Author:  Rhea Liang

Editors:  Nadia Perera, Antonia Clarke

 

Since I became a surgeon more than a decade ago, countless medical students and junior doctors have rotated through my unit. The vast majority are motivated, intelligent, and compassionate – all excellent traits for a surgeon. But many of them have already decided that surgery is not for them, and when I enquire about the reasons why I rediscover stories and surgical stereotypes that are unchanged from when I first heard them myself… last century.

Some of these myths are simply elitist, others are only half-truths, and many are rapidly becoming untenable due to changing societal expectations. It is important to debunk these myths because dissuading good people from surgery limits the diversity and ability of surgical applicants, with negative effects on the quality of our future surgical workforce. Here are the ones I hear most commonly.

 

Myth #1 – Surgeons have to sacrifice their personal lives

Historical data shows that surgeons have sacrificed their personal lives. A recent systematic review showing that 40% of surgeons meet criteria for burnout, 21% have been divorced, and 6.4% report suicidal ideation in the previous year [1]. Surgeons work more than 50 hours per week on average, and surgeons in every specialty group report that they would prefer to work fewer hours than they do [2].

But ‘have’ is not the same as ‘have to’. There is increasing recognition that work-life balance and improved mental health are linked to robust overall functioning and clinical performance [3]. There is also evidence that average work hours for doctors in Australia are steadily decreasing over time, consistent with trends in other developed countries [4].

Although flexible and part-time options during training are still limited, the good news is that once you are a consultant, you have more control. Diverse practice patterns are becoming more common, whether you choose to work part time, share a practice, work flexible locum shifts, mix it up with academic or other interests, or create something entirely new (telemedicine, permanent Fly-In-Fly-Out, surgical app developer, medicolegal work…).

 

Myth #2 – I am not coordinated enough to be a surgeon

There are ‘gross motor’ operations that involve power tools similar to the ones in your tool shed. There are ‘fine motor’ operations that involve anastomosing microscopic blood vessels with sutures finer than human hair. There are operations that involve both skills in the same operation, such as neurosurgery or complex limb reconstruction.

Thankfully, the literature shows that surgeons are made, not born [5]. The American College of Surgeons reassuringly points out that ‘some of the most wise and revered surgeons in practice today were not known for their dexterity when they were medical students or junior surgery residents’ [6]. You may already know that you enjoy activities that require coordination and dexterity if you play sports, play a musical instrument, or have a craft hobby. But even if not, as long as you are prepared to practise, you will develop the necessary skills as you progress through training.

 

Myth #3 – Surgical training is incredibly hard to get in to

This is a myth that has persisted even though the training programme it relates to, a two-tier programme with a bottleneck between the first and second tier, was replaced in 2007 by the current Surgical Education and Training (SET) programme. The SET programme has clearly specified entry criteria and a stepwise selection process. Prevocational preparation for SET application has been strengthened by the additional JDocs framework, which provides online and physical resources for aspiring surgical applicants [7].

In 2017, across the nine specialty training streams, there were 890 applications to the SET programme, of which 256 were successful [8]. This is a success rate of approximately 1 in 3. In almost any other job interview, those would be considered very reasonable odds. Would you really not apply for a job with a 1 in 3 chance, if that was a job that you genuinely wanted?

 

Myth #4 – Surgeons are just in it for the money

Surgeons do have the highest annual income of any occupational group in Australia [9]. However, they also have one of the longest training programmes, with ongoing and significant costs for training fees, compulsory courses, and the cost of moving location every 6 – 12 months. A surgical career is often limited by age-related changes in eyesight and coordination, and over half of surgeons over 50 years of age plan to retire within 10 years, [10] significantly earlier than the usual pension age of 65.  The high annual income must therefore be taken in this context of a limited active working period.

 

Myth #5 – Surgeons are disrespectful, and unacceptable behaviours are widespread in surgery

The Expert Advisory Group report in 2015 showed that nearly 50% of Royal Australasian College of Surgeons (RACS) Fellows, trainees and International Medical Graduates reported being subjected to discrimination, bullying or sexual harassment [11]. This was shocking and clearly could not be allowed to continue.

