The Hands-on Guide to Surgical Training E-Book

Matthew Stephenson

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Serie: Hands-on Guides
• Sprache: Englisch

Seitenzahl: 534

Veröffentlichungsjahr: 2011

Beschreibung

Thinking about a surgical career? About to start surgical training? Do you know what to expect and how to thrive?

The Hands-on Guide to Surgical Training is the ultimate, practical guide for medical students and junior doctors thinking about taking the plunge into surgery, and also for surgical trainees already in training. It’s full of invaluable, practical information and career guidance to ensure you get the most out of your surgical career.

It offers general guidance and advice on surgical training, together with detailed information on each of the nine surgical subspecialties, each written by seniors and consultants, as you make both clinical and career-based choices.

Undoubtedly one of the most comprehensive resources for surgical trainees available, The Hands-on Guide to Surgical Training will be essential reading throughout your training and surgical career.

Take the stress out of surgical training with The Hands-on Guide!

Leseprobe

Table of Contents

Cover

Title page

Copyright page

Preface

Introduction

Contributors

So you want to be a surgeon?

I’m a medical student, what should I do now?

What kind of surgery?

Career structure overview

Abbreviations

Clinical

Chapter 1 THEATRES

Surgical instruments

Introduction

Commonly used general instruments

Sutures

Introduction

Absorbable versus non-absorbable

Monofilament vs braided (polyfilament)

Size (thickness)

Needle type

Specific examples

Theatre etiquette

Introduction

Before the operation

During the operation

After the operation

Patient safety and the WHO surgical checklist

Introduction

The patient safety checklist

Summary

How to write the operation note

Introduction to operative sections

Appendicectomy

Introduction

Procedure

Notes

Summary

Inguinal hernia repair

Introduction

Procedure

Notes

Summary

Dynamic hip screw

Introduction

Procedure

Notes

Summary

Chapter 2 WARDS

Surgical ward rounds

Handover

Drains and tubes

Wounds and ulcers

Managing complications

Sick patients

End of life care

Chapter 3 CLINICS

Seeing new patients

Seeing follow-up patients

Dictating the letter

Keeping track of serious cases

Specialty-specific investigations and procedures

Chapter 4 ON CALL

Some practicalities

Referrals

Resuscitation essentials

Trauma

Non-clinical

Chapter 5 THE FOUNDATION YEARS

Overview

Recruitment to foundation training

Aims of foundation training

Courses

Examinations

Progression

Chapter 6 THE CORE TRAINING YEARS

Overview

Recruitment to core training

Academic clinical fellowships

Aims of the core training years

Syllabus

Membership of the Royal College of Surgeons (MRCS)

Courses

Annual Review of Competence Progression (ARCP)

Chapter 7 THE SPECIALTY TRAINING YEARS

Choosing a specialty

Overview of specialty training

Recruitment

Aims of the specialty training years

Out of Programme

Courses

Annual Review of Competence Progression

Postgraduate degrees

Fellowship of the Royal College of Surgeons (FRCS)

Chapter 8 GENERAL SURGERY

Introduction

The subspecialties

The general career path

What’s it like being a general surgical core trainee?

Recruitment to Specialty Training

What’s it like being a general surgical specialty registrar?

Courses during general surgical specialty training

Exit exams

What’s it like as a consultant?

Chapter 9 UROLOGY

Introduction

The general career path

What’s it like being a urology foundation doctor?

What’s it like being a urology core trainee?

Recruitment to specialty training

What’s it like being a urology specialty trainee?

Courses during urology specialty training

Exit exams

What’s it like as a consultant?

Summary

Chapter 10 CARDIOTHORACIC SURGERY

Introduction

The general career path

What’s it like being a cardiothoracics core trainee?

Recruitment to specialty training

What’s it like being a cardiothoracics specialty trainee?

Courses during cardiothoracic training

The exit exam

What’s it like as a consultant?

Summary

Chapter 11 ORAL AND MAXILLOFACIAL SURGERY

Introduction

The general career path

What’s it like being an OMFS core trainee?

Recruitment to specialty training

What’s it like being an OMFS specialty trainee in?

Courses during OMFS Specialty Training

Exit exams

What’s it like being a consultant?

