Personal Views: Dilemma of a surgical trainee
Authors: Bettina Lieske
Journal: BMJ (2005)

On finishing my basic surgical training and after gaining membership of the Royal College of Surgeons, I was keen to proceed in my chosen career in general surgery as quickly as possible. I was shortlisted for specialist interviews in early summer and offered a training number in the Oxford Deanery. Everybody who has been through this process can imagine how happy I was. Proud of my achievement, I was looking forward to my training as an SpR.

My first appraisal went well. I am currently attached to the vascular firm, but since I am not aspiring to a career in vascular surgery and I am at the beginning of my training, the targets that my trainers identified for me include genuine surgical experience: By the end of my vascular attachment I “should be able to expose the groin vessels unsupervised, to have refined the performance of common femoral anastomosis, and be capable of performing primary long saphenous vein surgery and inguinal hernia repair unsupervised.”


How am I supposed to become a consultant and be expected to operate on complicated cases when I am not trained to perform the primary procedures?


During my previous training as a senior house officer I had already performed varicose vein surgery and hernia repairs with varying degrees of supervision, so it seemed a logical and manageable step to move on to do these procedures unsupervised.

Unfortunately, a few weeks into the job, just after my appraisal, the Thames Valley priorities committees (Oxfordshire primary care trusts) issued two policy statements on elective surgery for the treatment of inguinal and umbilical hernia in adults and surgery for varicose veins. These stated that the surgical treatment of inguinal and umbilical hernias in adults as well as the surgical treatment of varicose veins was a low priority treatment and that patients would not normally be offered surgery.

As from the beginning of November all patients on waiting lists for these operations have been withdrawn. They are now awaiting assessment by an independent party to see whether they fall into the category of patients who need surgery because of, in the case of hernias, sufficient pain and disability to affect their normal daily living, and, in the case of varicose veins, persistent ulceration secondary to venous stasis, recurrent phlebitis, or significant haemorrhage from a ruptured superficial varicosity.

Meanwhile several operating lists have been cancelled, including a day case list, comprising mostly hernia repairs and varicose vein surgery. This would have been ideal for a junior surgical trainee like me to gain experience in carrying out these procedures, with a consultant available at all times.

A few months ago trainees became increasingly worried about the decline of exposure to surgical procedures and time spent in theatres as a result of the European working time directive. This directive led to the introduction of shift systems all over the country, as well as the introduction of surgical care practitioners (SCPs), who were thought to reduce training opportunities for doctors even further, as they are meant to be trained in the same basic surgical procedures that junior surgical trainees need to become competent in.

The problem that I face at the moment is not the dilemma of whether to go home instead of to operating theatres after a night shift, or having to compete for every operative procedure with an SCP—it is that I simply don't have a theatre list to go to at all.

Varicose vein surgery and hernia repair are so-called index operative procedures, specifically highlighted in trainees' log-books as markers of competence. As a trainee in general surgery I am concerned that I will not gain appropriate exposure to training in these two basic surgical procedures, if, as the statements of the Thames Valley priorities committees suggest, these procedures are from now on only carried out as an exception rather than as part of a surgical routine in my deanery.

How am I supposed to become a consultant and to be expected to operate on complicated cases of recurrent varicose veins and strangulated hernias when I am not trained to perform the primary procedures? I welcome any views and advice about this. The only answer that I don't want to hear is “surgical skills laboratory.”