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Inspiring the next generation of surgeons
  1. Shujhat Khan
  1. Department of Medicine, Imperial College London, London, UK
  1. Correspondence to Shujhat Khan, Imperial College London, London SW7 2AZ, UK; sk7015{at}ic.ac.uk

Abstract

The shortage of applicants looking to enter surgical specialties is well documented. Indeed, there are a number of reasons for this ranging from potential flaws within the training pathway to a lack of both financial and social support in what is undoubtedly a stressful career pathway. However, it is important that we discuss these shortcomings and exploit such opportunities to make surgery a more attractive prospect. These changes include adapting student’s experience while still at medical school through changes to the medical curriculum and surgical rotations. In addition, it is important to assess what factors applicants prioritise when applying for specialty training, and addressing the gender divide within surgery so as to remove barriers for progression in surgical training. Similarly, by encouraging research within surgery, it improves treatment options for patients as well as motivating those more academically inclined to pursue this specialty. This can produce more proficient surgeons and improve the competitiveness of training posts within remote regions in the UK. Ultimately, these changes will likely translate to more satisfied trainees and improved patient care.

  • medical education and training
  • surgery

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Introduction

For generations, doctors have had the responsibility of controlling bleeding, manipulating organs and healing tissues. Surgery itself has undergone a large transformation through this time. Many of the constraints for surgeons are gone and, after the introduction of anaesthesia, many of the difficulties patients endure have also gone. Along with this came the evolution of greater respect within the community and the medical world, financial perks and a more integrated role of women. However, despite this, current medical students appear less inclined to pursue surgery. While there are many attractive facets in surgery, the lack of interest from current medical students is being deemed a crisis.

Medical curriculum and training

In 2014, it was not possible to fill every surgical training post. In addition, the NHS has seen an increase in 30% for vacancies of specialty training in surgery in just a year1—a fact compounded by half of foundation trainees now choosing not to carry on to specialty training.2 There are a number of reasons attributed to this. Students have listed the lack of support during foundation surgical posts as a major reason as to why they decide not to pursue specialty surgical training. Indeed, this lack of support in surgical training is also particularly evident in medical school. Take for example students graduating from Imperial College London, which consistently has among the highest proportion of students entering core surgical training among medical schools in the UK.3 However, students only have a dedicated 4 weeks out of a total of 6 years in a specialty of their choice. Furthermore, much of this time may be spent in the outpatient department or on the wards as opposed to time in theatres, which limits exposure to highly specialised surgical fields. Indeed, quality time in the theatre can have a marked effect on a student’s desire to pursue surgery and allows positive relationships to develop between the trainee and mentor—a feature that should be further exploited in undergraduate education.

Moreover, surgical training tends to require several further years of training than other specialties. While there are obvious reasons for this, differences in surgical training times between countries suggest improvements are possible. Within the UK, for example, general surgery training will take 10 to 12 years post-graduation. This also includes 2 years of foundation training where trainees rotate through multiple surgical and medical specialties. However, the US model allows surgical trainees to be able to perform a similar number of operations in a residency of 5 to 7 years. By shortening the length of time it takes for surgeons to complete training, it will motivate the future generation to pursue surgical training and will also produce competent surgeons much quicker, which further acts to address the shortage of qualified surgeons in the UK. It is important to note that the length of the UK surgical training pathway is likely to become reduced in the future with the advent of greater subspecialisation. Furthermore, the costs for surgical training can be very high and surgeons are encouraged to attend training courses regularly to progress. These can often be highly expensive which can deter potential surgeons—a factor that is accentuated considering many medical students are burdened with large student debts. A simple resolution would be to provide financial assistance to those requiring it.

Inadequate preparation also seems to dissuade students from applying for surgery.4 Student surgical societies seem to fill a gap where the undergraduate curriculum does not comprehensively teach anatomy and provide ample exposure to surgical specialties.5 However, perhaps a reform of the undergraduate curriculum is required to provide students with more confidence when looking to apply. Within the UK, the medical school curriculum is influenced by guidelines set by the General Medical Council who often try to address the training needs of the UK as a whole, and this in turn influences decisions by medical school boards. As such, other specialties will also advocate for emphasis on their content within the curriculum, and so it is understandably a difficult task to balance teaching commitments to all specialties. It may therefore be useful to run summer schools to provide further surgical exposure to those who are interested.

Regional differences

In addition, applicants are reluctant to accept surgical posts in certain parts of the UK. While 100% of surgical posts are being filled in areas of the UK such as London, only 45% and 75% of surgical posts in Northern Ireland and Scotland are being filled, respectively.6 This is despite the number of applicants far outweighing the number of posts available. Perhaps this is indicative of doctors eager to work in a location where they would be happy to live. This phenomenon is emphasised by trainees refusing to use clearance opportunities to obtain vacant posts, and a large proportion of successful applicants are also withdrawing from the recruitment process in favour of pursuing specialties in more desired locations.6 Indeed, trainees may often prioritise larger academic institutions such as those in London because they offer training in minimally invasive or key-hole surgery that are not available in district hospitals. This is, however, a complex issue and will likely require considerable effort to solve. First, incentives should be given to applicants to apply to less competitive deaneries to ensure no surgical posts go unfilled. Second, by injecting money into deaneries that are less competitive, and increasing the number of specialist centres, it may make such centres more attractive prospects. However, it is difficult to influence applicants who prioritise surrounding elements such as transport links, reputation of schools and socialising opportunities. Such factors require government intervention to better the regional infrastructure. Moreover, there appears to be regional differences in the quality of core surgical training with large variations in the pass rate scores for Membership of the Royal College of Surgeons (MRCS) Objective structured clinical examination (OSCE) results.7 Further analysis may be required to show conclusive results as there can be other reasons accounting for the variation such as the undergraduate university the applicants attended. In order to address this issue, there should be standardised teaching throughout all the deaneries in the UK.

