How lucky are you! A “Breaking The Bottleneck” Interview.

This time we have a guest writer: Amaan Din. Amaan is Surgical SHO in London at the moment, but will shortly be starting as an ST3 in vascular surgery.

Amaan didn't take the conventional path in surgery. He never did Core Surgical Training(CST). But he got into surgery anyway.

Here is his account on how he did it.

SUNDAY CLERKING: BREAKING THE BOTTLENECK

🏥🪡 How I Skipped Core Surgical Training And Got Into Vascular Surgery.

As competition ratios rise, the alternative to formal Core Surgical Training (CST) – using a completed CREHST form to apply directly to ST3 - is becoming increasingly popular. Despite this, there isn’t much good quality information out there on how it all works. As someone who has successfully done this and gained an ST3 number at first attempt, I wanted to share what I have learned during this process.

My Story

After completing foundation training, I had an interest in surgery but wasn’t sure whether I was fully committed – therefore I didn't apply for CST in FY2. Toward the end of FY2, I planned a move to London with a friend and to gain more experience accepted a JCF post in vascular surgery (my main interest).

Around the same time, a few Reddit posts made me aware of the CREHST route, and I realised that I could potentially use this to turn my JCF job into my own core surgical training. I discussed it with my clinical supervisor, who wasn't familiar with CREHST but was open-minded and agreed in principle to support me.

After completing 12 months of vascular surgery, I did a further 12 months of general surgery at the same trust, using ISCP and the eLogbook to document progress. Following this, I had the form signed and successfully applied for an ST3 post in vascular surgery.

The Basics

As most will know, surgical training in the UK typically follows this path:  

Foundation programme (2 years) → Core Surgical Training (2 years) → Higher Surgical Training (6 years) → CCT

The key thing to realise is that CST can be extremely hit and miss, and by all accounts true surgical training (unfortunately) starts at ST3 – which is where the bottleneck is. This means that getting into CST is not the goal - ST3 is. You just need to figure out the best way to get yourself there.

To be eligible to apply for ST3, the bare minimum you need is:

- To be a CT2/have completed CST, OR to a have a completed CREHST form

- Full MRCS (by offer date, usually April)

- Met any specialty-specific requirements – usually minimum time in specialty and minimum operative numbers e.g. appendicectomies for general surgery, DHS for T+O

Alongside this, you need to have developed a portfolio that is competitive when aligned with your chosen specialty’s ST3 scoring criteria. You should also do the BSS and ATLS courses

How Do I Get A Signed CREHST Form?

You can view the form here. Any surgical consultant can sign the form, as long as they are satisfied that you meet all of the competencies and have worked with you for at least 3 months. A combination of consultants can sign it for you as long as all of the competencies are signed. 

If you have already worked in surgery for a while and have consultants who are happy to sign you off, that is fine – there’s no specified evidence requirement. However, I’ll target the rest of this article toward someone with no experience in post-foundation surgery. Whilst technically there is no minimum time requirement in order to get your CREHST form signed either, I think you need at least 2 post-foundation years in order to 

1) Be able to actually do the job of a registrar and 

2) Convince the average surgical consultant to sign your form. 

The most important thing you need is a decent job with a supportive department and supervisor. The competencies on the form are extremely generic — it's not particularly difficult to demonstrate these if you have a good environment and work ethic.

Ideally, you're on the same rota as CSTs. At a minimum, you need semi-regular access to theatre and a bit of clinic time. Departments are extremely variable in this respect, but there are good ones out there - I was fortunate to have minimal ward responsibilities and an identical rota to the CSTs. When you are interviewing for the job, mention that you are interested in pursuing CST equivalence and sound out if the department is generally supportive of this/ do they know what you are talking about.

Once you’re in the job, you must ensure that your supervisor understands what you are trying to do and is happy to sign your CREHST form provided you hold up your end. You want to get into specifics – what do they expect to see from you and over what time period. Have this discussion early and try to choose a boss who will be engaged and provide some mentorship.

On a related note, an increasing numbers of trusts seem to now offer 2-year ‘local CST’ programmes - structured posts with 6-monthly rotations that promise to give you a supervisor, study budget and lead to a signed CREHST form at the end of the programme. This is a good idea and should take care of most of the above for you – the only drawback may be that it gives you less choice over which specialties you work in. 

A note on timing – if you are in proper CST, you can apply for ST3 midway through your CT2 year. You may wish to try and get your form signed a bit ‘early’ to emulate this timing and allow you to apply at the equivalent point. Again, something to be discussed with your supervisor.

Once you've got the job:

• Use ISCP – this is the portfolio used during all formal surgical training. It's not mandatory, but will make life easier as all of your bosses will already be familiar with it. Collect evidence that demonstrates you meet the competencies on the form – act like you are a deanery trainee. Sadly it costs around £200.

