Sarah Grimble

Becoming an SAS surgeon after a 17-year career break

Miss Sarah Grimble was on a surgical specialty training pathway in March 2002, and expecting her first child.

Sarah Grimble

Miss Sarah Grimble was on a surgical specialty training pathway in March 2002, and expecting her first child. What happened next surprised her. The training rotations were rejigged and there was no place for Sarah to return to after her maternity leave. “There was no conversation about my return to training. The regional training director just didn’t include me in the rotations”, she says. There was no-one she felt able to take this up with, having transferred to the region only nine months before. So, she stepped back from surgery and focused instead on her new family.

Finding a route back to surgery.

“There was always a thought in the back of my head about coming back to work and I think that’s why I kept my GMC registration live,” says Sarah. In May 2018, she began making enquiries about returning to surgery. “Every week I would sit at the desk and do the next stage of prodding or poking, sending an e-mail to the college or the regional training directors,” she says. These sources proved to be of little help – something the College is working to address – and it was interacting with other doctors via doctors.net that led Sarah to approach the director for medical education (DME) at her local hospital, Queen’s Medical Centre (part of Nottingham University Hospitals NHS Trust).

“There’s no obvious access route for people who have been out of medicine for a long time,” says Mr David Humes, Head of Service and consultant colorectal surgeon at Queen’s Medical Centre. He, together with the DME and the return to work ambassador for the Trust, met with Sarah and designed a pathway back to surgery. The pathway had to be tailored to her specific needs and advances in surgical practice in the preceding 17 years. Laparoscopic surgery was in its infancy when Sarah stepped back from surgery, and investigation pathways had altered, with greater use of imaging. IT systems and governance expectations had also changed in the intervening years. “She had to be re-educated in a modern system, which is what we put together for her,” says David.

Getting a foot in the door

Sarah was invited to undertake a month’s observership (an unpaid placement within a hospital to observe clinical practice, sometimes called a clinical attachment) during January 2019. This involved following a consultant within the surgical department or, on some days, other medical or nursing staff. “You watch what’s going on. You’re not allowed to touch any patients. You’re not allowed to contribute to any clinical care” says Sarah.

Having completed the observership, in February 2019, she was offered a supernumerary position in the surgical department, undertaking the work usually given to a foundation year one doctor. Despite 17 years away from surgery, Sarah remembers that her knowledge of how to manage clinical situations came flooding back. “The problems of the patients hadn’t changed. The core aspect of being a doctor doesn’t change. And if you’ve had good previous training, I think that’s still quite embedded in you,” she says.

David emphasised the importance of making Sarah truly supernumerary, with appropriate supervision in place, adding: “I didn’t want her to be exposed to something that then resulted in an incident where she was unsupported.”

Sarah’s career journey

2022-present

Specialty doctor Colorectal Surgery, Queen’s Medical Centre, Nottingham University Hospitals NHS Trust

2019

Returned to work in colorectal surgery, Queen’s Medical Centre, Nottingham University Hospitals NHS Trust

2002-2019

No surgical practice; raised two sons. Worked as a book seller, academic support worker, school governor and research ethicist

1997

FRCS The Royal College of Surgeons of England

1994-2002

Senior House Officer posts – Leicester, London, Portsmouth, Isle of Wight, Winchester, Southampton – and three locum appointment for training (LAT) posts on Gloucester, Reading and Derby

1993-1994

House Officer, General Surgery, Orthopaedics and General Medicine, University Hospitals of Leicester NHS Trust

1993

Bachelor of Medicine, Bachelor of Surgery (MB ChB), University of Leicester Medical School

Creating a trainee-like pathway

After several weeks at foundation level, David suggested that Sarah join the core rota (including on call) and to work on demonstrating the competencies of a core surgical trainee. She was employed on a Trust grade contract (ie a locally employed doctor). Like trainees, Sarah used the Intercollegiate Surgical Curriculum Programme (ISCP) to record her progress. “From a trust point of view, you have to prove you’ve taken reasonable steps to retrain, re-educate and demonstrate competence, which is what we did,” says David.

Sarah was assigned an educational supervisor. She says: “An educational supervisor was definitely important for the first two years because we really focused on getting me back up to speed and collected all the evidence on new platforms to show I was appointable as a surgical registrar”.

Over 18 months to 2 years, Sarah compiled a portfolio of evidence. This required her to undertake courses in advanced trauma life support, basic surgical skills and in basic laparoscopic surgery (see box). In August 2020, she began acting up into slots on the registrar rota and in 2021, she joined the registrar rota fully. Sarah describes how well supported she felt at each level and this helped her feel ready to take on the next challenge.

