Getting into Core Surgical Training


— by Raisa Khan

Hi all,

I have been successful in getting Core Surgical Training this year and have received quite a few messages from people looking towards building a surgical career seeking guidance. So, I decided to share my experience here. Hope you find it useful.

My Background:

I graduated from Pakistan (2016)

Completed my FY1 /housejob in my home country (2017)

Came to the UK in February 2018 and worked as FY2 equivalent SHO post in London. I did 6 months of Neurosurgery then switched jobs and did 6 months of A & E because not being in a proper FY2 training program I wanted to get mixed exposure of all specialties and I thought A&E is the best way to learn.

It was during this year when I started building my CV towards a career in surgery and sat the interview in round 1 (2019)

Restricted Labour market test (RLMT):

Now this topic has been discussed many times but just to review as many new IMGs are still unaware.

UK recruitment process in general has two rounds annually. If the training placements do not fill up in round 1, a second recruitment round is opened.

According to UK legislation, if you are a non-European/non-UK citizen, you cannot apply for Surgery in round one as you would be subjected to RLMT which means that European and UK citizens would automatically get preference over you. Technically you can apply to round 2 of certain specialities like GP and IMT but because some specialities like surgery and radiology are quite competitive, all the posts get filled up in round 1 and there is never a round 2.
There is a way to get around this (there always is!)

  • If you are a UK/ European citizen no RLMT
  • If you are on spouse visa of a UK national no RLMT
  • Get into another specialty training program instead first with relatively less competition ratios. These programs would be open for round 2, and you should be able to pass RLMT if you are selected. You will then be sponsored a HEE TIER 2 visa. So, once you’ve got National Training Number, you will be exempted from RLMT. You can now openly apply for any training programs in round 1. Popular specialities to get into include Medicine/A&E and GP training. Use this time well to build on your portfolio for Surgery or any other speciality you wish to pursue.

Note: I would also advise applying to an FY2 LAT post especially if you are FY2 level and I know one or two people personally who have been successful in obtaining a surgical number via this route. I was exempted from RLMT otherwise would have favoured this route because it’s a more structured pre-speciality training programme with more opportunities to build your portfolio. However, bear in mind that once you have been invited for interview (whether you have British passport or not), it all depends on your interview score regardless of Nationality. You compete openly with all candidates.

Applying for surgical training

Person Specification:

It is extremely important to go through the person specifications for surgery which are updated every year to know where you stand and what you now require to do from this point. Below is the link.

https://specialtytraining.hee.nhs.uk/portals/1/Content/Person%20Specifications/Core%20Surgical%20Training/Core%20Surgical%20Training%20CT1.pdf

Note: The most important clause in the person specification is you are only eligible to apply if you  have 18 months or less experience in surgical specialities (excluding foundation modules) by the time of intended start date.

Now this becomes confusing because most of us are not in a proper foundation program so we are unsure exactly in what way this applies to us. It is the two year experience that we have had after graduation (internship/ SHO job etc) which counts towards foundation modules equivalent. Then you can do another 18 months of surgical experience on top of that if you want to but not more then that by your intended start date.

So many IMGs have become ‘over qualified’ to apply having not been aware of this rule.

Building a portfolio:

This stage stressed me the most because I sat the CST interview having less than 10 months experience in the NHS at that time and was worried all year thinking how I would I be able to build a surgical portfolio in less than a year with only one year of post grad experience. In the end I really did not have very much on my portfolio, but I realised I didn’t need to.

Here is the link to all what is needed on the portfolio of a core surgical applicant.  https://www.pathway.oriel.nhs.uk/Web/Sys_Documents/ec260250-b7fa-428e-9f13-281d9404e39c_2019%20Self-Assessment%20and%20Portfolio%20Guidance%20for%20Candidates%20-%20for%20advert%20V3.pdf

But here I will just summarise my own portfolio sharing my personal experience which may help people who are in the same situation as I was.

1.Postgraduate/undergraduate qualifications:

I did not have any undergraduate qualifications. Many IMGs have a BSc I did not even have that. Technically speaking I did not have any postgraduate qualifications either but I claimed marks in this category for FCPS Part 1 in Surgery (the postgraduate exam which is a pre-requisite to surgical training in Pakistan) and kind of considered MRCS A equivalent and got scored for it. Many interviewers know about the FCPS.

2.Surgical courses:

1 mark per course relevant to surgery and maximum 4 marks. During my year I had done

ALS and ATLS

BSS (Basic surgical skills course)

Red dot radiology courses (Chest X-ray course and A&E survival course)

EVD stimulation neurosurgery course locally and

a local start surgery related course from Pakistan not the RCS one.

