The new lost tribe

Authors: Kathy Oxtoby 

Publication date:  07 Oct 2010

A BMJ Careers investigation has found that hundreds of surgical trainees have been forced out of programmes as competition ratios for ST3 posts soar to almost 15:1 in some specialties. Kathy Oxtoby reports

It was in his final year of medical school that Philip (name has been changed) realised he wanted to be an ear, nose, and throat surgeon (see box). “I was practical by nature, so by the time I graduated I knew that surgery was the right specialty for me,” he says.

Case study

“Philip” has trained to core trainee year 2 level this year but was unable to achieve a specialty trainee year 3 post

Most of us going into surgery weren’t afraid of competition but were very aware of it. At first there was no careers advice—and no one tells you how to get a training number. Later, those senior to me told me what I needed to do to improve my curriculum vitae, including the importance of attending conferences and presenting publications.

I started applying in February through the national selection process and was prepared to work anywhere in the country. By May, the offers had started coming to my peers, but there was nothing for me. Eventually I emailed the national selection team, who informed me I hadn’t been successful.

I believe part of the reason I wasn’t given a post is that there are too many trainees going through the system. Also the selection tools are not very good. It’s devastating that you’re going through a system thinking that you’re doing better than your peers, only to face a superficial selection process where you’re questioned by people you’ve never met before who talk to you for 10 minutes and don’t even get past the surface in terms of your knowledge, skills, and experience.

I know others who are top drawer surgical candidates who also haven’t got jobs. But we support each other, learn from each other, and it helps us to get a better insight into what our strengths and weaknesses are, which is helpful given that you get little feedback elsewhere.

I don’t really want to be a general practitioner or go into radiology. I’ve invested in ear, nose, and throat and if I can’t do that I won’t stick around.

Knowing he would be facing fierce competition for a specialty trainee year 3 (ST3) post, during his two years of core training Philip did everything he could to ensure he had a strong curriculum vitae. He took the advice of his consultant mentors, attended the necessary conferences, and had papers published. He performed well and felt he was on a par with his peers.

Despite his efforts, this year he was informed that his application had been unsuccessful. “I thought I was one of the better trainees: one consultant reviewing my competences said I had one of the best CVs,” he says. “So after years of wanting to be an ear, nose, and throat surgeon, not getting an ST3 post was devastating.”

Such a story may not seem that unusual for a competitive specialty, but this year similar tales are near universal in some parts of the country. Philip believes far too many surgical trainees are being put through the system. His view is supported by the Centre for Workforce Intelligence, the national authority of workforce planning and development, which was established in July 2010 to provide advice and information to the NHS and social care system.

Too many core surgical trainees

In its report Recommendation for Medical Specialty Training 2011, published in August, the Centre for Workforce Intelligence asked: “If each year there are a minimum of 333-523 CST [core surgical training] year 2 trainees who do not progress to ST3, why are so many trainees being taken into CST programmes?”[1] The report notes that not only does this have a significant training cost, “it also runs counter to the medical workforce training model of training 6000 plus trainees for 6000 plus higher specialty training posts.”

The report’s findings show that while many doctors in core training are unable to go beyond core trainee year 2 (CT2), surgery is the specialty worst affected, with less than 6% of posts leading to a certificate of completion of training. It also says, “The level of mismatch between those being trained in some of the surgical specialties, for example plastics, and ST3 training opportunities mean that each year a large proportion of trainees will not progress and will need to reconsider their career options.”

In the north of England, the future for surgical trainees looks bleak. Figures obtained by BMJ Careers show that no core trainees were shortlisted, let alone appointed, in general surgery at Yorkshire and the Humber Deanery. At the Northern Deanery, none of the trainees in general surgery or trauma and orthopaedics surgery achieved an ST3 appointment. There are also signs there is a dearth of ST3 surgical posts in other parts of the country, with just seven core trainees getting appointments in the Severn Deanery, and in the Kent, Surrey and Sussex Deanery less than five core trainees were able to progress to an ST3 post.

