Specialising for Generalism: Reflections on a Rural Surgical Fellowship

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Stuart J Fergusson reviews his Rural Surgical Fellowship ahead of work in the Shetland Islands. Stuart details the diverse experiences, procedures, and skills acquired during the fellowship, highlighting its role in meeting the unique healthcare needs of remote communities like the Shetland Islands.

  

The Need for Rural Surgical Generalists

The place of generalists versus specialists in surgical care provision has long been studied and debated. In some areas of surgery, surgeon specialisation has been associated with improved outcome.[1] However, less well-resourced healthcare settings cannot support the expense of a multispecialty approach to healthcare delivery and generalism is a necessity. Even within a high-income country such as the United Kingdom, surgeons operating in smaller units will usually operate across a wider range of pathologies than colleagues in the larger tertiary units.

In the UK, Rural General Hospitals are at one extreme of this continuum. There are six designated Rural General Hospitals in Scotland which serve small remote or island communities of 19,000 - 25,000 people with a typical surgical complement of 3 consultant general surgeons.[2] Rural General Surgeons therefore offer elective general surgery across subspecialty areas of general surgery, but also including core urology, minor plastic surgery and minor orthopaedics. They also supervise the emergency assessment and treatment of every kind of surgical case, which can include the operative management of hip and ankle fractures, ureteric stenting, scrotal explorations and very occasional emergency craniotomy or thoracotomy for life-threatening bleeds.

The Rural Surgical Fellowship

Around three-quarters of surgeons in training express the intention to complete a ‘Clinical Fellowship’.[3] These aim to enhance the clinical and operative skills of senior trainees, typically involving intense exposure to a subspecialty area of practice, and improving employability.

Clearly the training needs of surgeons intending to work in remote and rural environments is quite distinctive. For many years, NHS Education for Scotland has offered Rural Surgical Fellowships, a bespoke opportunity for general surgeons to undertake peri-CCT training for subsequent use in one of Scotland’s Rural General Hospitals. The Fellowship provides 4 months to 2 years of experience tailored towards the surgeon’s intended rural practice and previous experience, and crucially is a supernumerary position, giving maximal flexibility to the trainee. The Fellowship can be offered as a stand-alone post, but is ideally combined with a ‘proleptic’ (ahead of time) appointment to a rural surgical consultant post, allowing tailoring of the experience to a specific environment.

My Fellowship Experience

Following a CCT in Colorectal and General Surgery, I was proleptically appointed to the role of Consultant Surgeon in the Shetland Islands, 110 miles north of mainland Scotland. In preparation I undertook the Rural Surgical Fellowship from August 2021 – July 2023 at Aberdeen Royal Infirmary. During this 2-year period I also undertook monthly weekend locums in Shetland, where I was mentored by existing surgical colleagues, and I also had a month-long visit to a remote and rural hospital in Zambia.

The design and oversight of my Fellowship was supported by a local educational supervisor in Aberdeen and a future consultant colleague in Shetland. My local educational supervisor initiated discussions with other specialty areas on my behalf and provided regular reviews and support. Fellowship objectives were written with reference to the 2016 report by the Royal College of Surgeons of Edinburgh, “Standards informing delivery of care in rural surgery”, which gave recommendations for training.[4] In Shetland, the general surgery elective service remains very broad (including breast and colorectal resections) and provision in urology extends up to transurethral resection of prostate and bladder tumours, together with minor orthopaedics such as carpal tunnel release and percutaneous fasciotomy for Dupuytren’s. Routine emergency service provision by the general surgeons includes ureteric stenting for obstructing stones, hip hemiarthoplasty, cannulated hip screw and ankle fixation for simple fractures. I had no previous formal training in urology and had some limited junior experience in trauma and orthopaedics 12 years ago.

My training time was therefore focused on trauma/fracture management and core urology. I also undertook regular work in general surgery (at consultant level) in order to enhance and maintain existing clinical, operative and endoscopic skills. Additional time was spent in obstetrics, paediatric surgery, neurosurgery, ENT, ophthalmology and cardiothoracics. This meant attendance at many out-patient clinics, Multi-Disciplinary Team meetings, operating lists and teaching sessions. After initial modular placements in year 1, by year 2 I was able to target optimal learning opportunities on a day-by-day basis, giving a hugely varied working week, as illustrated in Box 1 which is a direct extract of a week from my year 2 diary.