Out of these only BSS, ATLS, EVD stimulation and START surgery was related to surgery so I claimed marks for those. All courses are available on RCS website.

https://www.rcseng.ac.uk/education-and-exams/courses/surgical/#Surgical=True&Dental=False

Note: You do not necessarily need to have completed the high-profile RCS surgical courses such as BSS, ATLS, Ccrisp to claim a mark. Any course related to surgery gives you a mark if you can validate it. It may even be a 1-hour local hospital course or an online module or workshop. However, the RCS courses broaden your surgical knowledge and can help in the interview. Book in advance because they can be taken up very quickly. For this reason, I could not do the CCrISP (Care of Critically ill Surgical Patient) course before interview.

3.Additional achievements:

This I believe was my strongest area as I had some distinctions in various subjects during medical school and a gold medal in Paediatrics. I scored full 5 marks in this category.

Any prize, scholarship, grant that you have received which is open to all trainees is a national prize.

4.Quality Improvement program:

I did only 1 QIP. The portfolio section on this point is quite clear you do not need to participate in many QIPs rather do 1 and claim the highest points if you do it properly i.e if you design, lead, implement change and present it at a regional or national meeting. I teamed with one of my senior more experienced colleague and very good friend and we came up with the idea for the audit ourselves, closed the loop, implemented the changes and submitted it as a poster to present at the upcoming Society of the British Neurosurgeons national autumn meeting. (I was in neurosurgery at that time). I got full marks for this.

Note: Your audit doesn’t have to be very fancy, mine wasn’t even related to surgery, it was a neutral topic. You can easily present findings at a local meeting (gives you two marks less than the full marks) and also if you submit to regional/national conferences lots are willing to accept.

5.Teaching experience:

I had to go in retrospect to collect evidence for this. Any teaching I had given to colleagues/ juniors or any medical topics related discussions during medical school and FY1 year, I contacted them through social media requesting to fill feedback forms for me. Where I could not do this, because it is difficult to collect evidence in retrospect, I put the feedback I had received over facebook, whatsapp , lifted the comments put them within quotation marks, printed them on a paper and stuck it in my portfolio (my interviewers liked this idea). Then I compiled the results and showed them on pie charts and line graphs demonstrating that I had reflected on positive and negative feedback I had received. I had done a lot of informal teaching especially helping people with IELTS and marking essays for them that I didn’t want to miss out on but like many IMGs we do not have the trend of keeping evidence, so I had to go in retrospect.

I discussed with the teaching lead in my trust and designed group tutorials on anatomy related topics for medical students to be delivered over a series of months. (1 half hour teaching once a month for 4 months) I got a certificate for that. I scored well in this section.

6.Training in Teaching:

I had no qualification in teaching or any diploma. I had done a short local course in teaching methodology and requested a certificate for that. I would advise doing the ‘teach the teacher’ course so that you have some sort of training in teaching. I had not done this at that time. So, didn’t score much here. Here is the link.

https://www.medical-interviews.co.uk/product/teach-the-teachertrain-the-trainer-course?gclid=CjwKCAjwqLblBRBYEiwAV3pCJhJ0o1O5DYqMvPEZzdHxmMbXf7T7CtPK42iQfMmLfiaMurVhZ-zKphoC3TMQAvD_BwE

7.Presentations:

I put the poster presentation presented at a national meeting in this section as mentioned under the QIP category. Try to do a national oral presentation which will give you the maximum marks. I also printed out slides of a few local presentations I had done and stuck them in my portfolio.

Note: I claimed points for the same poster presentation in both presentation and QIP section. You can do that. One achievement can give you marks in other areas as well.

8.Publications:

I scored 0 marks for this section. I had no publication at all neither am I aware of proper research methodology. This is my weak area on which I plan to focus now however, it may be reassuring to some that it is quite possible to get a decent portfolio score with no research experience at all. I had collected data on an AI based surgical project which I just put down on a paper explaining the objectives and expected outcomes and stuck it in my portfolio which at least showed my commitment to speciality if not give me any marks.

9.Leadership and management:

I had to collect evidence in retrospect for this category. I was part of the blood donor’s society in my college and got a certificate made. I managed the house officer rota during FY1 rotation and got a letter made for that as well. I was part of an NGO (non-medical) in my home country during college years before medical school and presented at an annual function related to that. I had a very old certificate which I put in my portfolio. Here is the link.

http://www.kef.org.pk/

Note:  In our home countries we do not have the trend to keep evidence for every small thing we do. So, for evidence that you may need to collect in retrospect you can type statements yourself and email them over to people concerned to electronically sign for you and send back. You do at times have to struggle to chase people up, but it is doable.

