Out of 299 respondents, 216 met the inclusion criteria. Of these 216, 159 (73.6%) were male, 54 (25.0%) were female, 1 (0.5%) was non-binary, and 2 (0.9%) did not wish to reveal their gender (Table 1).

Most of the cohort were currently in core surgical training 128 (59.3%), 57 (26.4%) in Core Surgical Trainee-Year 1 (CT1) and 71 (32.9%) in Core Surgical Trainee-Year 2 (CT2). 49 (22.7%) were in ‘non-training’ orthopaedic registrar posts, and 39 (18.0%) were working in Junior Clinical Fellow (JCF) posts. In addition, participants were from a huge range of geographical areas as seen in Fig. 1.

Fig. 1.

Distribution of respondents by Deanery. Figure created using Google Sheets (Google LLC, Mountain View, CA, USA).

Out of 216 respondents, 91 (42%) would consider going LTFT. 56/159 (35%) of male respondents reported they would consider going LTFT compared to 34/54 (63%) of females. The difference between these two groups was statistically significant (p 0.001).

The most common responses to the question ‘If you were to do LTFT, what would be your reasons?’ were childrearing/caring for a dependent (53%), burnout (36%), travelling (23%) and business interests (13%) (Table 2).

Men and women were similarly likely to cite childrearing as a reason they would consider going LTFT with males 40% and females 44%. There was no statistical significance between either gender (p = 0.589).

48% of female respondents cited burnout as a reason for going LTFT compared to 31% of men.

When asked ‘What potential barriers would stop you from pursuing LTFT training?/What barriers have you faced?’, the most common responses were increased length of training (68%), financial reasons (46%), negative perceptions of colleagues (36%) and worsening of surgical skills (34%). Female trainees were significantly more concerned about worsening of surgical skills compared to male trainees 26/54 (48%) vs 46/159 (29%) (p = 0.010) and the negative perceptions of colleagues 31/54 (57%) vs 44/159 (28%) (p 0.001) (Table 3).

65 (30%) respondents reported hearing or seeing negative behaviour towards the idea of being an LTFT trainee. The majority of this came from senior surgeons (consultants or senior registrars) with 39 (18%) respondents having seen this. Women were twice as likely as men to experience this negative behaviour from seniors, 28% compared to 14%. Overall, women experienced more negative behaviour towards LTFT training than men: 23/54 (43%) vs 39/159 (25%). Other sources of negative behaviour towards LTFT training were hospital managers (6%) and peers (6%), with the remainder of respondents not specifying where they had witnessed this behaviour (Table 4).

Only 59 (27%) of our respondents felt that there is information readily available regarding LTFT training.

When asked to rate the orthopaedic specialties receptiveness to LTFT training, on a Likert scale of 1 (not receptive)–10 (extremely receptive), participants gave an average score of 4.9 $\pm$ 2.1. The Likert scale is a widely used tool for measuring attitudes and perceptions, and it has been shown to provide valid and reliable data in similar studies [11].

Our research has identified four barriers which may prevent orthopaedic trainees from pursuing LTFT training: concerns about extended training duration, the financial implications of opting for LTFT, worries about declining surgical skills, and perceived negative perceptions from colleagues regarding LTFT training. A career in orthopaedic surgery is an expensive pursuit; in 2017, the estimated cost of achieving a Certificate of Completion of Training (CCT) in trauma and orthopaedics was £21,405.50 [12]. These costs will have increased since then approximately in line with inflation and a number of these costs are fixed to the amount of time spent in training. LTFT trainees will not only sacrifice a percentage of their earnings to become LTFT, but these fixed costs will remain, ultimately reducing their expendable income disproportionately as they will spend more years in training. To reduce this burden, it may be pertinent for memberships to the Joint Committee on Surgical Training (JCST) and the British Orthopaedic Association (BOA), for example, to be paid adjusted to the trainees’ LTFT schedule, with trainees paying the same amount over their training career, independent of how many years it takes them to complete training.