Summary

Chapter 12 EAR, NOSE AND THROAT SURGERY (OTORHINOLARYNGOLOGY – HEAD AND NECK SURGERY)

Introduction

The general career path

What’s it like being an ENT core trainee?

Recruitment to specialty training

What’s it like being an ENT specialty trainee?

Courses during ENT specialist training

Exit exams

What’s it like being a consultant?

Summary

Chapter 13 PAEDIATRIC SURGERY

Introduction

The general career path

What’s it like being a paediatric surgery core trainee?

Recruitment to Specialty Training

What’s it like being a paediatric surgery specialty trainee?

Courses during paediatric surgery specialty training

Exit exams

What’s it like as a consultant?

Summary

Chapter 14 NEUROSURGERY

Introduction

General career path

Recruitment to specialty training

What’s it like being a neurosurgery specialty trainee?

Courses during neurosurgery specialty training

Exit exams

What’s it like as a consultant?

Summary

Chapter 15 ORTHOPAEDICS

Introduction

Subspecialties

The general career path

What’s it like being an orthopaedic core trainee?

Recruitment to specialty training

What’s it like being an orthopaedic specialty trainee?

Courses during orthopaedic specialist training

Exit exams

What’s it like as a consultant?

Chapter 16 PLASTIC SURGERY

Introduction

The general career path

What’s it like being a plastic surgery core trainee?

Recruitment to specialty training

What’s it like being a plastic surgery specialty trainee?

Courses during plastic surgery specialty training

Exit exams

What’s it like as a consultant?

Chapter 17 APPLYING FOR JOBS

Introduction

Key principles in applying for jobs

Portfolio

Curriculum vitae

Application forms

Interviews

Common questions

Getting career advice

Coping with failure

Chapter 18 FLEXIBLE TRAINING AND WOMEN IN SURGERY

Flexible training

Introduction

Maternity leave

Women in surgery

Chapter 19 ACADEMIC SURGERY

Overview

Academic surgery for interviews and vivas

How do I get a publication?

Research in practice

Chapter 20 OTHER ISSUES IN SURGICAL TRAINING

Who’s who and what’s what?

Recent historic changes to surgical training

New Deal and the European Working Time Directive

Money

Chapter 21 FELLOWSHIPS

Introduction

Pre-CCT fellowships

Interface fellowships

Post-CCT fellowships

International fellowships

Where to find out about fellowships

Summary and general tips

Chapter 22 APPROACHING CONSULTANCY

Introduction

Finishing training

Certificate of Completion of Training (CCT)

Certificate of Eligibility of Specialist Registration (CESR)

Making yourself competitive

Deciding which consultant job to apply for

Finding out which jobs are coming up

The consultant application process

The application form

The interview

Transition from trainee to consultant

Appendix 1: PREOPERATIVE ASSESSMENT

Pre-assessing elective patients

The perioperative management of specific conditions/ medications

Patients on antiplatelets

Appendix 2: CONSENT

Introduction

Assessment of capacity

Patients with capacity

Patients without capacity

Special circumstances

Summary

Appendix 3: LOCAL ANAESTHETICS

Index

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Library of Congress Cataloging-in-Publication Data

Stephenson, Matthew.

 The hands-on guide to surgical training / Matthew Stephenson.

p. ; cm.

 Includes bibliographical references and index.

 ISBN 978-0-470-67261-7 (pbk. : alk. paper)

ISBN 978-1-118-26870-4 (epub)

ISBN 978-1-118-26867-4 (mobi)

 I. Title.

 [DNLM: 1. Specialties, Surgical. 2. Surgical Procedures, Operative. 3. Vocational Guidance. WO 100]

 617´.9076–dc23

2011034251

A catalogue record for this book is available from the British Library.

Preface

It is a most gratifying sign of the rapid progress of our time that our best textbooks become antiquated so quickly.

Theodor Billroth (one of the founding fathers of abdominal surgery, 1829–1894)

There has been a need for a coherent resource for surgical trainees along the whole pathway of training for many years now, to offer some career advice and practical advice. The problem with writing such a book is in striking the balance between generic advice and specific advice. The former can make the book too vague and unhelpful, the latter means that by the time of publication the book is already long out of date, and this is particularly true in these changeable times post-MMC. Hopefully this book has struck a reasonable balance, but necessarily a book like this can only be historical, future-proofing the contents is impossible.

