What was the experience of ophthalmologists in training in 2023, and how does this compare to previous years? Jordan Marshall, RCOphth Policy Manager and Sam Simpson, specialty trainee and Ophthalmologists in Training Group (OTG) representative, summarise the key findings from the GMC’s 2023 National Training Survey.
The General Medical Council (GMC) conducts an annual survey of trainees and trainers across the UK. This covers a range of issues relating to education and training, wellbeing at work and patient safety. Its purpose is to monitor the quality of postgraduate medical education and training.
Over 49,000 trainees responded to the 2023 survey – and while that represents 74% of trainee doctors in the UK, 94% of ophthalmologists in training completed the survey, emphasising the engagement of our trainees and supports the validity of this data.
The below is just a summary of key data. Do explore the full GMC dataset or contact [email protected] if you have any questions.
Quality of teaching, clinical and educational supervision
It is encouraging to see that trainees continue to rate their quality of teaching and clinical supervision very highly, especially comparing across all specialties. This is testament to the hard work of all our trainers. Key facts are:
- 82% of ophthalmologists in training rate their quality of teaching as good or very good, compared to 74% across all specialties.
- 85% rate the quality of their overall training experience as good or very good, slightly higher than the 83% across all specialties. This figure has remained stable over the last five years, ranging from 83-88% between 2018 and 2022.
- 70% receive informal feedback from colleagues either weekly or daily, significantly higher than the 58% across all specialties.
- 88% rate the quality of clinical supervision as good or very good. This fell to 70% for out of hours however, slightly lower than the 73% across all specialties.
- 92% of ophthalmologists in training say their educational supervisor is easily accessible, with 89% agreeing that the level of contact from their educational supervisor is appropriate.
Workload and burnout
One concerning finding in this year’s survey is that ophthalmologists in training experienced the largest increase in high risk of burnout out of all specialties. 22% of ophthalmologists in training are at high risk of burnout, up from 15% in 2022. From the data it is not possible to identify why this is the case, and burnout is a growing problem in all specialties. However, it is notable that in addition to this increase in burnout risk, over half of ophthalmologists in training (53%) work beyond their rostered hours weekly or daily, compared to 42% across all specialties. This was an increase on 2022, when 49% of ophthalmologists in training worked beyond their rostered hours weekly or daily.
In addition, 42% of ophthalmologists in training said their working pattern left them feeling short of sleep at work every month or more often, while 40% found their work emotionally exhausting. Both these figures are lower than the average across all specialties, although clearly are concerning in the context of rising burnout risk if we want to support trainees to have long fulfilling careers in ophthalmology.
Progression
| 2019 | 2021 | 2022 | 2023 | |
| Fewer than 51 cataract procedures (end of ST2) | 12% | 22% | 35% | 32% |
| On track to meet curriculum competencies for cataract surgery (ST5 and above) | 94% | 78% | 79% | 87% |
|
On course to undertake indicative number of operative/practical procedures for their stage of training (all grades)
|
This question not asked prior to 2021. | 52% | 59% | 69% |
The table above illustrates that the progression of ophthalmologists in training has improved again year-on-year, but it is concerning that progression is still well below what was typical pre-pandemic.
Cataract exposure is the main concern with regards to trainees fulfilling surgical competencies. It is encouraging that 87% of senior trainees are now on track to meet cataract curriculum competencies, but worrying that almost a third of trainees have completed fewer than 51 cataract procedures at the end of ST2. With the new curriculum requiring trainees to reach level 4 in cataract competency during ST5 to pursue careers in many special interest areas (SIAs), it is vital that ophthalmologists in training have access to these training opportunities.
There is some variation across the four UK nations in terms of progression. 89% of trainees in Scotland and Wales, and 100% in Northern Ireland, are on track to meet their curriculum competencies for cataract surgery – compared to 87% across the UK. There is also significant variation in progression across deaneries within the nations; in the North East of England only 76% are on track to meet their curriculum competencies for cataract surgery.
While overall 32% had completed fewer than 51 cataract procedures at the end of ST2, this rises to as high as 71% in Yorkshire and the Humber and 55% in the West Midlands. In the three London deaneries all trainees had completed over 50 cataract procedures.
While 69% of all trainees are on course to undertake the indicative number of procedures for their stage of training, there is again significant regional variation. This rises to as high as 88% in North Central and East London, 84% in both South London and North West London, and 82% in Kent, Surrey and Sussex. On the other hand, in the West Midlands this figure worryingly drops to 46% and for Yorkshire and the Humber it is 50%.
Other key facts relating to progression from the 2023 NTS include:
- The impact from COVID-19 continues to abate, with 49% of respondents saying there has been no change to their training as a result of the COVID aftermath, up from 42% last year. 19% still say they worked service provision role this year that slowed down their training, down from 22% in 2022.
