The Role Of A General Surgeon
General surgery is the art of having a broad knowledge base combined with model execution - a profession that attracts those with high levels of manual dexterity, unfaltering determination and a desire for perfection.
A career with a large proportion of acute emergencies, the general surgeon acquires the skills to make vital and rapid changes to a patient’s quality of life in high pressure circumstances.
The word ‘general’ can be misconstrued, a sweeping statement that sounds imprecise and vague. However, it is general surgeons that use their wide range of knowledge and skill to treat patients of all ages, from the removal of an appendix, to the resection of a bowel tumour and even the replacement of a kidney, it all starts with training in general surgery.
As one of the largest surgical specialties in the UK, general surgery specialists make up 31% of consultant surgeons. The role of a general surgeon has a strong emphasis on acute abdominal problems, though due to their range of competencies, they are essential in all kinds of surgical emergencies, making them a crucial member of A&E departments and trauma teams.
Away from the emergency department, general surgeons undertake many elective and outpatient procedures, a large proportion of these being gallbladder removals and hernia repairs.
Yet, this does not waive the ability to sub specialise into more specific territories such as colorectal, endocrine and breast surgery. No matter the subspecialty, general surgeons remain part of large multidisciplinary teams both inside and away from the operating theatre, be it in the A&E department, on ward rounds or conducting outpatient clinics.
A Typical Week
With a sizable proportion of general surgical patients presenting acutely with abdominal pain, it is understandable that emergency surgery can reach up to 50% of the workload of a general surgeon. With emergency theatres available 24/7 a consultant can still expect a heavy on-call rota, with at least two consultants on-call at all times; a toxic megacolon will wait for no one.
The regularity of on-call work will depend on the size of the hospital, a consultant in a large teaching hospital can expect to be on call for 1 week out of 10, whereas a district general hospital may require more time to be dedicated to emergency on-call work.
Work as a general surgeon is largely clinical and consultants can expect to juggle between inpatient theatre lists, day surgery theatre lists and outpatient clinics alongside non-clinical supporting professional activities (SPAs) such as admin and education in a 48-hour week. Below is an example week of a general surgeon with a subspecialty in colorectal surgery.
A typical week: Ms H Dorrance, consultant colorectal surgeon.
- Mon AM - Colonoscopy list
- Mon PM - Outpatient clinic
- Tue AM - Admin
- Tue PM - Outpatient clinic
- Wed AM - Theatre list
- Wed PM - Theatre list
- Thurs AM - Ward round and multidisciplinary meeting
- Thurs PM - Trainee education
- Fri AM - Day surgery list
- Fri PM - Admin
The Route To General Surgery: 5 Steps Towards Becoming A General Surgeon
1. Apply for core surgical training (CT1- CT2)
After 2 years of foundation training, begins 2 more years of core surgical training. The aim of core training is to prepare trainees to enter their specialty of choice by acquiring basic surgical skills and other competencies. At the end of core surgical training you can still choose to specialise in any surgery type with the exception being neurosurgery, which is a predominantly ‘run through’ specialty.
Applications must be made via the NHS Oriel website and competition is strong. In 2019, there were 1,896 applicants for 648 posts across the UK.
General Surgery Run Through Training IST Pilot
In 2018, the Improving Surgical Training (IST) initiative introduced a general surgical run through programme. This programme is suited towards those who after foundation training already know that they wish to pursue a career in general surgery and do not feel that they need a taster in other surgical specialities that core surgical training would offer.
You enter the programme at a ST1 and must meet minimum requirements and pass an interview stage to progress to ST3. However, you are not competing against those joining general surgery specialty training from the core surgical training pathway.
Applications for this pathway are also made via the NHS Oriel website. As a new programme, competition ratios are yet to be published, but enhanced security of job progression into ST3, they are likely to be competitive posts.
2. Pass the MRCS exam
Trainees wishing to continue their surgical training at specialty level must complete their membership of the Royal College of Surgeons exam (MRCS) by the end of their CT2/ ST2 year.
