{'fraction_non_alphanumeric': 0.02205946464382248, 'fraction_numerical': 0.007847240387130526, 'mean_word_length': 5.143545795393679, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 1, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Clinical Teaching Fellows, the new norm?—Experiences of fellows and education faculty

Abstract Background In the United Kingdom, there is an increasing tendency for doctors in the first 2 years after graduation, to step off the training pathway and take up Clinical Teaching Fellow (CTF) positions. We aimed to explore stakeholder experiences of CTF positions to inform future planning and support. Methods Individual semi‐structured interviews with 10 stakeholders (five CTFs and five education faculty members) from one institution in England were conducted. Interviews explored the participants' views of the CTF position, its benefits and challenges. Inductive thematic analysis was performed. Results CTFs and education faculty views strongly aligned and three themes were identified. These were (1) developing a career, (2) developing confidence and competence as a clinical teacher and (3) developing a position that works for all. Participants reported that the CTF position allowed time for specialty decision making and curriculum‐vitae strengthening and provide CTFs with the opportunity to work autonomously and to establish a better work–life balance by stepping away from training pressures and focusing on other aspects of life. There were differing thoughts on how the position should be structured, although retaining a clinical role with boundaries to constrain competing responsibilities was important. Conclusion A brief hiatus in clinical training, where individuals feel supported to progress personally and professionally and to renew their energy for the next steps of clinical training, seems important. The ideologies of providing the CTFs with autonomy, time to explore options, recharge and form connections with colleagues should be considered when structuring the posts.

training pressures and focusing on other aspects of life. There were differing thoughts on how the position should be structured, although retaining a clinical role with boundaries to constrain competing responsibilities was important.
Conclusion: A brief hiatus in clinical training, where individuals feel supported to progress personally and professionally and to renew their energy for the next steps of clinical training, seems important. The ideologies of providing the CTFs with autonomy, time to explore options, recharge and form connections with colleagues should be considered when structuring the posts.

| BACKGROUND
In the United Kingdom, clinical training requires individuals to complete an undergraduate degree that takes 4, 5 or 6 years depending on whether a graduate entry, standard entry or entry with intercalation route is taken. This is followed by 2 years of Foundation training, usually involving a rotation around six clinical specialties. After this point, trainees embark upon specialist training, taking between 3 and 8 years depending upon specialty. This pipeline is designed to deliver the appropriate number of senior doctors, general practitioners or consultant grade specialists, to meet the health care needs of the UK population.
There has been a growing trend for UK trainees to take a break following Foundation training. The number of doctors not proceeding directly into training now exceeds those that do (65.1% in 2019), 1 with strong indications that doctors are pausing so that they can recharge, gain skills and consider their career options. [1][2][3][4] Most continue to practice clinically, but not in training posts. 1 Although there are obvious implications for workforce planning, it is important to support the significant number of doctors who take this route, especially as there is evidence that taking this option can lower risk of burnout later in their career. 4 Some trainees feel that when they step out of training, the information about the different options and the support to return to a training programme is limited. 2 One established route that UK trainees take is to become a Clinical Teaching Fellow (CTF), 5 with those taking this route citing that they do so for the same reasons as mentioned above. [6][7][8][9] Typically, these 1-year posts combine delivering undergraduate medical education and providing clinical care, although there are varying contractual arrangements. The employer may either be the clinical service provider or the educational institution, and the role may span one clinical or educational department or several. Although there are surveys 6,7 and personal accounts 8,9 of doctors taking the CTF route, there are few studies that offer deeper insights, and an absence of reports from the education faculty, who work alongside CTFs.
Given the lack of in-depth research into this topic, and the increasing tendency of junior doctors to take on posts of this nature, a greater understanding of the experiences of CTFs and the faculty members, that they work alongside, could better inform how to structure these CTF positions. This will ensure that CTFs have a supported and valuable experience, whilst contributing meaningfully to the clinical and education workforce needs. It may also provide insights into how a short hiatus in clinical training may contribute to the reduction in burnout rates later in a clinical career.
The aim of this study was to explore stakeholder experiences of CTF positions to inform future planning and support. In particular, we are interested in whether there are benefits associated with the CTF position to both the CTFs and the educational faculty.

