Financial burden of surgical trainingBMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h3788 (Published 05 August 2015) Cite this as: BMJ 2015;351:h3788
- Kathryn Oakland, surgical research fellow, Oxford Deanery,
- Sumrit Bola, core surgical trainee, South West Peninsula Deanery
A survey by Kathryn Oakland and Sumrit Bola reveals the high cost of surgical training
The accrual of debt does not stop when a medical student graduates—training, especially surgical training, is expensive. As well as the mandatory courses a core surgical trainee must complete, many take on extra commitments such as higher degrees and additional courses to help secure highly competitive training posts and to prepare themselves for their role as surgical registrars.
Our survey of core surgical trainees has shown that the average cost of training is £10 240, including both mandatory and additional courses. On average, trainees who managed to secure a national training number spent more than those who did not.
This debt comes on top of the financial burden many doctors carry over from their student days. A 2011 national survey by the Association of Surgeons in Training reported that 78% of their members had student debts. As tuition fees are now uncapped, a five year medical degree will cost students a minimum of £45 000 in tuition fees and an estimated £12 056 a year in living costs (£13 388 a year for London), with loans for living and maintenance available for up to £9497 a year (£11 875 for London).
We have investigated the current cost of core surgical training and estimated how much trainees are spending on non-mandatory commitments and whether this differs between the surgical specialties.
We contacted all 13 local education and training boards, requesting that they send our 14 question e-survey to the 2013/14 group of core surgical training year 2 (CT2) doctors. The survey was also advertised on social media.
The survey was live for eight weeks between June and July 2014, and we collected data on expenditure on courses, extra materials for membership of the Royal College of Surgeons (MRCS) exams, postgraduate qualifications, attendance at conferences, and specialty training year 3 (ST3) interviews.
Eleven of the local education and training boards agreed to distribute the survey, resulting in responses from 85 CT2 doctors in 13 postgraduate regions. The greatest number of responses came from the North West, where 24 doctors completed the questionnaire; followed by the East of England, where we had 12 responses; and 11 from London.
Respondents came from nine different subspecialties, mostly general and vascular surgery (31 respondents) and trauma and orthopaedics (25 respondents). Nine respondents applied to more than one subspecialty and two applied for a training post in a non-surgical specialty.
Seventy three respondents gave complete responses, which allowed quantification of their spending before their ST3 interview. Exclusive of compulsory courses, the mean total spend was £5220.
Most respondents had done three other courses in addition to the mandatory basic surgical skills, advanced trauma and life support, and care of the critically ill surgical patient courses. For the subspecialties of general and vascular, trauma and orthopaedics, otolaryngology, and urology the most common additional non-compulsory courses were core laparoscopic skills, basic principles of fracture management, advanced paediatric life support, and operative skills in urology modules one and two. Forty one respondents had completed a train the trainers certificate, and 19 had done a leadership or management course. The mean spend on all non-compulsory courses before ST3 was £3200. Two respondents reported spending £6000 or more on courses alone.
Thirty two doctors reported more than one attempt at MRCS part A, with nine reporting four or more attempts, and 17 respondents had two or more attempts at passing MRCS part B. Not including examination fees, the average spend on MRCS exam supporting materials (courses, books, online tools, and so on) was £980.
Thirty respondents had done a BSc or MSc, eight a diploma, and eight a medical education certificate; 13 of these spent more than £5000. Forty five respondents had not done any form of postgraduate qualification. Fifty six respondents had attended three or more national or international conferences and 27 had attended five or more. The average spend on conferences was £1660.
Study budget variation
There was considerable variation between deaneries in the provision of study budget. Fifty six core trainees were allocated between £500 and £700 a year, whereas four reported that they had no available funding, in contrast to eight who reported excess of £900 a year. The mean total spend on conferences and courses was £5400 for general and vascular, £4800 for trauma and orthopaedics, £5600 for otolaryngology, and £5500 for urology.
Nearly nine out of 10 (89%) respondents said they had felt financially stretched attending courses or conferences. Some said that they had been unable to attend courses as they could not afford to pay for them even if study funding was available on completion.
At the end of CT2, 64 reported attendance at a surgical interview for an ST3 post, with 31 successfully gaining a national training number. On average, successful applicants spent £5400 in total compared with £4670 by those who were unsuccessful. Successful applicants spent £3520 on courses compared with £2920 by unsuccessful ones, and £1900 on conferences compared with £1740.
In total, the average cost of core surgical training was £10 240 (£5220 plus compulsory requirements).
Results of this survey show that most candidates are attending far in excess of the basic requirements for courses and conferences and that this has an associated high financial outlay. As there is no guarantee in gaining a national training number to pursue their career, many may not find this acceptable.
The highest proportion of this extra expense was on non-essential courses. In the online survey some respondents questioned the high nature of these costs, particularly for courses with minimal numbers of trainers or necessary surgical equipment.
The most frequently reported study budget was £600 a year, meaning that the average applicant would need to find an extra £1000 a year to spend on these non-compulsory courses. Candidates also have to pay exam fees of £503 for MRCS part A and £912 for part B, which traditionally are not recoverable from the study budget. The extra conferences attended by trainees add to their costs, most of which they have to pay from their own pocket.
There are online careers documents that warn of the cost of surgical training,1 but owing to the lack of recent data on the cost of training it is likely that many candidates enter surgical training with little idea of the contribution they will have to make from their own finances. This is made more unpredictable by the geographical variation in the provision of study budgets shown by this study. There seems to be little rationale for the variation. Whether this would influence surgical trainees’ choice of deanery is beyond the scope of this paper, but it may be the case. It would seem fair to suggest a national standard for the amount of funding available.
Several respondents reported that they could not attend desirable courses or conferences even if they had study funding as they did not have the capital available to invest before claiming it back once they had attended. Some reported that international conference fees were excluded from their study budget. In a specialty that encourages high level research among its trainees, this seems counterintuitive. It may be beneficial to relax the current spending regulations to allow trainees more choice on what they spend their funding on.
Among trainees, there is a belief that certain subspecialties are more expensive than others, but of the ones considered in this research we found little evidence to support this.
Although the total number of respondents was small, we had responses from 11 deaneries, giving good geographical distribution. The data collection period was timed to be after the ST3 recruitment process, but this meant that respondents were calculating expenditure from several years previously, which may affect the accuracy of their recalled spending habits. Regardless, the mean spend was fairly consistent between respondents. Data were collected on number of conferences attended but not on whether the applicant had presented work, which may independently influence success at ST3 interview. We did not collect data on grants, scholarships, or bursaries, and the survey was limited in that it did not include costs from ST3 applicants who were not core surgical trainees.
The figures in this paper are far greater than previous estimates for basic surgical training. Our findings highlight to what degree an individual should be expected to fund their own training. As medical students graduate with higher debts, a surgical career may be simply unaffordable for some candidates, regardless of their ability.
Competing interests: We have read and understood BMJ’s policy on declaration of interests and have no relevant interests to declare.