Introduction
Higher surgical training refers to advanced training programmes designed to train surgeons in a specific specialty within the UK. It is a rigorous and demanding process that typically takes several years to complete and requires a high level of commitment and dedication. The purpose of higher surgical training is to equip doctors with the knowledge, skills and expertise required to provide high-quality and specialised surgical care to patients.
Candidates will generally have completed a primary medical degree, followed by foundation training (two years) and then core surgical training (two years) before applying for a specialist training post as a specialty trainee year 3 (‘ST3’) (first year of higher surgical trainee).Reference Hurreiz1 Conversely, a small proportion of candidates will have not undertaken core surgical training, instead reaching requirements for ST3 training by obtaining a Certificate of Readiness to Enter Specialty Training. It is important to note that after foundation training, some may undertake a foundation year 3, and a foundation year 4, and so on. These years are not part of the formal training programme. In some specialties, including otolaryngology, a pilot programme of ‘run-through training’ was introduced in 2018 that meant candidates could be appointed to specialty trainee year 1 (‘ST1’) posts and would continue to specialty trainee year 8 (‘ST8’) without the need for competitive interview at ST3.2 Successful candidates held a median core surgical interview rank of 27 (out of 1883 applicants interviewed), highlighting the competitive nature of this programme.Reference Heward and Kumar3 The pilot programme has now been stopped and otolaryngology no longer offers run-through training, with the last offers being made in the 2021/2022 application cycle. This decision has been taken by the Joint Committee on Surgical Training as a result of core surgical trainees being disadvantaged by insufficient ST3 post availability.
Surgical specialties will each have their own requirements for successful entry, consisting of a person specification and a portfolio. The portfolio offers candidates the opportunity to gain points across various domains that are then amalgamated into a score used to determine invitation to interview. It is important to note that the portfolio undergoes an annual review and its contents are subject to frequent modifications. Furthermore, there is a significant financial cost associated with building a competitive portfolio. This can be attributed to factors such as gaining postgraduate Masters or Doctor of Philosophy degrees and presenting at conferences, which command a fee for participation. It is estimated that the average cost per point is £382 and the overall cost is £28 650 to achieve a mean portfolio score in otolaryngology as per the 2018 application cycle.4 This figure may now be lower as the portfolio has changed significantly, for example courses no longer carry points.
Recruitment for otolaryngology is now conducted at a national level in the UK, with Scotland joining the programme in 2013.Reference Green, Steven and Haddow5 Currently, Health Education England – Yorkshire and the Humber is responsible for the recruitment process for otolaryngology. The application cycle opens around November, with interviews between March and April, and concludes with offers shortly after that. There is no fixed number of places available for ST3 nationally, with the number of posts changing year on year, which can further increase competition. In the 2022 cycle, there were 47 posts nationally, with 169 applicants, resulting in a 3.60 competition ratio.6 In the preceding year, 35 posts were available, with 155 applicants and a 4.43 competition ratio.7
Securing a place as an otolaryngology higher surgical trainee continues to be highly competitive, and prospective candidates should possess a clear understanding of the rigorous selection process and its demands. The aim of this study was to provide aspiring otolaryngology candidates with an overview of the current higher surgical trainees’ application backgrounds and general profiles.
Materials and methods
Google Forms was used to generate a survey assessing the educational background of current otolaryngology higher specialty trainees and their entry route to ST3. The survey was emailed to all training programme directors in England and Scotland, who were asked to distribute it to their trainees. The survey included a mixture of short answer and single best answer questions.
The question topic ranged from the medical school the trainee attended and whether they undertook any additional undergraduate degree, to how many attempts were required to secure a training place in core surgical training and subsequently in ST3. Trainees were further questioned on more specific details such as how long before applying to ST3 did they decide they wanted to pursue otolaryngology and if they had completed an ENT-themed core surgical training, non-themed core surgical training or a run-through programme.