Application ratios

The large disparity between core trainee posts and ST3 surgical specialty posts in England is known to the government. The Medical Programme Board, which oversees and makes recommendations to ministers for the Modernising Medical Careers programme in England, held meetings this year discussing the issue. In June 2010, Alison Carr, dean adviser for Modernising Medical Careers England, gave a detailed presentation to the board, which shows doctors applying from core surgical training currently have a limited likelihood of success at entering ST3 higher surgical training.

According to minutes from that meeting, Dr Carr’s research reveals that in 2010, competition ratios for ST3 surgical posts ranged from 4.4 applicants per post to 14.9 applicants per post.

Overall, her findings show a considerable mismatch between core surgical training posts and ST3 opportunities. This ranges from approximate matching of 1.4:1 in urology to up to 7:1 for plastic surgery. Her presentation also suggests there is a bottleneck for surgical trainees, some of whom have been waiting as long as 13 years for an ST3 post.

Trainees’ experiences of applying for posts this year confirm the mismatch between core training and ST3 surgical posts. This year, after finishing her CT2 post at the Royal Surrey County Hospital in Guildford, Kate Lyne achieved an ST3 post in general surgery. But she says many of her fellow surgical trainees have been unable to obtain an appointment “and have nowhere to go, other than to start in another specialty.” Henry Ferguson is about to start an ST3 post in the West Midlands, but is concerned about “the enormous number of people who are as good, if not better than me but who have not got posts.”

“Figures are shocking”

Shreelata Datta, chair of the BMA’s Junior Doctors Committee, says the lack of posts for CT2 surgical trainees this year is “absolutely shocking,” adding that, “these figures are an embarrassment. Poor practice is allowing these doctors to simply flounder after training.

“There’s a group of frustrated junior doctors who want to go into surgery and are more than competent, yet once they are onto the training ladder there are no guarantees of a surgical training post,” she says.

Putting too many surgical trainees through the system with no hope of an ST3 post comes at a price—which for the NHS could be around several million pounds a year.

“By the time each doctor finishes their medical degree they are around £37 000 pounds in debt. By the time they’ve trained it has cost around a quarter of a million to the tax payer,” says Dr Datta.

No chance of progression

There is also the price trainee surgeons pay for pinning their hopes on a career where they have little or no chance of progression. The Centre for Workforce Intelligence states that while doctors are pursing a career in surgery via core surgical training, they are not available to train in other specialties where progress through training is more likely. And those who are partly trained, but with no hope of an ST3 this year, “will need to think about starting at the bottom of the ladder again and training in a different specialty,” says Dr Datta.

Ben Wild was unsuccessful in gaining an ST3 post this year, and is instead doing a two year research post in vascular surgery in Leicester. He believes junior surgeons’ inability to progress further in their training could result in a two tier consultant system. “You could envisage a large amount of junior surgeons who aren’t progressing, who reach middle grade and higher but end up becoming junior, rather than senior, consultants,” he says.

Dr Ferguson warns that because so many surgical trainees were unable to obtain posts in 2010, this could result in “a ‘lost tribe’ all over again,” as occurred after the problems with the Medical Training Application Service in 2007, when many trainees were left adrift during their training. “A certain number will disappear in the system, which is merciless,” he says.

Faced with no hope of an ST3 post, some may choose to “look elsewhere and take their skills abroad,” while others may leave medicine altogether, “which is a loss to NHS investment,” says Dr Datta.

Inevitable disparity

Despite figures showing that so many surgical trainees have been unable to gain an ST3 post in 2010, there appears to be a prevailing attitude within government and parts of the medical profession that the problem is somehow inevitable because of the competitive nature of surgery. Responding to the concerns of BMJ Careers about the mismatch in posts, a spokesperson for the Department of Health states: “Surgical training has always been highly competitive. The profession knows this and is supportive of it—competition helps to ensure that the best candidates progress in the field.”

Bob Greatorex, council lead for workforce planning for the Royal College of Surgeons, says: “Surgery is incredibly popular as a career, and there have always been many more young people wanting places than there are to train them.”

