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How do we improve surgical training?

28 Jul 2015

Ian Eardley and Karen Smith

Surgical services need to change. Seven-day care is required to reduce weekend mortality; integrating health and social care would help to care for older people with multiple conditions; and services providing complex surgery need rationalisation to improve outcomes for patients.

These changes inevitably require the development of new ways of working, and potentially a new workforce, which will challenge historically held views about professional boundaries.

We can either sit back and allow these changes and challenges to be addressed around us and without us, or we can engage with the service and the policy makers to ensure any changes benefit surgical patients, their quality of care, and their safety. To this end the College is engaging with the debates on the wider surgical team and changes to medical training. We see both as opportunities to address problems in surgical training, particularly in the early years.

No one who has any involvement with surgical training can deny that the quality of training that we deliver, particularly in the early years, is less than desirable. We can continue to debate the reasons for this; the European Working Time Regulations, the New Deal contract, shifts, rotas etc. or we can choose to do something about it. 

Many national reviews have tried, and yet the GMC’s annual national training survey continues to demonstrate that surgical trainees are the unhappiest of all the medical specialties with their training.1 Satisfaction scores are particularly low for those in foundation and core training. This is hardly surprising given that an imbalance of service vs training results in trainees with little or no surgical experience in the first three years of training; gaps in rotas mean that training in daylight hours is diminished; shift patterns often result in trainers hardly seeing their trainees.2 These problems all need to be addressed with solutions that involve the whole surgical team, not just those who are medically qualified.

We already know of many examples across a variety of surgical units where other healthcare professionals have clearly defined roles within the team in delivering surgical care. We need to build on this and work with these colleagues to learn from these examples and encourage this trend to develop.

The College’s view is that it is time the profession came together to deliver the solutions. This is why we want to work with Health Education England around the wider surgical team and the ‘shape of training’ agenda. We wish to use these issues as vehicles to address the worst aspects of surgical training, celebrate the best, and drive innovation in the service to enhance care delivered to patients.

More contentiously, we cannot support a system that continues to produce sub-specialists when the clear service need is for surgeons who can deliver effective and safe emergency care. Of course we must ensure that specialist skills are available when needed by our patients and the debate around improved outcomes when a specialist rather than a generalist sees patients, when this is necessary, are well rehearsed and widely accepted. However, the balance of generalist versus specialists must be better matched with patient and service needs.

The opportunities are there to achieve a system which will provide better training, better support for both trainees and other members of the wider surgical team and ultimately to deliver better care for patients. While the road to achieving this will require commitment, innovative thinking and acceptance that change needs to happen, the future is bright for surgery.

Ian Eardley is Vice-President of the Royal College of Surgeons and a Consultant Urologist.

Karen Smith is Director of Professional and Clinical Standards at the Royal College of Surgeons.

1. The state of medical education and practice in the UK 2014


2. These problems are highlighted from the Association of Surgeons in Training: International Journal of Surgery, Improving the future of surgical training and education: Consensus recommendations from the Association of Surgeons in Training, 2012.

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