Surgery used to be one of the most sought-after medical specialties. Ian Eardley, Humphrey Scott, and David Wilkinson consider why it is attracting fewer candidates Historically, surgery has been one of the most popular medical careers and there has almost always been a surfeit of candidates over vacancies. In 2014, however, while selection into specialty training for the 10 surgical specialties was as competitive as ever, it was not possible to fill every training post. Since 2011, the introduction of single centre national selection processes has made it easier to find out the exact numbers of candidates for core surgery. The number of applicants and the number being interviewed for core surgical training have remained relatively stable, but the overall fill rates after the first round of recruitment have reduced. In 2014, the fill rate for core surgery lagged behind acute care common stem (100%), anaesthesia (98%), clinical radiology (100%), ophthalmology (100%), and public health (100%). The surgical specialties that recruited into run-through training at specialty training year one (ST1)—neurosurgery and cardiothoracic surgery—also achieved 100% fill rates. Geographical differences Further analysis of the data shows that appreciable geographical differences partly explain these figures. In Northern Ireland and Scotland, for example, just 45% and 75% of posts respectively were filled, compared with 100% in the north east and east of England, London, and Kent, Surrey and Sussex. Furthermore, 134 of the 2014 applicants who were successful at interview withdrew from the core surgical recruitment process and accepted posts in other specialties. It is clear to us that several things are happening. Firstly, trainees are becoming increasingly specific about where they want to work, with many wanting to train in the south east. For example, 36% of trainees put London as their first choice despite only 12.3% of the available posts being in London. Secondly, remarkably few trainees are using clearing to obtain any of the vacant posts. This implies that either they did not wish to work in locations that were still open or they had obtained a post in another specialty in a location more suited to them. This geographical differential in fill rates is something that has been seen in other specialties, most notably general practice. Although recruitment is still relatively strong, it seems that applying for core surgical training is less popular than it was in the past. But why is this the case? Sex factors One factor could be the increasing numbers of women in medicine, for whom surgery is still not a popular career option. Between 2012 and 2014, 36% of applicants for core surgical training were women, although they accounted for around 55% of medical school graduates in 2012. If surgery continues to be seen as a male dominated discipline and women choose not to apply, we shall be fishing in an increasingly small pond. The decreasing numbers of international medical graduates entering the United Kingdom could also be to blame. In 2007, one in seven doctors under the age of 30 was from overseas, but in 2012 this had fallen to one in 20. Many of these graduates had previously sought surgical posts. Another reason may be the general decrease in number of doctors who enter any specialty training having successfully completed foundation year 2 (F2). In 2011, 71% entered specialty training from F2, but in 2013 this had fallen to 64%. The perception that a surgical career makes greater demands on one’s work-life balance than other postgraduate medical careers is another important factor. One recent survey of final year medical students found that the single most important reason for not entering a surgical career was that “it doesn’t fit with lifestyle or family commitments.” This was particularly a problem for female trainees, 85% of whom cited this reason compared with 12% of men. Male trainees were more likely to cite poor anatomy teaching as a reason—74% of men raised this point compared with 57% of women. There is also the general dissatisfaction with surgical training that is repeatedly shown in the General Medical Council trainee survey. In 2014, surgery once again was at the bottom of the league table of medical and surgical specialties, with 77% satisfaction compared with general practice at 89%, anaesthesia at 86%, and radiology at 84%. The decreasing popularity of core surgical training may also reflect the differential satisfaction shown in the 2014 GMC survey between specialty surgical training and core surgical training. Satisfaction in specialty training was relatively high at 86%, falling to 77% in core surgical training, and falling even further to 72% in foundation surgery. The findings in the 2015 GMC survey are similar. Lack of support This last issue is perhaps a major problem. If trainees have a poor experience in foundation surgical posts, they may well choose not to pursue a surgical career. Surgical F1 posts are different from the surgical house jobs that more senior surgeons may recall. Although the hours were long, the jobs were less intense and there was continuity of patient care, with a coherent firm structure. Today’s surgical F1 posts are usually part of a shift system, and many trainees feel poorly supported. Trainees are often faced with much ward based and administrative work with few opportunities in theatre and the outpatient clinic. Surgical foundation posts are being removed to increase exposure to primary and community or psychiatric care as part of the Broadening the Foundation initiative.[3] If no action is taken, there is a danger that service pressures on the remaining trainees will increase, further reducing educational quality. If these are the problems, what are the solutions? Solutions With the reduction in surgical F1 posts across the UK, we need to develop different models of surgical care, perhaps using physician associates, surgical care practitioners, and advanced clinical practitioners. This has the potential to improve the learning environment for students and trainees by sharing some of the administrative and ward based jobs that form much of the work of a junior doctor. It would require the commitment of higher education institutions and employers to new workforce models, but surgeons will need to ensure that these professionals are valued and supported as an integral part of the surgical team. The profession needs to dispel the perception that surgery is a male dominated specialty. This is not just about work-life balance, which is also important, but also about dealing with perceptions of the culture and the difficulty of fitting in. Recruitment into surgical specialties that offer run-through training has maintained 100% fill rates, and it may be that surgery should re-examine this. Run-through training may be attractive because of the security that comes from not having to compete for a job again at ST3, although it does mean that trainees need to decide at an early stage what they want to do. The profession and colleges should also examine the place of surgery and the surgical sciences, most notably anatomy, in the medical school curriculum. Most importantly, however, trainees need positive role models who will engage and inspire them and dispel myths and stereotypes about sex, personality, and lack of work-life balance. Surgeons everywhere have a responsibility to engage with and support all their surgical trainees but particularly those at foundation level to ensure that surgical training does not become increasingly unpopular.
