The way I see it . . .

Spend some time abroad during your training

Authors: Michael Clarke 

Publication date: 14 Jun 2008

The journey to become a specialist registrar has been challenging. This is unlikely to change, particularly for those trainees competing for specialty training 3 jobs in the future. Training is also getting shorter and there is limited time within which to acquire the knowledge, practical skills, research, audit, management, and teaching experience required for your specialty. How then can we as trainees ensure we retain a competitive edge in future medical job applications?

Historically, research has been the answer to this question. With the changes occurring in medical training, however, this will no longer be encouraged among all trainees. Although many may see this as welcome relief, trainees will be forced to find other opportunities to enhance their CV.

One possibility is to spend time abroad during your training. Indeed a number of my colleagues departed for Australia soon after completing their junior house officer year to gain medical experience, and they are now enjoying the pleasures of outdoor life in a warmer climate. I felt, however, that spending an unstructured period abroad so early in my training, with few specific aims or objectives, would be unlikely to prove valuable in my future training applications. Instead I was keen to work abroad at a later stage and for a shorter period. This would be easier in terms of both personal and professional life and was more likely to be accepted by my regional training committee. But what can you hope to achieve in such a short period of time?

Practical experience

There is no doubt that the European Working Time Directive is having an important impact on training, particularly within surgery—where exposure to index operations is reducing. Experience gained abroad can very often help to fill these voids in your operative logbook. Fellowships taken after the certificate of completion of training tend to focus more on learning advanced skills using modern technology and are therefore more valuable towards the end of your training. In contrast, visits to a developing country, which I opted for, often focus more on the management of unusual or more advanced pathology than in the United Kingdom, using basic equipment, and can provide valuable hands on experience to trainees at all levels. Both clearly present their own challenges and undoubtedly lead to advancement of technical skills, particularly in the management of complex cases.

Research experience

Conducting good research requires careful planning. This is particularly true in studies requiring patient data collection and when conducted in developing countries, where the infrastructure for research may be limited. Combining a research project with practical experience, however, can not only strengthen your application for sponsorship but can also provide opportunities for future presentations and publications. Although simple projects are normally easier to run, with appropriate planning over the four to six months before your visit, it is surprising how much data can be collected in five days.

Overseas fellowships

Currently, the UK study budgets available for doctors are inadequate to cover the cost of even the most basic courses. These funds are also not generally accessible for a trip abroad. It is therefore the responsibility of the trainee to seek funding if they are to pursue this opportunity. There are many potential bursaries and awards available through the royal colleges and other professional medical organisations. These generally require a clear outline of the aims and objectives of the trip; a detailed itinerary; and information about the destination hospital. This clearly requires prior planning and will also ensure that you are clear in your own mind what it is that you hope to achieve. It is important to appreciate that being awarded such a fellowship is not only extremely valuable in helping to subsidise the trip but is also another key item in your ever evolving CV.

My experience

Operation Hernia is an organisation that was established in 2005 with the aim of performing and teaching hernia surgery in Africa. This was only its third mission and involved travelling to western Ghana for one week with a team of five consultant surgeons from the UK and the Netherlands. The reported incidence of inguinal hernia in rural Ghana is around 60 per 100 000 population, with only 25% being repaired each year.[1] Of these, 65% are performed as emergencies, with a bowel resection rate of 24%, a mortality of 6% in strangulated hernias, and a mortality of 87% for patients who do not reach hospital.[2] We operated at four regional hospitals in Takoradi over a five day period, during which time we performed 140 hernia repairs, implanting sterilised mosquito-net mesh, predominantly under local anaesthetic. I performed 17 of the hernia repairs, which ranged from simple groin hernias to massive inguinoscrotal and incisional hernias. In addition I led a research study during the week, which involved collecting patient data questionnaires, in order to calculate the cost per disability adjusted life year (DALY) averted by our hernia surgery in Ghana. This composite health measure is used in cost-effectiveness analyses to quantify the burden of disease and facilitate healthcare resource allocation. This highlighted the enormous impact that projects such as these can have in returning patients to work and restoring financial income. For example, 43% of our patients were labourers, farmers, or fishermen, with some having up to 11 dependants at home. In addition, due to pain and disability, patients had missed an average of 55 days of work since developing their hernias, which in some cases equated to a loss of earnings of $1000 (£509; €647).

This was an experience of a lifetime providing not only excellent practical operative experience, but also opportunities to conduct a research project and gain insight into the difficult conditions that patients and healthcare professionals in the developing world must face.

Final thoughts

It is important to seek out opportunities to ensure you remain competitive in future medical training applications. Spending time abroad is now actively encouraged and can lead to enormous gains in terms of practical experience, research opportunities, prizes and awards, and eye opening adventure in a period as short as a week.

Acknowledgments: This trip was funded by an overseas fellowship awarded by the Association of Surgeons of Great Britain and Ireland (ASGBI).

Michael Clarke specialist registrar in general surgery Torbay Hospital, Devon

mgclarkey@doctors.org.uk