Innovation within surgery

Surgery is by definition a profession that requires body invasion to treat injuries and disorders. Consider for example the obvious brutal nature and exposure to internal organs that can make surgery an unattractive prospect to medical students who seek to treat illness without the constant exposure to the internal body. Modern healthcare systems have made tremendous strides over the past 100 years. In the early years of surgery, loud cries from patients would echo around operating theatres. It was only after the introduction of anaesthesia that the screams were silenced, and focus shifted to patient care. Such innovations have been crucial in modelling modern healthcare practice. Recent technological advancements have also seen surgery become less limited. While previously, surgeons had to carve large incisions, laparoscopic surgery allows surgeons to create smaller cuts—usually up to 1.5 cm. Importantly, these advancements have added an extra dimension to surgery, and the violence has significantly lessened—changes that will make surgery more appealing to a large proportion of medical students.

Gender differences

Despite the rise in the number of women entering medical school, surgery remains a male-dominated field and many female medics have misconceptions about surgical life. This includes the lack of flexibility within surgery to raise a family as well as the reputation of surgeons as being hostile and egocentric. This impression seems to stem from the portrayal of surgeons in the media and a lasting reputation that has stuck with surgeons since the 20th century. As such, an obvious starting point to address the shortfall in surgical applicants would be to attract more female surgeons. With the introduction of the 48 hours working time directive for junior doctors, the NHS has made strides towards aiming to balance excellence in surgery with a more healthy perception regarding social life. Furthermore, there is a national initiative to encourage more women to apply for surgical applications termed ‘Women in Surgery (WinS)’. This aims to support and educate women who have surgical ambitions through local events, offering advice and by raising the profile of women in surgery. Such efforts are instrumental in motivating women—who make more than half of the medical student population—to apply for surgery. Concerningly, there also appears to be barriers for progression in surgery for women. These are not completely understood and are likely a combination of multiple factors. There are lower numbers of women among leadership positions, and women also have a reduced number of publications and citations. To address these issues, the academic surgical pathway is useful as it provides a seamless integration of research while training. However, there needs to be a greater number of female mentors to provide career and lifestyle guidance.8

Research and support

Surgery is an unusual field, which can often involve manipulating the nature of anatomy. From transplantation medicine to the emergence of regenerative medicine, the value of research within surgery has always been instrumental in delivering better patient care. In 1812, for example, Johns Warren, a surgeon at Harvard, published a novel method to treat cataracts. Warren discussed inserting a broad cornea knife at the outer angle of the eye, through the cornea, until its point approached the opposite side of the cornea. Subsequently, Warren withdrew the knife and the aqueous humour was allowed to drain followed by protrusion of the iris. With great difficulty, he then proceeded to insert forceps into the collapsed orbit. A bandage was applied, and the patient was sent on his way. Crucially, the patient recovered and was able to identify objects many weeks later.9 Driven surgeons have often had to struggle to deliver cutting-edge research. Of concern, many surgeons are now turning away from research as evident by the falling number of grants and publication from surgeons.10 Numerous surgeons state the lack of time for conducting research as a key reason for this. Indeed, this may deter medics from a surgical career if they wish to invest heavily in research. While surgeons such as Warren were able to find patients willingly and had less ethical constraints, modern surgeons have to apply for grants and can find it time-consuming to perform the administrative duties of performing research. There is obvious logic behind this, but perhaps a better solution for this would be for policy-makers and hospitals to create an environment where surgeons are encouraged to apply for grants through incentives and are afforded the time to do so. This will encourage students who are interested in research to pursue surgery and will also create an intellectual environment that fosters better treatment options for patients.

Conclusion

The surgical field, with its ability to attract those seeking to pursue financial remunerations and social prestige, will always remain central to medical advancement and patient care. Meanwhile, urgent modification is required to inspire the next generation—that is, before the NHS witnesses the impending large shortage of surgeons.

List of learning points

  • The medical curriculum needs to be adapted to promote surgical specialties and have a greater focus on anatomy

  • Research and support from mentors should be encouraged for trainees

  • Barriers discouraging females from entering surgical training should be explored and solutions sought

  • The surgical training pathway needs to be reformed and ideally shortened to make it a similar length to the surgical training pathway in other major countries

  • Financial support should be offered to support trainees

  • Increased specialisation of hospitals in remote regions alongside better regional infrastructure and incentives to trainees will make surgical posts in these regions more attractive

References

Footnotes

  • Contributors SK is the sole contributor to this article.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; internally peer reviewed.