Career focus: A career in surgery

Amit Bidwai shares what he found out from the surgical careers day at the Royal College of Surgeons and Ardeshir Bayat gives a surgical trainee's view

Surgery has become increasingly advanced since the days of the barber surgeons. Of course, all of us will have a qualification in surgery when we finish medical school, but how does a medical student become a consultant surgeon?

An excellent source of information is the surgical careers day held several times a year at the Royal College of Surgeons in London. There are guest speakers from every step of the surgical career pathway. Each speaker is then subjected to a question and answer session. The day concludes with a tour of the college and a surgical skills session. Each student also receives an information pack about CV skills and the career pathway. I have summarised what I was able to learn at the careers day last March.

Medical student

Those students who want to be surgeons can show their interest early on - for example, by choosing to be on a surgical firm for a special study module. It would be useful to be involved with research papers or any other projects. This will help when applying for both medical and surgical preregistration house officer (PRHO) jobs.

But do not forget that consultants like well rounded personalities on their team, and applicants should always have interests outside medicine on their CV. It is important to start preparing early by getting your CV into good shape with both academic and extracurricular activities.

Preregistration house officer

Consider what type of PRHO job you want. Many jobs are advertised in BMJ classified, but most medical schools run matching schemes for these jobs. The college recommends that medical students remain within the matching scheme of their own medical school.

There is now an alternative option to the traditional six month medicine and surgical posts. The new composite posts consist of four months of medicine, four months of surgery, and four months in an alternative specialty - for example, general practice, obstetrics and gynaecology, or ear, nose, and throat.

The traditional six month posts allow a degree of flexibility in terms of where you work in the country, but the composite jobs tie you to one area of the United Kingdom Consultants have a mixed view of the posts. Some see them as new and exciting, other see them as two months of missed surgery or medicine, or some feel that it does not matter as long as you have made the most of your opportunity.

If you decide on the traditional six month jobs you should think whether surgery or medicine comes first. There are pros and cons. Some say that the "more challenging" medical job prepares you to perform better on the surgical job. However, starting off with a surgical job shows interest for others, confirms your own interest in pursuing a surgical career, and gives your consultant more time to assess your performance when you ask him or her for a reference for your next job.

Consider who to work for. Working for a consultant you know well may bring out your personality and you will perform well. Landing a job on a professorial team may look good on paper, but you may be intimidated, your personality may not shine, and you may perform poorly. It is better to have a good reference from a regular consultant rather than a mediocre reference from a professor.

Senior house officer

To progress from PRHO to senior house officer (SHO) jobs you need to confirm that you want to be a surgeon early on, to be in plenty of time for the application process. The SHO jobs are advertised in BMJ classified and are part of the basic surgical training programme. You will need to ensure that the post advertised is recognised by the regional postgraduate dean. In case of uncertainty, it is best to confirm this with the relevant royal college of surgeons and the regional postgraduate dean's office. For example, the educational approval of basic surgical training posts in England and Wales is granted by the Royal College of Surgeons of England's hospital recognition committee. Each training post is intended to provide maximum educational and training opportunities for SHOs. This is something to bear in mind when applying for surgical jobs in the future.

Basic surgical training runs for a minimum of two years. Throughout the programme, different stages of the surgical exam are taken to finally make you a member of one of the royal college of surgeons. It is designed to teach the principles of surgery in preparation for higher surgical training. The basic sciences are revisited, including anatomy, physiology, and pathology, in a combination of teaching, private study, and educational courses.

Surgical rotation

SHO posts can be either stand alone, which are of six months' duration only, or made up with another sometimes less popular specialty for a period of 12 months. You would require enough jobs of the right grade to satisfy the royal college training board requirement to make up your own surgical rotation. The popular alternative is the surgical rotation, usually put together by the health authority or board to provide the necessary training requirements. The advantages of rotations include knowing which part of the country you will be based in; no worries about applying for a job every six months; time to concentrate on training and education; and the satisfaction that jobs are recognised for training (stand alone jobs are not always recognised).

Most basic surgical training programmes last for three years to allow enough time to pass the MRCS exam or to provide experience in a specialty that you might be considering. A logbook of all the operations performed during the basic surgical training programme is needed for the MRCS examination. Even if you decide not to continue with a career in surgery at the end of your training the MRCS exam will also enable you to apply for specialist registrar posts in specialties, such as radiology and emergency medicine.

The basic surgical training is completed when the required number and types of jobs have been completed; the consultant's assessment of your performance is satisfactory; and the MRCS exam has been completed - losing the title Dr and becoming a Mr or Miss.

The MRCS exam involves two parts, the written followed by the clinical. The written part of the exam is taken first and is in the form of multiple choice questionnaires. The clinical exam is divided into clinical cases or scenarios and vivas.

Specialist registrar

Following successful completion of the basic surgical training and the MRCS exam, you should be aiming to get yourself a specialist registrar (SpR) job in the specialty of your interest. Getting a desired SpR post in your chosen specialty in a specific part of the country can be tricky, and you will usually find yourself competing with a large number of candidates for a few numbered posts. Most trainees end up spending a variable period of time in senior SHO posts or in surgical research before getting appointed as a SpR.

SpR jobs are part of the higher surgical training programme. The aim of the programme is to expand clinical experience, take on increasing responsibility, and especially to develop an interest in a particular surgical specialty.

The posts are again advertised in BMJ classified. Higher surgical training lasts between five and six years during which time you will work in different hospitals within a region, commonly changing posts every six to 12 months, although this may vary in different regions. Every year there is an assessment of performance, and after the fourth year the intercollegiate specialty exam can be taken. This leads to the FRCS qualification in the chosen higher surgical training specialty - for example, FRCS (ORL-HNS) (fellow of the Royal College of Surgeons in otorhinolaryngology, head and neck surgery).

When the training and the examinations have been completed you are awarded the Certificate of Completion of Specialist Training (CCST). Your name is then placed on the General Medical Council's specialist register. Once on the register you are eligible to apply for consultant jobs in your specialty.

Consultants

Once appointed as a consultant, education does not stop. Consultants are obliged to learn new skills, continue research, develop new techniques, and to teach doctors and students. This is known as continuing professional development (CPD). Training and performance assessment of all consultants will also continue in the future in the form of revalidation, so the joys of continual examination will never stop.

Those consultants with an interest in surgical research can choose to work in academic units. Consultants can also opt to have contracts with NHS trusts so that they can continue to work both in clinical practice and research. Those with academic intentions can be appointed as lecturers, senior lecturers, or readers, perhaps leading subsequently to professorships in surgery. And, of course, there is always the option of private practice, if you are so inclined.

The training programme in surgery is intensive. This may not suit those of us with other commitments and interests outside medicine. Flexible training can be arranged through the regional deaneries for those people who meet certain criteria. Other options include part time training and job sharing. Obviously these programmes would involve more time spent at each level of the career pathway.

Surgery can be a very satisfying profession, with a mixture of analytical and manual skills. But there are disadvantages-long hours and commitments often interfere with your personal life. However, all the effort can be worthwhile, as most surgeons will tell you, there is no specialty like surgery where you can have fun as well as get the chance to perform life saving operations.

Amit Bidwai, fourth year medical student, University of Manchester

Ardeshir Bayat, MRC fellow in plastic surgery, Manchester
Email: ardeshir.bayat@man.ac.uk


studentBMJ 2001;09:217-260 July ISSN 0966-6494