Increased time in training is a common concern for those entering LTFT orthopaedic training. CCT is competency-based rather than time-based [13], and thus it can be confusing for trainees to estimate how long LTFT will extend their training as there is little clear guidance on which sessions they will miss each week. This varies based on the time they take off and how that fits into the department they are currently rotating through. Clearer guidance on this matter could alleviate some concerns, but this may be logistically challenging given the variance between each trainee’s work schedule across different deaneries and within each orthopaedic department. A change in the structure of surgical rotations may partially alleviate some of these issues. Currently, LTFT arrangements are agreed upon when trainees rotate to a new department. Longer placements agreed upon further in advance could allow better planning of work schedules to support training experience.

A key concern seen in our study is for LTFT training leading to worsening surgical skills. Our study showed 48% of females were concerned about worsening surgical skills compared to 29% of males. This may be because women typically have longer periods out of training for parental leave [14]; as such there may be concern that LTFT may compound any existing decline in confidence or skill.

Surgical exposure in training has markedly reduced in recent years due to the introduction of the European Working Time Directive (EWTD) and 48-hour work weeks. The Temple report [15], which was carried out to assess whether working within EWTD limited hours is detrimental to surgical training, concluded that delivery of surgical training is possible in a 48-hour work week, but not if trainees have significant roles in out of hours (OOH) services, are poorly supervised or lack access to learning opportunities.

Reduced hours mean that a greater proportion of shifts for trainees are OOH to ensure service provision. During these shifts, trainees will be exposed to learning opportunities, though they are less likely to involve surgical skill development. Trainees who are LTFT will experience further reductions in clinical exposure in theatres, leading to concerns about whether 60% or 80% LTFT is sufficient, even though the Temple report deemed 48 hours to be adequate. This issue would benefit from further research.

Since 1996, women have comprised over 50% of medical school entrants [2, 16]. However, as of 2020, only 7.3% of consultant orthopaedic surgeons were female, marking the lowest representation among the ten surgical specialties. Similarly, orthopaedics also exhibited the lowest proportion of female registrars at 20.6%. Though there is increasing representation of women in orthopaedics. It is projected that at the current rate parity is projected to be achieved in 2070 [17].

Our study focusing on prospective higher specialty training orthopaedic applicants found that 63% of female respondents expressed willingness to pursue LTFT training, in contrast to 35% of males. To ensure a diverse surgical workforce, it is crucial to enhance accessibility of orthopaedic higher surgical training (HST) for female trainees.

Many studies have shown that female medical students are often deterred from entering surgical training due to the perceived poor ‘work life balance’ [18] and the need to adopt LTFT training at some point in their training to balance work and family life [19, 20]. In our study, 9% of women cited work life balance as a reason to consider LTFT compared to 1% of men, showing that this is an ongoing valid concern that female trainees have once they have started upon a surgical career path and making LTFT an accepted and valid option will serve to make surgical training a more attractive option to those medical students.

In our survey, 48% of female respondents cited burnout as a reason they would consider going LTFT compared to 31% of male respondents. Burnout is an increasingly prevalent concern amongst doctors in training with 23% being at high risk of burnout across all specialties and 26% in surgical specialties [21]. In 2023, research revealed that 90.3% of UK orthopaedic surgeons across all grades experienced moderate to high levels of burnout [22]. Reducing burnout is not only of benefit to the trainees themselves, but also to the departments that they work in and the patient populations that they serve as it can negatively impact staff productivity and patient outcomes [23, 24].

To foster a diverse surgical workforce, implementing LTFT training could serve as a strategy to not only reduce burnout within the specialty but also, appeal to a greater number of female applicants. Our research indicates that females are more inclined to consider LTFT training due to burnout, making it a potentially effective method for attracting, retaining, and sustaining diversity within the orthopaedic specialty.