There are also of course variations in terms of location – some things are done differently between the regions of the UK. Where it’s relevant, for instance in matters of recruitment, since the majority of trainees work in England this has generally been discussed pri­marily; however, where there are regional differences these have all been described.

Never more so is an author setting himself up for becoming out of date almost immediately than when publishing current prices. There would be an argument not to have included money talk at all, but the most recent figures have been included as a rough guide to give the reader an idea of the financial impact surgical training can have. It would be nice to see one set of these financial figures, our salary, become out of date as soon after publication of this book as possible; however, at the time of going to print, the government has frozen doctors’ salaries for two years so it’s likely, unfortunately, that these will be roughly accurate for longer than we would like.

This is a ‘mixed ability’ book. There will be bits that may seem irrelevant and too junior for you, or the other way around. Just ignore the bits that aren’t helpful to you. The aim of this book is to be useful to a whole range of surgical and would-be surgical trainees. If you’re a man, for instance, you probably won’t find the Women in surgery section in Chapter 18 very helpful. There is also a need for overseas doctors coming to work in the UK to understand the system, which explains why sometimes the absolute basics are explored.

Finally, whichever career path you decide to follow, be it surgical or non-surgical, hepatopancreaticobiliary or otorhinolaryngology – I wish you the very best of luck.

Introduction

The life so short, the craft so long to learn.

Hippocrates (c. 460 BC–370 BC)

Surgical training has come a long way, for better or for worse. Until the mid-19th century you didn’t need to go to university to become a surgeon. If you had the inclination for cutting people open with little or no anaesthetic, you would attach yourself to an already established surgeon. Much like becoming a tradesman’s apprentice. Meanwhile our wealthier medical forebears would be living it up at university gaining a doctorate. They’d become ‘Dr So and So’, while we’d still be Mr (and no one’s changed that system since, in most of the UK). We would at least have had to take an examination at the end of our apprenticeship and in London this was conducted by the Surgeons’ Company, formed in 1745 as a break-away group from the Worshipful Company of Barbers. This illustriously named group was formed in 1308.

Back in those days a religious monk would be your GP, attending to all your medical and surgical needs. However, under papal decree they weren’t allowed to spill blood, and given that practically all treatments back then involved spilling blood, this was an obstacle to them doing a good day’s work. So they would work with the barbers who would not only give you a short back and sides and a wet shave, but chop off your leg, too.

Over the centuries surgery gradually became more advanced, hence the split in 1745 following power struggles between the barbers and the barber surgeons. In 1800, the Surgeons’ Company became the Royal College of Surgeons of England. The Royal College of Surgeons of Edinburgh, however, claims a longer independent history, being formed in 1505 but with a not that dissimilar background of barber origins, too.

What on earth has all this got to do with you getting an ST3 job? Well not much actually. The more recent history of surgical training, however, will have an impact (see Chapter 20). It must be basic human nature that every generation believes themselves to be in the middle of the greatest change in history, be it in 1745, 1800 or 2012. Nevertheless, it can’t be disputed that Modernising Medical Careers, the New Deal, the European Working Time Directive, public disclosure of outcome figures and even the fallout from Harold Shipman, have rocked our modern world of surgery. They have resulted in reduced working times, altered career progression and changes in how we prove our competence and probity. However, whatever changes politicians, managers or even senior doctors make, the core fundamentals of learning how to be a surgeon remain the same as they were during the time of the Worshipful Company of Barbers: study the theory of surgery and practise the art.

As a surgical trainee you’ll spend your working day between four specific clinical categories: theatre, wards, clinic and on call. So that’s how the clinical chapters have been arranged. The aim is not to repeat the basic science of surgery – that’s been covered extensively elsewhere – it’s to help with the practical aspects of working as a surgical trainee. For example, what are all those surgical instruments called? How do you effectively lead a surgical ward round? How long postop do you take out a T-tube and why? A complex discussion about aetiopathogenesis it is not. Furthermore, the clinical section is weighted towards general surgery. This is because general surgical jobs are far commoner than paediatric or cardiothoracic surgical attachments and to go into the minutiae of clinical management in each of the surgical disciplines would make this into a very different book.