Since then, rapid and significant progress has been made through a whole raft of initiatives such as education workshops, an increase in diversity and inclusion, and the establishment of a complaints hotline [12]. The mandatory Operating With Respect online module means that no surgeon, International Medical Graduate (IMG) or trainee can claim to be unaware of what constitutes unacceptable behaviour. The negative stereotype of the ‘surgical personality’ will in time become a rarity, with recent research from the United Kingdom indicating that the actual ‘surgical personality’ now includes a statistically higher incidence of good traits such as agreeableness, openness and conscientiousness [13]. The same research shows that the trait of neuroticism, which is associated with negative emotions such as anger, anxiety, depression and vulnerability, tends to be associated with older age. This may represent a generational change. Medical students and junior doctors should feel confident that this myth is rapidly becoming untenable, and that by embarking on surgical training, they can become part of the change.

 

In conclusion, I implore medical students and junior doctors to see surgical myths for what they are. Instead of myths, let’s create some new surgical legends. Imagine a diverse surgical workforce with surgeons of all genders, ethnicities, shapes and sizes. Imagine that every surgeon is welcoming, respectful, capable and available. Imagine that every surgeon teaches with encouragement and patience. Imagine that every surgeon makes the effort to look after their mental and physical health, and works with their team to enable everyone to have work-life balance. If this sounds appealing, then choose a surgical career and come join us in making the change. Don’t be a myth – be a legend!

 

References

1.  Dimou FM, Eckelbarger D, Riall TS. Journal of the American College of Surgeons. 2016;222(6):1230-1239.  Surgeon burnout: A systematic review. Available from:  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4884544/pdf/nihms-773035.pdf

2.  Royal Australasian College of Surgeons. Surgical Workforce 2016 Census Report. Available from:  https://www.surgeons.org/media/25115898/2017-05-26_2016-surgical-workforce-census-full-report_final.pdf, Figure 2.5.

3.  Dewa CS, Loong D, Bonato S, Trojanowski L.  BMJ Open 2017;7:e015141.  The relationship between physician burnout and quality of healthcare in terms of safety and acceptability: a systematic review.  Available from:  https://bmjopen.bmj.com/content/bmjopen/7/6/e015141.full.pdf

4.  Joyce CM, Wang WC, Cheng TC.  Medical Care Research and Review, 2015:72(5);605 – 621.  Changes in doctors’ working hours: A longitudinal analysis.  Abstract available from:  https://minerva-access.unimelb.edu.au/handle/11343/118221

5.  Sadideen H, Alvand A, Saadeddin M, Kneebone R.  International Journal of Surgery, 2013:11(9);773-778.  Surgical experts: Born or made?  Available from:  https://ac.els-cdn.com/S174391911301008X/1-s2.0-S174391911301008X-main.pdf?_tid=0b9042ef-d81d-480c-8e9e-5cabbdb04fea&acdnat=1537080616_ea2ffbcfa463ff23ced7dcd064d20420

6.  American College of Surgeons. So you want to be a surgeon. Section 1: Surgical Traits. Available from:  https://www.facs.org/education/resources/residency-search/traits

7.  Royal Australasian College of Surgeons. JDocs: Best practice, Better practitioners. Available from:  http://jdocs.surgeons.org/

8.  Royal Australasian College of Surgeons. Activities Report: For the Period 1 January to December 31 2017. https://www.surgeons.org/media/25670553/2018-05-09_rpt_activities_report_pdf_final.pdf, Table SET.4

9.  Australian Taxation Office. 2015-16 Tax Stats released. Available from:  https://www.ato.gov.au/Media-centre/Media-releases/2015-16-Tax-Stats-released/

10.  Royal Australasian College of Surgeons. Surgical Workforce 2016 Census Report.  Available from:  https://www.surgeons.org/media/25115898/2017-05-26_2016-surgical-workforce-census-full-report_final.pdf, Figure 7.5

11.  Expert Advisory Group. Report to RACS: on discrimination, bullying, and sexual harassment.  Available from:  https://www.surgeons.org/media/22045685/EAG-Report-to-RACS-Draft-08-Sept-2015.pdf

12.  Royal Australasian College of Surgeons. Building Respect, Improving Patient Safety: 2017 Progress Report.   Available from: https://www.surgeons.org/flipbook3d/Digital/BRIPSProgressreport2017/index.html

13.  Whittaker M. Annals of the Royal College of Surgeons of England, 2018:100(1);72-77.  The surgical personality: Does it exist?  Available from:  https://publishing.rcseng.ac.uk/doi/full/10.1308/rcsbull.2018.130

 

Useful resources

Podcast – A career in surgery with Dr Titus Kwok

Blog – How to forge a career in academic surgery by Dr Michael Byrom