This was presented at the recent University of Melbourne Medical School lecture for students interested in surgery. This advice is unique to the Australian system. If you’re in the US you match directly into a specialist training program straight out of Med School. Not in Australia.
The surgical journey is long and arduous. If you are a medical student, here is a rough road map for the years ahead.
We start with a year of internship where you need to do a term in surgery, medicine, emergency, and other optional terms. If at all possible request for surgical and emergency terms earlier in the year so you get early exposure to life in surgery and can apply to get into surgical stream in second year. If you can get a second surgical term that would be even better.
PGY2-4 are your surgical residency stream. Typically in most health networks, the residency years are divided into streams: surgical, medical, critical care (ED, anaesthesia, ICU) and general (O&G, GP, etc). Request for surgical stream so you will spend time being a resident in various surgical specialties. In this period you need to really start focusing on your specialty of interest to work towards that. I suggest having a couple of options depending on interest and job opportunities.
Somewhere around PGY 4 to 6 are your unaccredited surgical years. This is where you become a registrar and you learn to take on the responsibilities of a registrar but you’re not yet officially in the training program. Other states call it service registrar. This is when you seriously fine tune your application for accredited specialist training program. Check the unique minimum requirements for each specialty. They differ from specialty to specialty.
If you’re lucky, you get on the program around PGY 6 to 10 or thereabouts. From that point onwards, there is a clear curriculum for five years towards FRACS. Multiple assessments, exams, courses, workshops, at every point. But by then the road is clearly mapped out.
PGY 10++ is post fellowship training. You travel interstate or overseas to do subspecialty training within your specialty. This is finally the honeymoon period. You have your FRACS and you get to do the subspecialty area of your passion. I was in Canada doing Facial Plastic and Head & Neck Reconstruction, then Brisbane and Auckland to do Paediatric ENT.
As you can see it takes about 10 years after med school on average to become a surgeon. If you are really lucky and exceedingly gifted you might do it in seven or eight years. Most do longer. That’s the broad road map.
Typically, there are specific requirements for each surgical specialty With regards to your CV, referee and minimum requirements. For example, you will need a term in your chosen specialty but also a term in emergency or ICU or some other specific requirements. Therefore, the real pressure points happen somewhere between PGY 2 to 6 where you are in your residency/uncredited registrar years and you need to do lots and lots of things which are unfortunately very costly financially and on your time. These are the things like accredited courses like ASSET, CCrISP, EMST, EMSB, etc. You need to pass the GSSE exam. You need to be doing research presentations and publications. You need to do extra curricular activities that count for your CV. You might need to think about doing a higher degree such as postgraduate diploma, Masters, or even a PhD which may or may not be tied to your training program. These are the really tough years because there is a lot to do, a lot of competition and unfortunately there is also a significant amount of uncertainty with regards to jobs year on year.
And there is life! Remember you have a life to live. You need to balance the costs of applying into surgical training with the duty and delight of life. You may have spouses, partners, children, elderly parents, mental health, physical health, social connections you want to maintain. The selection is extremely competitive. You are competing with others who are just as driven, committed and competitive as you are. And the odds are not always for you. For example there are only two trainees who got onto the ENT training program in Victoria this year. There is also a maximum number of attempts at application so you need to be wise in the timing of your application so you don’t max out on your attempts. Be wise and get a lot of advice from people you trust.
The reason why training numbers are limited is because training programs are locked into a minimum number of supervisors, clinic and operating exposure. The surgical training must allow for that minimum golden number of 10,000 hours of operating to be an expert. Non-procedural specialties can potentially cram a lot of knowledge around a case. Multiple trainees can learn from a single case. However, in a surgical specialty, every trainee has to master techniques individually over thousands of hours of operating. There are no shortcuts to learning to operate. So you can’t be an ENT trainee if there’s no access to ENT operating theatres. And in that regards specialty such as paediatric surgery, neurosurgery, and cardiothoracic surgery have much lower numbers of training positions than the bigger training programs like orthopaedics and general surgery.
Now that you know the road map ahead you can start calculating the costs of moving forward. I must admit I personally never thought I would be a surgeon and for a long time I resisted the urge because I knew the cost to my life and my family will be great. However, after resisting for some time I knew that I could not do anything else but surgery. Hence it was a decision made with the blessing from my dear wife for me to commit to competing towards surgical training.
Here is some practical advice in no specific order.
- Have a broad interest and don’t put all your eggs in one basket. The odds are challenging so if you put all your eggs in one particular basket you risk hitting a dead end. You might meet an outstanding mentor in a different specialty who might catalyse your career. Don’t close yourself to other possibilities because the next big opportunity might be in the peripheries of your vision.
- Research. Consider getting involved in a couple of small research projects at any one time. Carefully consider whether or not Masters or PhD is right for you. Commitment to small projects can get you the right exposure to presentations and publications at the right time at the right place. If you do meet a great supervisor then Masters of PhD might be possible but remember that having a PhD does not guarantee you getting into the program. I have seen PhD‘s changing their specialty career pathways.
- Be prepared to handle disappointments and rejections because the selection program is a numbers game, not about human worth or value. The system is imperfect so sometimes you might get lucky and other times other people are luckier than you.
- Do what you love but also remember to love what you do. Each year you’re doing residency or unaccredited years are years of learning to help you become a better doctor and of course hopefully a better surgeon. But remember that you may need to change your end point goal depending on circumstances and connections.
- Have Plan B and be absolutely open to changing your plans. You might find that surgery is not for you. I discovered ENT pretty late in my surgical residency but fell in love with it so I had a change of plan. Also have an exit strategy. The rule is four attempts at applications and you’re out. Therefore consider other surgical specialties or even other specialties such as anaesthesia, emergency, ICU, Radiology, general practice. Every medical specialty is good, noble and worthwhile.
- Be prepared for long hours. This is not an exaggeration but a public open data: surgeons on average work 10 hours more per week than other specialties. This means that the surgical trainee works longer hours than a non-surgical trainees in Australia. Be prepared for missing lots of social and family events for your training. Be prepared for long unpaid hours doing research and study.
- Comparison is the thief of joy. This is a lesson I am still learning and have not mastered yet. The world can seem unfair. You have sacrificed your blood, sweat and tears but somehow someone else is luckier than you. This is life. You can always compare yourself with others and discover that someone else is always a little bit luckier than you. Again remember that your work as a doctor is noble and life changing and many people would envy your position. This is a lesson I am still learning. Every day.
- This is probably a big one. Have your personal Jedi Council of mentors. Have different mentors in different surgical specialties. Have mentors who are accredited SET trainees. Be open to advice. At every point in your career, seek multiple advice. The broader your Jedi Council is the better informed you will be. They might give you research projects. They might give you advice to proceed or not to proceed. They will be able to advise you on your CV and where you are in the competition. Have lots of perspectives on your career so you can detour if needed.
It’s bloody tough and I have seen many heartaches from residents who are outstandingly good but for whatever reason can’t get into the program. My heart truly breaks for them. But I do also see them flourishing in other specialties. Not getting into a surgical program is not the end of the world because all of medicine is noble, interesting worthwhile and exciting.
I hope this has been helpful. Please get in touch with me if you needed a chat. ericATericlevi.com