The other main section of the book is related not to clinical work, but to all other non-clinical areas, much of it to assist in career guidance. There are three chapters relating to the three stages of training: foundation, core and specialty, which cover the generic aspects of those years. Each is divided into sections such as the aims of that stage, recruitment processes and competition, courses to attend and exams to take.

Following this there is a detailed look at each of the nine surgical specialties written by a senior trainee or consultant working in each of them, giving you an inside look at the specialty: how that specialty recruits, what it’s like at core training level, specialty training level and consultant level, along with recommended courses to attend.

Finally we look at the process of getting jobs, women in surgery, flexible training, research and clinical governance, political issues affecting surgery and the end game of training: consultancy.

Contributors

Mr Sam Andrews MA, MS, FRCS (Gen.Surg)

Consultant Vascular Surgeon

Medway NHS Foundation Trust

Mr Sion P Barnard MSc, FRCS (C-Th)

Consultant Thoracic Surgeon

Freeman Hospital, Newcastle

Miss Ginny Bowbrick FRCS (Gen.Surg)

Consultant Vascular Surgeon

Medway NHS Foundation Trust

Mr Richard Burnham MFDS, MRCS

Specialty Registrar Oral and Maxillofacial Surgery

West Midlands Deanery

Mr Christopher M Butler MS, FRCS

Consultant General Surgeon

Medway Maritime Hospital

Miss Clare Byrne FRCS

Consultant General and Colorectal Surgeon

Lewisham Healthcare NHS Trust

Miss Sophie J Camp MA (Oxon), MRCS, PhD

Neurosurgery Specialty Registrar

Charing Cross Hospital, London

Ms Tamzin Cuming FRCS (Gen.Surg)

Colorectal Specialty Registrar

North East Thames Rotation

Miss Helen Dent MSc, MRCS

Surgical Trainee

Medway Maritime Hospital

Mr George HC Evans MA, MChir, FRCS

Consultant General and Vascular Surgeon

East Sussex Hospitals NHS Trust

Mr Iain Findlay MRCS

Trauma and Orthopaedics Specialty Registrar

King’s College Hospital, London

Mrs Cheryl Funnell RGN

Lead Practitioner, General and Emergency Team and Registered Nurse

East Sussex Hospitals NHS Trust

Dr Shelly Griffiths MB, BS, MA (Cantab)

Core Surgical Trainee

South West Peninsula Deanery

Mr Amyn Haji MA, MSc, FRCS (Gen.Surg)

Consultant Colorectal Surgeon

King’s College Hospital, London

Mrs Lisa Leonard BA, MSc, FRCS (Tr and Orth)

Consultant Orthopaedic Surgeon

Brighton and Sussex University Hospitals

Mr Wasim Mahmalji MSc, MRCS

Urology Specialty Registrar

South Thames Rotation

Miss Petra Marsh BSc, MRCS

Surgical Specialty Registrar

South East Thames Rotation

Mr James E Mitchell MRCS

ENT Specialty Registrar

St George’s Hospital, London

Mr Max Pachl MRCS

Paediatric Surgery Specialty Registrar

Birmingham Children’s Hospital

Mr Sofiane Rimouche BMedSci, MRCS

Plastic Surgery Specialty Registrar

North Western Rotation

Mr Matt Stephenson MSc, MRCS

General Surgical Specialty Registrar

South East Thames Rotation

Stephen Whitehead MChir, FRCS

Consultant General Surgeon

East Sussex Hospitals NHS Trust

So you want to be a surgeon?

You must always be students, learning and unlearning till your life’s end, and if, gentlemen, you are not prepared to follow your profession in this spirit, I implore you to leave its ranks and betake yourself to some third-class trade.

Joseph Lister (British surgeon, 1827–1912)

Few careers could possibly offer as much opportunity for witnessing human suffering and being able to cure it, or for acquiring such a vast scientific knowledge and applying it to something so tangible. Not to mention the job security, the earning potential, the global portability and even the social status.

