Core surgical training: what’s the difference between programmes?

Themed and unthemed core surgical training

Themed core surgical training is biased towards a particular surgical specialty and often entails spending 12 to 20 months of a two year programme in the themed specialty. The remainder is spent in unrelated or, more often, allied specialties. Conversely, unthemed core surgical training refers to programmes that provide more generic training, with exposure to a greater number of specialties.

Most UK deaneries have moved towards the delivery of two year themed training, but unthemed training is provided by the following deaneries: London; Kent, Surrey and Sussex; Wessex; East Midlands South; East of England; and Northern Ireland. These deaneries aim to provide at least six, and sometimes 12, months in chosen specialties if possible. West Scotland is unique in that it offers a mixture of themed and unthemed programmes, although everyone still does 12 months in general surgery.

There are advantages and disadvantages to themed and unthemed programmes. If you are completely confident in your chosen specialty when you are ready to apply, then themed training has several advantages.

Themed training often provides maximal clinical experience in your chosen field. In preparation for ST3 applications, it is likely to provide more opportunities to tick the audit, research, teaching, and publication boxes in your desired specialty. Themed training also gives greater opportunities to develop relationships with colleagues and consultants from your chosen field, whose support will be important for the ST3 application process.

However, with themed training, if you are unsuccessful in securing your desired theme for core training you will be stuck with another specialty. Themed posts are restrictive if you change your mind and decide to pursue another specialty at ST3 level, unless the deanery can accommodate this change.

Themed trainees may be “less rounded” surgically, although whether this makes much difference is unclear. Despite the new intercollegiate membership of the Royal College of Surgeons (MRCS) examination taking specialty preferences into account, I found that my exposure to a breadth of surgical specialties during foundation year 2 and CT1 was extremely helpful.

Those uncertain of their chosen surgical specialty would probably benefit from unthemed training, as it will expose them to a variety of specialties and give more flexibility in guiding CT2 composition. Unthemed trainees have more time to decide on their chosen specialty for higher surgical training. They can also keep more doors open, as they will usually be eligible to apply for more than one specialty at ST3 level. The main drawbacks relate to generally having less exposure to your specialty of choice and fewer natural opportunities for strengthening a CV in one final specialty.

Specialties

Most deaneries providing themed core surgical training offer general surgery; trauma and orthopaedics; urology; ear, nose and throat (ENT); and plastic and reconstructive surgery. However, the proportions of these posts differ across deaneries. It is therefore worthwhile researching which deaneries have the most jobs available in your chosen specialty.

For example, South West Peninsula deanery has provisionally allocated only one job in the specialties of urology, ENT, and cardiothoracic surgery for 2013 entry. If you are set on becoming an ENT surgeon and wish to ensure maximal exposure during core surgical training, your chances of securing an ENT job may be higher in other deaneries. The North West, for instance, has provisionally allocated 10 themed jobs.

Some of the smaller specialties, such as cardiothoracic surgery, paediatric surgery, and oral and maxillofacial surgery, are not catered for at all. You should therefore check before ranking deaneries if you are keen to pursue one of these smaller specialties. Yorkshire and Humber and East Scotland deaneries offer a vascular surgery themed core surgical training. This may reflect the recent recognition of vascular surgery as an independent specialty, with its own higher surgical training pathway starting in 2013.2

Experience of neurosurgery is sometimes provided during core surgical training, but the neurosurgical training pathway is distinct from other surgical specialties and run-through training into ST1 is selected for separately.3 Having said that, Yorkshire and Humber provides a themed job in neurosurgery, although it is the only deanery to do so. But candidates for this job would be ineligible for ST3 entry unless they had gained added experience between foundation year 2 and CT1.

Similarly, new for 2013, there are a few run-through training posts in cardiothoracic surgery, which again is recruited separately.4 Run-through training removes the need to reapply at the highly competitive ST3 bottleneck to secure a national training number. For those with an academic interest, there are a few ST1 academic clinical fellowships across a range of surgical specialties recruited annually,5 and these also enable successful applicants to secure a national training number.

