Barriers to getting into surgical training

Hi, just want to get your views on common barriers for surgical training. Here where some thoughts that were mention by some classmates

1) There is still significant amount of nepotism or being in a "network/circle of people" who tend to choose their own for opportunities such as research, educational roles or leadership roles etc.

2) Difficulty in find a mentor/source of help during foundation year. Issues regarding this include micro-aggression or racism (Eg tolerating remarks or jokes), sexism and peer pressures of drinking alcohol during during socials.

3) Money, money and money. Cost of courses gatekeep applicants (paying for courses + travel). Making it hard for individuals from low-income families or houses to enter into surgical careers due to competitive advantage offered by courses

4) A race against time in getting to training programmes as taking f3/4 etc Due to the risk of becoming ineligible from applying at ST3 etc

5) Heavy weighting to the amount of activities rather than quality

6) Lack of concern about the spaces of CST/ST programmes even though there is a fore-cast of backlog of surgeries that will likely continue. (Considering the increasing demand on surgical services begining to increase)

7) Due to COVID-19 surgical/medical electives were cancelled, not fair to assign points on CST for 2020 and 2021 graduates.

Reply 1

nexttime

Original post by Anonymous

1) There is still significant amount of nepotism or being in a "network/circle of people" who tend to choose their own for opportunities such as research, educational roles or leadership roles etc.

Yeah definitely.

Would also apply to things like getting work experience to get into medicine in the first place - slowly improving, but still very nepotistic.

Probably not to the same extent as almost any other profession, though? Where your bosses directly choose to promote you based on effectively whatever they want? Its just how our society works really - modern day corruption.

Doesn't sound like you're a medic? Just checking perspective.

2) Difficulty in find a mentor/source of help during foundation year. Issues regarding this include micro-aggression or racism (Eg tolerating remarks or jokes), sexism and peer pressures of drinking alcohol during during socials.

Yes, although I have to say in my experience the number of instances where juniors go out drinking with seniors is very limited, and pressure to drink wouldn't be the same as it would be at say uni. Or perhaps in some private sector companies where you have company socials/away days etc.

If it was going to happen anywhere, it would probably be surgery though!

3) Money, money and money. Cost of courses gatekeep applicants (paying for courses + travel). Making it hard for individuals from low-income families or houses to enter into surgical careers due to competitive advantage offered by courses

I'm not really sure what you mean by this. When you apply for surgery you've done ~1.5 years as an FY doctor already, and whilst doctors aren't paid loads straight from uni, it is above the national average wage. That should blunt a lot of impact that paying for courses might have. You also get a study budget at FY2.

Unless you're taking an international perspective? In which case you generally can apply to surgery straight from med school, but obviously selection criteria will be very varied.

4) A race against time in getting to training programmes as taking f3/4 etc Due to the risk of becoming ineligible from applying at ST3 etc

Again, not sure what you mean? Are you referring to the maximum surgical experience thing that I don't think exists any more?

5) Heavy weighting to the amount of activities rather than quality

Certainly the way doctors are selected can be very dumb - a high quality very impactful audit can score the same number of 'points' as a 2 hour audit that did nothing.

Not sure that is a barrier to participation though? The rules are at least the same for everyone?

6) Lack of concern about the spaces of CST/ST programmes even though there is a fore-cast of backlog of surgeries that will likely continue. (Considering the increasing demand on surgical services begining to increase)

I mean, I guess non-infinite numbers of surgical places is a 'barrier' yes! Its not very realistic though.

Certainly more surgeons would help medical care. My impression though is that surgery is not any more understaffed than anywhere else, and in fact it might be better? With less rota gaps? That claim has the potential to be very complicated and controversial, but basically you've got to consider that if you take trainees to one field you are removing them from another, so increasing surgical places is a complicated thing that generally doesn't consider how many/how much people want to be surgeons. And rightly so.

7) Due to COVID-19 surgical/medical electives were cancelled, not fair to assign points on CST for 2020 and 2021 graduates.

Electives went ahead - you just had to do them within covid restrictions i.e. likely within the UK or your local area. You wouldn't get points just for doing an elective abroad.

