Jason Ramsingh1, Jonathan Noël2
1Department of Surgery, Royal Victoria Infirmary, Newcastle Upon Tyne Hospitals NHS Foundation Trust, NE1 4LP UK
2Global Robotics Institute, AdventHealth, 380 Celebration Place, FL 34747 US
Urologic Oncology, Global Robotics Institute,
380 Celebration Place
FL 34747 US
Email: [email protected]
Copyright: This is an open-access article under the terms of the Creative Commons Attribution License which permits use, distribution, and reproduction in any medium, provided the original work is properly cited.
©2021 The Authors. Caribbean Medical Journal published by Trinidad & Tobago Medical Association
Surgical post graduate training is a rapidly evolving field that has seen major technological shifts in its delivery of care. Our aim in this article is to deliver a viewpoint of a contemporary roadmap for the University of the West Indies (UWI) graduate. The overall path and length of training schemes in the United Kingdom (UK), in respect to general surgery and urology is presented. It is important for the reader to understand that the UWI graduate has many different avenues they can pursue to gain entry onto a UK surgical training programme. The Caribbean should benefit from the connectivity and collaboration with our international colleagues.
Keywords: surgery, postgraduate, training, general surgery, urology, fellowship
Surgical post graduate training is a rapidly evolving field that has seen major technological shifts in its delivery of care; particularly in countries such as India, Brazil, the United States and the UK. Whether due to medical collegial ties or the history of the Caribbean, the UK’s National Health Service (NHS) is an island nation that benefited from Windrush Generation’s immigration from 1948. It still does to this present day.1
It is our aim in this article, to deliver a viewpoint of a contemporary roadmap for the UWI graduate that may assist in their career before and after earning their medical degree.
After graduating from medical school, a one year caribbean internship encompassing the four specialties of Obstetrics & Gynaecology, Paediatrics, Internal Medicine & Surgery, prepares one well for the challenges of transitioning to UK practise. After the General Medical Council’s (GMC) full registration is approved, the physician has the opportunity to apply for various posts. These range from Foundation Doctor (internship equivalent), Trust/Service grade or formal training post, the latter being paramount to the journey towards a Certificate of Completion of Training (CCT).
Data was collected from the literature, open access documents, Health Education England and the Intercollegiate Royal College of Surgeons online resources. The overall path and length of training schemes in general surgery and urology is presented. The associated certifying examinations and annual review of competencies progression (ARCP) is explored.
A career path and features that are unique to UK post graduate training are provided in Table 1a and 1b. In order to be fully registered with the GMC, the UWI graduate must demonstrate internship or Foundation Year (FY) 1 equivalency. A 2-year core surgical training (CT) programme is the first hurdle, and will allow exposure to surgical specialties that may not be related to their chosen career. However, the specialty rotations can be adjusted if trainees demonstrate early commitment to their specialty through teaching and research. The goal of CT is to acquire membership of the Royal College of Surgeons (MRCS) examinations while undertaking clinical audits, bolstering their experience through core procedures and surgical courses.
Following RCS ‘Improving Surgical Training’ plan, a ‘run-through’ training scheme began in 2018 in General Surgery and 2019 in Urology. This run through programme is geared towards trainees who have decided on a chosen specialty such as urology or general surgery and eliminates the need to enter core specialty training. These trainees will not have to interview at the ST3 level and ensures a smooth transition in training (see Table 1a). Trainees can apply after foundation training for run through training with a similar application process as core training. This is limited to a few regions in the UK.
Table 1a: Career steps to General Surgery & Urology CCT.