3. Apply for specialty training in General Surgery
If you are on the core surgical training pathway, to obtain a speciality training post (ST3) in general surgery is an annual national recruitment process and highly competitive. In 2019 there were 428 applications for 198 places, with a competition ratio of 2.16:1. Competition ratios may change in the upcoming years with the introduction of IST pilots.
4. Specialty training in General Surgery (ST3-8)
Speciality training allows surgeons to perfect their general surgical skills whilst rotating in various subspecialties. During the 5 years of speciality training, many trainees take the time to complete an MD and PhD in an area of interest to make their applications more competitive for future consultant posts. In the final two years of higher surgical training, specialty trainees must take the Fellowship of the Royal College of Surgeons (FRCS) exam.
5. Completion of training
On completion of specialty training, trainees are awarded a Certificate of Completion of Training (CCT) or Certificate of Eligibility for Specialist Registration (CESR), they will be added to the GMC's specialist register and will be eligible to apply for a consultant post or a fellowship for further, more specialised training.
Top tips for a competitive application
- Start early. Develop your practical skills and interest in surgery as early as you can. Keep a record of all surgeries you have attended online in eLogbook and keep it up to date- evidence is key.
- Be present. In a practical profession such as a surgeon, it is difficult to learn away from the operating theatre. Even if you are not scrubbed in, a lot can be learnt from close observation of your seniors.
- Develop your portfolio. Involve yourself in closed-loop audits as well as teaching and leadership roles. Make sure that everything you are part of is completed, and to a high standard as evidence of dedication to your work
Due to the broad-based training a general surgeon receives, the options for choosing a subspecialty as a consultant encompass a wide range. These include:
- Breast surgery
- Colorectal surgery
- Endocrine surgery
- Upper gastrointestinal including bariatric surgery
- Transplant surgery
While a pathway to subspecialising is embedded into the training curriculum, 80% of elective work that a consultant general surgeon takes on will be outside any subspecialty bracket. One exclusion for this is those who subspecialise in transplant surgery, where surgeons only undertake highly complex surgery within their specialty.
Developments In General Surgery
Gender imbalance has long been an issue in surgical specialities, with recent figures showing that only 12% of general surgeons are female. Going forward, initiatives such as Women in Surgery are dedicated to encouraging, enabling and inspiring women to fulfil their surgical career ambitions, with women now making up 30% of surgeons in training.
General surgery is a leading speciality in key-hole surgery, which adopts a minimally invasive technique allowing smaller scars and a quicker recovery for patients. Development in this field means that an increasing amount of surgical procedures are able to be done laparoscopically and moving into the future this method of surgery will become an essential part of the work of a general surgeon, especially with a increasing number of obese patients in the population.
As a consultant from 1 April 2019, you'll earn a basic salary of £79,860 to £107,668 per year, depending on the length of your service. Consultants can also supplement their salary by working in private practice if they wish. The opportunities available will depend on their specialty areas and the time they wish to spend on this outside of their NHS contracted hours.
General surgery is a specialty with some potential for private practice. According to an analysis by Independent Practitioner Today consultant orthopaedic surgeons earned an average of £72,000 per year from private practice in 2018.
JRSM reported in 2008 that private income for general surgeons was 0.62 times their NHS income, some way short of plastic surgeons (1.9 times) but well ahead of paediatric surgeons (0.16 times)1.
For more information on doctor's salaries within the NHS, please feel free to review The Complete Guide to NHS Pay.
A career in general surgery is constantly fulfilling, with new opportunities extending to beyond consultancy, whether it is in research and academia, teaching or management. To become a general surgeon requires a lot of hard work and dedication, for those that love what they do, this is not a hindrance but a reward.
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Morris S, Elliott B, Ma A, McConnachie A, Rice N, Skåtun D et al. Analysis of consultants’ NHS and private incomes in England in 2003/4. Journal of the Royal Society of Medicine [Internet]. 2008 [accessed 14 June 2020];101(7):372-380. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2442143/table/tbl3/