Results and analysis
In total, 60 trainees responded to the survey, and all returned surveys were completed in their entirety. Approximately half of the trainees started their higher surgical training in 2019 or later and the earliest trainee began in 2012 (Figure 1). Trainees were asked to report the point during their training at which they decided they wanted to pursue otorhinolaryngology (Figure 2).
Figure 1. Number of trainees that started specialty trainee year 3 from 2012 to 2023.
Figure 2. Number and percentage of trainees who decided they wanted to pursue otorhinolaryngology at certain points during their training.
Of the trainees who responded, 18.3 per cent had completed at least 1 degree prior to entering medical school, 1 trainee had undertaken a Bachelor of Science degree and a Master of Science degree, 1 trainee had 2 Master of Science degrees and all the others had only a Bachelor of Science degree.
All trainees surveyed graduated from a medical school within the UK, and 56.7 per cent had undertaken an additional intercalated degree during medical school (Figure 3).
Figure 3. Types of intercalated degree trainees undertook during medical school.
The three most popular foundation schools attended by the trainees were London (40.0 per cent), the West Midlands (11.7 per cent) and the East Midlands (8.3 per cent). Whilst undertaking their foundation training, 65 per cent of trainees had an otolaryngology rotation.
The survey responses showed that 86.7 per cent of trainees were accepted into core surgical training on their first attempt, 11.7 per cent of trainees needed a second attempt and 1.7 per cent of trainees were successful on their third attempt. Of those that were unsuccessful on their first attempt, 5 out of the 8 trainees (62.5 per cent) undertook an otolaryngology job and 2 of these trainees also worked as anatomy demonstrators alongside their otolaryngology job. One trainee was solely an anatomy demonstrator. Otolaryngology-themed core surgical training was undertaken by 68.3 per cent of trainees, 10 per cent of trainees were on run-through programmes and 21.7 per cent of trainees were either not on a themed pathway or were on a pathway for another specialty theme.
Most trainees were successful on their first attempt at gaining entry to ST3 (71.7 per cent), 21.7 per cent of trainees required a second attempt and 6.7 per cent of trainees needed a third attempt. In addition, 61.1 per cent of those reapplying to ST3 undertook an otolaryngology trust grade or locum job, 11.1 per cent undertook research and the remaining 27.8 per cent chose to work in accident and emergency (A&E), education, cardiothoracics or maxillofacial surgery. Finally, 78.3 per cent of trainees were awarded Member of the Royal College of Surgeons (MRCS)-ENT (the completion of MRCS Part A and Diploma in Otolaryngology – Head and Neck Surgery Part B) while the remaining 21.7 per cent completed both MRCS Part A and B and Diploma in Otolaryngology – Head and Neck Surgery Part A and B examinations prior to appointment. The Diploma in Otolaryngology – Head and Neck Surgery is an intercollegiate examination that higher surgical trainees are required to sit.
Discussion
Otolaryngology was among the first surgical fields to undergo a national selection process for higher surgical training. In 2012, 34 places were available, 155 candidates were interviewed and a study was conducted to determine what made the candidates successful.8 Our study has built on this initial survey to determine if the initial trends have continued over time. We obtained a wide breadth of responses from trainees beginning their ST3 training from 2012 to 2023. A significant proportion of trainees (81.7 per cent) had not completed a prior degree before commencing medical school. Our data suggest that 50 per cent of trainees had decided to pursue otolaryngology early on in their training (during medical school). Over three-quarters of trainees decided to pursue otolaryngology before beginning their core surgical training. This can have a positive impact on a trainee's ability to gain a national training number because it gives candidates time to familiarise themselves with the portfolio requirements and maximise scores. Conversely, one-third of trainees decided to pursue otolaryngology one to two years before application, which provides reassurance that success can also be achieved for those unsure of their specialty.
