sub-specialist interests and advertised jobs: ... in unpopular sub-specialties and to avoid training people for jobs that do not exist. ... their own sub-specialist field.
The Royal College of Surgeons of England
Ann R Coll Surg Engl 2001; 83: 275-278
Original article
Mismatch between general surgical trainees' sub-specialist interests and advertised jobs: a cause for concern? IC Cameron, MWR Reed, AG Johnson Department of Surgery, Division of Surgical and Anaesthetic Sciences, Royal Hallamshire Hospital, Sheffield, UK
The main aim of this study was to establish the primary sub-specialist interest of a group of senior general surgical trainees and compare these results with the required subspecialist interests in consultant vacancies advertised in the British Medical Journal between 3.1.98 and 25.12.99. Colorectal surgery was the most popular sub-specialty amongst trainees (29.4%) followed by upper gastrointestinal/hepato-pancreato-biliary (UGI/HPB) (27.2%) and vascular surgery (24.3%). The least popular sub-specialties were breast/endocrine (11.4%) and transplant (2.9%). A total of 324 consultant jobs were advertised, with the sub-specialist interest required as follows: Colorectal (25.6%o), breast/endocrine (23.5%), vascular (20.4%), UGI/HPB (12%) and transplant (5.6%). Although this study only covers a two-year period, there are obvious discrepancies between trainees' sub-specialist interests and consultant vacancies. Whilst the jobs to trainees ratios are well matched in colorectal and vascular surgery, it appears that there are not enough transplant or breast trainees and too many UGI/HPB trainees for the number of jobs available. This problem needs urgent attention to avoid service shortfalls in unpopular sub-specialties and to avoid training people for jobs that do not exist.
The past decade has seen many changes within 1 general surgery and general surgical training. One aspect of this has been the increase of sub-specialisation with the corresponding development of, and increasing role played by, the sub-specialty associations. A major change has occurred in general surgical training
following the introduction of the specialist registrar grade in December 1995.1 Training has been shortened to 6 years of which one year will often be spent in research and the final two years are spent in advanced subspecialty training. The end product of surgical training is, therefore, changing considerably from the broadly
Correspondence to: Mr IC Cameron, Flat 5D, Union Court, Fukin Street, Tai Wai, Shatin, New Territories, Hong Kong Tel: +852 2632 2789; Fax: +852 2637 7974 Ann R Coll Surg Engl 2001; 83
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Table 2 Sub-speciality specification ofadvertised jobs
Table 1 Primary sub-specialist interests of trainees
Sub-speciality
Colorectal
UGI/HPB Vascular Breast ± endocrine Transplant Gastrointestinal Other
Trainees (n) 40 37 33 15 4 4 3
Trainees (%) 29.4 27.2 24.3 11.4 2.9 2.9 2.2
Sub-speciality Colorectal Breast ± endocrine Vascular
UGI/HPB Transplant Gastrointestinal General surgery General + sub-specialty (to fit in with...)
Other
trained senior registrar with wide experience of all areas of general surgery to trainees who should be capable of participating in an emergency rota but whose elective surgical exposure is limited outside their own sub-specialist field. Recently, a survey conducted by the Association of Surgeons revealed that over 90% of trainees favoured the increase of sub-specialisation. In many hospitals, separate vascular on-call rotas have been established and the historical trend is for these subspecialties to become independent specialties.2 At present, general surgery is regarded as a single specially with regard to workforce planning and national training numbers, but this may have to change if general surgery continues to fragment into its sub-specialist branches. The aim of our study was to assess the main sub-specialist interests of general surgical trainees and to compare these against the subspecialist interests sought in advertised consultant vacancies.
