How to work in… general surgery
While digital imaging allows surgeons to probe deeper, working directives raise questions about their training. Sara Williams looks at a specialty that is constantly evolving and asks: is surgery for you?
What is general surgery?
In surgery you need to be a master of dissection and excision, and be both mentally and physically strong
General surgery is one of the biggest pullers of the nine surgical specialties, boasting 31% of the total number of surgeons in Britain. According to the Royal College of Surgeons, there are 1,756 NHS general surgeons in England, working in up to 2,900 operating theatres, where they assist in a bulk of the 4.2 million operations that take place every year. One in 12 people will go under the surgeon’s knife at least once in their lifetime. Many different sub-specialties fall under general surgery, including breast surgery, gastro-intestinal surgery, coloproctology, and oncological, transplantation and vascular surgery. Consultant general surgeons are usually practitioners in one of these sub-specialties. In surgery you need to be a master of dissection and excision, and be both mentally and physically strong enough to survive the gruelling hours spent in operating theatres.
Surgeons operate on all parts of the body, addressing injury, disease and degenerative conditions. Daily tasks include managing pre-op and post-op patients from both acute and elective settings. Consultant surgeons lead surgical teams and supervise the juniors, and treat patients in the wards and in out-patient clinics.
Training
Surgeons need a thorough understanding of physiology, biochemistry, pathology and anatomy. It is more scientifically based and dependent on audit and measurement of outcome than the other disciplines. There are a limited number of training courses, just as there are a limited number of consultant posts. Nevertheless, every surgeon needs to get appointed to a recognised basic surgical training post through the training board of the regional colleges of surgery. Over two years, trainees gain experience of general surgery, emergency work, orthopaedics with trauma and a surgical specialty. Trainees then sit for their MRCS or AFRCS; if successful, they can choose their specialist area and apply for a specialist registrar grade post, lasting six years. In order to become a fellow of the Royal College of Surgeons (FRCS), trainees have to take exams. Surgeons who pass are awarded a Certificate of Completion of Training (CCT) and are free to practise independently.
Surgery is notorious for not having enough training posts. Traditionally, consultant work only comes up when someone retires or dies. Wannabe surgeons may have to relocate to further their career, but staying put can have its advantages. Trainees tend to move around at ST1 and ST2 level but once a trainee reaches their specialist registrar, staying put could make it easier to get a consultant post.
Working in general surgery
To succeed, surgeons must be shrewd, confident, focused and, above all, dedicated to the role
“The only weapon with which the unconscious patient can immediately retaliate upon the incompetent surgeon is haemorrhage.“ – William Halsted (1912 bulletin Johns Hopkins Hospital).
Surgeons find employment in both the public and private sectors, but competition can be fierce. To succeed, surgeons must be shrewd, confident, focused and, above all, dedicated to the role. Standing and bending for long periods of time requires surgeons to be fit and able to handle long unsociable hours on call and on night shifts. Dr Bryony Lovett is a consultant general surgeon with a specialist interest in colorectal cancers, bowel disease and microscopic surgery. She qualified in 1988 and was appointed a consultant in 2001. “I didn’t know when I started my house programme that I wanted to be a surgeon,” she said.
“I had always been extremely good at making things: as a child I was always problem-solving and building things. When I started I didn’t worry about removing things; I loved it, and I liked being in theatre operating on people. I chose a specialty that I would enjoy for the rest of my life. New doctors must choose a specialty that fits them, one that will not disappear or be replaced by a tablet. Surgery has potential; it is not a niche specialty.” Dr Lovett says it is vital to research surgery before embarking on it as a career. She encourages trainees to meet up with local surgeons and hospitals. Trainees go into theatre often and perform more emergency work, so chat to them to find out what it’s like at the coalface.
Dr Lovett adds: “A patient will come in for a laparoscopy and the registrar will do it; I would only be called down if they couldn’t do it. So the work juniors do is done under a consultant’s name. In surgery you make a diagnosis, make a decision, plan an operation and do it – it’s a continuous timeline but you can make such a dramatic difference.” Being competitive and driven is the key to success. Dr Lovett says: “I was a competitive athlete as a junior. Most of the surgeons I know do something at an outstanding level. A lot of them are either musicians or sports people. They are focused, slightly obsessive people, and this has made them great surgeons.”
What the future holds
With medical advances such as laparoscopic surgery and digital imaging, a surgeon’s work is constantly evolving. “My colleague is retiring soon; he started as a general surgeon doing operations that we don’t do anymore,” says Dr Lovett. “You don’t come into surgery to be comfortable; operations and procedures are always evolving. We recently developed an enhanced recovery programme where patients only stop drinking two hours before surgery, are out of bed on the second day and home by day five.” Clinical advances such as these benefit surgery as a profession, but it has been argued that the European Working Time Directive has brought changes that may not allow trainee surgeons to get the training they need.
Dr Lovett notes that a culture is developing in surgery where people finish their shift and leave: "There’s a lot of emphasis on social activities outside of work now. I’m not saying that is a bad thing, but the issue is how do you strike a balance and ensure that people come out of training actually fit for the purpose of being consultant surgeons. Trainees can opt to stay later or come in for procedures but you can’t coerce them. It will be difficult working within the 48-hour limit; obviously, enthusiastic surgical trainees won’t want to go home halfway through an operation – they would want to stay and finish it.”
She predicts that a way around this could be to produce future surgeons who are more specialised: “There are a lot of bright, enthusiastic trainees who will continue to develop the service, but their training needs to be more focused. As a consultant, I need to ensure that I’m furnishing them with the right attributes; it’s not just an ability to operate that makes a great surgeon, but the ability to manage, to teach and to communicate properly, and represent the profession.”
Boxout
- Personality – Manual dexterity above all, caring attitude, good hand–eye coordination, organisational ability, good communication skills, stamina, focus, being receptive to new ideas
- Best bits – Giving life back, working as a team, using practical skills, challenging operations
- Worst bits – Complications, getting out of bed at 3.30am, overbooked clinics, complaints
- Stress – Moderate to high, prolonged stress
- Salary – £60,000-80,000 (NHS), £500,000 (dependent on private practice)
- Competitive – Very