The Certificate of Eligibility for Specialist Registration (CESR, also called Article 14) is an alternative route to the General Medical Council’s (GMC) specialist register for persons who do not enter higher specialist training. As with a Certificate of Completion of Training (CCT), CESR allows doctors to apply for a substantive, honorary or fixed term consultant post in the National Health Service (NHS) [1]. The CESR pathway is perceived to be lengthy and complex [1, 2]. Evidence submitted as part of a CESR application is evaluated against the Ophthalmic Specialist Training (OST) curriculum and CESR candidates’ experience and training is considered to be “current and maintained” if within 5 years of the application [3].

A recent survey [4] indicated that the COVID-19 pandemic has disrupted the training of CCT candidates through redeployment, the suspension of elective surgery as well as a significant decrease in outpatient activity in 2020 and the postponement of The Royal College of Ophthalmologists (RCOphth) examinations. Since that publication, there has been a further period of reduced clinical and surgical activity from January to February 2021.

The factors listed above, along with illness, shielding and less formal training support, would be expected to also affect CESR candidates. To explore this impact, a 31 question, online, self-administered survey was developed by the authors.

Demographics

Seventy-eight (78) doctors completed the survey between 11/09/2020 and 19/11/2020. Fifty-three percent of respondents (39) were specialty doctors or associate specialists. About a quarter (24.4%) of the participants were working in the London area which was one of the regions most affected by the pandemic [5].

RCOphth exams

Fifty-nine doctors (75.6%) were in the process of taking RCOphth exams. Forty-three (55.1%) felt that they had been affected by RCOphth exam cancellation and all three parts of the exam were equally affected.

Impact on current working (Fig. 1)

The overwhelming majority of respondents (n = 75, 96.2%) felt that COVID-19 had affected their CESR preparation. For 65 (83.3%), the main reason was the reduced clinical activity. Of note, 15 (19.2%) had been redeployed to non-ophthalmic departments and for 20 (25.6%), the on-call rota had changed, mainly to an increased frequency of on-calls. Cataract was the most affected subspecialty (48.7%) and 46.1% of respondents had completed ≤200 cataract surgeries. Paediatric ophthalmology and strabismus (20.5%) was the second most affected subspecialty. Surgical training (87%) and clinic attendance (60.3%) were the most affected aspects of evidence collection.

Fig. 1: Impact of COVID-19 on CESR Preparation.
figure 1

a Do you think your CESR preparation was affected by COVID-19? b Why was your preparation affected? c What aspect was most affected (choose all that apply) d Which specialty was most affected? (choose one).

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Sixty (76.9%) doctors did not think that the reduction in clinical activities had given them time to work on other aspects of the CESR application and only about 12.8% thought they could prepare for the exam. Overall, total numbers of CESR application submissions and pass rates across all specialties had decreased in January to June 2020 compared with the same period in 2019. In ophthalmology, the numbers of submissions were the same (n = 13), but the number of successful applications had increased from 2019 (n = 5) to 2020 (n = 7) [6].

5-year limit

When asked to choose all the aspects of CESR preparation that were of concern, participants identified the 5-year limit on evidence set by the GMC (80.8%), followed by surgical numbers (71.8%) as troubling. When selecting only one area that most concerned them, 47.4% chose the 5-year limit (Fig. 2).

Fig. 2
figure 2

Most concerning aspects of CESR preparation.

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Fifty-nine (76%) participants are still in the process of collecting their evidence and 89% had been working on CESR for 5 years or less. Almost 75% of respondents planned to use a mixture of prospective and retrospective data, or only retrospective data. This raises the possibility of the older evidence being out of the 5-year limit due to COVID-19 related delays. Almost 70% said that they would not be able to submit their evidence within 5 years. Similar concerns had been raised by the Staff and Associate Specialist Doctors Committee (SASC) of the British Medical Association [7]. Hussain et al. also found that senior trainees were more likely concerned about examination postponement and achieving all workplace-based assessments (WPBAs), possibly related to limited time remaining in training [4].

Impact on future working

Almost 80% said that they could not continue to collect evidence at the same pace as ‘pre-COVID’. 92.3% thought that the new post-COVID work style will affect the rate of completing the requirements for CESR application and 87.2% thought that teleconsultation and directing patients to community care would influence future CESR planning. As part of their trust’s recovery plan, 95.6% have had a reduction in clinic capacity, with 70.5% reporting a ≥50% reduction. This was also reflected in the reduction in cataract lists and all other subspecialty surgical lists.

Support

Seventy-one (91%) are not in a local CESR training programme which suggests they may not have the structure and formal support to be prioritised for collecting the required WPBAs and surgery.

Health and well-being

Fifty-six (71.8%) had to take sick leave during the pandemic, of which 13 (16.7%) took about 2 weeks. For 63 (80.4%), the effect of COVID-19 on CESR progress had negatively influenced their mental health.

Conclusion

These survey results demonstrate that ophthalmic doctors working toward a CESR application are concerned that the COVID-19 pandemic has, and will continue to, negatively affect various aspects of evidence collection. Juniors in training programmes will be supported to gain their competencies but there is no obvious support for most CESR applicants. Specific support at the local and national level is needed to lessen this impact. We suggest it would be helpful for the GMC to consider an extension of the 5-year requirement for CESR candidates who have been affected by the negative impact of the COVID-19 pandemic on their CESR preparations.