• Thou shalt log all of thy cases in eLogbook (as many STS as possible)

• Do ATLS - you should do it anyway, but it’s good evidence for the trauma competencies on the CREHST form if you don’t work in a major trauma centre.

What Else Do I Need To Do To Get The ST3 Job?

Remember that CREHST is only one part of the puzzle – you need to do the other things which make you eligible to apply for ST3, and then you need to make your application competitive. You should: 

• PASS YOUR EXAMS – this is in capitals for a reason. I have seen many good doctors get held up because they haven’t done their exams. Get it out of the way early. Part A is a pain, but Part B does teach you some useful information and it will make you a more confident and capable surgeon. It will also give you credibility, and dropping the title of Doctor is a rite of passage - you will get asked “are you Mr/Miss X or Dr X” when someone is writing the op note - you'll feel good when you can give the right answer! 

• Plan your jobs sensibly - work in your target specialty and allied specialties. I wanted vascular, so did a year of vascular and a year of general surgery. Generally, once you have a job somewhere, it's easier to extend your contract and make internal moves to other departments.

• Get the operative numbers your specialty requires - get familiar with the ST3 application criteria NOW.

• In the same vein, do all of the portfolio building nonsense that is required - audit, research, presentations, leadership etc

• ACTUALLY LEARN TO DO THE JOB - a bit of a soapbox moment for me, but it's my article so I'll do what I want. You will encounter colleagues who are so focused on buffing their CV and sweet-talking their supervisors, that they forget to actually become clinically competent. To be honest with you, my portfolio wasn’t the strongest - I hated portfolio-building. However, I knew my stuff clinically and I knew what was required to make the step up – this shone through in my interview, and that was what got me my number. Learn to do the job.

The Challenges of This Road

The main challenge of doing this yourself is that you need to be fairly organised and self–directed. When you are in CST, there are people keeping an eye on you and encouraging you to do what you need to, whereas as a trust-grade it’s all on you. 

You will also be treated a bit differently than a deanery trainee, although the extent of this will vary. The following are some ways this may manifest:

• Some people will assume that you aren’t as good as a proper CST (at first).  If you are good, you can disprove this notion pretty easily. In the same vein, CSTs might indirectly get better training, e.g. more opportunities from the consultants when in theatre.

• Access to theatre/clinic may be prioritised for CSTs.

• As a locally employed doctor, you can't complain to the deanery if you aren’t getting training opportunities.

• You might have a lesser study budget.

• You won’t get deanery teaching.

• The process of applying for CST forces you to do some portfolio building and gives you interview experience – all of this may make it easier for you to succeed in your ST3 application. That said, many people have succeeded in ST3 applications without this.

The Advantages of This Role

There also some advantages to doing things this way – hence why I never applied to CST.

• The main advantage for me was that I got to choose where I worked, in which specialty and for how long. This allowed me to move to London with my mates and work in some very well-regarded hospitals and departments, which taught me a lot. I also didn’t have to do rotations in specialties I wasn’t interested in. I appreciate this is probably more difficult now as everything is getting more competitive.

• You don't have to mess about building a CST portfolio - last time I checked the CST portfolio criteria were a lot more convoluted than the ST3 criteria. This means you can put more energy into doing things which will get you into ST3, which is the main goal.

• If you don't get into CST, this is a way to avoid 'falling behind' - instead of applying for CST 3 times in a row and prolonging your future CCT date further and further, you can progress in parallel and hopefully get into ST3 on a similar timeline than if you had gotten into CST first-time.

In Retrospect, I’d Recommend Doing This

Overall, I am happy with the route I took - I got to live and work where I wanted for a couple of years, got experience in the specialties I wanted to, and got my number first time. 

That said, I think it was probably more stressful than doing CST – worrying about whether I would get my form signed, sometimes worrying whether I was 'behind' or 'not as good as' the CSTs, having to negotiate contract extensions. One of the reddit posts I read said that no one will ever be quite convinced by you until you get your number, and I think that’s very true.

My main reflection on the experience is that building strong relationships and receiving mentoring from senior colleagues is vitally important, especially in an ‘apprentice-style’ discipline like surgery. I did a good job of this with my registrars and got a lot of benefit from it, but I wasn’t confident enough to do it with consultants which probably made my life more difficult than it needed to be. 

I think that formal CST is certainly the more straightforward and less stressful path, but CREHST is also a very viable route to ST3, which is being proven by the many succeeding in this way. If you don't get into CST or want/need greater control over where you work, I wouldn't hesitate. Questions welcome – and good luck!

If you want to get in touch with Amaan and speak personally about his journey. Contact him on his Linkedin here

If you are unsure of what you want to do in medicine. That’s okay. If you’d like to gain some clarity. Reply to this email with the speciality YOU want to hear from and stage in their career.

In return, please share The Handover with 1 friend, who would find this content useful.

Thats not all. If you share The Handover with 2 friends you’ll get access to our growing catalogue of CV’s from doctors we interview on this platform. For Free!

Share with your personal link below 👇️