ASGBI_1_training_08.20.24

Hello and welcome to Behind the Knife. We're unbelievably excited to announce a new partnership in collaboration with our close friends from across the pond at the Association of Surgeons in Great Britain and Ireland. Similar to the American College of Surgeons in the United States, the ASGBI is the most prominent surgical society in the United Kingdom, and we couldn't be happier to team up and educate and inspire surgeons around the world.

We'll be dedicating a whole series of episodes to comparing the field of surgery on both sides of the Atlantic, covering Awesome topics such as training the job market health systems as to how they apply to surgical care practice styles and General and specialty surgical care as well for each topic you as the listeners out there will get to decide for yourself Who does it better?

I'm John Williams one of the behind the knife fellows and an American and a resident of in general surgery, and I'll be hosting the series with two UK based co hosts, Kelly Bateman and Jared Wolgamut. Kelly and Jared, feel free to introduce

yourselves. Hi, I'm Kelly Bateman. I'm a ST6 general surgery registrar based in Wales, currently in Cardiff.

And I'm also president of the ASGBI Moynihan Academy, so their trainee association. And I've also done various roles in the past as a trainee lead, as a Welsh clinical leadership fellow and trainee rep on the Royal College of Surgeons, Edinburgh as well. Hello, I'm Gerard Volgemuth. I'm an ST6 in General Surgery in Scotland.

I'm a PhD candidate at the Centre for Trauma Sciences, Queen Mary University of London. And I'm also the Co Vice President of the ASGBI Moynihan Academy in the UK. Awesome. Thanks, Jared and Kelly for all your work and collaboration on this. So for today's episode, we're going to go ahead and take a deep dive comparing surgical training in the United Kingdom versus the United States, all the way from fostering interest when you're a student to completing general surgery training, as well as specialty training beyond that, if that's

your chosen path, and every other step along the way.

Things can be pretty different for surgical trainees between those two countries, but there may be some similarities as well. And we'll get into that in further detail, but in order to get down to that, we need two incredible expert surgeons who spent a lot of time in the surgical training space. And so we're lucky to have Dr.

John Lund from the UK and Dr. Jeremy Littman from the U. S. to join us to talk about this topic. Yeah. So I'd like to introduce Professor Lund who's joining us from the UK is one of our resident experts. There's Professor and Head of Department of Surgery at the University of Nottingham and Derby and Consultant Colorectal Surgeon at Royal Derby Hospital.

But he's also got a role as Chair of the Joint Committee on Surgical Training, or JCST and before that has been Surgical Director of the Intercollegiate Surgical Curriculum Program and the Online Training Management System, which we use to keep a record of all our training within the UK.

And he has also recently been appointed as

Dean of Education at the Royal College of Surgeons Edinburgh. And Dr. Littman is a colorectal surgeon at the Cleveland Clinic and Director of Graduate Medical Education for all training programs at the Cleveland Clinic. Additionally, he's an Associate Dean for Graduate Medical Education and Professor of Surgery at Case Western Reserve University.

After going to Boston College for his bachelor's degree, he obtained his medical degree from Drexel University College of Medicine in Philadelphia. Subsequently, he completed his general surgical residency program at Case Western and his colorectal surgery fellowship at the Cleveland Clinic. After practicing at Metro Health Medical Center, where he served many training and educational leadership roles, he returned to Cleveland Clinic as faculty, where he remains today.

All right. Once again, Professor Lund and Dr. Lipman, thank you so much for joining us. So to kind of kick things off, I think it probably is worth just going through some basics of surgical training and how things are structured in both the UK and then the United States.

So Professor Lunn, do you mind giving us just a broad overview of how surgical training works as a process in the UK?

Yeah, of course. Thanks very much. So after medical school all UK graduates go into a two year Foundation program, which is a broad based program which bridges the gap between medical school and specialty training in the hospital specialties or general practice training. And during that time, foundation books become fully registered medical practitioners with the GMC after successfully completing the first year of that.

And then. go into the second year. They have to do at least three months of general medicine, in that first year, and we'll also do, you know, three to six months of general surgery, most often. General surgery isn't mandatory anymore, hasn't been so since 2007, but it's so sort of traditionally ingrained in that, that, that most

foundation doctors will do that.

And then in the second year, the scope is much wider, That will encompass all kinds of specialties, including psychiatry, pathology, general practice and many other specialties. So there's a really broad base to training during which doctors will have new qualified doctors that have exposure to to general surgery and some other kinds of surgery as well.

And then on successful completion of those two years Doctors can apply for specialty training or general practice training. And so in surgery that means applying through a national selection program to core surgical training. And core surgical training lasts for an indicative two years and makes them, it sort of trains them in the, as the name suggests, in the basics of surgical training and makes them ready to move on after two years of successful into specialty training, one of the 10 surgical specialties in the UK.

Mostly these days, the core two years of

core surgical training will be themed to one of those 10 surgical specialties. So at least a year of those 10. Two years in general surgery or plastic surgery, orthopedic surgery, vascular surgery, or any one of the 10 UK surgical specialties. And during that time, I'll pick up all the core technical, clinical and professional skills in surgery, as well as developing the generic professional capabilities.

So those things that you need to be and to develop to be any kind of doctor. And these include things like research and audit skills, as well as non technical skills and and so called soft skills. And once they've progressed through core surgical training, it's time to move on into specialty training into specialty, being a specialty registrar.

And specialty training in the UK takes, for most specialties a six, an indicative time of six years to complete. And what happens there

is the doctor then develops the skills in the all the emergency aspects of the specialty so that they can manage the the unselected emergency take the generality of the of the elective aspects of the specialty.