*Specialty trainee (ST1/ST2) for ‘run through’ post with direct progression to ST3.
|Steps||UK||General Surgery Details||Urology Details|
|1||Foundation Year 1
|FY 1 and 2 years are equivalent to Internship, with exposure to a less standardised specialties compared to UWI (e.g GP, Pathology, Research).||Same.|
|2||Foundation Year 2
|Same as for FY 1. MRCS taken to improve CT application.||Same.|
|3||Core Surgical Trainee (CT1)*||In CT, exposure to specialties that may or may not align with chosen specialty. (range from ENT to Orthopaedics etc)||Same.|
|4||Core Surgical Trainee (CT2)*||As for CT1. The core model is uncoupled to progress to Specialist Training. Competitive application to ST3/National Training Number (NTN)||Same.|
|5||Specialist Registrar/Trainee (ST3 – 7/8)||Training is ST3 – ST8. Leading to CCT.||Training is ST3 – ST7. Leading to CCT.|
|6||Post CCT Fellowship||Local or Nationally led Fellowships (Post CCT) enables concentration in a field of your specialty. (Robotics, Endocrine etc)||Local or Nationally led Fellowships (Post CCT) enables concentration in a field of your specialty. (Robotics. Neuro-Urology etc)|
Table 1b: UK Postgraduate Training Organisations & Features
|UK||General Surgery Details||Urology Details|
|Medical Practitioner Registering Body||GMC|
|Qualification||Certificate of Completion of Training|
|Curriculum committee||Joint Committee on Surgical Training||Specialist Advisory Committee: General Surgery||Specialist Advisory Committee: Urology.|
|Additional organizations in the UK for training support||Association of Surgeons in Training (ASiT)||Association of Surgeons of Great Britain and Ireland (ASGBI)||British Association of Urological Surgeons (BAUS)|
|Number of ST3/NTN positions in 20202||123 general & vascular surgery posts at ST3.||64 urology surgery posts at ST3.|
|Examinations||Membership of the RCS prior to ST3||Fellowship of the RCS (General Surgery)||Fellowship of the RCS (Urology)|
|Research requirements||To progress to ST3, advisable.||To CCT: 3 first author publications and presentations respectively.||To CCT: 2 first author publications and presentations respectively.|
Some UWI graduates would have gained extensive experience in surgery after their Internship at a Senior House Officer or Registrar. This cohort can alternatively apply after their membership of the Royal College of Surgeons (MRCS) examination, to an ST3 national training number (NTN) post. Their equivalency of training in the Caribbean, is approved by the RCS.
A UK Path to Surgery in General
As mentioned, core training involves rotating through various surgical subspecialties such as ENT/Plastics/Orthopaedics/Urology/General Surgery/Vascular. This is particularly useful for trainees interested in surgery but unsure of which branch they may prefer. It allows these candidates exposure so that an informed decision can be made. The Improving Surgical training (IST) programmes obviates the need to rotate through surgical specialties, as mentioned earlier, that may be niche depending on a candidates general preferences, such as ENT, plastics and orthopaedic surgery in relevance to this article.
A proportion of trainees take time out for research, termed out of programme for research (OOPR), during which they spend 2 or 3 years focusing on a particular field of study leading to a research degree such as a doctorate of medicine (MD) or doctorate of philosophy (PhD). Many trainees use this as an opportunity to develop an academic interest and increase their publication profile. Out of programme for experience (OOPE) is similar to OOPR, where a predefined timeline is agreed with Training program Director, and months of exposure to specialised units nationally or internationally are possible. After the OOP period, the trainee returns to ST training at the level they were prior. These out of programmes for research and experience are often taken during the ST3-8 years.
Specialty Registrar training (ST3-ST7/8) involves rotating through numerous hospitals with differing subspecialties. Workplace based assessment (WBAs) such as procedure based assessments (PBA), case based discussions (CBD) and clinical evaluation exercises (CEX). Operative competency and numbers, research, presentations, quality improvement projects and attendance at courses are all assessed yearly by an annual review of competency progression (ARCP) panel, in order to progress every year. Failure to progress may result in repeating the year or additional support.
In the final 2 years of ST training, trainees are expected to complete their Fellowship of the Royal College of Surgeons (FRCS) exams. These 2 years are also spent in their subspecialty of choice:
- General Surgery: endocrine, colorectal, oesophagogastric, breast, hepatopancreaticobiliary or transplant.