Our study revealed that childrearing emerged as the predominant motive driving aspiring orthopaedic surgeons toward pursuing LTFT training, with 40% of men and 44% of women expressing this as their primary reason. The escalating expenses associated with childcare may provide some explanation for this; recent national data shows that the average monthly cost of nursery care for a single 10-hour day per week amounts to £248 post-tax income [25]. For individuals with multiple children, the financial advantages of going 80% LTFT are evident, particularly considering the substantial savings in childcare expenses which alone can offset the financial costs. Moreover, this arrangement affords the added benefit of allocating more quality time to nurturing relationships with their young children, thereby addressing the evolving needs of the workforce.

A key factor in directing surgical trainees away from LTFT training is perceived negative perceptions from colleagues and seniors, with 81 (38%) respondents citing this as a barrier. 70 (32%) respondents reported they had witnessed negative or discriminatory behaviour towards the idea of being an LTFT trainee with this mainly coming from senior surgeons 40 (57%) along with hospital managers 12 (17%) and from peers 14 (20%) with the other 4 not reporting where they had witnessed this behaviour.

Female respondents were also more likely to be concerned about negative perceptions from colleagues with regards to going LTFT, with 57% (compared to 28%) seeing it as a barrier to them entering LTFT training. It is well documented that surgical trainees, orthopaedic trainees in particular, are often exposed to bullying and undermining behaviours during their training; this is more commonly directed towards women and those from ethnic minority backgrounds [26, 27].

With this in mind, applicants may feel less empowered to choose LTFT, fearing scrutiny from seniors and colleagues for deviating from the conventional training pathway. Fostering a more receptive and inclusive senior surgical body would empower trainees to make personal choices that enhance their quality of life, improve job satisfaction, and reduce the risk of burnout, ultimately improving their overall well-being.

32% of respondents (43% of females and 25% of males) reported having witnessed or experienced discrimination or negative behaviour towards going LTFT in training. This is primarily observed among consultants and senior registrars. To foster greater receptivity toward trainees opting for LTFT training, it is essential to implement education and awareness programmes highlighting the benefits of LTFT training for both trainees’ professional development and personal well-being. These programmes should emphasize the significance of accommodating diverse needs and promoting work-life balance within surgical training. Additionally, efforts should focus on fostering a positive organizational culture that values diversity and respects individual career choices, creating an environment conducive to open communication and mutual support between trainees and senior staff. The disparity in LTFT uptake between surgical trainees (10%) and trainees across all specialties (19.5%) underscores the urgent need for a shift in attitudes and practices within surgical departments [7, 8]. Providing targeted training and resources for consultants and senior registrars, particularly in effective mentoring and coaching techniques, is essential. Equipping senior staff with the skills and knowledge to support and guide trainees pursuing LTFT training can enhance trainee well-being and foster a more understanding and accommodating approach to trainees’ preferences and needs.

Only 27% of respondents felt that there was adequate information available regarding LTFT training available to them.

Without access to comprehensive information about the process, benefits, and potential implications of LTFT training, trainees may struggle to fully understand their options and make well-informed choices regarding their career paths. This lack of information can lead to uncertainty, anxiety, and hesitation among trainees, potentially deterring them from pursuing LTFT training even if it aligns with their personal or professional needs.

Furthermore, inadequate information may perpetuate misconceptions or negative perceptions about LTFT training among trainees, senior staff, and healthcare organizations, contributing to the existing barriers and resistance towards LTFT arrangements within surgical specialties. With further accessible information and widespread integration into the surgical curriculum, these problems could be addressed.

This study has some limitations. The data we have used is all self-reported which may introduce some bias as respondents may have provided socially desirable answers or interpreted questions differently. The study’s sample, drawn from a group of orthopaedic webinar registrants, may also not be fully representative of all aspiring UK orthopaedic trainees, potentially limiting the broader applicability of the findings. Requiring questionnaire completion to register for the teaching series may have led to less thoughtful or rushed responses if respondents viewed the questionnaire as a barrier to accessing the webinar. While we have identified key barriers to the uptake of LTFT training, we have not quantitively assessed the impact of these barriers on actual training outcomes or progression. Further research would be needed to determine how LTFT impacts skills development and Annual Review of Competence Progression (ARCP) outcomes for orthopaedic trainees.