The ‘Out-of-Programme Experience’

Mention an ‘Out-of-Programme Experience’ to colleagues and the result is often a somewhat bemused expression or some reference to the not-too-dissimilar-sounding, ‘Out-of-body-experience’. This has been the response on almost every occasion I have mentioned this, the official title for the 12 months I recently spent working as a senior registrar in old age psychiatry in Melbourne, Australia.

This article describes and outlines the stages necessary for the arrangement of an Out-of-Programme Experience, with specific reference to specialist registrar (SpR) training and, where appropriate, this is illustrated from my own experience.

What is an Out-of-Programme Experience?

There is no official definition of an Out-of-Programme Experience. It can last up to 12 months and is designed to allow SpRs a period of temporary leave away from their higher-training schemes without losing their national training number (NTN). The purpose is to give them an opportunity to pursue a particular interest or to work in some capacity outside of their scheme. When the agreed period is completed, they can re-join their scheme and continue with their training towards the award of a Certificate of Completion of Specialist Training (CCST).

The nature of the experience may vary enormously — no experience would be automatically rejected although, in practice, it is unlikely to be approved if it is not felt to be relevant to psychiatry or to the applicant's career. For example, 12 months training golden retriever puppies to become guide dogs, while being perfectly honourable and of great benefit to society, might not be enough to gain the approval of the programme director.

Experiences likely to be regarded favourably will more often include a research secondment, a full-time pursuit of a specialist interest or work as a locum. Another option is to work as a psychiatrist in another country, as I did in Australia.

Arranging it

Obviously, the first stage in any application for an Out-of-Programme Experience is to secure agreement from whichever department, service or employer you would like to spend this time with. Agreement would have to be sought directly with the organisation involved and may prove to be very difficult to obtain, depending on what kind of experience is being sought. Finding a suitable supervisor in an academic department to oversee a particular specialised research topic might prove more complicated than perhaps, as in my case, responding to an advertisement calling for psychiatrists to work overseas. Every case will be different. As many readers will know, various schemes up and down the country do have approved exchange arrangements with those in other countries for psychiatric work or training. Here, the hard work of getting approval for the experience has already been done and the only concern might be competing with colleagues for the valuable post. Exchange arrangements are not considered to be true Out-of-Programme experiences.

Getting it approved

Once a proposal has been made to pursue an Out-of-Programme experience, and a description of how the time might be spent has been drawn up, approval must first be sought at a local level. The best place to start is with the programme director, where an informal discussion can start the whole process moving forward. If the plan is not acceptable at the first tier of approval, the proposal will probably be rejected at this relatively early stage, thus saving any further time and effort.

If the plan is accepted in principle, the programme director will then require a written application, usually in the form of a letter outlining the proposal, the nature of the experience and the reasons for wishing to leave the scheme temporarily. In addition, there will probably be a specific Out-of-Programme experience application form, which, as well as requiring the details and reasons for applying, will also need to be signed by three levels of regional approval. The first would be the programme director, the second, the regional advisor, and either the area dean or his or her deputy would be the third.

In general, most deaneries will not approve a break of more than 12 months unless there are very special circumstances. Reasons for this can vary, but it must be appreciated that training numbers are limited in each deanery and excessive delays in producing fully-qualified consultants would give even further shortfalls in the workforce and be unpopular at a higher, political level.

College accreditation

Everything I have described is sufficient to arrange an Out-of-Programme Experience at a local level. If the post is accredited by the College, it will count towards a CCST, so it is worth trying to arrange this. This can be done before or after the placement. The former has several advantages. The most important is that it is impossible to return from the placement and alter various aspects of the experience retrospectively. Certain standards are required for the College to approve a post. If any elements are missing, these are unlikely to be met.

Once deanery approval has been given, the programme director can apply to the College. Approval by the College has two important requirements. The first is that the proposed placement is satisfactory in terms of the nature of the post. In order for this to be assessed, a reasonably detailed timetable must be submitted. The College will look for evidence that the proposed work is of an acceptable nature and is broadly equivalent to approved posts at SpR level. The inclusion of at least one hour's face-to-face supervision with the trainer is very important. Other aspects such as access to academic programmes, teaching opportunities etc. will also strengthen the chances of the post being approved. If special interest and research sessions are to be included in the post, then a description of these will also be required.

The second requirement is that the educational supervisor or trainer for the post must be approved by the College. This is conducted in a manner not dissimilar to the approval of any consultant psychiatrist applying for ‘trainer’ status. In practice, the proposed trainer must forward a curriculum vitae to the College. Providing the College is satisfied that the proposed trainer has the necessary qualifications and experience, approval will be granted.

Presently, up to 12 months of an Out-of-Programme Experience can be submitted to the College for approval towards a CCST. If College approval is sought upon completion of the placement, the experience must be subject to the same record of in-training assessment (RITA) procedures as any other SpR post. Again, time and effort can be saved if the necessary RITA forms are completed towards the end of the placement rather than retrospectively, after it has finished.

Should you get your Out-of-Programme Experience accredited?

An interesting issue is raised here. The important point to remember is that, even if an Out-of-Programme Experience has been accredited by the College and has been subject to a satisfactory RITA, the choice of whether or not to submit it towards a CCST is entirely at the discretion of the SpR. It has been likened to a ‘joker’ in a card game that can be played to the individual's advantage if it is felt to be necessary.

There is a common perception among SpRs that higher training — especially with single CCST numbers — is relatively short, running at 3 years, spanning the time from senior house officer to consultant. If an individual was to spend 12 months training in psychiatry in another country, this would leave a period upwards of 24 months to complete higher training in approved posts here in the UK. While it can be argued that the approved Out-of-Programme Experience is a perfectly satisfactory training experience, one of its great benefits is an opportunity to experience alternative methods of patient care and health service organisation. It can also complement the training received here. It is debatable, however, whether 24 months, which for most SpRs would be two higher-training posts, can be regarded as adequate preparation for consultancy in the UK's National Health Service.

Having an approved Out-of-Programme Experience brings the best of both worlds and allows for greater flexibility. It might be wise not to submit an approved one if there is a sense that training is too short or a delay might be fruitful (especially if consultant vacancies are being mooted in the not-to-distant future). This can increase time spent at this grade to 4 or even 5 years if dual CCSTs are being sought. Alternatively, if rapid career progression is preferred, or a particularly desirable consultant vacancy appears within the final 12 months of higher training and before you would ordinarily be allowed to apply, the playing of the Out-of-Programme Experience ‘joker’ can result in sudden eligibility for such posts.

The survey

Finally, in order to investigate the knowledge of Out-of-Programme Experiences and attitudes to them, I conducted a simple telephone survey on a random selection of SpRs in the West Midlands' higher-training scheme. This scheme was chosen because to survey SpRs on my own scheme and colleagues may have introduced unwanted bias. A total of 43 SpRs took part, representing all sub-specialities at this level.

The most striking feature was that only 9% (n=4) had heard of an Out-of-Programme Experience and knew what it was. A further 33% (n=14) had heard of it in principle although they were not familiar with the title. The remaining 58% (n=25) were not aware that such an experience could be pursued. Only one SpR of the 42 (2%) had actually organised one.

Following a brief description of what the Out-of-Programme Experience was, 67% (n=29) claimed they would consider it as part of their training. Common reasons given included the attraction of experiencing psychiatry in other countries. Another reason put forward was that it offered a means of extending the length of SpR training. The 33% (n=14) that claimed they would not consider it tended to be in the later stages of training and commonly gave reasons such as the negative impact of upheaval on their domestic life. This was especially true for those with families.

The experience is a tremendous opportunity to further interest in a particular field or to work as a psychiatrist in another country. It offers huge potential benefits both professionally and personally, especially when care is taken to prepare and accredit the experience beforehand. My survey illustrates the perception of Out-of-Programme Experiences among SpRs. It also reveals that a large proportion would be interested in such an experience and that those who have heard of the idea in principle are actually in the minority. Would I do it again? Absolutely, and I would encourage any SpR colleagues to do the same.

Declaration of interest

None.