- Urology: endourology, robotics/uro-oncology, female, functional & neuro-urology, paediatrics, andrology.
Following completion of their final year and satisfactory outcomes from supervisors, they are awarded the Certificate of Completion of Training (CCT) and are eligible for specialist registration with the GMC.
From UWI graduate to UK specialty training and specialist
It is important for the reader to understand that the UWI graduate has many different avenues they can pursue to gain entry onto a UK surgical training programme. The authors’ suggestion is to plan early, by engaging with GMC to understand the requirements for entry on the register. While not an absolute prerequisite, attaining the MRCS as a postgraduate qualification, combined with prior surgical experience in the West Indies, improves the full registration application also.
It is highly recommended that an electronic record of all surgical cases the graduate is involved in is collected, as the case for equivalency of experience to core training in the UK can be made. A certificate of equivalence will need to be completed by a supervising consultant from UWI. The UWI graduate, currently in the Caribbean, can also gain evidence for a successful interview by performing audits, publishing research, teaching medical students and presenting at grand rounds, national and regional conferences.
Undertaking a research degree in the UK, allows contact with trainees and consultants to enhance understanding of postgraduate surgical training nuances. In addition, the ability to understand research methodologies and furthermore employ them, will add points to any UK interview level: be it ST3, Fellowship or Consultant. Being based in the UK also allows you the opportunity to attend courses and conferences which will add to your evidence for the interview.
The ST3 interview involves clinical, an academic/portfolio and technical stations. This has temporarily changed with COVID-19 to online interviews. Preparing a hardcopy portfolio starting from the internship year, with clear sections on audits, publications, presentations, teaching and additional degrees are mandatory for success in progressing in the UK.
The path from UWI graduate to becoming a specialist can be approximately 6 – 8 years duration if applying at the ST3 or CT1 level respectively. However it may take up to 11+ years depending on time out for research, unsuccessful attempts at previous interviews, or working in non-training positions in the UK.
Fellowship opportunities for UWI graduates
There are opportunities for UWI postgraduate students to obtain fellowships in various subspecialties. The medical training initiative (MTI) is a programme designed to allow international medical graduates to train in the UK for up to 24 months to gain valuable clinical experience in the NHS. These are funded positions and candidates must have had full GMC registration and postgraduate qualifications such as MRCS or FRCS.
The Royal College of Surgeons of England has a list of approved fellowships that receive many applicants, majority of candidates being UK trained. It is possible for UWI postgraduates to obtain these fellowships provided they meet the selection criteria. If possible, visiting the Hospital to meet current Fellows and Trainers is insightful, and virtual platforms should be employed where necessary. The Department’s annual procedure numbers, research portfolio and previous Fellows current accolades are benchmarks to help in choosing the best program for the applicant.3
UWI graduates can successfully obtain postgraduate training in the UK. The advantages are exposure to high volume centres of excellence, establishing professional links to continue in sharing technical skills during and years after specialisation. The Caribbean can benefit from connectivity and collaboration with international colleagues. These avenues for entry into training programmes is the first step in this direction. The requirements and competition ratios for NTN, should outline to UWI graduates how to build a surgical portfolio that will challenge not only the UK, but any international counterpart.
- Simpson JM, Esmail A, Kalra VS, Snow SJ. Writing migrants back into NHS history: addressing a ‘collective amnesia’ and its policy implications. J R Soc Med. 2010;103(10):392-396. doi:10.1258/jrsm.2010.100222
- Royal College of Surgeons of England. Surgical Subspecialities; 2021. Available from: https://www.rcseng.ac.uk/careers-in-surgery/trainees/foundation-and-core-trainees/surgical-specialties/
- Royal College of Surgeons of England. RCS Senior Clinical Fellowship Scheme – Providing a quality mark for surgical education; 2021. Available from: https://www.rcseng.ac.uk/education-and-exams/accreditation/rcs-senior-clinical-fellowship-scheme/