Checking the current ST3 person specifications on the Modernising Medical Careers website (www.mmc.nhs.uk) is useful. If possible, it would also be helpful to look at application forms for the specialty you are interested in pursuing long term.

All specialties require two years of core surgical training and six months’ experience in the respective specialty at this level (or equivalent) by the time of appointment. An exception is oral and maxillofacial surgery, which requires only one year and does not specify a minimum requirement of experience in the specialty. General surgery and trauma and orthopaedics both require at least 10 months’ experience in the respective specialties, excluding foundation years.

Length of posts

Generally, rotations are six months in duration. Some deaneries provide rotations of four, eight, and 12 months. The advantage of four month rotations is that they provide a greater breadth of training and the opportunity to sample different specialties. This may be useful during CT1 for those who are uncertain about their chosen career path. But four months is a short time to spend in one department. After taking into account on-calls, days off due to the European Working Time Directive, annual and study leave, even six month rotations fly by. The longer the rotation, the better the chances of developing a productive working relationship with trainers and getting to grips with the specialty.

CT3 year

National guidelines set the duration of core surgical training at two years, but just under a third of deaneries still offer a CT3 or extra year in training. Others may still provide an extra six to 12 months’ experience, should candidates fail to pass their MRCS examination or annual review of competence progression. However, this is likely to be in the form of a locum appointment for service and is judged on a case by case basis.

Only a third of trainees gain an ST3 national training number during CT2, so a potential third year in training provides a useful safety net for those candidates who are unsuccessful first time round. A third year in training also provides an opportunity to gain further clinical exposure in your chosen specialty and strengthen your CV while you are still in a training job.

Competitive CT2 allocation during CT1

For most deaneries, allocation of CT2 rotations does not require an extra competitive step. Rather, allocation of the two year programme depends on your national selection interview score. However, some deaneries—London; Kent, Surrey and Sussex; East Midlands South; and Oxford—allocate CT2 rotations based on performance during CT1. This provides flexibility but means you have to excel compared with your colleagues at CT1 level and there is uncertainty regarding the composition of your second year. Whether this is a positive or negative aspect will depend on the individual. Anecdotally, some deaneries are more flexible than others in terms of catering for individual preferences. Many deaneries advertise their flexibility, but I recommend talking to current trainees to get a feel for this.

What do consultants think?

Across specialties and deaneries, senior consultants concerned with training seem divided on the optimal delivery of early surgical training. Many senior consultants think that the general skills and breadth of experience gained from working in several specialties during core surgical training is invaluable. Others say that it is more useful to get a handle on your chosen specialty before entry to ST3.

When asked directly, most training programme directors say a two year programme is adequate to establish the necessary competences before higher specialty training. Most programme directors believe a third year is unnecessary in what is already a long postgraduate training compared with other countries.

Final thoughts

All core surgical training programmes, irrespective of their structure, aim to provide core competences in surgery according to the Intercollegiate Surgical Curriculum Programme and prepare their trainees for ST3 application.

The information given in this article on the variation in training programmes should give junior doctors food for thought when choosing a specialty for core surgical training. It is also important to consider a range of other factors. These include personal circumstances, competition ratios, deanery size, potential for long distance commuting, and information on the quality of training, such the General Medical Council’s national training survey. For some people, personal ties to a particular geographical location will outweigh anything else. Prospective candidates may also find it useful to look at the surgical recruitment for the NHS website (www.surgeryrecruitment.nhs.uk), the NHS specialty training website (www.mmc.nhs.uk), and individual deanery websites.

Despite all the variations between programmes, in reality it is unlikely to make an appreciable difference to trainees who are motivated to succeed. Core surgical training provides the foundation for learning to be a surgeon. As has always been the case, it is up to the trainee to make the most of this opportunity.