And in most specialties will develop a special interest in a certain aspect of that specialty. So in general surgery for instance, you know, trainees will do four years across all of the all of the general surgery, but then develop a special interest in a particular part of that. So it might go into spend the last two years finishing off the technical skills to become an independent practitioner in colorectal surgery or upper GI surgery or hepatobacteria.

Pancreatic, pancreatic umbilical surgery or any of the other special interest in general surgery. And then unsuccessful completion of that and passing the exit exam, which is the fellow of the Royal College of Surgeons exams or the intercollegiate

specialty exam to give it its proper name that they'll be eligible to be gone specialist register and then apply for substantive consultant jobs.

And what a consultant. Surgeon in the UK, someone who can manage the unselected take and the elective aspects of the specialty with a special interest independently. So it's not an end to learning, it's not an end to development of skills and picking up new skills, but it will allow someone to deliver a high level of skill.

of care in their field of expertise, often working as the head of the team of trainees and other grades of doctor there. So it's a stepwise process foundation followed by quite broad base to gain core and then funneling down into specialty and then to special interest to the consultant practice that's relevant for the national health service as a day one consultant.

Thank you very much for that comprehensive review and Dr. Lipman, how does this compare in the U. S.? My current reference is only from Grey's Anatomy so

far, so I need a dummy's guide. That's basically it. So if you've seen Grey's you've got it. So I don't have much to add. So in the U. S. It's very different.

So following four year bachelor degree, which is very, very broad. Only five courses of study are necessary in order for someone to be eligible to apply to medical school. They in the first two years, but most of the time doing mostly basic science and core competency type things before getting to the third year.

They were traditionally. more of the clinical experience develops. General surgery is a part of that experience but quite variable across different programs. In some places it can be as little as four weeks, and in some places it's as much as three months. The fourth year traditionally is where students get to do more specialization, and for those interested in surgery, they'll spend usually three or four months doing what are called acting internships or sub internships,

where they really function as a junior trainee on a service getting more detailed exposure into a specialty.

From there, they'll apply through our National Registry Matching Program, the NRMP, or the MATCH to one of our 267 General Surgery Residency Programs. Each year there are over 5, 000 applicants for around 3, 000 positions across the country. That process, as a result, is incredibly competitive.

There's interview processes and mostly virtual at this point. Lots of letters of recommendation, personal statements, those kinds of things. All of the grades and process academically that's gone on to that point becomes very important. And the, then have the match process, which uses an algorithm is actually developed for by economists that have won the Nobel prize.

It's the same

algorithm that's used to allocate organs for transplant in the United States. But the applicants will make a list in order of the programs that they want to go to. The programs will make a list in order of the applicants that they want in their program. It goes into the system and for some unknown reason it takes several weeks to spit out an answer which then Is where you're going and that is it.

Prior to the match, all of the applicants and all of the programs sign an agreement that basically binds them so that whatever is happening, that's where you're going. So there's a day called Match Day, which happens every year in the spring, and it's a big event. They still do it traditionally at many medical schools where they give you an envelope and you open it up and see where you're going.

Although in reality, it's available online and. There are many tears of happiness and many tears of not so happiness, but you're sort of locked in. So then you go to your residency program. We the first year is

used to be called internship. We've sort of moved away from that. It's a little bit disparaging.

So first year residency residency is five years. The fifth year is considered the chief resident year, so all of our final year residents are considered chiefs and they have special requirements that are looked at from them. Many of our residents take multiple years within their program to do professional development, and whether that's research or some type of advanced degree or international travel and international work.

Typically, that's done after the second or third of the five years. Towards the end of residency about 70 percent of our graduates nationally go on to pursue a fellowship, which is an advanced year or two or three of training. And those are again, mostly through another match process. https: otter.

ai and that's where people subspecialize from general surgery into things like colorectal, or I guess there are other specialties, but colorectal seems like the best one as evidenced by our call today. Following fellowship there are often so there's a set of boards in general surgery, and then there's often a second set of boards in whatever subspecialty people are pursuing.

And after that, they are hired as attendings and attending is the final level. So that is the ultimately responsible staff person for every patient. They're involved in training, research, education, clinical. If they're at an academic center many of our graduates though do go directly into a strictly clinical practice where there's no academics, no teaching, no research at all, just taking care of patients.

And that's sort of a pathway that the graduates decide upon. Okay. That sounds great. Thank you both for giving a perspective across the

water. So the first topic is fostering interest in surgery and applying and selecting the selection process. You've both already alluded to this, but let's start from the beginning.

How do medical students foster an interest in surgery during their medical school and what's the process for applying and being selected for a career in surgery? Okay. Maybe we could hear from you, Prof Lund, first in the UK perspective. Yeah, so, I think everyone watches Grey's Anatomy, I think or if you're a bit older, ER, and and things like that, you know, and people get really interested in surgery, and so at med school surgery, and by the time people leave med school, surgery is the most popular career destination.

And part of this is, you know, surgery, surgery is really established in the media, isn't it? Nearly all medical programs would be about surgery, either factual or fictional. And it's a great thing to want to do for a lot of people. And that's enhanced in the UK. There's lots of undergraduate surgical.

student societies.

So I'm mentor to the Scrubs Society at the University of Nottingham, which is the biggest undergraduate society in the med school. And they host some fantastic events through anatomy and developing laparoscopic skills and really get involved in in that, you know, careers evenings, et cetera.

So really foster that early interest. in surgery. And then people can go on elective, so there's elective time in medical school to go off and and do whatever you like. And lots of people will choose to do surgery overseas and and in some medical schools have placements in other hospitals as part of their undergraduate training.

And people, again, can choose for this to be in surgical specialties. So it's really well, you know, exposed and lots of exposure to surgery. And this is probably a good thing because in the undergraduate curriculum and the rotation, the placements much have a much smaller place than they used to in years gone by.

And certainly when I was A medical student, and I think it's probably a side

effect of it being so popular is that people weren't trying to pursue careers in the less popular, less exposed specialties, and so surges had to take a real step back. And, you know, this is a bit of a cause for concern.

Nevertheless, we are still the most popular destination specialty when people leave medical school. And then what happens after that, they go to foundation, which I talked about earlier. And I think it's about how much people feel they want to get involved in that. And I think that's probably by the time to get the end of foundation, there's a lot fewer people want to do surgery.

And I think something we really need to pay attention to in the UK is really looking after our foundation doctors when they come attached to us and really get them involved a bit more because it can be sort of just glorified admin. If we don't look after people and we need to get people to theater and get them scrubbed and get involved in cases and doing a bit of case because that's the exciting part of surgery and that's, it's great when you see people and you see the, you know, the smile on their face and even after the first bum abscess, or,

you know, taking the appendix off or close the wound that look of delight and they rush outside to phone their significant other to say what they've done.

And, you know, we need to, we need to get back to that. And then, you know, during foundation as well, you know, if you're interested you can have taster days. So you have a certain number of days in foundation where you can choose to go and be with a specialty of your choice and that's often surgery.

And again, it's just about making it fun and getting people involved in that. Because, you know, what we do need in surgery is, it's not just a lot of people, we need the best people from medical school to to apply to surgery. And and then. So they finish med school, they finish foundation and then they apply through a national selection process to core surgical training.

There are lots and lots of people apply to this and it's three or four times oversubscribed. And so we have an online test. Situational judgment test, basically, to make sure that we have, we can interview. We have enough interview capacity to interview. We interview about twice as many

people for the 1200 or so places in core surgical training, and then people will find their core jobs.

And they, we go through a ranking process, probably might win an Ig Nobel prize rather than a Nobel prize, but it means that People can rank where they want to go across all of the UK and and then they will be allocated to that region according to their rank. So the first, the person who comes top gets their first choice and so on down, and the computer again will work this out.

I always tell people, do not put somewhere down that you don't want to go and live. Because almost inevitably, that could be a place that you end up at and sometimes people unhappily end up. So, but there's no compulsion to go anywhere like it sounds like there is in the UK. You don't have to go somewhere you can choose to do that.

And there are, it's a really stressful time for people. I get that, you know, and if you're in a relationship or you have care responsibilities, and need to be a certain geographical region, then that can be a really difficult

time. But there are opportunities to pair applications with your partner or significant other.

As well, there are also opportunities to move afterwards if you find that that region isn't a good fit for you for all kinds of reasons. And then the same happens for most specialties. There's another interview at that gap between core and specialty training, another national selection process. And another ranking process.

And again, yes, another another stressful time as well. We do our very best to make sure it goes as smoothly as possible. And most people end up with the jobs that they want, the ones that they had ranked. And, you know, and so Most of the time, with a few exceptions, people, people end up there where they want to go and seem to be reasonably happy where they end.

There's lots of stuff we need to do about addressing that, about the geographical spread and things like that, but I think we're probably going to touch on that later. So I'll I'll leave that there. Okay. Thank you very much, Professor Lunt. So it sounds to summarize for the

Americans, we've gotten a lot of clinical rotations, but it sounds because surgery, surgery is so, popular it's, there's the pressure to for medical students to go through general surgical rotations is not there compared to other subspecialties Dr.

Lippman, you said that that American medical students will spend anywhere between four weeks and three months in surgery on placement. And is there, is it also one of the more popular things to match into surgery? It is it's in the top five. It's not the most popular here. It is among the most competitive.

Students will get exposure to surgery even earlier, though, in those that come in with an interest. Many medical schools have surgery interest groups and opportunities for shadowing for people to come and just see what it's like to be in the or to be in the clinics. And then as they. Move into the third year they're required to do a general surgery experience.

And then

in the fourth year, again, they have the opportunity to really specialize much further. You know, as I highlighted, they apply through the the matching systems actually separate from the application system, the application system is through the Association of American Medical Colleges and it's called ERAS, which is spelled the same as Taylor Swift's recent tour, but pronounced differently but I think just as popular.

And so through ERAS. The applicants provide their CV, a personal statement, letters of recommendation, their exam scores our exams are mostly medical knowledge. We don't have a standardized situational judgment test, like it sounds like you do, or any type of technical skill proficiency exam for that transition from medical school into, to medical school.

Into residency training. They also submit something called the medical student school performance evaluation, which used to be called the Dean's letter, and it's a summary of their performance in medical school and

in great, great detail, including all of the feedback they've received on all of their different rotations, written feedback, their grades, how they performed compared to others.

special things that they've accomplished, special situations, and also any bumps in the road they may have hit, professionalism issues, remediation, those types of things as well as their transcript. That application process has really blossomed quite a bit. The average applicant submits 71 Applications on the average program receives over 1100 applications.

And that's for the maximum of 13 spots. The largest program in the U. S. has 13 positions. And everyone is receiving about that many. So this has been a real focus right now by the AAMC, by other organizations about how we can try to narrow it down to make it a little more reasonable for programs to review because it is quite cumbersome

and more than likely many very well qualified applicants can be overlooked by a program just because they don't have the time or resources to look at every single person in detail.

That's incredible. It sounds like a lot of admin work for the For the administrators of these programs I wanted to touch base on another thing that Prof. Lund said. I wonder, Dr. Lippmann, in America, do you have, do the medical students have societies that they can join that are related to subspecialist interests like surgery and do they also experience or get an opportunity to have medical electives?

So, for example In the UK, you can go away for several weeks on elective either somewhere in the UK or somewhere abroad. And usually you have to do some sort of written program, written project or a research project as part of that to satisfy the curriculum. But a lot of people use it as an opportunity to see witness and experience how healthcare is performed and undertaken

in other parts of the world.

I went to Johns Hopkins, for example, in Baltimore, and I really enjoyed it. I know other people have gone to as far as Timbuktu, if you like. So do medical students in the U. S. have opportunities for either surgical societies in undergraduate? medical school or medical electives. Yeah, so most of the surgical societies welcome medical students and have make it fairly easy for them to participate and to join either with no or very low cost.

The American College of Surgeons. has a whole area dedicated to medical students and trying to welcome them and incorporate them. Our national meeting of the American College of Surgeons, which is the clinical Congress, has a whole medical student section each year. That's a three day program only for medical students.

And has, you know, the president of the American College of Surgeons speaks to them every year. Very high level, really trying to welcome and

get people into the groups they do have the opportunity to do what we call away electives where in, usually in the fourth year, they can go usually within the United States to another medical school or a residence or a hospital that has a residency program they're interested in to get a look at what it's like there.

It helps them in some cases to showcase their abilities. Again, they're trying to stand out amongst, you know, thousands of other people to a program, and it helps the programs to also see. You know, who's interested and who's not in their programs. Some do international electives. That's a little less common, but certainly is available to them if they can align with the right resources.

I was just going to add as well, I think one thing I forgot to say was the work that specialty associations ASGBI in the course. They find people of the Moynihan Academy who who have, you know, very active medical students in, on

your committee and do a lot of work with that as well. And as well as the colleges themselves, and particularly in trying to get underrepresented groups into surgery.

So I think that's another thing. I think in the UK that there's lots and lots of people doing a lot of work to make sure that we attract the brightest and the best into surgery. And you know, the Moynihan group is right at the front of that. So well, well done guys. Thanks. Yeah, I do find there's so many bright young medical students and in many ways they're pulled in many directions.

I think you know, especially the ones that are keen are, I find continually encouraged into people's specialties that they work in. So I generally try to advocate for surgery every day. on the wards and in theater and some people heed, heed the the call, some people don't.

But yeah, I think surgical specialties like ASTBI do try to really reach out and have a place of belonging, a home for medical students. Yeah. And just to give the, you know, the US

perspective as well, that definitely exists both at the societal level. In fact, there's at least a handful of specific societies dedicated to promoting this field of surgery for Underrepresented minority communities in the United States, and they have excellent you know, scholarship programs and sponsorship programs to allow for more experiences at the med school level and as well as engagement past the medical school to residency transition.

And then even institutions to, I think. Certainly, the last 5 to 10 years or so, I've kind of developed these homegrown initiatives to allow for promotion of, you know, populations of students that are interested in surgery, but may not have the the financial or otherwise means to go on these travel or away rotations, which I think is meaningful because the 1 limitation of the way rotation is that.

Your medical school isn't going to pay for it. And so a lot of times that requires you to incur further student loan debt or something

like that to allow for that away rotation experience, which can be really important for the professional development of students as they're not only deciding whether they want to do surgery or not, but also decide where they may want to pursue their surgical training.

Another thing I that has impacted people I know is the Royal Colleges. So not just the associations, but also the Royal Colleges. They some of them have audit and research days that medical students can present their work and start that aspect of their professional development, as well as essay prizes and obviously many courses that they can come on to learn about surgery.

Do you have something like that in the U. S.? Yeah, I would say that there's a number of surgical societies. The American College of Surgeons certainly is at the forefront. It's probably the largest example, but there are additional national surgical societies as well that actually, some of which are very centric towards trainees and students promoting their academic work.

And so, the academic surgical congress, for

example, is another nation based surgical society that really is very welcoming to medical students who are pursuing various academic projects and want the experience and the learning opportunity to go ahead and discuss their work on the national scale.

And I think that's a really promising experience, not just from the perspective of learning those kind of non technical skills of. Scientific inquiry and presenting your work, but also networking. I remember being a medical student and meeting some of my current bosses at one of those conferences while I was presenting my, you know, five minute project or something like that.

And so I think that's an interesting angle that people sometimes overlook is that it's not just the clinical experience. There's also experiences outside of the clinical space. We also have a number of affinity group organizations for medical students from underrepresented backgrounds, like the Student National Medical Association, the Latino

Medical Student Association, groups like that.

They really cater and provide a lot of opportunities to trainees that otherwise would be underrepresented in surgery and medicine. Yeah, it sounds like there's plenty of opportunities on both sides of the pond for interested students to try and foster that interest in surgery and, you know, it's definitely a role for mentorship and bringing people through.

So let's go on to now, if you're lucky enough to get that specialty training number, get enrolled in training, what makes a good technical surgeon? Dr. Lippman, you know, I hear a lot about the long hours that American surgeons work. Do you think that it's hours that people need or case numbers or what are your rules and regulations in the U.

S. How do you manage that? Yeah, so, you know, historically, it was sort of, you know, you hated taking every other night call because you missed every other night's cases.

That was the mindset many, many years ago. In the 80s with work hours reforms and the creation of the Accreditation Council on Graduate Medical Education or the ACGME, they're the accrediting body for general surgery residency programs here.

With that, there have been a lot of regulations put into place around work hours and so those exist. Historically, the training programs have focused on time and number of cases. So, you have to do 60 months of training, and you have to do 850 cases. And there's a breakdown of what those cases should be.

Now that is in evolution right now. It's a really exciting time shifting towards that model towards something closer to competency based education with the introduction of entrustable professional activities. By the American board of surgery. So our current

PGY ones in order for them to be eligible to become board certified, they will need to demonstrate entrustability in the 25 different.

EPAs and trustable professional activities for surgery. So they are being given these micro assessments. Ideally multiple times a day, but certainly multiple times a week in each of these different areas. And at the end of their training will only be board eligible if they have demonstrated entrustability in all of them.

So that is a huge seed change that's happening here right now and certainly for the better. Now, will that eventually translate to a shift away from time based training to true competency based training remains to be seen. Many, many complexities exist with that here. Our system is in

no way Set up for that.

Unfortunately, in my opinion you know, ideally, you would come in once you've achieved all of your EPA's, you would move on to the next phase of your career. That's really what it should be about. That's not how it's designed here. That would I mean, I don't think It's too much hyperbole to say that it would grind surgical care to a halt or certainly drive up the care, the cost of care, which is hard to imagine given the cost of care already in the United States.

So, We're not there yet, but this, the EPAs have been a tremendous first step. That sounds similar to some of the changes going on in the UK as well to move towards more competency based. Professor Lund, do you want to come in about you know, how many numbers do you think we need to make a good surgeon?

How many operations does the training need to do to complete training or competency? Yeah. So I think it's more than that, isn't it? It's not, you know, surgery is not just, The technical aspects, and there's that whole idea you

can teach anyone to operate. It's about when, when not to operate. That's the thing.

So the technical skills are probably, again, some things that surgeons do, but it doesn't make a surgeon, it certainly doesn't make a good surgeon. A long time ago, we used to do a lot of hours, but I think training's probably better now. And we can teach people faster and more safely. With better supervision and and more hands on, whereas it was kind of quite a lot of self directed learning used to happen in the old days.

And I think things have moved on there. I mean, so we do have an outcomes based curriculum. And not just for technical skills. So you can finish training only when you're ready to be a day one consultant. So when you're fit for purpose to be the independent practitioner in the NHS, in your specialty.

And we have to demonstrate that competence in the generic professional capabilities, which are all those things that any doctor needs. And also, we don't have as many EPAs. So we, when we were designing these, we'll have a look at some of the American things. I think pediatric

gastroenterology, we had a look and it had 120 or something like that.

And that just seemed way too many things. So we have five. And these are kind of integrated skills where you have to use knowledge and clinical skills and professional skills and communication skills, as well as technical skills to do a ward round manage the OR. Or in imperial the the the operating theater outpatients or office, I guess, over the pond.

The unselected emergency take and the the MDT meeting as well. So those are just the five. EPAs that we have, and you have to demonstrate that you can do those to the level of a day one consultant. To kind of underpin that in terms of technical things, we do have to reach a certain skill level, so level four able to do independently on the whole, and a certain number of cases for those index procedures, which are the kind of the sine qua non, the things that without that, your specialty wouldn't really be the specialty.

So in general surgery, that would be, you have to do 1,

600 cases. In total, we're a bit flexible about that, and these are all indicative numbers. You'd have to reach to me after that combination of numbers for experience and breadth of experience in different people, different cases, different scenarios and also competence.

And so, you know, an indicative number of 100 laparotomies by the end of higher training. 80 appendicectomies, 50 gallbladders, and then your special interest area. So, you know, we're all chiropractor surgeons. That's the best I think it was established. So 30 anterior sections, 50 segmental colectomies, 20 fistulas, and some other things as well.

And so we have to demonstrate that to the level of being what's required for a day one consultant. And then just sort of underpin the knowledge in a certain number of critical conditions. So these are the things that will affect life or limb that come in the middle of the night. And these include so you have a chat with somebody to demonstrate you have the knowledge with one of your supervisors and it would be things like acute GI bleed, an asthmatic leak sepsis, intestinal ischemia, necrotizing fasciitis, and things.

So those things where you could be on your own,

no one can hear you scream, and you've got to get on with it yourself, so you have to demonstrate competence in that. And then we have a formal test, of course, of knowledge. and clinical and professional skills, which is the intercollegiate specialty exam, or the FRCS, which is taken within the last two years of specialty training.

And we kind of fit all that in within that six years, and within 48 hours a week, which we've had to kind of, well, at least normally live by an average of 48 hours a week since the European working time, regulations became law in the in the noughties. And, you know, and we have to get the balance right, of course, between emergency and elective things as well.

So lots of things are about being creative with rotors and doing things in blocks to make sure we make the absolute most of every encounter. And what good a good training relationship is between trainer and trainees really getting the most out of every single patient encounter where you're there together.

And then we assess the competence in these capabilities in

practice, which are what we call the PAs, the intrusive professional activities which by those people that you're training with. So the consultants that you're, who's, who's a team you're on will sit down in the middle training training placement because there's no point getting to the end and say, John, you were terrible.

You're really useless. Tell me that halfway through and then tell me what I need to do to get better. And I might be able to do something about it. So we have this formative feedback. The multiple consultant report was given back to training and trainees. And it says what you need to do. concentrate on in that part, the next part of the placement or the next placement to move towards that goal of being a day one consultant.

And then those multiple consultant reports and the grading of the of the CIPs the interestable activities, as well as all sorts of other things. So capabilities in, in research and audits. And logbook numbers, et cetera, assessed on an average about once a year at our annual review of competency progression.

And then people will move to the next year

if they've done enough to achieve that competency for that year or move into next year. But with some things to address, they haven't quite got there. There's a few things need to concentrate on very much next year. Or not progressed the next year if you haven't quite got got through enough for that year.

And and training can be extended. We, it's a really supportive thing. I don't think it necessarily feels like it when you're in the middle of it, maybe. And particularly if you have, you know, you have to work on something and not progress in quite such a smooth fashion. But it's very supportive.

We have very few trainees who are asked to training because of failure. To progress through training and of course, you know, like patient sent patient safety is essential everything So we need people to be competent and if people can't get those competencies after considerable support Then they will be allowed to leave surgical training But we get the vast majority of people very very few one one maybe two percent of people, leave surgical

training once they've embarked on it So I mean, that's an overview.

So it's not about time. It's about quality of training and it's about outcomes based. We need somebody ready to be that day one consultant so that they can go out and deliver a really good service for the population and do that safely. Yeah, I think I would agree across the UK. We're quite good at sort of standardizing the training processes that we have to, as you say, ensure that we have those safe day one consultants that can deal with any emergencies.

How do you think our training compares in developing subspecialty interests and the role of fellowships at the moment in comparison to the US? Yeah, so well, fellowships are interesting, aren't they? So. The aim is to deliver a day one consultant, and that should be the vast majority of of people coming through training.

So they should be ready just to move straight into a job and a consultant job. And there is a sort of a bit of a gap there sometimes. Fellowships, I

think, should be reserved for those really niche areas at the cutting edge of surgery or those things that require more than one specialty background. So, JDCST runs several trainings called the Training Interface Group programs, which are a year after you after completion of standard training, but there are things like spinal surgery, cleft palate, some major trauma or oncoplastic or advanced oncoplastic breast surgery.

But the curriculum overall should get people to be a day one consultant and fellowship shouldn't be needed for the vast majority of people. And I think there's a couple of reasons for that radio quite apart from, you know, if we're not getting people going straight into jobs, and we need to look at what our syllabus is.

He's saying what the end point is because we don't want to drop people off a couple of stops. Talk short of the terminus. And we can just I mean, we're going currently going through a phase of re looking at that and adjusting things to make sure that we still deliver a day one consultant, but also in terms of equity.

So, you know, you get to your mid thirties is what most people are when they get the end

of training and not everybody is able to go on a fellowship. So they don't have the money, they have caring responsibilities they have geographical commitments, and so can't just up sticks and move to another part of the country or go abroad.

And that tends to affect some groups of people more than others, and so it isn't really fair. And then the other thing, of course, is that you don't get on the consultant pay scale. So your mates from medical school, or anaesthetists, or do healthcare, they've been consultants for years. and they'd be moving up the consultant pay scale.

Surgeons get there a bit later because, you know, we need to develop all these technical skills that sometimes take quite a while to, to develop to level of day one consultant. And so we're lagging behind on that consultant pay scale. And so another, you don't need another year not being on that pay scale, not progressing.

And it's particularly important now. It's a bit boring about finance here, but we have a career average pension now. So every year that you're earning a bit less, it affects you in 20 or 30 years time as well. So we really ought to make sure that we, people don't have to go on fellowships. You might want to go to the Mayo Clinic for a year

or to Australia for a year and do a, you know, fellowship in surgery and surfing or something like that.

But it absolutely shouldn't be a requirement. Thank you. And Dr. Lippman, how does that compare than in the US? You know, in your training programs and how they're structured throughout their career? Yeah, it's interesting. It's a, it's very different. I think I mentioned earlier about 70 percent of our general surgery graduates go into a fellowship.

So that is far more of the rule than the exception. And it creates a lot of challenges because as a general surgeon, You are expected to have a very broad base skills and competencies. Across many things that most people will not practice in the long run. So certainly there are, you know, I love Professor Lund's comment about, you know, they can't hear you screaming you know, those kinds of things when you're in the operating room and no one's around, everyone

needs to be able to do.

And that I think is covered very well, but then there are other things like a pedibiliary surgery, transplant surgery, and some of the complexities of colorectal surgery pediatric surgery, surgical oncology, and these things have taken on so many different facets that it really is challenging to get everything completed in one residency program, and so I think that's where the fellowships have developed.

There is always this question about what is the future of the true general surgeon in the United States even as a trainee, there were people that I was training under who did lipples, livers, appies, inguinal hernias. Perennial disease, everything. I couldn't don't think I could name a single person that does all that stuff.

Now that just doesn't exist anymore here. Yeah, thanks for a great perspective. And I do think that that does seem to be a fundamental difference is this concept of further discussion. Specialty or subspecialty

training is kind of the, the norm rather than the exception in the United States where, whereas in the UK, it seems that that is distinctively different and the specialty training or the 6 year meat of the surgical training really addresses, not only your ability to handle those high yield emergent surgical problems that everybody should be dealing with, especially if they're on call overnight, but also tailored towards their specialty, whether that be colorectal or something similar.

So I think that. All of us here can attest that the profession of surgery and the training process is challenging, both from a time and physical effort perspective, but certainly worthwhile. I'd like to learn a little bit more about how the training process in both the UK and the US exists in balance with life outside of work.

And I think 1 topic within that, that certainly has come up already and comes to mind immediately is the sheer hours spent training. I know Dr. Lund, you mentioned a 48 hour work week, which sounds. Remarkably luxurious to

my 80 hour work week in the US , although obviously both training pathways are set out to acco accomplish the same goal of producing a competent surgeon consultant or attending by the end of the program.

So could you elaborate a little bit more about how you feel like the day-to-day hours spent as a trainee are effectively used to produce a competent surgeon? And how that integrates into the system of what trainees are, aside from learners, they're also service providers, you know, we're providing lots of service and healthcare to people as residents, despite the fact that we're still in the training mindset and how the interface between institutional service demands of trainees and learning processes interact.

Well, to a certain extent, training is. service and services training. So every case that you do, you learn something new, the patient's a bit different, you consolidate your skills. But we do have to be very careful to make sure that training happens and training is supervised. I think

this is one of the challenges that we have in the UK, particularly after COVID.

We have a huge waiting list and the political pressure and the patient pressure is all about addressing that waiting list. And we are going to launch a campaign in the autumn to remind people that your consultant colleagues. That they need to remember where they came from and train trainees because they are, they're not trainees, they're colleagues.

They're what I used to be and you know, I used to be a trainee and trainees will be me in time where it is, it's just one continuum. And but I think in the day-to-day things when there's lots of pressures and people are giving you a hard time about your waiting list as this, that, and the other is forgetting that.

And there's, I think there's a misconception that training takes longer. And I don't think it particularly does, and you can more actively help, but it's about agreeing at the start of the list, what people will do in that list. So, okay, so we're going to get, we have got, you know, three hernias on today and I'll do one and I'll take my colleague, my trainee through these other two.

And we'll finish on time because I've got to remember the other staff there as well and agree that and just make every way that training is an essential part of the day to day activities of any doctor is training the next generation. And but we sort of undermine that a little bit because there is no particular reward either financial or otherwise for training other than that fabulous feeling of seeing the light bulb go on over the head when somebody does you know realizes a new concept or the big smile on the face when someone's done a new.

procedure, you know, from start to finish by themselves. So there's, there's lots of altruistic reward and you know, it's a really good feeling and people ought to remember that. And also remember the people who trained them as well. So we all have, you know, role models and and mentors and things, and just remember, you know, and we all ought to want to be that for somebody else, but it is quite a difficult thing.

And just, I think being proactive, if you're a trainee as well, it's just reminding people. So, you know, I always tell people, you should always say, Throughout training. Can I do that? They should be, that should be, you know, have a little badge on. Can I do that? And

just ask, because people forget, I think, and say, Oh, just agree what you're going to do.

So, you know, I can do this. And in this case today, I would like to further my things by doing this. And so, you know, be a part of that. And don't be, don't be shy to actually ask to do things. And everybody needs to get the most out of every single patient encounter, particularly at the moment, we've seen in the UK that we are literally millions of cases behind where we would have been had COVID not happened.

In training, and even in those cases that trainees are going and assisting much more often than they used to rather than participating, even in part, we really need to go through that because it's what we wanted to time bomb we are, you know, we, it's, you know, our slogan has been no training today, no surgeons tomorrow.

And it's as simple as that. If we don't train now in 5 to 10 years time, there'll be nobody there who's competent enough to do that. To train. So we owe it to the patients, the future and ourselves, because we're all going to be patients one day as well. So, you know, even if it's just that someone's going

to do your hip replacement nicely, train them in the future or your appendicectomy or your piles, whatever.

I don't have any of those things, you know, just. Well, what do you think, Dr. Lipman? Do you think that we should tell the ACGME we can go down to 48 hours a week or how does the interplay of Yeah, I, I encourage you to email them and see what they say. They do have a new executive director, new CEO.

So yeah, in the U S it's you know, we're limited limited to 80 hours a week. Trainees can't work more than 28 hours at a time and have to have eight hours off in between and a day off per week, which. Is a huge improvement compared to where we were people living in the hospital or sort of the free for all of time, but it's still not great.

It's still an awful lot of time. I heard on another podcast, a trainee say, you know, just because you don't You got hit by a truck and I'm getting hit by a sedan. It's still not great. So

there is room for growth there. You asked about wellness and life outside of the training environment. And I think there has been a lot more focus on that.

Probably the biggest change that we've seen are in some of the opportunities for leave. And that's been driven a lot by the ACGME and the American Board of Surgery. providing requirements that trainees can take time off to attend to things that they need to, whether it's growth of their family, care for others that are ill, or, you know, even if they just need time off for other reasons, there's a lot of flexibility there, which didn't used to exist.

I think within programs, we're also seeing a lot of growth in that area where we're moving away from a lot of activities after work on weekends, you know, at times when people should be expected to be doing those outside activities rather than focusing on work. There's a long way to go, though, and I think finding a

way to provide all of the.

Necessary training within the context of how we do things right now. It is tough. It was easy. It would have been modified a long time ago. Yeah, I wonder if I could just add as well. I mean, so I don't think 48 hours. Is easy because it shifts and quite constraining and you know, I've only done shifts one when I did the ER when I, in my first job on a surgical rotation, it was horrible and having a whole career of that, of moving from days to nights and having your circadian rhythms messed with, it was actually, it seemed to be a lot easier just to stay up all the time because at least you knew what would stay and what was nice.

And I think it's very different. There are lots of. health detriments to do with shift working and moving those things around. And, you know, it can actually shorten one's life working just nights and getting those things out of kilter. In the UK, there's an increasing well, it is very easy to work flexibly.

And there's all sorts of opportunities to do this until we're

less than full time and actively encouraged. I think in the UK we recognize that burnout in training is a very genuine thing and there is support there. We know in an outcomes based curriculum it makes it quite easy. All you have to be is good enough to be a day one consultant.

It really doesn't matter how long it takes to get there. You know, you shouldn't look at the path, you should look at the end points and people can choose a different path to go down much more easily. I think we're much more liberal in those aspects and supportive than in the US. And I think to the benefit of everybody involved.

