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BMJ 1999; 319 doi: (Published 23 October 1999) Cite this as: BMJ 1999;319:S2-7217

Basic surgical training

  1. Sian Falder, specialist registrar,
  2. Hayley Hannah, Senior House Officer,
  1. Countess of Chester Hospital, Liverpool Road, Chester CH2 1UL

    Sian Falder outlines the new landscape for all surgical trainees

    The training and examination system of junior surgeons has recently been overhauled. What does this mean for junior doctors who choose to embark on a surgical career? How does the new set-up compare with the old one?

    Although newly qualified surgeons will still lose the hard won title “doctor”, they will not be able to write after their name the initials FRCS, first awarded to Mr W J Erasmus Wilson in 1837, until they complete the exit exam some years later. The examination to become a fellow of the Royal College of Surgeons (FRCS) has now been superseded by the introduction of a diploma for membership of the Royal College of Surgeons (MRCS). The first MRCS paper took place in April 1997, and the final opportunity to complete FRCS is October 2000.Practically speaking, basic surgical training culminating in the MRCS lasts a minimum of two years and replaces the two parts of the FRCS—applied basic science (ABS) and clinical surgery in general (CSiG). The existing intercollegiate examination (exit exam for each specialty) stands unaltered and becomes the final fellowship exam.The MRCS diploma involves a minimum of two years” clinical training, completion of a basic surgical skills course, and a three part examination.

    Mandatory clinical training

    Hospital posts must be approved by one of the four royal colleges of Edinburgh, England, Glasgow, or Ireland. The two years must include six months each in any two category 1 posts, which are posts in specialties that involve general care of surgical emergencies or care of critically ill patients—such as general surgery with emergency work, trauma and orthopaedics, and accident and emergency medicine. The remaining 12 months must be spent in approved posts in other specialties, which the senior house officer can choose—other category 1 posts or category 2 posts such as cardiothoracic, neurosurgery, and urology.

    Most surgical training posts are now incorporated into rotations of 24 months or longer. Overall, basic surgical trainees must train in at least three separate surgical specialties, but no more than six months should be spent in any one. Demonstrator posts in anatomy or physiology are still encouraged and are considered beneficial, but they do not count towards the two years of clinical training.

    The MRCS exam

    There are three parts to the exam: the written papers, the clinical section, and the viva. These can be taken together at the end of training or separately at intervals during training.

    Unlike the FRCS course, the MRCS syllabus integrates basic science and clinical knowledge. It is agreed by and is common to all the four royal colleges, but each college formats it differently. For example, the Royal College of Surgeons of England divides the syllabus into 10 modules—five “core” modules (topics relating to all branches of surgery, such as preoperative and perioperative management) and five “systems” modules (specialist components). However, the syllabus of the Edinburgh college has 17 modules.

    The written papers

    There are two papers, the first relating to the core modules and the second to the systems modules. At least a third of all questions in both papers cover the basic science subjects of anatomy, physiology, and pathology. Each paper lasts two hoursóabout 90 minutes of true/false questions and 30 minutes of extended matching questions. The structure of the multiple choice questions has moved away from standard, five part questions to extended matching questions, which are thought to be a better test of knowledge.1

    Both papers must be passed at the same college. It is possible to resit each of these papers as often as necessary, and, joy of joys, there is no negative marking.

    The clinical section

    This can be taken after 20 months of clinical training. The exam lasts about an hour and is based on several “short cases”selected from five bays entitled (a) superficial lesions, (b) musculoskeletal and neurosurgery, (c) circulatory and lymphatic, (d) trunk, and (e) communication skills.

    The viva

    This final part requires that the written papers and clinical section have been passed, a basic surgical skills course has been completed, and 18-22 months have been spent in approved posts. The viva covers the whole syllabus and consists of three oral exams of 20 minutes each in (a) applied surgical anatomy and operative surgery, (b) applied physiology and critical care, and (c) clinical pathology and principles of surgery.

    Failing the exam

    There is no limit to the number of attempts at the multiple choice section, but the exam as a whole must be completed within two years of the first attempt at the clinical section.

    What happens after MRCS?

    Possession of the diploma (if you like, a certificate of completion of basic surgical training) should equate with approval to enter a programme of higher specialist training. However, there are not enough type 1 higher surgical training programmes for the number of basic surgical trainees seeking one. Certain specialties are particularly notorious for this, such as cardiothoracic surgery and neurosurgery.2

    The basic requirement to address these problems is expansion of the number of consultant posts. Although this may not help basic surgical trainees in the shorter term, other measures have included the recommendation for three year rather than two year basic surgical rotations, the third year being flexible and tailored to the trainee's preferred career choice.