| Study design
We approached this study from a phenomenological perspective, employing an interpretive approach. To explore the experience of CTF positions from the perspectives of CTFs and educational faculty, we used one-to-one interviews. The study design recognises that the research team, who were, or had been, CTFs and academic faculty, would bring their own perspectives to the research, from the positions that they held.

| Study setting
This study was conducted in a single UK medical school in South West England that have utilised CTFs to deliver anatomy, biomedical sciences and clinical skills education to pre-clinical medical students since 2013. The CTFs had completed their Foundation training across different geographical locations in the United Kingdom.

| Data collection
Between January and September 2019, any CTF who had worked at the medical school (n = 7) and any faculty member who had worked closely alongside them (n = 20) were approached by e-mail to participate in this study. Individual semi-structured qualitative interviews were conducted either face to face or by telephone, to explore the participants' perceptions of the CTF position (topic guide in Table 1). The interviews were conducted by a non-medical undergraduate student T A B L E 1 Topic guide for the semi-structured interviews (JS) and a clinician researcher (DC) who had previously worked as a CTF at the same institution. Interviews were audio recorded and transcribed through an independent transcription service.

| Data analysis
Thematic analysis was conducted through the steps of data familiarisation, coding and creation of themes. 10 The interviewer (DC) and another member of the research team (SB) independently coded the CTF and faculty transcripts. The analysis was inductive, although one researcher (SB) was alert to the relevance of the theories of social cognitive career choice 11 and multidimensional burnout. 12 Themes and subthemes were created from the CTF interviews initially and applied back to the dataset. Particular care was taken to look for agreement and dissonance between the CTFs and the faculty member interviews. Discussion, expansion and collapsing of themes occurred throughout the process (DC, JT and SB). A reflexive approach was taken, whereby the study team questioned and challenged each other's viewpoints throughout.

| Member checking
Study themes were also shared at a UK National Clinical Fellow con-  Table 2 for descriptors and quotes; Figure 1 for a summary).

| Theme 1: Developing a career
Participants reported that the CTF position provided space to make informed career choices. They felt that this was particularly important given the length of time that they would spend in their future special- CTFs were surprised about the level of responsibility provided to plan their own work and be accountable for their teaching. The amount of time spent training and supporting CTFs was an important consideration for the education faculty.

| Member checking
Ten comments were received from CTFs attending the conference, all aligning with the themes of this study (Table 3).

| DISCUSSION
The findings of this work complement those existing in the literature but provide deeper insight about the benefits and challenges of the CTF position.
In accordance with other studies, the CTFs were found to be using the opportunity to decide upon their future careers, 8,9,13 enhance their CV, 6,9,14 develop skills as an educator 8,9,14 and take some time for their lives outside of clinical practice. 6,7,13  Although CTFs wanted to build their CVs, their professional development was far more than this. They described increased levels of responsibility within this position and the feeling of being valued and equal to other members of the teaching team. Control to make decisions and a positive sense of community are protective features of the multidimensional theory of burnout. 12 They also resonate with self-determination theory, 17 whereby individuals, who feel competent, connected and autonomous, have improved motivation, performance and well-being. 15 Working autonomously as a CTF may also help trainees to prepare for the next level of clinical training, where the expected levels of responsibility will increase.
CTFs described being valued and equal to other members of the teaching team.   18 and this may also work to reduce the training burden for education faculty. We would recommend that this idea is promoted.
It was important that clear boundaries between clinical and education work were set so that the CTF did not become overcommitted.
The number of health care professionals reporting burnout within their careers is increasing worldwide. 19,20 Burnout has negative consequences, not just for the individual but also for recruitment and retention of clinicians, and ultimately the quality and safety of patient care. 20  Flexibility in clinical training may support doctors to develop protective strategies that prevent burnout later on.

| Strengths and limitations
This study does provide a rich insight into the lived experiences of CTFs, and the education faculty that work alongside them, in the United Kingdom, which to our knowledge is a new contribution to the field. The small number of participants constrained to one geographical locality limits this study. The research participants may have also felt unable to share fully their experiences, despite reassurances from the interviewer. It is reassuring, however that when the data were shared with wider members of the CTF community, that they related to the themes.

| CONCLUSIONS
Ultimately, the study provides insights into how CTFs can have a supported and valuable experience and how a short hiatus in clinical training may promote well-being. This is particularly important when considering how to create a workforce that is both retained and enthusiastic to inspire the upcoming generations of medical students for whom they are a role model.