Intercalated degrees in medical school are additional qualifications that can be obtained by students who wish to delve deeper into a specific area of medicine. These degrees are typically pursued between the second and third year of medical school and involve taking a year out of the medical programme to undertake research or study in a related field. They provide students with valuable research skills and the opportunity to gain a deeper understanding of a particular area of medicine. Approximately one-third of students decide to intercalate every year.Reference Agha, Fowler, Whitehurst, Rajmohan, Gundogan and Koshy9 Students were previously encouraged to intercalate to increase the chance of getting their chosen foundation post as intercalation added points to their application, but as of 2023 this is no longer the case.Reference El-Hassan10 Similarly, intercalation no longer carries any weight in the core surgical training portfolio. Approximately half of trainees intercalated, with a Bachelor of Science being the most popular degree. The advantage of intercalation is that it can help students gain exposure to different specialties or gain further insight into a specialty they are confident in. However, this comes with the burden of lengthening their undergraduate degree by an additional year and increasing their financial outlay. Our results suggest that intercalation is not necessary to achieve a successful appointment.
Trainees had attended a variety of foundation training deaneries. The most popular were London and the Midlands. Two-thirds of trainees had an otolaryngology rotation during this training. This is likely to have helped them gain exposure to the specialty as otolaryngology is significantly underrepresented at undergraduate level.Reference Khan and Saeed11 Furthermore, trainees would have been exposed to colleagues in the process of applying for higher surgical training and therefore could have received guidance.
The majority of trainees were accepted into core surgical training on their first attempt and those that were not undertook an array of jobs before reapplying. Notably, two-thirds of trainees spent further time in otolaryngology during their reapplication year, a worthwhile undertaking as it provides the resources needed to strengthen their portfolio. However, those not choosing to do this may already have had significant exposure to otolaryngology, such that any further time would have negatively impacted their application. A proportion of trainees used the time to gain exposure to allied specialties such as cardiothoracics, A&E and maxillofacial surgery, which also add points to their portfolio. Understandably, over two-thirds of trainees were on an otolaryngology-themed core surgical training programme. This means trainees spent a significant proportion of their two-year programme in the specialty, further increasing their chances of maximising portfolio points.
Similarly, most trainees were successful in gaining appointment to ST3 on their first attempt (71.7 per cent). Of those trainees who were unsuccessful, 61.1 per cent chose to pursue further otolaryngology experience, and the risks and benefits of doing so are the same as those that apply to core surgical training. Lastly, the majority of trainees gained Member of the Royal College of Surgeons (MRCS)-ENT prior to appointment. Those that gained MRCS and the Diploma in Otolaryngology – Head and Neck Surgery were likely to be unsure about their chosen specialty. However, the Diploma in Otolaryngology – Head and Neck Surgery written examination has now been removed. Candidates may no longer be awarded Diploma in Otolaryngology – Head and Neck Surgery, instead taking the MRCS Part A written and MRCS (ENT) Objective, Structured, Clinical Examination to be awarded MRCS-ENT.
• There is a strategic advantage of committing to otolaryngology early on in training
• There are benefits to securing otolaryngology rotations during foundation and core surgical training
• Candidates encountering initial challenges in obtaining core surgical training or specialty trainee year 3 positions need to show resilience and determination
• Actionable insights and guidance are provided for aspiring otolaryngology higher surgical trainees
This study was limited by sample size (n = 60), thus it may not be representative of the entire population, but we believe the sample size does provide meaningful data. Furthermore, all survey questions were completed by trainees. Additionally, the portfolio requirements used to guide entry to higher surgical training have changed throughout the period and may affect some aspects of the results. The coronavirus pandemic has also affected higher surgical training as during those years, the number of ST3 posts was significantly reduced, which may also bias results. Further investigation that focuses on the differences in higher surgical trainee application trends prior to, during and after the pandemic would enhance this study.
Conclusion
Applications for higher surgical trainee remain competitive across all surgical specialties, including otolaryngology. Candidates wishing to pursue otolaryngology must be aware of the dedication and time needed. The removal of the run-through programme now means all potential candidates must undergo competitive interview, therefore selecting an otolaryngology post during foundation training will provide the necessary exposure for candidates to begin building their application. This can be continued by undertaking a themed core surgical training programme which will aid in building one that is competitive. However, it is important to stress that failing to be appointed to a core surgical training or ST3 post first time round should not dissuade candidates.
