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Surgical specialties

Organ transplant

Surgery is a hugely rewarding discipline with a good balance between intellectual input and physical interaction. While largely providing for the needs of operative intervention, surgeons maintain a key role in the diagnosis, investigation and medical care of patients in emergency and elective practice.

Surgery is one discipline where doctors can immediately see the results of their work in an environment where physical approaches are adopted in the treatment of health problems. It is most suited to those who prefer an active approach to medicine with an aptitude for dealing with problems in a straightforward manner.

Trainees identifying surgery as a possible career path have to select one specialty within surgery. There are nine specialties to consider:

  • cardiothoracic surgery
  • general surgery
  • neurosurgery
  • oral and maxillofacial
  • trauma and orthopaedic surgery
  • otolaryngology (ear, nose and throat surgery)
  • paediatric surgery
  • plastic surgery
  • urology surgery
  • vascular surgery
  • Skills, rewards and challenges

    Skills

    • Manual dexterity
    • Good knowledge of physiology
    • Ability to think and act quickly and decisively
    • Ability to cope with the risks and complications of surgery
    • Self knowledge and self discipline

    Rewards

    • Immediate results
    • Variety - every day brings a different challenge
    • Gratitude of patients

    Challenges

    • Demanding training
    • Stamina and commitment - you must be prepared to make the pursuit of surgery your life's work
    • Maintenance of surgical knowledge and skills in a fast moving environment
  • Training

    Following the foundation training programme, trainees are expected to do a further two years of core surgical training. Core surgical training maybe linked or themed to a particular specialty or could compose a generic surgical training programme. This is then usually followed by six years of higher specialty training.

    Training in all specialties is competence-based and therefore varies in length, although there are indicative times set out in each syllabus.

  • Inside look: Cardiothoracic surgery

  • Inside look: Consultant orthopaedic surgeon

    What factors influenced your decision to choose this branch of medicine

    Surgery always appealed to me because you physically have the problem in your hands and often have an opportunity to make a clear change.

    I also like the thought process - a lot of time and thought goes into what to do and whether to go ahead, but for the operation itself you just do your best. In orthopaedics, you develop an excellent rapport with the patients - you do what they feel they want done (eg total hip replacement) to improve their quality of life.

    Half the work is trauma, and again you negotiate with the patient about their lifestyle and treatment options. Apart from a few 'set pieces' there is always time to think and plan. Very little operating has to be done immediately at night.

     

    What are the hours like? How intensive is your work schedule?

    The hours have a reputation for being tough, but in reality most trauma work is scheduled for an operating list on the following day.

    Trainees follow the European Working Time Directive of 48 hours per week: most at 'Core Training' level are on full shifts, often covering many surgical specialties; 'Higher Trainees' (also known as Specialty Registrars) have their weekly training included in the 48 hours, some are on full shifts and some are 'non-resident on-call'.

    For a consultant, a typical weekly Job Plan will be:

    • Monday: all day operating
    • Tuesday: fracture clinic in the morning, trauma list in the afternoon
    • Thursday: morning clinic, afternoon: day surgery list
    • Wednesday and Fridays free for other interests

    Most consultants are on-call 1-in-6 or less frequently, and also you have some administration to do, and (short) ward rounds. Operating days start early, and days after you have been on-call start at 8am. Mostly theatre lists and clinics are finished by 5.30pm.

    The 2003 consultant contract acknowledges that consultants do 'Supporting Professional Activities' (SPAs): examining, interviewing, committee work, research, teaching, etc depending on their interests, at other times.

    I did my training when hours were 80-110 per week, before rotations, so the work today does not seem as intensive! All the consultants of today are those who survived that gruelling era - I can see how future cohorts of surgeons will be very different.

     

    Is there scope for flexibility, for example part-time work?

    As a consultant, there may be no need to work flexibly - if you can manage financially without private practice, the NHS work has a lot of flexibility around where and how you do the 'Supporting Professional Activities'. Consultant posts are advertised for '10 PAs' meaning ten 4-hour sessions, but this can be negotiated up or down with your managers (and includes SPA time). Many consultants work part-time nearing retirement.

    All training posts can be done as 'Less Than Full Time Training' posts (LTFT), if there is a reason to work less than full time (family commitments, sporting or educational reasons or disability are common reasons to choose LTFT training). This is arranged through the postgraduate deanery in the area. The training time is lengthened and the salary reduced pro-rata (eg 80 per cent for someone working 80 per cent of normal hours). It is possible that now the hours have reduced to 48 hours per week, this option will be less popular. It can take a while to organise (there is information on deanery websites about this).

     

    What are the highlights and advantages of working in this specialty?

    Physically fixing a problem - decompressing carpal tunnels, fixing ankle fractures, fixing hip fractures. Watching a patient walk again. There are many sub-specialties to develop into (paediatric orthopaedics, sports surgery, trauma surgery, revision joint replacement surgery, hand surgery, etc). Good team working. Meeting a huge range of patients (age, lifestyle, etc) and potentially having the ability to help each one.

     

    ...and the challenges and disadvantages?

    Seeing an operation you have done go wrong - infection in a joint replacement can be devastating for the patient, for example. Seeing someone's life change in an instant due to an injury.

    Politics: The relentless demand for orthopaedic surgery - this is sometimes called the 'un-met need'. The old image of the orthopaedic surgeon being a thick-set male who wasn't very clever but was very strong still lingers, despite lovely new kit and very competitive entry.

     

    What are the routine aspects, if any, of your role?

    Fracture clinics - these are quite fun - you have a gentle discussion with the patient about the natural history of their injury and spot the few that would do better with an operation. It is very sociable.

     

    ...and the more unusual experiences to date?

    Seeing people from the same car crash rehabilitate together.

     

    Please describe your duties in a typical day

    The following is a typical surgical day:

    • 9am - drop kids at school
    • 9.15am - fracture clinic
    • 1pm - administration and emails in office
    • 2-5.30pm - day surgery
    • 5.45pm - home
    • 9-11pm - hospital emails at home and preparing talk (after kids in bed)

     

    What are the necessary personality characteristics for this career?

    A sense of humour, the ability to think of a range of options and the ability to get on with a range of people.

     

    What advice would you give to someone interested in pursuing a career in this branch of medicine?

    Don't be put off by other people's stereotypes. Be aware that it is very competitive, so you need to do anything that will look good on your application form. This includes doing audits, getting some abstracts accepted for conferences, getting some management experience, doing relevant courses, learning anatomy and getting a teaching qualification. You should keep a log of operations you have seen, read up about them first and reflect on them afterwards.

     

    How competitive is this specialty?

    Very. However, someone has to succeed, and it is a big specialty, so there are more opportunities.

     

    Additional comments...

    There is some overlap with plastic surgery. It is worth doing a post or at least a 'taster week' to see which you prefer. Some 'core training' rotations are generic for any specialty afterwards, and some are 'themed' for orthopaedics only.

  • Inside look: Consultant in oral and maxillofacial surgery

    Why did you choose oral and maxillofacial surgery?

    My A-levels indicated medicine, dentistry, veterinary science, pure science or teaching and so I proceeded to dentistry.

     

    When did you decide this was the right career for you?

    At age 21, I decided that a career in dentistry was not for me. I therefore proceeded to take a medical qualification and my qualifications in dentistry and medicine led to a career in oral and maxillofacial surgery.

     

    How intensive is your work schedule?

    It depends on intermediate cover, but can be very intensive with trauma.

     

    What are the highlights of working in oral and maxillofacial surgery?

    Making the correct diagnosis, performing a surgical procedure optimally and teaching.

     

    What are the challenges?

    Teaching, 'getting out of trouble' and 'getting others out of trouble'.

     

    What are the routine aspects, if any, of your role as a consultant in oral and maxillofacial surgery?

    There is nothing routine in surgery - this is one of the attractions.

     

    Please describe your duties in a typical day

    Seeing outpatients, surgical procedures, teaching, clerical, administration, management and 'trouble shooting'.

     

    Which attitudes lend themselves to a successful and fulfilling career in oral and maxillofacial surgery?

    Patience, tolerance and the ability to communicate.

     

    What advice would you give to someone interested in pursuing a career in this specialty?

    Are you innovative, flexible and reasonably good at hand-eye coordination?

     

    Additional comments

    In general, a career in surgery in the NHS has changed dramatically over the last few years: there is much more subspecialisation and much more pressure to be involved in the management process and to meet clinical deadlines and targets set by non-clinical managers.

    Training in oral and maxillofacial surgery is too long as it is necessary to have both a medical and dental qualification followed by fellowships in dental surgery and maxillofacial surgery. Most consultants are appointed in their late thirties at best.

    I would summarise my own mental attitude to what I consider to have been a most satisfying and challenging career (retiring next year after more than 28 years as a consultant) - 'I don't suffer from stress - I am a carrier.'

  • Inside look: Neurosurgery

  • Inside look: Specialist registrar in general surgery

    What factors influenced your decision to choose this branch of medicine?

    Good exposure to the specialty in the early stages of my postgraduate training. Motivated and enthusiastic consultants as mentors. An underlying interest in the subject. The opportunity to learn a wide array of practical skills.

     

    Is there scope for flexibility, for example part-time work?

    There is scope for flexible training.

     

    What are the highlights and advantages of working in this specialty?

    There are many advantages to working in this specialty. Current training provides you with a good grounding in all aspects of general surgery, with considerable skill acquisition and knowledge. Operating can be very exciting and surgery as a whole provides a unique opportunity in medicine to make a significant and often quantifiable difference in a patient's health.

    It is a specialty that demands leadership, commitment, teamwork and a sound knowledge base, making boredom highly unlikely.

     

    What are the challenges and disadvantages?

    Whilst you will have many surgical successes, as a surgeon it is inevitable that mistakes will be made by you or your team and these need to be identified, admitted, managed and learnt from. These mistakes can often be difficult to bear and in addition, the last decade has seen litigation rise exponentially in the UK.

    As surgeons have fairly clear end points (eg cancer resected [surgical removal of part of an organ] fully, or not) their outcomes are easier to audit and scrutinise making them good initial sectors to review critically. Clinical governance may reduce errors and increase care, but it is also likely to considerably increase the pressure on the operating team in the longer term.

     

    What are the routine aspects, if any, of your role?

    • Clinics - usually two per week where patients requiring surgery are assessed and consented, or the outcome of those post surgery is assessed.
    • Theatre - usually at least two sessions per week for elective cases with a varying number of cases requiring emergency surgery per week.
    • Ward work - a registrar's role is generally to run the ward round, identify problems and to ensure the smooth running of the surgical firm. Delegation is an essential skill as increasingly you are required in more than one place at any one time.
    • On-call duties
    • Teaching and training - a registrar will be in both these roles at selective times during the week.

     

    … and the more unusual experiences to date?

    In my current post, I am doing a post called 'General Surgery in Childhood'. The aim is to improve the care of children by adult general surgeons, who do not have paediatric surgical cover.

    My training is structured by a paediatric surgeon and for between six months and one year, I spend over 50 per cent of my time helping to manage and operate on children and neonates. What makes it so interesting is that say on Thursday, I may operate on an 80 year-old lady for her gallbladder problem, prior to looking after a newborn baby with a hernia - this keeps the brain and the hands very attentive!

     

    Please describe your duties in a typical day.

    The typical day starts at 8am (or 7.15am if operating that morning) with a ward round of patients, where operated patients are reviewed and new patients are assessed. The day then varies and so I enclose my own working week. On-call duty (after hours) is generally once a week, where you cover the emergency admissions until 8am the next morning. Generally, I will get home at 6.30pm on a normal day and midnight on an on-call day.

    • Monday - Ward round, clinic then research time
    • Tuesday - Ward round, theatre (paediatric), clinic (paediatric)
    • Wednesday - Theatre (adults), theatre (day case, adults) or half day
    • Thursday - Theatre (adults), theatre (paediatrics)
    • Friday - Ward round, teaching morning, alternate theatre list

     

    What are the necessary personality characteristics for this career?

    Energy, enthusiasm, tenacity, commitment, physical fitness, integrity and enjoy practical skills.

     

    What advice would you give to someone interested in pursuing this branch of medicine?

    This is an intense but rewarding specialty that is rapidly subspecialising. Although future surgeons will not have the variety of conditions to treat, which gave 'general surgery' its name, there will be the potential to become an expert in one field and significantly improve the quality of life of many people. If you are interested, find an enthusiastic doctor and glean as much information about the job from them, from anatomy to life outside. It's ultimately a life-long decision.

     

    How competitive is this specialty?

    It is probably fair to say that this specialty used to be the most competitive but lifestyle choices, training concerns and subspecialisation are some of the reasons why general surgery is less popular currently than orthopaedics, plastic surgery or urology.

    Competition for jobs does however remain strong, often depending more on past and present research projects and extracurricular activities than on actual clinical and operative skills. This may change in the future as research funding becomes increasingly scarce and more trainees are required to fill expanding training numbers.