How to succeed in ST3 general surgery national recruitmentBMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g1551 (Published 13 February 2014) Cite this as: BMJ 2014;348:g1551
- Goher Rahbour, ST3 general surgery,
- Katy Hogben, consultant breast and reconstructive surgeon, and general surgery London Deanery training programme director
The process for national recruitment into the third year of specialty training in general surgery requires considerable preparation. Goher Rahbour, who improved his rank from 347th in 2012 to 37th in 2013, and consultant surgeon Katy Hogben offer some advice for candidates
To obtain a post in the third year of specialty training (ST3) in general surgery through the annual national recruitment process, candidates should prepare for their interview with the same mindset as they would for an exam (box 1).
Everyone applying will have met the essential criteria, including gaining membership of the Royal College of Surgeons. They will also have met all the important desirable criteria and have committed to a career in general surgery. The selection process is therefore about doing better and ranking higher than everyone else. There is hope for everyone, however, and this article builds on previous guidance providing advice on achieving success in the selection process.123 The selection process lasts around two hours and includes eight domains: portfolio, academic, leadership and team working, communication skills, clinical, clinical management, technical skills and teaching, and audit (table 1⇓).
With the portfolio contributing only 20% of your final score, it is beneficial to organise this early. This will allow you to focus on preparing for the other domains. Practising the scenarios with a friendly and probing colleague is essential, and any help you can get from consultants who have an understanding of the current interview format would be valuable.
Interview courses are available and may be of some benefit, but they are often generic in nature. The interview process is geared specifically around issues that you may deal with on a daily basis as a general surgery registrar, rather than some of the material covered in courses, such as hot topics in the health service and financial issues. Also, in each of the five interview stations, there is less emphasis in the interview on matters such as body language and more on assessing whether you know the answers.
You should invest in a high quality binder for your portfolio, and the structure and order of your portfolio should conform exactly to any instructions provided. At the front of each section, you should put a summary consolidation sheet, with the relevant numbers, as this will make it easier to score correctly and save time. The interviewers have to flick rapidly through your bulging portfolio to obtain information, and during this process they may accidently fail to identify scoring opportunities. Three different score sheets are used, for candidates with fewer than five years, five to seven years, and more than seven years of experience since qualification. Table 2⇓ shows the sections your portfolio should use along with examples of how to score the maximum five points in each section. You are awarded marks on how you defend your portfolio. For example, you may be challenged on why a particular length of time was taken to achieve an objective. You should answer in a positive manner with justification, and try to pre-empt these questions.
The two and a half minutes allocated to reading at the academic station is a short time in which to understand an abstract. You will need to be confident of tackling any abstract and able to use simple language. The interviewers may well escalate to statistical questions with increasing difficulty. It is worth reading books with advice on how to understand the statistics within an abstract, such as Medical Statistics at a Glance by Aviva Petrie and Caroline Sabin. We would recommend the following approach to tackling any abstract: define the type of study; describe what the abstract is about; explain what the study has shown; set out the strengths and weaknesses of the study, including the level of evidence; and describe the statistical methods used (such as the P value, standard deviation, confidence interval, risk ratio, and odds ratio).
Leadership and teamwork
Scenarios may assess whether you appropriately delegate to juniors and are not afraid to contact the consultant. In your answers, you should show that you neither shun responsibility nor attempt to be a hero by taking everything on. Scores will be based on situational awareness, judgment, setting priorities, orchestration of the team, willingness to accept responsibility, negotiation skills, and discussion with colleagues. The situations presented to you may be along the lines of the scenarios listed in box 2.
There may be more than 10 clinical scenarios for you to read and prioritise. Identify two or three key patients whom you must not miss. It is a good idea to read the scenarios as quickly as possible so you have enough telephone time. The opening comments are important. After the introduction, summarise to the consultant what he or she needs to know and act on immediately: (1) unwell patients; (2) patients who need to go to theatre; (3) telephone calls the consultant needs to make, such as to radiology or regarding transfer of patients to another hospital; and (4) paediatric cases. You can then discuss the rest of the cases. You will be challenged at some point, possibly with an incorrect suggestion, and so it’s important to think and not to agree immediately. You will be scored on the clarity and conciseness of this conversation.
Scores will be based on recognition of the clinical issues, judgment and prioritisation, planning use of investigations and resources, and communication strategy. Higher scores will be obtained if information is provided without prompting. An opening statement in some scenarios could include: “The key issues identified are . . . and this clearly is an emergency situation which I would manage with . . ..” An example of a situation presented as a clinical scenario might be: “You are in outpatient clinic. Call from recovery nurse regarding AAA repair patient from earlier that day. Possible acute ischaemic limb. Consultant gone to funeral.”
Clinical management scenario
It is important to think about key issues, prioritisation, other team members available (such as the crash and trauma team), delegation, and instructions to colleagues in reporting back. It may be worth making a list of general surgical emergencies and practising and talking through the management with a colleague.