 

Box 1: A sample week from my Rural Surgical Fellowship

Monday	AM	Trauma theatre Cases: Hip hemiarthoplasty, tendon repair in foot, patellar tendon repair
	PM
Tuesday	AM	General Surgery theatre Cases: umbilical hernia repair, inguinal hernia repairs x2, rectal EUA, Karydakis flap for pilonidal sinus
	PM
Wednesday	AM	Breast theatre Cases: image-guided wide local excision + sentinel node biopsy (SNB) + LICAP flap, mastectomy + SNB + implant reconstruction
	PM
Thursday	AM	Admin time
	PM	Urology outpatient clinic
Friday	AM	Obstetric theatre Cases: Elective caesarean sections x 4
	PM

At the conclusion of my Rural Surgical Fellowship, I had participated in 810 procedures (abbreviated summary in Table 1) and undertaken 32 Procedure Based Assessments (PBAs). These PBAs were performed by the relevant specialists, documenting my readiness for independent practice in hip hemiarthoplasty, cannulated hip screw, tendon repair, ankle fracture fixation, carpal tunnel decompression, transurethral resection of prostate (TURP), transurethral resection of bladder tumour (TURBT), optical urethrotomy, circumcision, hydrocele and orchidopexy.

Reflections

The time spent in my Rural Surgical Fellowship was hugely enjoyable and very productive. I am now credentialed to offer a high-quality service in Shetland as an extended-range surgical generalist, thus maintaining services ‘on island’ and minimising expensive and time-consuming transfers. As an already-experienced surgeon, I was able to make rapid progress on skills acquisition in new specialties, as demonstrated by formal Procedure-Based Assessments. I found both junior and senior colleagues in other specialties very supportive of my Rural Surgical Fellowship aims, even though I absorbed some potential learning opportunities for other trainees and did not share their on-call burden. The professional relationships that I established in Aberdeen have already proven useful when needing to obtain advice or acceptance of transfer for patients in Shetland.

There may be challenges for some in undertaking the Fellowship. Since Fellowship funding is from NHS Education for Scotland, the Fellowship would require a personal and potentially family move to a Scottish city, before a further move again to the eventual rural destination (the breadth and depth of Fellowship experience requires a base in a teaching hospital or large district general). If the candidate were already based in Scotland, this should not be an issue since the necessary training opportunities could be provided in any major population centre.

For most potential candidates, there are financial disadvantages in undertaking the Fellowship. The remuneration is on the Specialist Registrar scale and is un-banded (i.e. contract for 40 hours a week, with no weekend or out-of-hours commitments). In my case, I largely made up this salary deficit by undertaking monthly weekend consultant locums in Shetland and occasional consultant locums elsewhere. This cost is not unique to the Rural Surgical Fellowship. A 2020 survey of 85 trainees who undertook RCS-endorsed Senior Clinical Fellowships found that although these posts were of high educational value, they involved a median salary deficit of £1,500 per month and additional non-remunerated monthly costs of £750.[5]

The highly bespoke and granular nature of this Fellowship means that it does require significant self-motivation and inter-personal skills. I constantly had to explain my situation and why I was not taking up a conventional slot on a rota. I was able to target optimal learning opportunities by establishing and maintaining strong professional relationships with junior and senior staff, and needed tact to avoid causing undue disadvantages to conventional trainees. In a large teaching hospital with plenty clinical activity, this was achievable. Within general surgery, my consultant-level work provided learning opportunities for the trainees I supervised, and my presence in other specialties had the additional advantage of raising awareness of rural surgery and its unique challenges.

The life of a rural general surgeon is a fulfilling one, but there are challenges in how some perceive this kind of generalist practice. A full decade has passed since the publication of Professor Greenaway’s “Shape of Training” report on the future of postgraduate medical training, which included amongst key recommendations that “patients and the public need more doctors who are capable of providing general care in broad specialties across a range of different settings.”[6] Despite this key endorsement of medical (and surgical) generalism, perceptions from medical school onwards[7] remain less flattering of generalists.