That so many surgical trainees have failed to get posts over the years but are still able to apply for ST3 posts could account for this year’s “bizarre competition ratios,” John Black, president of the Royal College of Surgeons of England, believes.

“This situation is very similar to that in 2002, when the attempted solution to the problem of the ‘lost tribe’ was run-though training from foundation,” he says. “This was imposed from above and led to the catastrophes of Modernising Medical Careers and the Medical Training Application Service. Many of those displaced at that time are still working in surgical or research posts and continue to aspire to a surgical career.”

Cheap generation of doctors

Others, like Richard Marks, head of policy at Remedy UK, believe there are more sinister reasons why the competition ratio is so high. “Far too many trainees are being put through the system,” he says. “It’s about training a cheap generation of doctors. When planning workforce numbers, I believe Modernising Medical Careers deliberately flooded the market with half trained doctors so it could fill in the service gaps with staff grade specialists.”

Angus Wallace, chair of the specialty advisory committee in trauma and orthopaedic surgery for the United Kingdom and Ireland, argues that the Department of Health has succumbed to pressures from hospital trusts and strategic health authorities to put far more doctors through the system than have any chance of getting a career in medicine.

Professor Wallace says surgical trainees are working as extended core trainees, staff grade or trust doctors, specialty doctors, or junior fellows—all of which are not currently counted in the training figures. “A lot of people are not doing their sums, and some are not inclined to because they don’t want to identify a career problem that will reduce junior support in hospitals,” he says.

To address the mismatch between core training and ST3 posts in surgery, BMJ Careers understands that the Medical Programme Board has set up a small task force to review career progression.

Surgical survey

The Royal College of Surgeons has also conducted an online survey of 1500 consultant and trainee members, “to try to see if we can work out a fair structure whereby there is reasonable competition,” says Mr Black.

Despite the fact that surgical trainees have faced unprecedented competition to gain posts this year, 95.5% of consultants and 91.6% of junior doctors responding to the survey are still in favour of most surgery training remaining uncoupled—the Tooke Report model of training.[2] The majority of consultants and juniors doctors surveyed (69.2%) also support a three year core training programme rather than the current two years.

Overall, 42% of respondents were in favour of a competition ratio between core and specialty training of above 2:1. And 54% of respondents thought there should be a limit as to how long or how many times a doctor should be allowed to continue to apply for specialty training after completing core training.

For Mr Black, these results show “that a large number of surgeons believe three years is needed for core specialty training.” Mr Black says he will be urging the Department of Health to adopt a three year core training period for surgery.

He also believes too many aspiring surgeons have been in the system for a long time and they should know “they are not going to make a surgical career and be looking elsewhere.”

Medical unemployment

Dr Datta, however, questions the effectiveness of the uncoupled training system. “Uncoupling doesn’t seem to work,” she says. “We need to look at the structure of training because what we are getting is hundreds of trainees finding they are not able to get an ST3 post. What we’re talking about here is medical unemployment.”

She says the mismatch in surgical training posts “hammers home the need for an urgent review in terms of training numbers,” and that the BMA is liaising with the Royal College of Surgeons and the Department of Health to “make sure the importance of career progression is prioritised in surgery.”

For Dr Marks there is no easy answer to the crisis. “Workforce planning in health care is never going to be right. Too many junior doctors are coming through the system,” he says. “To be fair on them we have to reduce those numbers, which means some are going to have to work in dead end jobs. But no one has had the courage to address this.”

Failure to address the mismatch in surgical training posts could mean trainees like Philip will become part of a lost generation of aspiring surgeons. For despite their many years of commitment to the specialty, and even with all their skills and experience, some of those faced with little chance of achieving consultant status will be forced to leave the profession.

Competing interests: None declared.


  1. Centre for Workforce Intelligence. Recommendation for medical specialty training 2011. 2010. [Link] .
  2. Tooke J. Final report of the independent inquiry into Modernising Medical Careers. 2007. [Link] .

Kathy Oxtoby freelance journalist London, UK

Cite this as BMJ Careers ; doi: