The training of surgeons

House Officers (PRHO)

After medical students qualify as doctors they spend one year as a resident pre-registration house officer (PRHO). The term "pre-registration" refers to the fact that they have provisional registration with the General Medical Council (GMC) and this year, spent under the aegis of an educational supervisor their consultant, is designed to confirm that they are suitable to be included on the full GMC register. During this year, some make the decision that they wish to become surgeons.

Senior House Officer (SHO)

Young doctors aspiring to become surgeons apply for an SHO post in accident and emergency medicine (A&E), or in one of the surgical specialties. In many surgical specialties there is no pre-registration house officer so they fulfil the functions of a PRHO in providing ward care and continuity for patients admitted under their surgical consultant. In A&E they gain very varied experience, much of it non-surgical. These posts are generally of six months duration. At this stage they would apply for an SHO - Basic Surgical Training - rotation. Such rotations are of two and a half to three years duration. These involve six months training in each of a variety of surgical specialties, occasionally including intensive care and accident and emergency medicine. During their surgical rotation they will be exposed to a formal educational programme and training towards the MRCS examination. The RCS has worked considerably over the years to produce an educational course which can be followed at their hospital of employment the STEP course. In addition the trainees are obliged to take a Basic Surgical Skills course and test and are strongly advised to take an Advanced Trauma Life Support course (ATLS) and a Care of the Critically ill Surgical Patient (CCrISP) course. Most SHOs take the MRCS examination, with its communication module, about two and a half to three years into SHO training.

On passing the MRCS, trainees seek a higher surgical training post with its national training number (NTN). These are rarely found at the first attempt and trainees need to seek other employment until an NTN is obtained there are many SHOs held up at this stage through lack of available NTNs; the number of which is controlled by the Department of Health. Many trainees in surgery undertake a period of research at this stage; partly to meet the requirement for higher surgical training; partly to fill the time until an NTN appointment is successfully achieved (and partly to improve their CV). Some trainees extend one year to a two-year period with a research grant. The RCS awards research grants for one year. This has proved a very successful scheme and has enabled many trainees to gain research and become very attractive candidates for a further year's funding from award giving bodies such as the Medical Research Council (MRC). A two-year period of research often allows trainees to complete the work for a thesis, which is then submitted to their undergraduate university for a mastership or doctorate award - MCh; ChM; MChir or MD (I received a mastership for surgery, ChM, from the University of Sheffield for my research).

Higher Surgical Training

This is now a structured, formalised six-year period of training; the first three years of which are generally undertaken in district general hospitals where trainees gain a wide spectrum of experience covering a number of the different sub-specialty disciplines. For example in general surgery, the trainees may work for surgeons who have a sub-specialty interest in: breast surgery; endocrine surgery (surgery of the glands (eg thyroid)); vascular surgery (on blood vessels particularly the arteries supplying the legs); the upper gastrointestinal tract (stomach, small bowel, liver and pancreas); or coloproctology (surgery of the large bowel, cancer, inflammatory bowel disease and the rectum and anus (haemorrhoids etc)). One of the six years is designated for research which may have already been fulfilled prior to the gaining of an NTN. In this case, trainees are then exempt from repeating this. The final two years of the higher surgical training are usually spent in the sub-specialty of choice of the trainee. During the final year the trainee takes the intercollegiate specialty examination. The trainee can choose whether he is examined in his nominated sub-specialty or in the generality of, for example, general surgery. Surgical trainees can take higher surgical training in: neurosurgery; cardiac surgery; ear, nose and throat (ENT); trauma and orthopaedics (with all its sub-specialties); paediatric surgery; urology; or oral and maxillofacial surgery.

CCST (Certificate of Completion of Specialist Training)

The CCST is awarded to those trainees who have satisfactorily completed the designated period of training (six years); have had satisfactory appraisals at the end of each year; and have passed the intercollegiate specialty examination. Their name is then put forward by the Specialist Training Authority (currently comprising the medical royal colleges with representatives of postgraduate deans and the Department of Health but soon to be superseded by the Postgraduate Medical Education and Training Board) to the GMC for inclusion on the GMC specialist register. When surgeons have their name on the specialist register they are then free to apply for a consultant surgical post in the NHS. They are regarded as fully trained surgeons.

Surgical training is of course never complete and considerable concern is currently expressed that this relatively shortened training period combined with the considerably reduced hours of employment, fails to adequately prepare the trainees to fulfil their role as consultant with confidence. For this reason, some form of semi-formal mentoring by senior and more experienced consultants for newly appointed consultants is being proposed. Further, the formation of structured team working between consultants, trainees and others is essential.

Consultants in post are all expected to keep up to date and have to register their continuing professional development with their College. Certificates of attendance at courses and meetings are now issued and kept by the consultants in their "portfolios" or "folders". These are examined each year at the formal annual appraisal and are required for revalidation and the issue of a licence by the GMC to continue practicing.