What kind of surgeon do I want to be?
There are nine recognised specialties within surgery, each of which will provide you with different challenges and rewards throughout your career:
- cardiothoracic surgery
- general surgery
- oral and maxillofacial surgery
- otolaryngology (ENT)
- paediatric surgery
- plastic surgery
- trauma and orthopaedic surgery
- academic surgery
There are some factors that are common to all specialties. For example, in all specialties you can expect to undertake some teaching, research and management. However, there are also differences between the specialties. This section covers each of these nine specialties: the type of work involved, working conditions (on call, emergency work, clinics, administration, etc), working options and how competitive the specialty is. As you become more adept in your chosen specialty, you will have the opportunity to sub-specialise further. This section also outlines some of main areas of sub-specialisation within surgery and will also touch on Academic Surgery which runs alongside the main 9 specialities.
Deals with illnesses of the heart, lungs, oesophagus and chest. These include: cardiac surgery (heart and great vessels), thoracic surgery (organs within the thorax, excluding the heart), transplantation and heart failure surgery, oesophageal surgery and congenital surgery in adults and children. Procedures tend to be major and often complex.
Within cardiac surgery, the most common operations are coronary artery bypass grafting and valve operations.
In thoracic surgery, the most common operations are lobectomy or pneumonectomy for carcinoma of the lung.
Clinical time is generally split evenly between operating, outpatient work, time spent with patients and families, and administration. A lot of time is spent in intensive care and high dependency units. Most work is elective (pre-booked, non-emergency) but there is some emergency out-of hour’s work.
Heart transplant surgery involves long, demanding surgery, often at night. There is a relatively low volume of patients but you will continue to see them for a long period of time. Cardiothoracic surgery involves less emergency work than general or orthopaedic surgery.
There is scope for research and academic activities.
Cardiologists now treat some conditions previously treated by surgeons, meaning fewer cardiothoracic surgeons are required. It is projected that there may be a shortage of consultant posts for future trainees. In 2008 there were 5 cardiothoracic surgery posts at ST3 level with an average of 23 applicants per post*.
A large specialty containing many sub-specialties including: breast, colorectal, endocrine, upper and lower gastrointestinal (GI), transplant (of kidney, liver, pancreas) and vascular. Laparoscopic surgery may also be practised as a sub-specialty and is used across all general surgery. Most emergency general surgery patients suffer from acute conditions of the abdomen. However, other conditions, including trauma, require a holistic approach and a wide range of skills and experience that may involve working with colleagues from different specialty areas.
A relatively high proportion of emergency work. Vascular surgery has a high volume of urgent and emergency admissions. Many vascular surgeons still have acute general surgical commitments. Larger teaching hospitals have pure vascular specialists. Colorectal surgery has a heavy workload as many patients suffer from large bowel cancer and present as emergencies requiring urgent treatment. Breast surgery has less on-call commitment as most work is elective. However, clinics can be busy. You can choose how specialised to become. Some smaller hospitals need generally trained surgeons competent in the management of the common conditions of the GI tract. Military surgery involves providing non-orthopaedic trauma service. Most military surgeons maintain a full range of general surgical skills as a consultant GI or vascular surgeon. Remote and rural surgery is required in areas (often outside the UK) where there is great geographical distance between cities. General surgeons in such areas require a wide range of competencies, including some from other surgical specialties.
In 2008 there were 80 ST3 posts in the UK with and average of 19 applications for each post*.
Involves the brain, central nervous system and spinal cord. It covers all aspects of brain surgery, from pre-operative imaging to removal of tumours. You may focus on: paediatric neurosurgery, neuro-oncology (treating cancer of the brain), functional neurosurgery (surgical management of a wide range of neurological problems, including intractable pain, epilepsy and movement disorders), traumatology, neurovascular surgery, skull-base surgery or spinal surgery. Spinal surgery is the largest sub-specialty, accounting for more than 50% of the operative workload of some departments. It is possible to practise spinal surgery exclusively. Paediatric neurosurgery accounts for 10–15% of all neurosurgical activity.
Emergency work accounts for more than 50% of neurosurgical caseload, with much of this being trauma. On call work can be intensive with out-of hour’s emergency operating.
Most consultant neurosurgeons spend 4–5 sessions in the operating theatre per week. The remainder of their time is spent on pre- and post-operative ward care, outpatient clinics, teaching and other administrative duties. There are neurosurgery units in most major cities but you may be limited in where you work outside these.
Entry to neurosurgery training is via core neuroscience training. Neurosurgery training follows directly from this, with no additional recruitment stage at ST3 level. In 2008 Neurosurgery had 5 applicants per post at ST1 level, fewer than other surgical specialties*.
Works on the facial bones, face and neck. Procedures range from minor surgery to complex major head and neck surgery. Uniquely, OMFS involves surgery on both hard and soft tissue. Specialist areas include: head and neck oncology, adult facial deformity, orthognathic surgery, cleft surgery and facial trauma management.
Relatively low on-call commitment compared to other surgical specialties. Large volume of trauma cases. Most time is spent in clinics or operating. Remaining time is spent teaching, doing administration or on call.
To enter the training pathway, you must have both a medical degree and a dental degree. However, you can work as an oral surgeon with a single qualification; there are currently a number of staff grade surgeons who have pursued this route.
There are currently two entry points to OMFS specialty training. You can either apply to join a pilot run-through training post at ST1, or apply to ST3 (having first completed all core training competencies). In 2008, there were 17
posts with an average of 13 applicants per post*.
Includes all aspects of the head and neck region, skull base and facial plastic surgery. Specialist areas include: paediatric ENT, head and neck, voice and complex airway, otology (ear) and rhinology (nose). ENT manages surgical and medical disorders and involves many paediatric cases.
A significant amount of work is performed in diagnosis and 70% of otolaryngology practice is outpatient with a day-case base. There is a significant medical element to ENT. Elective surgical sessions are likely to involve no more than two days a week. Emergency work is light but is often dramatic when airway specialists are required. ENT has little emergency work so may be well suited to flexible working.
In 2008 there were 19 ST3 posts in the UK with 14 applicants per post on average*
The surgical treatment of diseases, trauma and malformations of childhood years which encompasses foetal period to teenage years. Specialist areas include: neonatal surgery, urological surgery, hepatobiliary surgery, GI surgery and oncological surgery. Paediatric surgeons perform 11% of all operations on children. The remaining operations are performed mainly by surgeons from other specialties who have an interest in paediatric conditions.
It is likely that you will have a commitment to an emergency workload although the nature of its delivery will vary between units. A large proportion of the clinical workload comprises day-case surgery.
Paediatric surgery has a low level of emergency work so may be well suited to flexible working. There are few centres that specialise in paediatric surgery so you may be limited in your geographical location. If you are interested in both paediatric surgery and another specialty, you may train in the other specialty and specialise in paediatric cases.
This is a relatively small specialty. In 2008 there was only 1 post at ST3 and there were 40 applications*.
Involves the restoration of normal form and function; 80% of all plastic surgery is reconstructive. Urgent and emergency work may include: hand trauma, burns and scalds, and soft tissue injuries involving face, trunk or limbs.
Elective cases may include: reconstructive surgery for congenital and acquired abnormalities, cleft lip and palate and other facial deformities, breast reconstruction, reduction and augmentation, or hand and upper limb surgery.
Much of the workload involves dealing with urgent or emergency cases. There is a busy on-call commitment. Most out-of-hours work involves burns injury and the treatment of severe facial, hand and lower limb injuries.
UK plastic surgeons have a strong tradition of travelling abroad, including work in disaster zones helping to tackle large demands for reconstructive work. An increasing number of trainees complete a cosmetic fellowship following CCT. This may become compulsory in a bid to ensure that cosmetic surgery is carried out by appropriately trained individuals.