There are many great things about being a surgeon but there are also some drawbacks, some big drawbacks. Few careers could possibly offer as much opportunity for witnessing human suffering and making it even worse, or take so long and so much effort to acquire the vast scientific knowledge and experience required. Not to mention the unsociable hours, the career dead ends, the burdensome responsibility or the low pay compared with equivalent positions in the city.

Despite all this, surgical training remains highly competitive. It’s not worth bothering unless you’re sure that the pros outweigh the cons for you. The problem there is how could you possibly know until you’ve tried it? And not just as a foundation doctor or core trainee. Until you’ve felt the pain of an operation you’ve performed go badly wrong, or the gut wrenching ache of a major decision you’ve made lead to a serious adverse outcome, or had your finger up an nonagenarian’s backside at 3am on a Saturday night because you’re still doing nights well into your thirties, can you really see past the glamour of life as a surgeon.

In the not too distant past, trainees had, to all intents and purposes, as much time as they liked to try out different surgical jobs in the form of senior house officer posts – gaining experience, preparing for exams and confirming or refuting in their minds whether surgery was right for them. Modernising Medical Careers changed all that and you are now expected to commit at an earlier stage and choose a specialty much sooner. Neurosurgery, for instance, currently recruits nationally from FY2 to run-through training to consultant level. Because of the European Working Time Directive you’ll also have less time at work to get the experience you need to make up your mind.

All of that said, you need to decide carefully – very carefully – and after taking as much advice from people as you can, that surgery is right for you. Many people don’t, won’t or can’t see beyond the glossy side. If you’re in it, at worst for the money and social status or at best because you like the idea of cutting things out of people and making them better, think again. There are other jobs that pay far better and for all the patients for whom you have the satisfaction of a clean, complication-free operation, there are many more you’ll have to treat for chronic conditions, non-operative conditions or conditions serious enough that they’re in ITU for months. Not everything in surgery will give you such quick gratification.

People often have misleading notions about who makes a good surgeon and you need to be cautious when interpreting their advice to you and establish why they think you’ll be a good surgeon. For instance, you will not be better suited to surgery just because you are: (a) a rugby player; (b) dislike medicine; (c) like making snappy decisions; (d) have a type A personality; and (e) are male.

Forget the stereotype. Gregarious male rugby players who dislike the slower pace of medicine and like making snappy decisions do not make better surgeons than anyone else. Being a good surgeon requires a distinct skill set unrelated to sporting prowess.

1 You must be intelligent, at least as intelligent as a medic. You need to grasp in full detail, complex anatomy, physiological principles and the pathology that affects them.

2 You must be able to make a decision. Not a snappy one, you need a mind that can quickly and efficiently process information, weigh it, come to a conclusion and deliver your decision. And it must be with the acceptance that it might be wrong but you will learn from it. To be excessively scared of making difficult decisions quickly for fear of getting it wrong is a contraindication to surgery as a career.

3 You must be able to cope under pressure and retain your judgement.

4 You must be reasonably dextrous, with good hand–eye coordination and spatial awareness.

5 Whatever any moderniser says, you must accept a work–life balance heavily weighted towards work. Not only may you still be doing nights 10 years after qualifying when your family is at home, but to get the necessary experience you’ll have to accept coming in on days off and staying late where necessary.

6 You must be tough skinned enough to cope with your own failure, with suffering, with covert bullying, with not getting jobs and with the hours, but not so much that you don’t lose your humanity.

7 You must be prepared to jump through hoops: audit, exams, courses, interviews, publications, etc., and be patient enough to still be competing with others for career development and doing exams even though your contemporaries may have already reached the heights of their careers.

8 You must be a good communicator, like any other doctor.

9 You must like working in a team, taking both team participant and team leader roles readily.

10 You must like problem solving, although this is by no means specific to surgery.

Despite all the challenges and drawbacks of choosing to train in surgery you will be rewarded with some indescribably wonderful experiences in life if you do. It’s difficult to compare the satisfaction from saving life or limb, in a way that no other specialty does. Learning the craft of surgery – the feel of putting knife to skin, dissecting out a tumour, identifying and preserving structures that you become familiar with like old friends, fixing broken bones, decompressing suffocating neural tissue, taking out old worn-out and putting in new – brings a kind of pleasure to your work that’s impossible to explain to one who’s never experienced it. Once you’ve had a taste, you’ll know if it’s for you.