Carving out a niche

David arranged for Sarah to start undertaking more independent activities, such as ward rounds supervised by a consultant. This was followed by two-week wait suspected cancer clinics and then more specialist clinics (one-stop rectal bleeding).

Sarah had found her niche within colorectal surgery and so effort then went into putting her on a specialty doctor contract. This took almost a year to approve and was confirmed in November 2022. Sarah is happy to remain at this level, pointing out that it takes six or seven years to learn laparoscopic surgery and that she does not have the time (or drive) for that. David emphasised how this clarity regarding her career has helped in carving out a niche for her within colorectal surgery. He says: “She made it very clear from the beginning that she wasn’t looking for a pathway back into surgical training to become a consultant… She felt that she could offer something again. She wasn’t 100% sure what it was in terms of the exact specifics. But that that’s why we kind of came together to create it”.

Mr Ayan Banerjea, divisional director of surgery and a colorectal surgeon agrees, he says: “People didn’t really have a clear understanding of the value of Sarah until she started, but I think everyone can now see that actually she’s an excellent member of the team”. He adds: “You’ve got to find a mutually beneficial arrangement that works for the individual and works for the organisation. I think where it becomes disastrous is where one party thinks that they’re on a certain path and the team has no intention of ever getting there”.

Demonstrating impact

Sarah is contributing value across the whole patient pathway, according to David. In addition to undertaking ward rounds and undertaking routine surgical procedures (such as haemorrhoidectomy, pilonidal sinus operations and examination under anaesthesia), she supports the colorectal cancer pathway, which has led to an improvement in the two-week wait performance and in the first diagnostic standard target. Sarah brings her life experience to bear in her colorectal cancer clinics, which often involve discussions with patients and families regarding invasive and potentially harmful investigations. She undertakes day case surgery, saying: “I don’t get to do the great big, exciting laparotomies, because I can’t, but actually that doesn’t matter because a lot of being a surgeon is correct decision-making”. She adds: “Within surgical departments, they need people that understand surgical disease, how to manage surgical disease, how to investigate surgical disease and they don’t necessarily have to be the person who operates on it.”

Ayan highlights the impact Sarah has had on other surgeons within the team: “It has had benefits for the consultant workforce and the registrar workforce because in effect she is providing a service that allows the trainees to go off and train, which they might not otherwise have been able to do”. David explains that her one-stop rectal bleeding clinic has freed up post-CCT fellows to spend more time operating or undertaking endoscopy lists.

The costs of returning to practice

If you are returning to surgery after time away, there are several upfront costs to be aware of, which may need to be paid before you receive your first pay check.

  • Before you can do anything, you’ll need to pay for GMC registration and licensing, and professional medical indemnity.
  • Membership subscriptions to the British Medical Association and medical royal colleges may also need to be budgeted for.
  • You may be asked to undertake an unpaid observership. You’ll need to budget for costs such as travel and food, the care of any dependents, mortgage, rent and utilities. There are also the opportunity costs of not earning whilst undertaking an observership. Some units charge doctors to undertake clinical observership programmes. Some offer discounted rates on accommodation.
  • SuppoRTT (Supported Return To Training) provides learning and support resources for doctors returning to training, including a period of enhanced supervision, funding for supernumerary time, and refresher courses.
  • There are benevolent funds for doctors and their dependents needing financial support. Doctors Help brings together five independent charities that offer this type of support.

Other potential costs include training courses:

“I’m the oldest female surgeon in our department. I’m older than most of the consultants and they will come and tell me all the things they’re worried about. But also, because I’ve worked as an F1 and as a core trainee, the core trainees tell me everything that they’re worried about, as do the registrars and so on. I’m a sort of a safe pair of ears.”

Sarah’s role is opening the door for other SAS roles within the colorectal surgery department, particularly for doctors in training who do not wish to pursue a consultant position and instead like the idea of a role built around them. “People don’t necessarily want the responsibility of being the consultant. There’s a group of people who would just like to be doing the job… And that’s what this role offers. You still get to practice independently to a degree, but always with some kind of oversight. And that makes them much more relaxed and willing to work, says David. Ayan agrees. He says: “We probably have a different generation of people coming through [training] who aren’t quite as fixated on the same sorts of things that people were prioritising when I came through. That gives you the option of finding different ways of building your workforce.”