The RCSEd’s Faculty of Remote, Rural and Humanitarian Healthcare aims to “improve the health outcomes of individuals living and working in remote, rural, austere and life-threatening areas of the world,” and the key challenge to this objective is the lack of healthcare workers in rural environments.[8] I believe my Fellowship experience demonstrates that even in this modern era of highly specialised training within tight boundaries, well-targeted broad training and a can-do attitude can create the generalists required for rural communities. I am grateful for the Faculty’s support in raising awareness of this training opportunity.

Table 1: Abbreviated logbook summary

General Surgery	Number
UGI/LGI Endoscopy	152
Hernia repairs - inguinal, femoral, umbilical, incisional	34
Laparotomies/laparoscopies – for obstruction, perforation, appendicitis	19
Laparoscopic cholecystectomies	17
Colorectal resections – right, subtotal, Hartmanns	17
Rectal EUA/peri-anal work	22
Breast cancer resections – mastectomy, WLE +/- SLNB/ANC	11
Urology
Diagnostic cystoscopy	59
TRUS-guided prostate biopsy	35
TUR- bladder tumour	27
Rigid cystoscopy +/- procedure (Botox, diathermy of lesion, cystolitholapaxy, hydrodistension etc)	25
TUR- prostate	17
Assorted other procedures: circumcision, ureteric stenting, urethrotomy, ureteroscopy, hydrocele repair, suprapubic catheter insertion, orchidectomy, repair of bladder injury, scrotal exploration	65
Trauma and Orthopaedics
Hip hemiarthoplasty	45
Intramedullary fixation	18
Cannulated hip screw	11
Ankle fracture ORIF	20
Wound management - debridement/abscess drainage/removal of metalwork	22
Assorted other procedures: tendon repairs (quadriceps, patellar, biceps, foot, hand), joint aspiration/arthogram, trauma THR, split skin graft, BKA	18
Dupuytren’s contracture percutaneous fasciotomy	13
Obstetrics
Caesarean section	27
Neurosurgery
Burr hole biopsy of cerebral tumour	2
Craniotomy for extradural haematoma	1
Craniotomy for frontal tumour	1
Otolaryngology
Tonsillectomy +/- adenoidectomy	7
Nasal cautery for epistaxis	2
Removal of nasal foreign body	1
Cardiothoracics
CABG	2
Aortic valve replacement	1
Drainage of pericardial effusion	1

Abbrevations: UGI/LGI: upper gastrointestinal/lower gastrointestinal; EUA: examination under anaesthetic; WLE: wide local excision; SLNB: sentinel lymph node biopsy; ANC: axillary node clearance; TRUS: transrectal ultrasound; TUR: transurethral resection; ORIF: open reduction and internal fixation; THR: total hip replacement; BKA: below knee amputation; CABG: coronary artery bypass graft

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References

[1] Chowdhury MM, Dagash H, Pierro A. A systematic review of the impact of volume of surgery and specialization on patient outcome. British Journal of Surgery 2007; 94(2): 145-161.

[2] Grant AJ, Prince S, Walker KG, McKinley AJ, Sedgwick DM. Rural surgery: a new specialty?. BMJ 2011 343:d4761.

[3] Fitzgerald, J.E.F., Milburn J.A., Khera G., Davies R.S., Hornby S.T., Giddings C.E. Clinical fellowships in surgical training: analysis of a national pan-specialty workforce survey. World J. Surg., 37 (5) (2013 May), pp. 945-952 Daniels S, Elanko A, Court S, O’Flynn P, and Wyld L. RCS Senior Clinical Fellowship Survey: motivations, outcomes and cost of senior surgical fellowships. The Bulletin of the Royal College of Surgeons of England 2020; 102:2

[4] Short-Life Working Group on Rural Surgery, Royal College of Surgeons of Edinburgh. Standards informing delivery of care in rural surgery. March 2016.

[5] RCS Senior Clinical Fellowship Survey: motivations, outcomes and cost of senior surgical fellowships. Daniels S, Elanko A, Court S, O’Flynn P, and Wyld L. The Bulletin of the Royal College of Surgeons of England 2020; 102:2

[6] Greenaway, D. Shape of Training: Securing the future of excellent patient care. GMC, London. 2013.

[7] Misky, A.T., Shah, R.J., Fung, C.Y. et al. