We recently asked our undergraduate Affiliate Network to submit questions for our President, Mr Ian Ritchie. Wide-ranging responses came from individual students and university surgical societies and raised topics including the changing shape of training, gender balance in medicine and issues around subspecialisation
The RCSEd would like to thank all students and surgical societies who submitted questions for the President.
Q: What are the strengths of the current surgical training programme and what changes would you like to see in the next five years? (Vlad Paraon, 4th year, University of Cambridge)
The current surgical training programmes have significant strengths, not least the intercollegiate co-operation in producing curricula for each of the 10 surgical disciplines. The intercollegiate surgical curriculum project (ISCP) is a world-leading programme which defines what surgeons need to know to practise surgery in the UK. The fact that it is allied with a logbook that helps to identify and confirm competences which have been validated by surgical trainers is also a significant achievement by the surgical community in the UK. Our trainee surgeons are very fortunate to have some of the best surgeons in the world as their teachers. All these things contribute to a very high quality training programme in all branches of surgery.
In relation to the changes I would like to see in surgical training over the next few years, I think that the most important thing we have to do is consider the relationship between training and service. It is my firm belief that our responsibility to our patients means that we have to provide a service which doesn’t rely on trainees to the extent that it does at the moment. At a stroke (admittedly an expensive one) we would improve surgical training by ensuring that trainees develop good skills while delivering service but are not so essential to the service that training suffers. I am firmly convinced that the General Medical Council’s desire to accredit trainers in medicine is a step change in how we will have to look at our surgical trainers. The Faculty of Surgical Trainers (FST) of this College is a major step in the direction of supporting trainers in the excellent job they do in training the next generation of surgeons.
Finally, I am convinced that simulation will become mandatory for all surgeons before they practise surgical skills on patients. It cannot be right that we experiment on our patients when developing new techniques, or when learning highly complex skills. I am firmly convinced of the benefits of simulation in surgical training and I believe that this will become increasingly important in training the next generation of surgeons.
Q: As the number of female medical students compared to male students is rising, ultimately surgery at some point in the near future is going to become more female-dominated. How do you think this will affect surgery and the training of surgeons? (Carla Harris, 4th year, University of Manchester)
We have long recognised that the gender balance in medical practice is changing. We also acknowledge that there is increasing interest in less than full-time training from both men and women. Given this change in the gender balance then it is inevitable that the surgical profession will have to adapt. In many ways, the European Working Time Regulations (EWTR) will help us in adapting. I believe that we have to change our approach to delivering a safe service as well as surgical training within a 48-hour working week. I am not going to tell you that it is easy to do this, however, I do believe that we have a responsibility to think imaginatively about the problems that face us and to deliver solutions that more closely match the aspirations of our potential workforce, for a balance of family and work, as well as a desire for a fulfilling career.
Q: With obesity predicted to affect 60% of adult men and 50% of adult females by 2050, how do you think this will affect surgery? (Carla Harris, 4th year, University of Manchester)
Obesity is a problem of lifestyle and prevention is the most effective way of dealing with this problem. The prediction of 60% of adult men and 50% of adult women being obese by 2050 is only a prediction, it is not a fact. It could be less than that or it could be worse but, either way, the most effective way of dealing with this problem has to be prevention.
However, if we accept the proposition that obesity is going to be a bigger part of our working practice as surgeons, then we will have to find ways of dealing with the problems that are going to result. These involve delivering safe surgery to people who are overweight and also delivering surgical solutions for the problem of obesity. Surgical practice is full of successful and innovative solutions to an immediate problem but I don’t think we can only take the rather narrow view that we provide an immediate response to the problem of obesity by carrying out bariatric surgery, or providing safe surgery for people who are overweight. We must also go back to the problem of prevention, and as part of our professional response to the health of the population as a whole, encourage people to avoid getting into problems of obesity in the first place.
Q: How will undergraduate students and foundation doctors benefit from the creation of the Faculty of Surgical Trainers? (Alexander Walker, 5th year, University of Cambridge and VP of the Cambridge Surgical Society)
The Faculty of Surgical Trainers is an initiative of this College because we recognised that anyone aspiring to a career in surgery should have the highest quality training. In developing the Faculty we anticipate that this will bring together, in one place, surgical trainers of high quality who have a common ambition to improve the quality of training that is already delivered for surgeons. It will also form a focus of influence to help direct the development of surgical training in the future. If this influence is beneficial for trainees in core and specialty training, then inevitably this will have its effect on medical students and foundation trainees as well. As you know, the Faculty is open to surgical trainers at all levels including surgeons in specialty training.
I have an absolute conviction that surgical training is not the exclusive domain of people who have a CCT. During my surgical training, I received a great deal of valuable and expert training from registrars and senior registrars who did not have their CCT but who were excellent teachers. Whatever shape the NHS forms in the future, we will need teachers at all levels to continue to develop the surgeons of the future.
Q: What would be the key advice you would give to keen medical students wishing to pursue a career in surgery? What would make the candidate stand out in future when so many are undertaking audits and research? (Glasgow University Surgical Society)
In the past, trainees considering a career in surgery had the opportunity of Senior House Officer posts to sample a variety of surgical specialties and, indeed, other medical specialties before making a final decision. This is no longer open to newly graduated doctors. I believe that medical students who are interested in a career in surgery should be approaching our Regional Surgical Advisers in their region and asking them to facilitate contact with surgeons in the 10 surgical disciplines. In this way, medical students will understand what a career in surgery means, not only in terms of the pathologies being dealt with, but also in relation to such issues as lifestyle, on call commitments and the effect that a surgical career has on surgeons and their families. This type of contact will inform the decisions that medical students will make about a potential future career in surgery.
The question of how to make an individual stand out for surgical selection is an interesting one. We are fortunate that the attraction of a career in surgery is sufficiently high to ensure stiff competition for surgical training posts. I sincerely hope that this remains because we need to have applicants in surgery who are of the highest standard and who are willing to deliver more than is considered to be the minimum or even the average. It is difficult to predict exactly what will be required in terms of selection in future but I have no doubt that the criteria for selection into surgery will change. There are also other factors to consider such as the changing gender balance, the effect of the EWTR on surgical training and also whether the length of surgical training will change in response to the changing needs of the NHS. Thus, I am not clear what the requirements will be for surgeons in training, however, I am clear that high calibre individuals are required to deliver the life-saving and life-changing treatments inherent in surgical practice.
Q: With ongoing sub-specialisation of surgical careers and the requisite to determine in which of these you will train at earlier and earlier stages, where do you see training pathways moving over the next 15 to 20 years? Fernadez-Cruz (Annals, 2004) and Fischer (JAMA, 2007) have both recognised the value of experience in general surgery in the education of all surgical trainees but also recognised that the role of the true ‘general’ surgeon is in slow decline. Where does this highly-specialised training, with minimal access to elective general cases leave the modern surgical trainee when having to deal with emergency general admissions on call? What can trainees do to ensure that they maintain breadth in their technical aptitudes? (Cardiff University Surgical Society)
This is a very interesting question. I acknowledge the increasing degree of sub-specialisation that is happening within surgery but I also recognise that patients continue to present with a large number of common conditions that require surgical treatment which are not necessarily highly sub-specialised.
In my opinion, we need to move to a position where we train surgeons to deliver the service that is required by our patients, the vast majority of whom will require fairly straightforward procedures. This will include the emergency work in all surgical disciplines, much of which is not highly sub-specialised. The very sub-specialised work is needed by a relatively small population of surgical patients but, of course, very sub-specialised work is of great interest to surgeons. I believe that we should be encouraging surgeons to commit to a career which, in the first instance, requires them to deliver the routine and essential work required by most of our patients. Sub-specialisation could come at a later stage and will perhaps involve relatively few surgeons compared to the needs of the service as whole. I was interested to hear from surgical trainees in Northern Ireland recently that they wish to get to a position of being comfortable in the generality of their chosen specialty before they then move on to increasing sub-specialisation later in their careers.
In my opinion, we will have to move to a position where a CCT is awarded earlier than it is at present. However, the CCT is a mark of competence which is not the same as experience. I anticipate that a surgeon who has been awarded a CCT will be employed in a position where he/she will deliver the routine work and acquire experience. Sub-specialisation would develop later. These principles are stated in a paper produced by the Forum of Surgical Colleges under the authorship of Professor John Macfie and I think that represents a realistic way forward for surgery. Most importantly, this recognises that delivering routine work is important and valuable and is something that we, as a surgical profession, should recognise and support.