As director of surgery, Ayan has asked all surgical services to ensure all SAS surgeons are using the ISCP, with arrangements for educational supervision, as this provides a mechanism for assessing the competencies of new SAS and locally employed surgeons. Neurosurgeons within the Trust benchmark SAS doctors against the following three tiers: core/early specialist trainee, middle specialist trainee, senior specialist trainee. “It’s good for the individual because they know what they’re being benchmarked against and it’s good for the team because it makes them think about those individuals and how their careers are progressing,” says Ayan. Consideration is being given to creating inhouse surgical rotations for core/early level doctors.

Sarah’s advice for surgeons taking a career break

  • Retain your GMC registration – it will make it easier for you to return and resume your licence to practise.
  • Keep your network of contacts up to date – they can be useful when you start the process of returning.
  • Keep your knowledge of the health service and medicine up to date by reading journals and doing elearning modules or quizzes where you can.

Medical Director perspective

“There is a group of doctors out there that aren’t working, but if they had the opportunity to work and we could make that easy for them, we would attract them back into clinical practice”, says Dr Keith Girling, trust medical director. He cites the example of the trust’s deputy medical director who became an Associate Specialist in Community Paediatrics having had several years away from clinical practice to raise a family. He says: “There are a group of female doctors who step out of clinical practice to raise families, and they look to come back to practice later but there’s no easy route for them”.

Keith applauds David and the team for seeing the potential in Sarah, investing in her return, and realising the benefits. He says: “she’s come to us now with significant life experience. She’s raised a family and that comes with an ability to appreciate what service users may be experiencing in ways that you wouldn’t necessarily be able to understand early on in your career.” He credits the colorectal surgery department with being particularly inclusive and keen to embrace diversity, with advanced care practitioners and physician associates adding to the mix.

The Trust has several active CESR programmes underway in emergency medicine, anaesthetics, and some surgical specialties, which is supporting consultant recruitment in areas where recruitment has been difficult. Keith says, “It’s a big investment, but the loyalty and commitment from those doctors who have completed the CESR programme is fantastic. They really feel that the organisation has invested in them, and their training is absolutely equivalent to national trainees.”

There are a few doctors on the new specialist grade contract. Keith emphasised the thought and preparation required to support the creation of specialist grade roles. He adds: ‘It also needs a balance between the doctor’s ambition to move to that contract and the specialty’s willingness to create that role and be confident that the doctor can work at that level.’ He explained that Sarah’s specialty doctor contract took time to set up, as it had to be bespoke to her situation.

The Trust has two SAS tutors and discussions are underway over whether to create an SAS avocate role. All SAS doctors are invited to attend medical staff committee meetings and receive the same communications from the medical director as the consultant workforce. Both Keith and Ayan insisted that there was no reason why SAS doctors could not step into leadership roles that would otherwise be taken by consultants. Keith says, “In my experience, SAS doctors are a phenomenal group of doctors who have for all sorts of reasons, made some slightly different life choices”.

Advice to medical leaders

  • Start with an open mind. Meet the individual and look to see if there is symbiosis between their needs and what your service is looking for. ‘If it doesn’t fit, don’t be afraid to say so,’ says Ayan.
  • Be clear about the benefit for the organisation in the longer term. SAS roles can be expensive (the equivalent of employing a “day one” consultant). David advises: “you’ve got to know that what that person is delivering either pays for itself or is adding value to your service”.
  • Arrange supervision for the returner, including making them supernumerary initially.
  • Create a package that will allow the returner to demonstrate their competencies.
  • Be prepared to defend your decisions to others within the hospital (such as why the returner might have no on call commitments for a period of time).
  • Make sure consultants understand the plan regarding the returner and the limitations to their scope of practice. Multiple consultant reports (MCRs) can provide useful feedback on how the returner is progressing.

Advice for surgeons considering a return to work

Sarah says:

  • Be flexible – “if the first route doesn’t work, try another way in”.
  • Be persistent – “once the ball started rolling, I knew I had to be persistent”.
  • Be confident – “remember you have done this before. You are a skilled, capable individual and you’ve already been through a lot of hurdles to get to the position you were in when you left”.
  • Find out if the organisation you are joining has an SAS tutor and SAS (or equivalent) and what support they can provide with returning to work.

David says:

  • Approach the director of medical education or the head of service if you know the department you are keen to join.
  • Consider what you can offer the service and be prepared to gather the evidence to demonstrate your competence in those areas.
  • Identify what it would mean for you to practice at the top of your licensing band and how the organisation could get most benefit from you. This will enable employers to see how you might fit and the type of job plan needed.
  • “Don’t expect to get back to the point you were at very quickly if you had a prolonged break”.

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