10.Commitment to surgery:

This may include a surgical taster or internship which I had not done. MRCS part A which I did not have. I had attended three surgical conferences. 2 in Pakistan and 1 in the UK I put certificate of attendance in portfolio. I was member of RCS, ASIT surgical societies which you can just mention in CV don’t really need to show evidence. I had also maintained a surgical logbook which is very important. You don’t need to put in major procedures in it. Don’t worry if you are not getting theatre time. You can put in simple wound suturing. In fact, you can put in multiple entries of simple wound suturing it just shows you are continuously improving your skills and have good hand eye coordination. My rotation in A & E injuries proved helpful to fill this slot. This is the e-logbook most people use and is free.

https://www.elogbook.org/

I even put in evidence of extra- curricular activities and linked them to surgery although this is not required e.g I am interested in photography and put in printouts of my best shots. The manipulation of the camera and fixating your eyes on the object is also an example of hand eye coordination as is playing cricket, piano etc. 

Note: MRCS A doesn’t have any marks in the portfolio section. It demonstrates commitment to speciality which can also be shown in various other ways. Even a failed MRCS A attempt shows commitment to speciality!

Lastly, don’t underestimate the importance of a well organised portfolio. There are 3 marks for a well-structured, thoroughly organised portfolio. There are many you tube links that show how to structure a surgical portfolio and what folder to use.

Interview Preparation:

The interviews took place in January this year. I started preparing during middle of December and gave the interview end of January. There are three stations in the interview and each station is 10 minutes long. Each station contains 33.3% marks. There are around 500 posts and around 2000-2500 people apply. I am not sure about the exact marking scheme but if anyone does please share.

I did not attend any interview course however I have been told the RCS interview course is helpful and costs around £400.

My preparation revolved around going through interview books lightly, writing down my own answers, practicing in front of the mirror, recording my own voice and listening to it and practicing with another colleague taking turns in being the examiner and candidate. I prepared for it the same was as we prepare for PLAB 2.

Interview books:

This ISC Medical interview book is standard for every CT/ reg interview and everyone uses it.

https://www.amazon.co.uk/Medical-Interviews-2nd-comprehensive-techniques/dp/1905812175/ref=sr_1_1?adgrpid=58716443688&hvadid=259146711005&hvdev=c&hvlocphy=9046003&hvnetw=g&hvpos=1t2&hvqmt=e&hvrand=16308274973141731571&hvtargid=aud-615159460541%3Akwd-315198738893&keywords=isc+medical+interview+book&qid=1554934510&s=gateway&sr=8-1

This is the specific core surgical interview guidebook. I went through both books but mainly used the surgical one.

https://www.amazon.co.uk/Core-Surgery-Interview-Definitive-Interviews/dp/0993113834/ref=sr_1_fkmr1_2?keywords=isc+surgical+interview+book&qid=1554934565&s=gateway&sr=8-2-fkmr1

Portfolio station:

I have already gone through this in detail. They basically have 10 minutes to go through your portfolio before you come in. Then they simply flip your portfolio and would ask you general questions about an audit you performed or a prize you received. Make sure you know your portfolio inside out and know where each thing is placed so that if they ask you to flip over to that section you can do so with ease. They mark you exactly according to the portfolio checklist link given above. So, you already have an idea of what you are scoring here.

Sometimes they may ask you general questions such as:

Tell us about yourself? Why surgery? Why train in the UK?

Is empathy important for surgical trainees? What do you like most/least about this speciality?

Example of good/bad communication? Are you a good team player/leader/manager/teacher?

What is your proudest achievement? Audit/research experience? Among many others.

Now all these questions are repeatedly mentioned in all interview books and everyone can go through them. What will set you apart is if you write down answers to these main questions that are most likely to be asked (not all) according to your experience and keep on practicing them. Always remember a well-rehearsed but natural sounding answer will always come as a natural flow to you especially during under pressure interview time! While writing the answers always use the CAMP structure and it is hard to go wrong.

Example of a question using CAMP structure:

Where do you see yourself in 10 years’ time?

C-Clinical reasons: post CCT/FRCS, aim for international fellowship, confident in supporting juniors etc

A-academic reasons:  masters/PhD, teaching opportunities, clinical lectureship etc

M-managerial reasons: engaging in clinical governance, becoming clinical lead etc

P-personal reasons: marry, have kids, support family, travel etc 

I wrote my own answers points like this then practiced them. Recorded and listened to my own voice while practicing.

Management Station:

This station gives you a chance to claim max marks. It consists of two parts. The first part is a presentation. You are emailed the topic beforehand. It is usually always the same. Talk about your leadership experience and how you intend to apply this during your core surgical training. You have 3 minutes to talk so make sure you don’t exceed 3 minutes. It reflects poor time management. After that they will ask you questions from your presentation for 2 minutes. The best way to go about this is talk about your leadership experience with an example from work and then talk about experience out of work and finish by reinforcing how this would be useful in your CST for a well-rounded effect. Remember to reflect on certain qualities of good leaders and team players because those are the qualities, they are looking for in a good core surgical trainee.

For example:

Clinical leadership experience: If you talk about leading ALS reflect on it using leadership qualities and sell yourself. ‘I was quick to assess skill levels, delegated tasks appropriately, organised team through clear assertive communication, strived under high pressure environment, was decisive about treatments etc’

 Non clinical leadership experience: If you  decide to talk about demonstrating leadership by your experience of heading a surgical/medical society during medical school highlight points like ‘properly engaged with my committee, prioritised events, time management, provided autonomy to members, encouraged them to think creatively and come up with own ideas’.

Clear presentation reflecting such views will constantly remind interviewers that you know exactly what it takes to be a good leader and team player.

The next half of the station (5 mins) you will be asked a general management question like dealing with difficult colleagues, angry patient etc that I will not go into the detail of and which are present in every interview book and come up in almost every speciality interview. The key is to use the SPIES structure that everyone is familiar with. If not, you will find it under management section in all interview books for sure.

Clinical Station:

They will judge your surgical clinical knowledge here, but it is actually more about a logical and structured thinking approach. The clinical scenarios in the surgical interview book mentioned earlier are more than enough to prepare from.

Whatever the clinical scenario may be the approach is always the same.

Just some tips from my personal experience of the approach I followed. People have different ways to come up with interview answers.

Initial management: ‘I will approach the patient using the standard ABCDE protocol (logical thinker) making patient safety my prime concern (safe doctor) I will make sure my patient receives adequate analgesia according to the WHO pain ladder. (empathy)

You have demonstrated to your interviewers three qualities of a good surgeon right in the very first sentence!

Go through your ABCDEs systematically and expand on where you think the problem is and fix it. Standard ALS/ATLS approach which I will not go into the details of. You need to keep on practicing them till they become second memory.

Differential Diagnosis: Often you may encounter scenarios where you may have to narrow down your diagnosis. They key is ‘categorise to survive!’ For example, post op fever (infective/non infective causes), hip fracture (extra/intra capsular), low urine output (pre renal/renal/post renal causes)

Investigations:

BBFIS (use a mnemonic so it makes it easy to remember)

Bedside- urine dip. ECG

Bloods

Fluids-pleural/ascitic tap

Imaging- X-ray/US/CT

S-Special tests (related)

Optimizing for theatre:

A: Anesthestist check/analgesia

B- Pre-op Bloods,group and save, cross match

C- CXR, Consent form

D- DVT prophylaxis, stopping blood thinners etc

E- ECG, Stopping Eating and drinking!

Management:

It revolves around surgical and non-surgical management.

I believe it’s worth doing the care of the critically ill surgical patient course for non-operative management. I have still not done it so can’t give a review about it.

For surgical management at post FY2 level it is not essential to know details of a surgical procedure but should know the basic incisions, surgical knots, basic anatomy etc.

Surgical topics to be aware of:

ASA Classification

WHO Pain ladder

WHO Theatre check list

Jenkin’s rule, type of sutures

Disinfection/sterilization

Capacity and consent

Post op complications

Key Points:

Getting into CST is quite doable. The only problem is lack of guidance because many people probably have not pursued this path so first hand experiences from people who have applied will help all.

Many people believe having visa restrictions is a big hurdle but in reality, once you’ve passed RLMT in any way you choose, it’s a fair game. It then depends solely on your interview preparation with no discrimination. A friend who applied to round 1 (visa restriction but in a psych training post) got a training number whereas a few UK graduates I know were unsuccessful in securing a job.

You do not need a very strong portfolio. As explained having been only 10 months in the UK I managed to collect a lot of evidence in retrospect. I initially thought having no publication or MRCS would affect my portfolio because people generally feed that into your mind, but it didn’t.

Solid interview preparation is a game changer! At least I believed that worked for me. You can read through interview books a million times but if you don’t practice in an interview setting it can become difficult. The more you practice with people, write down your own answers and sell yourself the better you will become at this. (Think PLAB 2). UK graduates go through a lot of interviews (med school, foundation modules, speciality training) so they understandably have a lot more interview exposure than IMGs do, not to mention the language barrier, so it is just a way of stepping up your game.

I have tried to write as detailed a review as possible. It is based on my own personal experience and lots of people may have different opinions regardless I hope it is found helpful. Good luck with all future training ventures. God Bless!

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