    Women in surgery

    Women are still particularly underrepresented in surgery, although female basic surgical trainees should take heart from the fact that the number is gradually increasing: in 1988 only 7%of surgical registrars were women, but in 1998 the percentage was 13%.3Flexible training is now more widespread, even in surgical specialties, and female senior house officers should not feel that a surgical career is incompatible with other commitments.

    Are these changes a good thing?

    Unlike those who sat the FRCS, MRCS candidates have been taught on a defined course to a defined syllabus. Holders of the diploma in competition for registrar posts should be of a uniform standard.

    Basic surgical trainees will benefit from having training goals that are clearly and formally defined—they will no longer have to acquire surgical expertise by a vague process of osmosis. These changes have been promoted from the top by the royal colleges and the postgraduate deans, and consultants are taking seriously their educating responsibilities. Basic surgical trainees now know what to achieve and can insist on formal teaching.However, trainees also have to assume more responsibility for their own training. The onus is on them to prove that they have the knowledge and skills expected of them, by means of regular assessments in post and an up to date log book. A course on basic surgical skills is now compulsory. This is a useful introduction to safe surgical practice in a controlled workshop environment, where there is time to be taught and practise technique without the pressures of anaesthetic time. The course covers open surgery, trauma and orthopaedics, and minimal access surgery.This integration of theoretical knowledge and formal training with clinical experience is fine in theory, but does it work in practice? Although senior house officers may ostensibly gain sufficient clinical experience, in reality their training may be deficient because of poor organisation of clinical activity and reduced training opportunities. 4 5 When applying for posts, senior house officers should consider whether there are house officers covering routine tasks so that they make the most of the limited experience that a six month post can offer. The MRCS is designed to shorten the time of training, which is good. Limited rotations of two years allow time to be spent in surgical specialties, which gives basic surgical trainees the chance to focus early if they are certain of their career pathway. However, orthopaedics and general surgery, which were previously compulsory, are so no longer. Provided that basic surgical trainees cover trauma and general surgical on calls—which may, for example, form part of a post in accident and emergency or urology—they satisfy current requirements. This means that a candidate can achieve the diploma without having spent even six months on a general surgical firm. As senior house officers now spend only six months in one post, including general surgery, and as it is their first surgical experience, they are unlikely to achieve proportionately as much “hands on” experience as they would over a longer period, particularly for out of hours work. However, the experience they do have is more likely to be supervised.The future for surgery seems to be increasing specialisation, and this seems to be happening even at senior house officer level. Although MRCS is designed to cover two years of training, the incorporation of a third year gives trainees the option for further exposure to their chosen specialty or to gain other experience.Taken together, these changes indisputably reflect a trend towards taught training with erosion of the traditional “apprenticeship” model. The MRCS, like the FRCS, assesses surgical knowledge but not competence. There is definitely a step forward in quality of education, but a risk (especially combined with reduced hours) that junior consultants will be neither expert in their own specialty nor fully equipped to cope with emergencies. This is not an inevitable outcome if training time is valued as much as service commitments and is fully used. Basic surgical trainees should think about this.


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    Useful contacts

    The STEP course A distance learning course, produced by the Royal College of Surgeons of England, mirroring the syllabus in form and content. Ten modules are studied over 20 months at the trainee's own pace. The course involves workbooks, audiotapes, self assessment exercises, and current readings. Affiliate registrationSenior house officers and house officers interested in a surgical career should register with their proposed college to ascertain that their posts are approved, to obtain a log book, and to receive assessment forms.

    • Royal College of Surgeons of England, 35/43 Lincoln's Inn Fields, London WC2A 3PN. Tel: 0171 405 3474. Fax: 0171 831 9438. URL:

    • Royal College of Physicians and Surgeons of Glasgow, 232-242 St Vincent Street, Glasgow G2 5RJ. Tel: 0141 221 6072. Fax: 0141 221 1804. URL:

    • Royal College of Surgeons in Ireland, St Stephen's Green, Dublin 2. Tel: 353 1 402 2187 URL:

    • Royal College of Surgeons of Edinburgh, Nicolson Street, Edinburgh, EH8 9DW. Tel: (+44) 131 527 1600 Women in surgical training. This organisation is committed to increasing the numbers of women in surgery and is a source of advice, information, and support for those entering or already in the profession.c/o the Royal College of Surgeons of England. Tel: 0171 312 6657. Fax: 0171 312 6623. Email: wist{at}

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