There have been enormous changes in surgical training: increasing specialisation; the technical advances of surgery and the ubiquity of advanced laparoscopic and other procedures. There are now several well-recognised surgical sub-specialties such as Breast, Endocrine, Upper Gastrointestinal (including Hepatobiliary), Lower Gastrointestinal, Vascular and Transplant surgery.
The essential criterion the would-be surgeon must possess, is, I believe, a genuine interest: it is very hard work and it can be a long road. Usually, it is interesting and mostly very rewarding but occasionally can be disappointing. During the F2 year, the budding surgeon will apply for Core Training for which there are about 90 places in Northern Ireland. The two Core Training years (CT1 and CT2), entail rotating through various specialities. During this time the trainee should complete an audit project and acquire the MRCS exam. They also will attend various courses such as the ATLS, and CRISP.
The Intercollegiate Membership of the Royal College of Surgeons (MRCS) has two parts. Part A is usually taken in CT1 year and part B in the CT2 year. Part A has two sections: Section 1 is applied basic science based on the single based answer format. Section 2 of part A is on the principles of surgery, examined using an extended matching question format.
Part B is in an OSCE format, testing anatomy, surgical pathology, surgical skills, patient safety, communication skills, applied surgical science, critical care, clinical skills, examination and history-taking.
There is (except for Scotland) uncoupling between Core and Specialist Training. The Core Trainee must apply to become a Specialist Registrar. This is a significant hurdle as there are only 15 trainees per year in all specialities. (At times in general surgery there may be only 1 or 2 trainees appointed to ST3 level). Most trainees will therefore complete a third year of core training. There are a number of ward and operating theatre-based competency assessments, such as peer assessments, mini PAT, clinical acumen, mini CEX, case-based discussions, observation of procedural skills, DOPS, procedure based assessment, log book experience, education supervisor reports and a Deanery interview. It is now increasingly recognised that not all trainee surgeons' progress at the same rate and training should now be ‘competency based.’ The trainee must demonstrate proficiency with different procedures before being allowed to progress.
The higher training years (ST3 – ST8) are based on a very well developed curriculum. Typically there are between 6 and 8 years of higher training. The early years involve general rotations. During the last few years of training the trainee will gradually (in the current environment) focus on a specialty.
The last major hurdle is the Intercollegiate FRCS examination. Typically, in year ST6, the trainee will take section 1 of the examination. This is a two part written paper: the first, a single best answer paper; and the second, an extended matching question paper. From January 2011, candidates will be permitted only three attempts. The current examination format for section one examines basic anatomy, physiology, pharmacology and statistics in addition to all the clinical aspects of the major sub-specialties within general surgery.
Section two, the clinical aspect of the examination, comprises a critical care viva as well as academic, general and speciality vivas and an emergency surgery viva. There then follows a one hour clinical examination, 30 minutes of which is spent in the generality of surgery and 30 minutes in the candidate's own specialty.
In addition to this rigorous examination system, a number of research-active trainees will take three years ‘out of practice’ to complete a PhD. More often, trainees will attain an education qualification, part-time and module based.
Ultimately, you become a consultant surgeon – what is your week? Typically, it will comprise 2 or 3 operating sessions; 2 outpatient sessions; 1 endoscopy or special interest clinic; 1.5 sessions for direct clinical care (ward rounds etc.), and 0.5 for indirect care. There will be a session for being on-call, generally, 1 in 5 or 1 in 6, and further provision for teaching, training, and self learning. For all surgeons, interprofessional team working is here to stay. Virtually all cancer patients, for example, are now reviewed before and after surgery by a multi-disciplinary team including the surgeon, oncologist, pathologist, radiologist, and specialised nurses.
A smaller number of surgeons will work for the University in an academic role. Traditionally half their time will be spent working clinically and half will be spent on academic matters. Education and research are valued equally, so some surgeons may major in education and some in research.
So you want to become a surgeon? Rewarding and satisfying? Yes. Teamworking? Yes. Future mentoring as a young surgeon? Probably yes. Will your work and career change over the next 30 years? Definitely yes. So you still want to be a surgeon – and this is your passion – GO FOR IT!