The Ultimate Career Manual for Aspiring General Surgeons

A General Surgeon's Role

General surgery is the art of combining a broad knowledge base with model execution - a profession that attracts those with exceptional manual dexterity, unwavering determination, and a desire for perfection.

A career that involves a high proportion of acute emergencies, the general surgeon learns how to make critical and rapid changes to a patient's quality of life in high-pressure situations.  

The word "general" can be misinterpreted as a broad statement that sounds imprecise and hazy. General surgeons, on the other hand, use their broad range of knowledge and skill to treat patients of all ages, from the removal of an appendix to the resection of a bowel tumor and even the replacement of a kidney.  

General surgery specialists account for 31% of consultant surgeons in the UK, making it one of the largest surgical specialties. A general surgeon's role focuses on acute abdominal problems, but because of their wide range of competencies, they are essential in all types of surgical emergencies, making them an important member of A&E departments and trauma teams.  

Away from the emergency room, general surgeons perform a wide range of elective and outpatient procedures, the majority of which are gallbladder removals and hernia repairs.

However, this does not preclude the ability to specialize in areas such as colorectal, endocrine, and breast surgery. General surgeons, regardless of subspecialty, are part of large multidisciplinary teams both inside and outside of the operating room, whether in the A&E department, on ward rounds, or conducting outpatient clinics.  

A Normal Week

With a significant proportion of general surgical patients presenting acutely with abdominal pain, it is understandable that emergency surgery can account for up to 50% of a general surgeon's workload. Despite the availability of emergency rooms around the clock, a consultant can still expect a heavy on-call rota, with at least two consultants on-call at all times; a toxic megacolon will not wait.  

The frequency of on-call work will vary depending on the size of the hospital; for example, a consultant in a large teaching hospital can expect to be on call 1 week out of every 10, whereas a district general hospital may require more time to be dedicated to emergency on-call work.  

In a 48-hour week, consultants can expect to juggle between inpatient theatre lists, day surgery theatre lists, and outpatient clinics, as well as non-clinical supporting professional activities (SPAs) such as admin and education. An example week of a general surgeon with a colorectal surgery subspecialty is shown below.  

Ms H Dorrance, consultant colorectal surgeon, has a typical week.  

• Mon morning - Colonoscopy schedule
• Mon evening - Outpatient clinic
• Tue AM - Administration
• Tue PM - Outpatient clinic
• Wed AM - Theater schedule
• Wednesday evening - Theatre schedule
• Thursday morning ward round and multidisciplinary meeting
• Thursday evenings - Trainee education
• Fri AM - Day Surgery Schedule
• Friday, 5:00 p.m. - Administration

The Path to General Surgery: Five Steps to Becoming a General Surgeon

1. Submit an application for core surgical training (CT1-CT2).

After two years of foundation training, two years of core surgical training begin. The goal of core training is to prepare trainees for entry into their chosen specialty by teaching them basic surgical skills and other competencies. After completing core surgical training, you can choose to specialize in any surgery type, with the exception of neurosurgery, which is primarily a 'run through' specialty.  

Applications must be submitted through the NHS Oriel website, and competition is fierce. In 2019, there were 1,896 applicants for 648 positions across the United Kingdom.  

IST Pilot Training for General Surgery

The Improving Surgical Training (IST) initiative launched a general surgical run through program in 2018. This program is designed for those who, after foundation training, already know they want to work in general surgery and do not believe they need a taster in other surgical specialties that core surgical training would provide.

To progress to ST3, you must first complete ST1 and then pass an interview. You will not, however, be competing with those who enter general surgery specialty training through the core surgical training pathway.  

Applications for this path are also accepted through the NHS Oriel website. As a new program, competition ratios have not yet been published; however, given the increased security of job progression into ST3, they are likely to be competitive positions.  

2. Pass the MRCS examination

Trainees who wish to continue their surgical training at the specialty level must pass the Royal College of Surgeons exam (MRCS) by the end of their CT2/ ST2 year.  

3. Apply for General Surgery residency training.

If you are on the core surgical training pathway, obtaining a speciality training post (ST3) in general surgery is a highly competitive annual national recruitment process. There were 428 applications for 198 positions in 2019, with a competition ratio of 2. 16:1 With the introduction of IST pilots, competition ratios may change in the coming years.  

4. General Surgery Specialty Training (ST3-8)

Specialty training allows surgeons to hone their general surgical skills while rotating through different subspecialties. Many trainees complete an MD and PhD in an area of interest during their 5 years of speciality training to make their applications more competitive for future consultant positions. Specialty trainees must take the Fellowship of the Royal College of Surgeons (FRCS) exam during their final two years of higher surgical training.  

5. Training completion

Trainees are awarded a Certificate of Completion of Training (CCT) or Certificate of Eligibility for Specialist Registration (CESR) upon completion of specialty training, and they are eligible to apply for a consultant post or a fellowship for additional, more specialized training.  

Best practices for a competitive application

• Begin early. Develop your practical abilities and interest in surgery as soon as possible. Maintain a record of all surgeries you have attended in eLogbook and keep it up to date- evidence is essential.  
• Be present It is difficult to learn outside of the operating room in a practical profession like surgery. Even if you are not scrubbed in, close observation of your seniors can teach you a lot.  
• Create a portfolio. Participate in closed-loop audits, as well as teaching and leadership roles. As proof of your dedication to your work, ensure that everything you are a part of is completed to a high standard.

Subspecialties 

Because of the broad-based training that a general surgeon receives, the options for choosing a subspecialty as a consultant are diverse. Among these are:

• Breast augmentation surgery
• Colon cancer surgery
• Endocrinology surgery
• Upper gastrointestinal surgery, which includes bariatric surgery
• Transplantation surgery

While a path to subspecialization is embedded in the training curriculum, 80% of elective work performed by a consultant general surgeon will fall outside of any subspecialty bracket. One exception is those who specialize in transplant surgery, in which surgeons only perform highly complex surgery within their specialty.  

Advances in General Surgery

Gender imbalance has long been a problem in surgical specialties, with only 12% of general surgeons being female, according to recent data. Women in Surgery initiatives, for example, are dedicated to encouraging, enabling, and inspiring women to pursue their surgical career goals, with women now accounting for 30% of surgeons in training.  

General surgery is a leading specialty in key-hole surgery, a minimally invasive technique that results in smaller scars and faster recovery for patients. With advancements in this field, an increasing number of surgical procedures can now be performed laparoscopically, and this method of surgery will become an essential part of the work of a general surgeon in the future, especially with an increasing number of obese patients in the population.  

Earnings 

As of 1 April 2019, you will earn a basic salary of £79,860 to £107,668 per year as a consultant, depending on your length of service. Consultants can supplement their income by working in private practice if they so desire. The opportunities available will be determined by their specialty areas and the amount of time they are willing to devote to this outside of their NHS contracted hours.  

General surgery is a specialty with some potential for private practice. According to Independent Practitioner Today, in 2018, consultant orthopaedic surgeons earned an average of £72,000 per year from private practice.  

According to JRSM, private income for general surgeons was 0 in 2008. 62 times their NHS salary, far less than plastic surgeons (1 9 times), but far outnumber paediatric surgeons (0 times). 16 times)1

Please see The Complete Guide to NHS Pay for more information on doctor's salaries within the NHS.

Are you still interested?  

A career in general surgery is constantly rewarding, with new opportunities extending beyond consultancy, whether in research and academia, teaching, or management. To become a general surgeon, a lot of hard work and dedication is required; however, for those who love what they do, this is not a hindrance but a reward.  

Additional Information

BMJ Careers-Related Job Sources

Other Comprehensive Guides from BMJ Careers

References 

1. Morris, S., Elliott, B., Ma, A., McConnachie, N. Rice, D. Sktun, et al. An examination of consultants' NHS and private earnings in England in 2003/4. [Internet] Journal of the Royal Society of Medicine [accessed 14 June 2020];101(7):372-380 Available at: https://www ncbi nlm nih gov/pmc/articles/PMC2442143/table/tbl3/