Career: Making the cut

AN ANONYMOUS wit once said that a physician is someone who knows everything and does nothing while a surgeon is someone who knows nothing but does everything.

One thing at least is true: surgery as a profession has always been about practical skills and active intervention in medicine. And even with the vast diversity and specialisation of modern surgery this still applies.

Surgical specialties are among the most competitive in medicine. To make it as a surgeon you need both high technical ability and a keen intellect. You will also require drive, perseverance and a clear sense of direction in your career choice.

A career in surgery has many benefits: it can often be immediately rewarding in terms of patient satisfaction. Your professional skills will also be in high demand; thus it offers both job security and a decent income.

An integrated specialty

General surgery is one of the largest of the nine surgical specialties accounting for around 31% of the consultant surgical workforce. Traditionally it has been considered an integrated specialty consisting of vascular, endocrine, oncological and gastrointestinal work. The Intercollegiate Surgical Curriculum Programme (ISCP) states that “a shared syllabus and the ability at the completion of training to manage an unselected surgical emergency ‘take’, provide a common purpose across the specialty of general surgery at the time of writing (2007)”. But as with many other disciplines there has been an increasing trend towards further specialisation within general surgery and the development of ‘areas of special interest’ including:

• upper gastrointestinal surgery (oesophagogastric and hepatopancreaticobiliary)

• colorectal surgery

• general gastrointestinal surgery or specialist GI surgery

• vascular surgery

• transplantation (renal, hepatic and pancreatic)

• breast surgery (including oncoplastic)

• endocrine surgery

Other less well-developed areas within the syllabus also include military surgery, general surgery of childhood, remote and rural surgery and academic surgery. General surgeons are expected to develop an area of special interest by the time they fully qualify.

All surgeons need a high degree of mental and physical stamina and general surgery is no different. NHS Careers describes the personal qualities needed to be a good surgeon as:

• the capacity to operate effectively under pressure the ability to remain objective when under pressure

• good communication skills

• the capacity to think beyond the obvious

• the capacity to monitor and anticipate situations that may develop rapidly

• effective judgement and decision-making skills

• leadership skills

• the capacity to manage time and prioritise workload.

Entry, qualifications and training

Upon completion of FY2, trainees with an interest in any surgical specialty must compete for entry into core training (CT) or specialty/run-through training in the regions where CT has not been adopted. Core training consists of a paid job in a hospital setting with experience provided in a range of surgical specialties but can also be ‘themed’ towards one particular specialty. Upon finishing core training a surgical trainee interested in general surgery can apply for that specialty along with other candidates. Selection for higher specialty training in general surgery then involves a further six years to achieve a certificate of completion of training (CCT).

Getting the job

Entry into surgery is obviously very competitive and planning should ideally begin in medical school. Identify what area of surgery interests you and start now to create a portfolio of experience, knowledge and skills demonstrating your commitment and aptitude in that specialty. Remember that very few people are lucky enough to land the exact job they want so second and thirdchoice options are advisable.

Check the websites of the Surgical Royal Colleges and the ISCP for more information on required competencies for entry into surgical training. Think creatively about how to improve your career portfolio and don’t limit this to work situations only. On their website, The Royal College of Surgeons of England suggests:

• attend/make presentations at courses, conferences, seminars

• join or organise a journal club

• explore membership of an association relevant to your career interests

• undertake self-directed learning

• teach and/or demonstrate (anatomy demonstration posts are particularly useful)

• take part in research

• write letters, articles, reports for publication

• take part in audit projects

• join and participate in local surgical societies.

You can also take part in ‘taster weeks’ during FY1 or 2 training and apply for surgicalrelated study leave in FY2.

Ensure you keep good records of the activities you undertake in order to easily compile your portfolio and write application forms. Ask for letters of support from any clinicians you have worked with outside the normal teaching programme. Check out the Pan-Surgical e-logbook (www.elogbook.org ) established to allow surgeons in the UK and Ireland to record professional and personal development throughout their career. You can register at any time in your training.

You should also contact the Surgical Royal Colleges for other opportunities to further demonstrate your interest and enthusiasm for a career in surgery. The Royal College of Surgeons of Edinburgh runs an affiliate scheme for any medical student studying at university or trainee who has not yet passed their MRCS. As an affiliate, you receive a range of benefits, including careers support and advice, career development events tailored specifically to your needs and access to the college’s library services and e-journals.

Being organised, focused and very determined will take you a long way toward getting your first choice of a career, be it in surgery or any medical speciality.

Jim Killgore is an editor at MDDUS

Q&A Mr Ben Stutchfield, ST2 in general surgery

• What attracted you to general surgery? During my surgical attachment in final year medicine I was really inspired by the general surgical on-call week, particularly watching slick operators opening abdomens and directly sorting out the patient’s problem. General surgery offers a great variety of patient presentation and operations – from emergency surgery controlling haemorrhage or sepsis, to major cancer resections. alongside open surgery, laparoscopy and endoscopy are having an ever increasing role. It is this variety that has been a major attraction for me.

• What do you enjoy most about the job? Operating is certainly the highlight and it is great seeing the change in patients postoperatively when their source of sepsis has been controlled or cancer removed.

• Are there any downsides? Going hand in hand with operating is the responsibility it brings. This is certainly not a downside in itself but it can mean many anxious hours after an operation, no matter how major or minor, if for whatever reason there is concern about the patient’s progress. This does not change, no matter how senior the surgeon is.

• What do you find most challenging? The general surgical on-call can result in a long list of admissions. assessing all the new admissions and reviewing previous admissions, ensuring the pertinent issues are covered before the morning theatre list starts can be quite a challenge. It is certainly a great test of organisation and efficiency.

• What do you think is the most important personal characteristic in a good surgeon? Being an effective decision maker is vital in a good surgeon. When to operate and, often more importantly, when not to operate must take into consideration many factors. Whether the patient is going to theatre or not, the plan of action should be clear for every patient.

• What is your most memorable experience so far? a middle-aged gentleman had suffered a ruptured abdominal aortic aneurysm while I was on call for vascular surgery. I had assessed the patient in a&E and he was rapidly transferred to theatre. During the operation the patient suffered a cardiac arrest but was successfully resuscitated and the aneurysm repaired. The patient was discharged from hospital fit and well ten days later. During the operation it had seemed like hope was fading fast for this gentleman. The case really highlighted the teamwork that was so important in getting this man through – from his quick transfer to theatre, the anaesthetic team leading the resuscitation during the operation, intensive care support postoperatively and then the nurses and physiotherapists working towards discharge.

• What advice would you give to a final year or FY trainee considering general surgery? Decide where the weaknesses in your CV are and put together a plan early in your foundation years of how to address these, whether it be writing papers, presenting at conferences, sitting examinations or assisting in theatre. It is not particularly helpful to try to do every course or exam available, but sit down with a senior trainee or consultant and plan out what would be best for you, giving you the best chance of selection on to your chosen training scheme.