I’m a Medical Student, What Should I Do Now?

So if you’ve given it the requisite thought and decided yes, I am going to ruin my life and become a surgeon, what should you do now to increase the chances of success. Actually there’s quite a lot, and it all relates to showing your early commitment to surgery.

1 Most importantly, start developing your portfolio (see Chapter 7). Obviously to begin with there won’t be much to put in it, but every little bit helps.

2 Join, or if there isn’t one already set up, a local surgical society at your medical school. The Royal College of Surgeons has information on its website to help form these. For bonus points you could sit on the Medical Student Liaison Committee (MSLC).

3 Take an elective with a surgical attachment.

4 Attend a free surgical careers afternoon at the Royal College of Surgeons (run twice a year) – you’ll get a free certificate to kick your portfolio off.

5 Become an affiliate member of the Royal College of Surgeons (£15 per annum).

6 Get involved in a surgical audit – best done during a surgical attachment – someone’s bound to be doing one, so get involved.

7 Do an intercalated BSc – it doesn’t have to be, but ideally would be surgically related. Whatever it is, work hard and aim to get a publication out of it. Even just one publication will stand you in good stead for years to come.

8 Unrelated to a BSc, ask around at your nearest surgical academic department and offer to do anything to get involved in research that might lead to a paper.

9 Work hard academically – winning prizes in medical school will provide more points on future application forms than you realise. There’s often a section for prizes and most people have to leave it empty.

10 Prizes prizes prizes. Apply for the Professor Harold Ellis Medical Student Prize for Surgery run through the RCS; the Hunterian Society offers a prize, as do many other local surgical societies – keep your ear to the ground.

11 Go on the Systematic Training in Acute Illness Recognition and Treatment for Surgery (START Surgery) course run by the Royal College of Surgeons for final year medical students and foundation doctors.

12 Join ASIT (Association of Surgeons in Training). This is now possible for medical student and costs £30 per annum. It will keep you abreast of current issues in surgical training.

13 If you’re a woman, join Women in Surgery (see Chapter 18).

What Kind of Surgery?

Obviously it isn’t enough just to say you want to be a surgeon, eventually (but not for a good while if you’re still a medical student or foundation doctor) you’ll have to decide which area of surgery interests you most. There are nine specialties within surgery:

cardiothoracic surgerygeneral surgeryneurosurgeryoral and maxillofacial surgeryotorhinolaryngology (ENT)paediatric surgeryplastic surgerytrauma and orthopaedic surgeryurology.

In addition to this, there is the field of academic surgery, which is heavily weighted towards research. Furthermore, by around 2013, it’s likely that vascular surgery will have split off from general surgery altogether to have formed its own independent tenth specialty. There are more detailed exposés of these specialties in Chapters 8–16, but the following is a brief idea. Besides each specialty is the number of ST3 posts that were available in that specialty nationally in 2008 and the ratio of applications to posts the same year (for a more thorough look at competition ratios, see Chapter 8).

Cardiothoracic Surgery (2008, 5 Posts; Ratio 1 : 23)

Heart, lungs, oesophagus and other chest disorders. You would eventually choose either cardiac or thoracic, not both usually. It also includes transplantation surgery. Common cardiac operations are coronary artery bypass grafting and valve operations, while thoracic ones are lobectomies and pneumonectomies, now more often thoracoscopic rather than open. Much of the work over the past decade has been extracted by cardiologists, as endovascular techniques have gained in popularity. It’s a very intensive career choice with often complex patients.

General Surgery (2008, 80 Posts; Ratio 1 : 19)

A very large specialty now in practice split into many smaller subspecialties. It’s no longer possible to become a ‘true’ general surgeon and be able to cover the whole range unfortunately. The main subspecialties are:

upper gastrointestinallower gastrointestinalhepatopancreaticobiliarybreasttransplantvascularendocrine

Generally, you would subspecialise in one of these but would continue to do a general workload so that there are enough consultants to cover the on-call commitments but your elective work will be more limited to your subspecialty. Often now, however, new breast consultants will specialise only in breast, and vascular consultants only in vascular. This trend will almost certainly continue.