Methods All general surgical trainees in eight training regions, representing almost 50% of UK national training numbers, were identified via the postgraduate deans in these regions. Telephone interviews were then conducted with specialist registrars who were either accredited and seeking a job or who were within 3 years of their CCST. They were asked a series of questions to ascertain their primary sub-specialist interest, any second interest, whether they had or were undertaking a higher degree and what consultant job they would eventually seek. Five senior trainees who were working abroad at the time of this study could not be contacted and were, therefore, excluded. British Medical Journal classified supplements between 3 January 1998 and 25 December 1999 were studied to identify all general surgical consultant vacancies, both NHS and university. The type of hospital and desired sub-specialist interest were recorded, but re-advertised jobs were not included. 276
70
Jobs (n)
Jobs (%)
83 76 66 39 18 14 12 8 5
25.6 23.5 20.4 12.0 5.6 4.3 3.7 2.5 1.5
-
60
50 40
30 20-
10 0
-
Colrectl
BreastJEn
Vascular
UGIHPB
Figure 1 Job distribution between DGHs (left columns) and UTHs (right columns).
Results A total of 136 surgical trainees were interviewed and their primary sub-specialist interests (defined as an essential component of any consultant job that they would apply for) are shown in Table 1. In addition, trainees were asked in which type of hospital they would prefer to work as a consultant. Forty-six (34%) expressed a desire to work in a teaching hospital, 64 (47%) in a district general hospital and 26 (1 9%) stated that they did not mind which type of hospital depending on the job. During the 2 year period studied, a total of 324 new consultant vacancies were advertised in the British Medical Journal and the subspecialty interests required are shown in Table 2. A sub-specialist interest was clearly stated in 304 (94%) of advertised jobs with only 12 seeking a general surgeon and 8 requiring a sub-specialty to fit in with needs of the surgical department. Eighty consultant vacancies occurred in university teaching hospitals (UTHs) with the remainder in district general hospitals (DGHs). The number of jobs in the main sub-specialties in DGHs (left column) and UTHs (right column) are shown in Figure 1. On examining these figures, it is clear that the number of jobs in DGHs is substantially lower in upper Ann R Coll Surg Engl 2001; 83
MISMATCH: GENERAL SURGICAL TRAINEE'S SUB-SPECIALIST INTERESTS AND ADVERTISED JOBS
CAMERON
35
30
25 20 15
10
Colorectal
UGlIHPB
Vascular
Breast/En
Transplant
Figure 2 A comparison between % trainees (left columns) with %jobs (right columns) according to sub-speciality.
gastrointestinal / hepato-pancreato-biliary (UGI / HPB) surgery than in breast/endocrine, vascular and colorectal surgery, whereas the number of jobs in UTHs is consistent across the four sub-specialties. A comparison of the percentages of jobs (right columns) to the percentages of trainees (left columns) in the five main sub-specialist areas of general surgery is shown in Figure 2. It is apparent that there are too few trainees in breast and transplant surgery for the number of jobs being created in these areas. In colorectal and vascular surgery, the percentages of jobs to trainees are well matched whereas in UGI/HPB surgery the percentage of trainees is far greater than the percentage of consultant vacancies. Overall, 36% of trainees dedared a second subspecialist interest, with considerable variation between sub-specialties, ranging from 60% of colorectal trainees (commonest second interest being breast) to approximately 25% of both breast/ endocrine and UGI/HPB trainees. Only one vascular trainee declared a second interest indicating the increasing polarisation of this subspecialty within general surgery. Trainees were also asked whether they had or were undertaking a higher degree and overall 76.5% stated that they were. The percentage of trainees was remarkably consistent across the four main areas of general surgery, ranging from 72.5% in colorectal surgery to 87% in breast/endocrine surgery. The sub-specialist area of the research corresponded to the trainee's chosen area of clinical sub-specialisation in 87% of cases.
