic using a short scenario,
followed by a question or questions, which take a variety of formats. Some of these have been
adapted from the FRCAQ.com website as we felt that many of their single best answer ques-
tions were appropriately written and covered common clinical topics that you would want
to refresh. Please do not consider any of the questions in this section to be a test. They are
written this way to engage you and to help you to start thinking like an anaesthetist again!
After each scenario and question(s), there follows a concise summary of the topic with ref-
erences for further reading if you are feeling particularly rusty on that topic. We have gone
for breadth of subjects – with 120 topics – rather than detailed discussions. By doing this
we hope that we have included many of the common cases that you will encounter on your
return to work, as well as the emergency situations that we hope you do not find yourself in,
but that you will be better prepared for having refreshed your knowledge! This section might
be best used in the few weeks before you return to work.
Section 3 contains important guidelines and checklists. This section is your companion
for your first few weeks back at work. The first chapter covers preoperative assessment and
includes the relevant National Institute for Health and Care Excellence (NICE) and Euro-
pean Society of Anaesthesiology (ESA) guidelines as well as reminders about what to ask in
an anaesthetic history and how to interpret preoperative investigations. Next we cover con-
sent and documentation with a recap of what risks to quote when you see your patients. After
this we have included a copy of the World Health Organization (WHO) checklist, which in
itself is a good prompt for what you need to consider in your anaesthetic planning, and also
a handy drug dose reminder that is probably made superfluous by the many apps available
now, but can be useful to carry with you if/when technology is not your thing. We have a
chapter on practical procedures, to remind you what you need to lay out on your trolley and
a brief refresher on how to use ultrasound. Finally, we have brief summaries of the AAGBI,
Difficult Airway Society (DAS), Resuscitation Council, NICE and ICU guidelines and sum-
maries of the National Audit Projects. We don’t anticipate that you will commit any/all of this
to memory prior to returning to work, but rather that you can dip in and out of this section
as necessary during your return to work period (and beyond).
We hope that this structure provides a logical approach to planning, preparing for and
accomplishing your return to work in anaesthesia. We are aware that time passes and guide-
lines are updated and so we have developed an accompanying website to this book which can
be updated more frequently than the book itself.

26 May 2017 at 16:17:01, subject to the Cambridge Core

terms of use, available at https:/www.cambridge.org/core/terms. https://doi.org/10.1017/CBO9781316227633
 Section 1 The Practicalities of Returning to Work
Chapter
A break from practice: the current

1 state of play
Carolyn Evans

In this chapter, Dr Carolyn Evans gives an overview of how the return to work process is
managed overseas and what the future holds in the UK.
If a clinician returns to a different clinical area of practice, agreement about a formal training
package with assessment of newly acquired skills and competencies automatically follows.
The clinician returning to the same area of practice is assumed to be capable of continuing
where they left off, even after a break of years. This return to the front line on day one back at
work still continues to be the accepted norm, especially for those returning after maternity
leave. Try explaining this approach to a member of the public; they would be, understandably,
appalled.

How is a break from practice managed in other countries?

The Australian and New Zealand College of Anaesthetists (ANZCA) have recommenda-
tions on practice re-entry available via their website[1] . The most recent version, PS50 2013,
advises anaesthetists that after an absence of more than 12 months, they should follow an
agreed refreshment of knowledge and skills programme before re-entering independent clin-
ical practice. The timeline suggested is 4 weeks supervision for every year of absence. Their
College prospectively approves an individual programme and seeks confirmation that the
participant has satisfactorily completed the programme. There is no mention of what hap-
pens in the event the individual does not meet the expected standards in the agreed timeline –
a further period of supervision would be the most likely way forward. A punitive outcome
such as referral for a formal assessment of an anaesthetist’s practice by their Medical Board
would undermine the current voluntary self-directed return to practice programme.
The American Medical Association (AMA) defines physician re-entry as ‘a return to clin-
ical practice in the discipline in which one has been trained or certified following an extended
period of clinical inactivity not resulting from discipline or impairment’. There is consider-
able variation between states around what is expected for physicians re-entering practice.
The AMA 2010 Physician Licensure Survey reported 51% of medical boards to have a policy
on physician re-entry, with a requirement to complete a re-entry programme after a physi-
cian had been out of practice an average of 2.8 years (range 1–10 years)[2] . Information from
those running re-entry programmes in 2009 gave a length of time to complete a re-entry pro-
gramme as between 6 weeks and 12 months, with a minimum cost of $6000. Relocation to
attend a programme can increase individual costs, so finance remains a huge barrier to active
Returning to Work in Anaesthesia, ed. Emma Plunkett, Emily Johnson and Anna Pierson.
Published by Cambridge University Press. 
C Cambridge University Press 2016.