Plastic surgery is generally considered to be one of the more competitive areas of surgery. It is a relatively small specialty with limited training opportunities. In 2008 there were 9 posts in the UK with an average of 23 applicants per ST3 post*.
Works on bones, joints and their associated soft tissues, including ligaments, nerves and muscles. Trauma work involves fractures and other injuries. Specialist areas include: lower limb joint reconstruction, hip or knee, ankle and foot, upper limb, spine, bone tumours, paediatric orthopaedics, rheumatoid surgery, and sports and exercise surgery.
Most consultants contribute to an emergency trauma workload dealing with injured patients admitted through their A&E departments. Trauma work can be late night and there is a relatively demanding on-call commitment. It is a very physical specialty but uses many specialist tools that reduce the need for excessive force. Orthopaedic consultants operate around 40% of the time, with the rest divided between clinics, ward work and on-call commitments.
There is considerable opportunities for research and sub-specialisation.
Trauma and orthopaedics is one of the largest specialties. In 2008 there were 50 ST3 posts in the UK with an average of 15 applicants per post*.
Deals with the urogenital system: kidney, bladder and urinary problems, as well as men’s sexual and reproductive health. This includes diseases of the kidney, urinary tract stones, cancer (prostate, bladder, testicle and kidney), prostate, incontinence, erectile dysfunction, etc.
Some time is spent managing chronic conditions. Investigating and treating patients with prostate symptoms or bladder cancer takes up a large amount of a urologist’s time. Specialist areas include: complex pelvic surgery, uro-gynaecology, andrology and paediatric urology.
Urological surgeons undertake 3–4 operating sessions a week, including day-case surgery. They also undertake outpatient clinics and (possibly) special clinics, management/administration, teaching and research. Urology treats a wide range of diseases and uses a variety of operating techniques, including open surgery, laparoscopy and robotic surgery. Urology on call is usually not arduous and in smaller units it is increasingly common to cross-cover with neighbouring hospitals to reduce the on-call frequency
Urological surgeons have many opportunities for working across specialties, such as with gynaecological and colorectal surgeons. ‘Office urology’, is a developing field. This involves work in clinics and day case procedures, with much use of endoscopy but no open theatre cases.
In 2008 there were approximately 14 posts at ST3 level in the UK with an average of 15 applications per post*.
Academic surgery involves some clinical work as well as some research or teaching in a higher education setting. To pursue this training pathway, you should be committed to both the clinical aspect of the job and the research. Approved academic posts (academic clinical fellowships and clinical lectureships) are relatively few in number. To succeed in obtaining one of these posts, you will need to have demonstrated excellence (or the potential for excellence) in academic medicine as well as in your clinical abilities. You should not expect to pursue this career as an easier option than the training pathway.
Early in your career (normally directly following the foundation programme) you can apply for an academic clinical fellowship (ACF). This is a specialty training programme and will eventually lead to the award of the CCT (assuming you complete the rest of your training). Clinical lectureships (CLs) are aimed at surgeons who have already undertaken some training in surgery and have completed some research. You may wish to consider applying for a CL following completion of an ACF. Alternatively, you could apply for a CL at a point roughly equivalent to ST3 level on the training pathway, as long as you have previously completed enough academic or research work to be eligible.
In the early part of your career, in an ACF post, you can expect to spend 75% of your time undertaking clinical training and 25% undertaking research or educationalist training. These posts last a maximum of three years, after which you can apply for a CL to further your academic career, attempt to re-enter the training pathway or apply for alternative posts, such as specialty doctor posts. CLs last a maximum of four years, during which time you will complete your specialty training. You can therefore expect to spend a proportion of your time undertaking clinical duties and the same training as your colleagues on the training pathway. The rest of your time will be spent undertaking research and teaching. Having completed your training in academic surgery, you can either pursue a higher career in research and academic surgery or you could apply for entirely clinical posts as you will have completed your specialty training.
*Taken from MMC Competition Ratios for 2008