Technical skills and teaching
It is also a good idea to watch the basic and specialist registrar skills course DVDs. For a better understanding of theatre instruments and suturing techniques, Basic Surgical Techniques by Raymond Kirk is recommended. In 2013, a teaching component was added to this station. For this you should introduce yourself; ascertain what, if any, knowledge the “student” (interviewer) has of the task; state that you will initially talk while performing the task; and then ask the student to perform the task, followed by feedback, questions and answers, further attempt, and discussion on the importance of attending a surgical skills course. You will not have time other than teaching and performing the task, but you would have highlighted the components integral for a teaching session.
You will be asked to read a scenario, after which you will have to explain how you would perform an audit of that issue. It is worth using the structure set out in box 3 as well if you are asked to describe one of your own audit projects.
Box 1: My experience—Goher Rahbour
After the 2012 recruitment process I was ranked 347 out of 530 candidates interviewed, and this was a devastating blow. I considered my options of applying for the few locum appointment for training specialty training year 3 (LAT ST3) general surgery posts, taking up a trust grade post, furthering my time in a research academic post, moving overseas, or taking a complete career change. After reflection and advice from trusted colleagues, I applied and was successful in obtaining a LAT ST3 post, albeit 300 miles from my home. In 2013, I was ranked 37 out of 542 and was successful in securing a place at my first preference deanery, London.
For the portfolio station, I learnt that a summary consolidation sheet should be placed at the front of each section of your portfolio, with the relevant “numbers.” Interviewers have to flick rapidly through your portfolio to find information, and during this process they may miss a possible scoring opportunity. Feedback from the deanery showed that there were inaccuracies and discrepancies in my score, and a difference in score between the two interviewers for the same station.
At the academic station in 2012, I encountered an abstract which, at the end of the allotted time, I simply did not understand; I was therefore unable to excel at this station. Having critically appraised papers in the past, I realised that a new approach was required. In preparation for the 2013 recruitment, I read every abstract from the British Journal of Surgery for the last three years. This process took two weeks, at the end of which I was confident in tackling any abstract.
Box 2: Possible scenarios
Leadership and teamwork
Staff in infection control are not happy with the number of people present on the morning ward round. The consultant, medical team, students, nurses, and drug and meal rounds are all taking place.
Unexpected sickness occurs in a colleague about to do a weekend on call.
There is an unexpected event in theatre and help is not immediately available.
You are an ST3 in a new hospital and have noticed a number of prescribing errors.
You are an ST3 in a new breast surgery firm and other senior doctors are doing all of the operations.
You are an ST8 and competent to do a distal gastrectomy, but the consultant is not letting you do this.
Consultant is unavailable. You have a theatre list with four cases and you can do only the first two. However, one of these patients has eaten, and the other requires a international normalised ratio measurement.
You have foundation year 1 and year 2 doctors. Informed at the morning handover that an anterior resection patient is tachycardic and has a temperature. Another patient seen by the night team has a swollen leg and is hypoxic. Foundation year 1 doctor comes to the ward smelling of alcohol. You have a ward round to do and then a teaching theatre list arranged by your consultant.
You are about to start a laparoscopic appendicectomy and are called by the intensive treatment unit about an unwell patient.
Disruption of an elective operating list by a ward emergency.
Technical skills and teaching
Excise a skin lesion (2011).
Laparoscopic excision of a triangle (2012).
Transverse arteriotomy/embolectomy plus teaching (2013).
Frequency of observations after Whipple procedure and postoperative deaths.
Colorectal patients not receiving postoperative antibiotics.
Delay in cross matched blood reaching theatre.
Delays in emergency theatre.
Medical issues management on a vascular unit.
Outpatient clinic complaints.
Box 3: Audit structure
What is the clinical scenario?
Why was there a need for the audit?
Were you auditing a process, resource, or outcome?
What standard did you use as the basis of your audit?
How did you collect and store data, and were there any issues around consent, registration, Caldicott guardians, or data protection?
How were data collected? How many data were collected? Who collected the data and over what time frame?
Will this be a covert audit, and what are the strengths and weaknesses of this and other approaches (considering Hawthorn and Rosenthal effects, bias, and design difficulties)?
What results will be presented, and where will the data be disseminated?
What changes were agreed and how will they be implemented?
Was a re-audit conducted to close the cycle?
Were the results of the audit presented?
Did the audit lead to a change in practice?
Were the results of the audit presented or published?
GR thanks Nuha Yassin for her dedicated help, support through the recruitment processes, and practice of scenarios highlighted in this article.
Contributors: GR had the idea for the article and wrote the draft. KH contributed to its conception and structure and revised it critically for content. Both authors gave final approval of the version to be published.
Competing interests: We have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.