Neurosurgery (2008, 5 Posts (ST1); Ratio 1 : 5)

Brain, spinal cord and peripheral nerves. For a small specialty it’s also quite subspecialised with areas including paediatric, neuro-oncology, functional neurosurgery, skull-base surgery and spinal surgery (the largest). The patients are often very high dependency and a strong grasp of neurology is essential. Neurosurgery is unique in that there is run-through recruitment at ST1 level, not ST3. Applicants frequently are very well qualified, often with postgraduate degrees.

Oral and Maxillofacial Surgery (OMFS) (2008, 17 Posts; Ratio 1 : 13)

Facial bones, face and neck. You have to hold both a medical and dental degree, so the training pathway is slightly longer, but not as much as you might think (see Chapter 11). On-call commitments are low. The unique thing about OMFS is the opportunity to combine operating on both bone and soft tissue in good measure.

Otorhinolaryngology (ENT) (2008, 19 Posts; Ratio 1 : 14)

Head and neck, skull base and facial plastics. There is a heavy preponderance of day case work – much time is spent on diagnosis and outpatient treatment. On-call commitments are quite low.

Paediatric Surgery (2008, 1 Post; Ratio 1 : 40)

From the fetal period to the teenage years (usually 16 is the cut-off). The vast majority of surgery on children is performed by non-specialist paediatric surgeons; however, some conditions require specialist input, especially in the very young or in oncology. Day case surgery is particularly common. You will be limited to the geographical location you can work; this specialty is small.

Plastic Surgery (2008, 9 Posts; Ratio 1 : 23)

Essentially surgery on the soft tissues, mainly reconstructive. Common elective cases are breast reconstruction, cleft lip and palate, and other facial deformities. Emergency work includes hand trauma and burns. On-call commitment is quite high, especially with burns, and severe facial and hand injuries. There is also the option of training in cosmetic surgery.

Trauma and Orthopaedic Surgery (2008, 50 Posts; Ratio 1 : 15)

Bones, joints and associated soft tissues. Also quite subspecialised to regional areas, e.g. knee, hip, foot and ankle, etc., although for emergency work you will continue to cover the whole range. There is quite a demanding on-call component.

Urology (2008, 14 Posts; Ratio 1 : 15)

The urogenital system. Common pathology you’d deal with includes renal stones, cancer (especially of the prostate, bladder, testis and kidney), incontinence, erectile dysfunction and prostate disorders. Much of urology can be done on a day case or even outpatient basis.

Career Structure Overview

As things stand, after qualifying as a doctor you will undertake two years as a foundation doctor. During this time you will want to undertake as many surgical jobs as possible, as well as an A&E post. You then apply for a core surgical training rotation, which lasts two years and generally comprises six-month jobs (or apply directly to ST1 run-through neurosurgery). It’s during this time you will be expected to get your Membership of the Royal College of Surgeons (MRCS) exams, and in the case of ENT trainees, your Diploma in Otolaryngology – Head and Neck Surgery (DOHNS) diploma. The pathway for OMFS trainees is entirely different (see Chapter 11). This is the time to get your final preparation in order for competition into higher surgical training.

Once you’ve completed your core training posts and obtained MRCS you would apply for ST3 in your chosen specialty – this is essentially a first-year regis­trar job. If you don’t have MRCS yet, or for various other reasons, you might do a CT3 year, which is essentially a grace year – you won’t be able to proceed to ST3 without MRCS. From ST3 you rotate through your region in six-month jobs covering various areas of your specialty, and you usually have to choose your subspecialty. All the specialties go up to ST8 except urology, which runs to ST7.

Once you’ve successfully completed your registrar years, and have passed the exit exam in your chosen specialty you can apply for a Certificate of Completion of Training (CCT), which entitles you to enter your name on the specialist register and apply for a consultant job.

Abbreviations

ABPIankle-brachial pressure indexACCSacute common care stemACFAcademic Clinical FellowshipAESassigned educational supervisorALSAdvanced Life SupportAPanteroposteriorAPLSAdvanced Paediatric Life SupportARCPAnnual Review of Competence ProgressionARRabsolute risk reductionASAAmerican Association of Anesthesiologists