The profession should be reshaped to provide more career opportunities for trained surgeons and those still in training – David Tolley explains why surgery has a supply and demand problem
 During the last six months, I have enjoyed meeting a number of you during our Regional visits, events at the College and overseas. A frequent topic of conversation is the plight of the aspiring surgeon who is unable to gain a foot on the first rung of the ladder and support for those who face the real threat of medical unemployment on completion of their training.
A shortage of career opportunities for would-be surgeons has been a feature of surgical training for as long as I can remember. The excess of demand over availability has now simply shifted towards the bottom of the training ladder. An obsession with number crunching presents a more accurate picture of the problem but the bottom line remains the same: there are more young doctors who wish to pursue a career in surgery than there are opportunities.
The Calman reforms, introduced in 1995, increased the certainty of entering and completing surgical training at an earlier stage. However, this simply moved the bottle neck downwards, eventually creating the SHO bulge, a ‘lost tribe’ for whom training was patchy and including those doctors from overseas who had little or no prospect of advancing further.
Modernising Medical Careers produced basic surgical training (BST) schemes, a further reduction in UK training opportunities for overseas doctors and (post-Tooke) the creation of fixed term specialist training appointments (FTSTA) in an attempt to accommodate the inevitable bulge created by the increased number of new medical graduates.
This has conspired to work against a generation of young doctors, many of whom now have little prospect of pursuing a surgical career – a problem compounded further by a reduction in the number of available training posts in some surgical specialties from 2011. At the same time, the previous flexibility, which enabled unsuccessful candidates to switch and pursue a career in a non-surgical specialty, was blocked. Added to this, a creative approach which has seen the introduction in Foundation Trusts of ‘Research’ Fellows and Trust Specialty Doctors to fill rota gaps generated by EWTR has allowed the pool of would-be surgeons to expand unchecked.
The result is Brownian movement between posts in an increasingly overcrowded pond from which the prospect of escape into surgical training is unlikely. We have created another ‘lost tribe’. There is now no easy solution to the problem. Competition ratios are high: the base of the present surgical pyramid is too broad. There are far too many aspiring surgeons seeking entry at the base and too few vacancies at the top for any quick solution to be found in a system from which the only realistic exit is to an NHS consultant post. As long as the demand for training created by aspiring surgeons exceeds the supply of vacated posts, the problem will remain.
The immediate solution is to limit entry to surgical training for a few years, at the same time reshaping the pyramid into an obelisk, in order to expand career opportunities for trained surgeons and those already in training posts. Patients now expect to receive the same standard of care, 24/7, 365 days a year: this can only be achieved by increasing the number of posts available for trained surgeons in order to provide out-of-hours care by the fully-trained specialist. Aspiring surgical trainees must recognise the intense competition which presently exists and should be aware that a hitherto regarded solution, which involves a move into an unregulated ‘holding’ post immediately after Foundation Training, in the event of failure to secure a recognised job, is no longer a viable option.
The removal of core trainee posts caused by reshaping the surgical pyramid will make it impossible to provide surgical care at all times and in all hospitals. There must, therefore, be an acceptance by patients and government that specialist and emergency care cannot be provided in all hospitals at all hours of the day and night. A rationalisation of service provision and a re-examination of EWTR are both essential components of the solution.
Failure to take decisive action now will simply mask the continuing problem for another day. Debate over the merits of run-through versus core training do not affect the simple arithmetic and will not help the plight of aspiring surgeons seeking entry to training in 2011. We now need to seek a wider debate with our trainees, specialty associations, other UK surgical colleges and health departments in order to address a problem which has now reached crisis point.
David Tolley
This e-mail address is being protected from spambots. You need JavaScript enabled to view it
 |
Subscribe to this comment's feed