- Cataract/refractive surgery (15%), oculoplastic/adnexal/lacrimal (15%) and paediatric/strabismus (11%) are the most common SIAs trainees (ST3 and above) are having difficulties fulfilling competencies for. There appears to be particular difficulties in some regions with some SIAs; 36% of trainees in the East Midlands are having difficulties fulfilling their cataract competencies. A similar number in Wessex (35%) are struggling to meet their oculoplastic/adnexal/lacrimal competency, while 22% in the North East report difficulties fulfilling their paediatric/strabismus competencies.
- 85% experience no difficulties in accessing simulation facilities. This rises to 94% in North West London and 93% in the North East, South London and Northern Ireland. This figure drops to 61% in Kent, Surrey and Sussex, where 18% are having difficulties accessing virtual simulation and 68% in Wales where 16% are having difficulties accessing both non-virtual and virtual simulation.
Independent sector
| 2022 | 2023 | |
| Need training opportunities in IS | 75% | 60% |
| If needed, easily able to access training opportunities in IS | 6% | 8% |
The table above shows that it remains very difficult for trainees to access surgical training opportunities in independent sector providers (ISPs), with little progress since 2022. RCOphth continues to tackle this situation, including through our Blueprint for cataract training in the independent sector.
Notably, there has been a drop in those saying they need training opportunities in ISPs – down from 75% to 60%. However, it difficult to ascertain the reason behind this drop, as trainees may feel they are able to take up increased opportunities within the NHS without the need to work in the independent sector. Similarly, there has been a rise in those saying they do not need ‘opportunities to make up the indicative number of operative/practical procedures to back fill what has been lost as a result of the pandemic’ – 35% say they do not need such opportunities, up from 20% in 2022.
It is important to understand the different regional patterns here. Of those who needed opportunities to make up indicative number of procedures to backfill what was lost in the pandemic, a fifth (21%) of trainees in the North West have accessed these either predominantly in ISPs or a mix of ISPs and the NHS. The next highest on this list were the South West (14%) and the East Midlands (13%). For those who undertook training in the independent sector, these training sessions took place more than once a month for over three quarters (75%) of trainees in the North West and South West, but for trainees in the East Midlands this dropped to only 14%.
. Although a slight improvement from 53% in 2022, this remains a concerning finding. Of those needing further opportunities, 40% had been given such opportunities at their NHS location, up from 32% in 2022, while 8% reported opportunities at a mixture of their NHS site and ISPs – up from 5% last year. Only 2.6% of trainees have been able to make up training all or predominantly within the independent sector. These findings underline a difficult, but slowly improving situation for ophthalmologists in training, with access to training opportunities within the independent sector remaining a challenge.
Culture
The culture in ophthalmology around ensuring the highest standards of patient safety appear reassuringly robust, although there remain areas for improvement. Key figures are:
- 87% agree they’ve been made aware of how to report patient safety incidents and near misses.
- 73% agree there is a culture of proactively reporting concerns, while 75% agree there is a culture of learning lessons from concerns raised.
- Out of hours, 65% say they have never felt forced to cope with clinical problems beyond their competence or experience – compared to 57% across all specialties. However, 8% report that they have felt forced to cope with such situations on a monthly basis. In 2018, 69% of ophthalmology trainees never felt forced to cope with such situations, while the figure for all trainees was 61% – suggesting this could be a growing issue across medicine as workforce and demand pressures increase.
Considering the culture that ophthalmology trainees experience more broadly, 79% agree their working environment is a fully supportive one. 11% report that ‘rudeness and incivility’ have negatively affected their experience in their post, slightly better than the 14% across all specialties.
It is concerning that almost a quarter (23%) of trainees do not feel confident about reporting discrimination in their workplace, without fear of adverse consequences. This is higher than the 17% across all specialties. RCOphth’s new Equity, Diversity and Inclusion leads will play a vital role in ensuring we foster excellent experiences across the workforce.
Discussion
This GMC training survey data shows a high standard of supervision is being maintained in ophthalmology, thanks to the continued hard work of surgical trainers across the country. However, the high workload of ophthalmology training (perhaps in combination with increased service demand) is leading to a concerning increase in burnout risk in our trainees, the largest increase of any specialty. This is at a time when some trainees are struggling to achieve their surgical competencies. Despite many trainees working in excess of their rostered hours, around a third of trainees of all grades are not on track to undertake the indicative number of operative/practical procedures for their stage of training. There is notable regional variation in access to training across special interest areas and simulation facilities.
Trainees continue to be affected by the aftermath of the COVID-19 pandemic and cataract surgery seems to be the main concern with regards to surgical progression. It is encouraging that there has been an increase in senior trainees feeling that they are on track to meet curriculum competencies for cataract surgery to 87% from a low of 78% during the pandemic. However, given the figures for more junior trainees we have to be aware that this statistic could worsen as trainees with less early experience become more senior.
It is of critical importance that opportunities for surgical training are prioritised within the NHS and independent sector, where the latter continues to play a small role in the overall volume of cataract surgical training. It is also vital that these data are taken into account around the implementation of the new curriculum from 2024, and training opportunities prioritised in order to support trainees to progress, flourish and enter their desired special interest areas well prepared for a successful career as a consultant ophthalmologist.