Discussion The recent changes in surgical training in the UK have inevitably led to problems. Some of these have recently been highlighted including the mismatch under the new Ann R Coll Surg Engl 2001; 83
system of senior house officer (SHO) to specialist registrar (SpR) ratios3 which will worsen after the reduction in SpR numbers in several surgical specialties. The problems created when trainee's sub-specialist interests do not correlate with the available training opportunities have also been described,4 but as yet no consideration has been given to the mismatch of trainee's sub-specialist interests with consultant vacancies. The situation in colorectal surgery appears relatively straightforward. It is the most popular sub-specialty amongst trainees, had the greatest number of advertised jobs and had a well matched percentage jobs-to-trainees ratio of 0.87. Vascular surgery is also in balance with a jobs-to-trainees ratio of 0.84. Vascular surgery is regarded by many as the area most likely to separate from general surgery and this is supported by several of the findings of this study. Only one vascular trainee declared a second interest and, of the 24 trainees who had done research, all except one had undertaken this in vascular surgery. Vascular trainees were further questioned about what consultant role they would like, with 26 expressing a desire to undertake pure vascular elective work and only 7 stating their desire to be general surgeons with a vascular interest. UGI/HPB surgery is the second most popular subspecialty with trainees, but had the lowest number of consultant vacancies. There were, however, considerably fewer jobs created in UGI/HPB surgery than in the other sub-specialties in DGHs. This may, in part, be explained by the fact that the Calman-Hine cancer accreditation process has not yet been applied to this sub-specialist field. It is hoped that this together with implementation of guidelines from the Association of Upper Gastrointestinal Surgeons5 regarding the requirements for an upper gastrointestinal unit will lead to consultant expansion. District hospitals possibly see this sub-specialty 277
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as the one most likely to be centralised into large units, as has already been suggested with regard to major cancer surgery, such as oesophagectomy and pancreatectomy. Transplant surgery is undergoing a recruitment crisis and currently there are many more jobs becoming vacant than there are trainees. A recent report6 looked closely at this issue, but offered few practical solutions to the problem of attracting more trainees to this sub-specialist field. Transplantation was the main interest of only 4 trainees and the second sub-specialist interest of none, and yet in two years there were 18 jobs advertised in this area. A similar problem is faced in breast surgery which is at present appears not to be an attractive sub-specialty. Sub-specialisation has occurred quickly in breast surgery, with all breast referrals being seen by one or two consultants in most departments. General surgeons appear to have been willing to give up their breast practice, but there has been great difficulty filling the large number of new jobs created by this process. There are dear discrepancies between the sub-specialist interests of trainees and those desired in advertised jobs in this study. Trainees now emerge from higher surgical training having spent their final 2 years concentrating on one area of elective surgery, often having spent a period of time doing research in that area and having declared this as their sub-specialist interest in the Intercollegiate Part 3 examination. They are, therefore, committed to applying for jobs focusing on this area, having effectively put all their eggs in one basket, but under the Calman system have only 6 months to find a consultant position before their contracts may be terminated.
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The issue of matching trainee sub-specialist interests to jobs must, therefore, be dealt with at the earliest available opportunity. Options indude dircting trainees to areas of shortage half-way dutough their SpR training, thus allowing short-term adjustments, but some trainees would inevitably be directed away from their chosen area of subspecialisation. An alternative solution may be to encourage trainees to train to a good standard in at least two subspecialties with training being extended to accommodate this change. In addition, the period of grace after CCST may need to be extended to avoid the situation whereby general surgical trainees find themselves unemployed, not due to a lack of jobs, but because they have trained in the wrong sub-specialist field.
References 1. Department of Heath. Hospital Doctors. Trainingfor the Future. The Report of the Working Group on Specialist Medical Training (The Calman Report). London: HMSO, 1993. 2. Watkin D. Can there be too many surgical specialties? Ann R Coll Surg Engl Suppl 1998; 80: 105-8. 3. Galasko CSB, Smith K. Ratio of basic surgical trainees to type I specialist registrar programmes 1999-2002. Ann R Coll Surg Engl Suppl 1999; 81:124-8. 4. Morris-Stiff GJ, Bowrey DJ, Clarke D, Harray PN, Carey PD, Mansel RE. The specialist registrar puzzle: do all the pieces fit? Ann R Coll Surg Engl 1999; 82: 76-8. 5. Anon. Upper Gastrointestinal Surgical Seruice Provision. London: The Association of Upper Gastrointestinal Surgeons, 1999. 6. Morris P. Report of the working party to review organ transplantation. Ann R Coll Surg Engl Suppl 1999; 81: 123 and 128.
Ann R Coll Surg Engl 2001; 83