So, you know, it wasn't around when I was training, so I'm probably not the person to ask. But I think going through again, apart from the shift, it looks like a much more supportive environment. Excellent. So I do think, you know, Dr. Lund, you mentioned earlier. A little bit about the boring finances using your words but I think it is worth talking about is the cost of going through these training pathways and doing

these types of career pursuits.

So I guess maybe Dr. Levin, do you mind starting with just briefly discussing the monetary aspect being the cost of medical school and then pay at the trainee level and kind of how that interacts from a financial perspective? So I think we're in a much better position in the UK. than the US. So if you go to university to do any course it will cost you the same and that's tuition fees are 9, 250 a year.

And obviously medicine's two years longer than most undergraduate degrees and and so that money has to come from somewhere. But it's affordable and there is, there is, Some support available for that universities in crisis in the UK and that those fees may have to go up as one of the options to fund that.

But the moment 9, 250 pounds a year. And of course, on top of that, you have to find your living expenses, et cetera, et cetera. The student loans and people people come out of medical school with reasonably sized. That that takes some time, some

time, some number of years to pay off. And of course when doctors start working.

So if you're a foundation doctor. So Imperial Monetary Measures 32, 398, UK pounds, is a basic salary for a foundation doctor, which goes up to 37, 300 by the end of foundation training, and you might get some more for overtime on top of that. So, you know, it's not the best salary in the world, but it's okay, and if you're in specialty training, it ranges from about 44, 000 to 50, 000.

To 63, 000 pounds a year, especially training can be really expensive. So what we're trying to do across the board is to minimize the number of mandatory courses that people need to go on. So there's a very few things you need to go on to get to the end of the curriculum. And so, that takes away some of that financial burden and those mandatory courses will be paid for, but there was a lot less money in the system and there's a lot less

support for It's tiddly for courses, and some people may feel they want to do other courses, and they might have to pay for some of those themselves.

One of the other things, of course, is rotational posts, so people will move between hospitals, and sometimes, even in the UK, through relatively large geographical areas, a moving house in the UK costs a lot of money. You know, if you buy another house, and so things like that, and the travel to work, etc., the long commutes, which can sometimes happen, are having to stay over.

A hospital that might be quite a way away from your home all adds up and unlike lots of other professions outside medicine that we seem to be have to pay for these things ourselves, rather than having supported by the companies that they work for. So, You know, I think it is difficult, and that's of course on top of the the non financial cost of training, and again, ASIT have recently done a survey of this just sort of showing, and it'd be an interesting read for anyone who's, you know, perhaps from the USA, and it might be echoed in the USA, but

just there's lots and lots of experiences that I think we could make a lot better in UK surgical training, probably just by making the geographical call.

Demands on on trainees less and making sure they can stay in a place for longer. But yeah, so not badly paid, probably not as well paid as it is, certainly not as well paid as it is in the USA. That's why lots of people move to that to the USA to try and, try that but it's okay and doesn't attract a huge debt set, I think, what we'll probably hear about in a second, I think.

Yeah, in the U. S. it's you know, people finish undergraduate with debt, usually. And then medical school, the average medical school graduate carries about 200, 000 in debt just from their medical school, in addition to whatever they incurred from undergraduate. Residents earn usually about 60, 000 or so thousand dollars a year in their first year, have a scale increase that can get them up to, you know, 70, 000, 80, 000 by the time they finish.

Thank you very much. But

then once they enter the job force, they are making considerably more. You know, the average U. S. general surgeon first year is around 250, 000. And depending on the practice model, can be much higher than that. For residents, it's 2, 000. It's very challenging because with carrying that type of debt, there's not a lot of options to go into something else.

I think that's one of the biggest downsides, is that if halfway through your residency, you decide, you know what, this isn't for me. I want to go back and teach public school. You have a huge problem because you're not going to be able to make the salary you need in order to pay back your debt.

Now, if you stay on the pathway, then it works out fine. Having said that, you know, I'm pretty far into my career and I still have debt that I'm paying but it's not you know, I'm not putting food on the table, either the residents in the U. S. You know, we pay them a salary. They're doing work. It's a job.

It's not

just a subsistence salary. Their true value is beyond what we pay them, and that's what we pay them in their education and the training that we provide. And so I think there's sort of those two things come together into what they're actually receiving. So, yeah, the debt is a huge problem here.

But resolved if you stay on path and go out and become a practicing surgeon, but certainly compounded if either you make a new choice or in the very unusual case where someone cannot complete their program, then they're left in a really bad situation. All right. Thank you. Well, this has definitely been a really, really thoughtful and interesting conversation, kind of comparing a lot of different aspects of surgical training between the UK and the U.

S. So I think we ought to try to. Wrap things up now and kind of get down to who does what better and what are the strengths and weaknesses of surgical training? Whether it be in the United Kingdom or the United States. So Jared,

do you mind trying to take the torch for the UK side of things? So on the side of the UK There are multiple strengths of the UK system from my perspective, I think comprehensive training pathways provide the opportunity to experience multiple fields of medicine and surgery prior to embarking upon a surgical career.

So I think that gives you a more broad understanding of medicine in general, before you go on to be a surgeon we are physicians first, is the way I see it. Surgical training is comparatively lengthy in times of years, while less intense in terms of weekly hours, as discussed. This may allow for better work life balance and reduction in burnout during training, and it might also allow for more time for other professional development, so involvement in research, education, or management.

Surgical training is, in the UK, there are regular rotations around different hospitals and units, which can provide the opportunity to experience. different surgical techniques and philosophies,

even within the same training program in a similar region, which I think is beneficial. There's not one way to skin a cat.

There are multiple exams to ensure we are competent to practice