1
27 May 2017 at 20:54:44, subject to the Cambridge Core
terms of use, available at https:/www.cambridge.org/core/terms. https://doi.org/10.1017/CBO9781316227633.004
 2 Section 1: The Practicalities of Returning to Work

physician participation in re-entry schemes in the USA. The Re-entry Programme Directors
report numbers served by their programmes as extremely small, with an average age of
51 years and predominantly male.

Are there any predictors of outcome after a break from practice?

Information is limited but the Center for Personalized Education for Physicians (CPEP) in
the USA published their retrospective outcome data for 683 physicians who were referred
between 2000 and 2010[3] , which concluded older physicians were more likely to have unsafe
assessment outcomes. However, this cohort of individuals was referred to CPEP for remedia-
tion so is a very different entity from the physician looking for ‘upgrading’ of knowledge and
skills after a career break.
A review of 62 physicians participating in the CPEP re-entry programme after a volun-
tary career break recognized an emerging pattern between years out of practice and increas-
ing physician age as predictors of poorer performance. Reasons for leaving practice were
predominantly family and health (60%)[4] . Twenty anaesthetists returning to practice com-
pleted a re-entry program which included simulation-based assessment. The outcome data
collected from this institution over a 10-year period included identification of two anaes-
thetists with ‘deficits significant enough to preclude likely improvement’ but loss of partici-
pants to follow up and the small numbers limited any further statistical interpretation[5] . It
was concluded that simulation was an effective means of assessing baseline competency in
this group returning to clinical practice.
In the UK, a General Medical Council (GMC) ‘Skills fade literature review’ published in
December 2014 confirms the paucity of further evidence around loss of clinical and profes-
sional skills following a break from practice[6] .

The way forward

The impetus for change worldwide is clinician shortage, the impact of gender change within
the workforce and a greater understanding of the impact of clinical inactivity on patient care
and patient safety. The fundamental principles of consistency between state medical licens-
ing boards, quality assurance of all re-entry programmes, programme funding and research
to inform re-entry programme development that the AMA is working to are themes we
would recognize and support in the UK. The General Practice funded returner scheme was
superseded in 2006 by an induction and refresher (I+R) scheme. Primary care organizations
expect a general practitioner (GP) returning after a break of 2 years or more to enrol in an
I+R scheme. There is no requirement in legislation for this, but it offers some reassurance
that these doctors are competent to practise in the NHS. Health Education England and NHS
England are due to introduce a new I+R scheme, 3–6 months in duration, recognizing the
different needs of those returning from work overseas as compared to those after a formal
career break[7] . The I+R scheme will be mandatory for those doctors who have been out of
clinical general practice for 5 years and recommended for those returning after a break of
2 to 5 years.
Within secondary care, the principles underpinning the return to work agenda have been
embraced by the trainee workforce. This is the generation who will normalize the ‘return to
work portfolio’, making it an expected submission for inclusion within an individual’s reval-
idation package. In the future, it is likely that what is currently voluntary best practice will
become an expectation from the regulator.

27 May 2017 at 20:54:44, subject to the Cambridge Core

terms of use, available at https:/www.cambridge.org/core/terms. https://doi.org/10.1017/CBO9781316227633.004
 Chapter 1: A break from practice: the current state of play 3

References
1. www.anzca.edu.au (accessed 2 January 2016).
2. American Medical Association Physician Re-entry website http://www.ama-assn.org/go/reentry
(accessed 2 January 2016).
3. E. S. Grace, E. F. Wenghofer, E. J. Korinek. Predictors of physician performance on competence
assessment: findings from CPEP, the Center for Personalized Education for Physicians. Acad
Med 2014; 89(6): 912–19.
4. E. S. Grace, E. J. Korinek, L. B. Weitzl, D. K. Wentz. Physicians reentering clinical practice:
characteristics and clinical abilities. J Contin Educ Health Prof 2011; 31(1): 49–55.
5. S. DeMaria Jr, S. T. Samuelson, A. D. Schwartz, A. J. Sim, A. I. Levine. Simulation-based
assessment and retraining for the anaesthesiologist seeking re-entry to clinical practice: a case
series. Anaesthesiology 2013; 119: 206–17.
6. http://www.gmc-uk.org/Skills fade literature review final report.pdf 60956354.pdf (accessed
2 January 2016).
7. www.england.nhs.uk/2015/01/26/boost-gp-workforce/ (accessed 2 January 2016).

27 May 2017 at 20:54:44, subject to the Cambridge Core

terms of use, available at https:/www.cambridge.org/core/terms. https://doi.org/10.1017/CBO9781316227633.004