I think you've probably missed the biggest one: people being put off of surgery before they've even applied. Absolutely happy to see an alternative opinion from a surgeon/someone else, but in my experience, surgical culture is quite different to other specialties, and it puts a LOT of people off. It is more competitive (as in, day to day), stricter hierarchy, less family friendly, and perhaps more controversially: has a lot more unpleasant people working within it. Its a stereotype and there are lots of lovely surgeons, but I'd say 85-90% of the time we hear about a bullying senior here on TSR, its a surgeon, and in real life the only cases of what sounds like overt bullying that I saw were surgeons. Even in departments that don't have such individuals, the reputation they have garnered definitely puts people off in droves.

It being relatively less family friendly, in terms of ability and numbers who go part time and in terms of being able to leave if there is a childcare emergency, is also a barrier.

The historic lack of female role models is probably another. There are a lot more female surgical trainees now, though in comparison to other specialties is still very male dominated (remembering that overall medicine is very female-dominated these days).

The mobility of the career - having to move cities every year, or sometimes even more often, whilst training - is another barrier, although it is one shared by most medical specialties.

You could maybe argue that exams, which tend to be done earlier in surgery, is a cost barrier.

Reply 2

surg36

Just expanding on a couple of points in addition to the solid/comprehensive ones above.

Spaces. The more spaces created at CT/ST, the larger the bottleneck at ST/consultant level respectively. Personally I’d rather more people were filtered into other career paths at pluripotent SHO level, than struggle to find a job post-CCT with a mortgage to pay/family to feed. Also an increased supply of CCT holders relative to jobs risks downward pressure on working conditions (‘subconsultants’ etc)

As above, workforce planning is also an inexact science. Next year’s CT1s hopefully won’t be dealing with the post-Covid backlog as consultants(!), but clearly there will be other demographic pressures. Counterbalanced, of course, by political and cost pressures. For example, we’ve underproduced radiologists for years now (reducing the exponential CT/MRI reporting burden is less sexy than, say, reducing the arthroplasty waiting list). And we probably need to train GPs more than any other kind of specialist. Arguably a zero sum game.

Courses. I didn’t go on any paid courses for UKCAT (such as it was), BMAT, medical school interviews, PSA, SJT, finals, AFP, MRCS or CST. Mainly on principle, but also out of pure stinginess. Would I have performed better at each stage with a paid course? Probably yes, but objectively they weren’t necessary to progress. Hate the game by all means, but you can still play to win.

(In the interest of transparency, I should say I finally chickened out for ST3 interviews, when I decided to pay for a local prep course. Easily affordable out of a regular monthly CT pay packet. No locum weekends/credit card needed)

Reply 3

surg36

Bullying & undermining. Very topical in surgery - c.f. a recent British Orthopaedic Association campaign on Twitter. Indeed topical on social media elsewhere - apparently Chrissy Teigen is now the latest celebrity to be cancelled….
My (n=1) experience has been of a net positive training environment, but I have still experienced and witnessed microaggressions on discriminatory grounds. It is less tolerated than in the past: withdrawal of trainees at best, suspension of trainer at worst (I have seen both, but not limited to surgery. So neither are idle threats).

So that particular barrier has certainly been lowered. Unashamed bias here, but the new generation is less tyrannical, occasionally works less than full time, and is increasingly gender balanced (even in T&O). Things have changed and are changing.

Incidentally my worst ever bullying experience in medicine involved an individual from the non-surgical specialty that helps pump IV co-amoxiclav to the bones… again, another specialty that doesn’t have the best rep traditionally. I remain an optimist!

Reply 4

Anonymous #1

Original post by surg36

Surgical courses*, Eg: BSS, etc

Reply 5

surg36

Usually desirable, not compulsory. E.g. I chose not to do CCRISP (was happy enough with the other boxes that were ticked). No need to go crazy with surgical courses, though the FOMO is often pretty strong.

ATLS commonly compulsory for ST3, BSS often a local exit requirement for CST. Both usually covered by the CT study budget.

I totally accept that doing both in F2 - on top of MRCS - can be a substantial early ‘price of admission’, as not usually covered in their entirety in foundation programme.

I guess the overall point is that the barrier is very much negotiable, certainly more than some of the other equally valid ones you mentioned (mentorship, nepotism…)

(Pretty sure all of the above are officially recommended for CT level anyway. But I would actually disagree with that for MRCS Part A, and try to get that done prior to CST.)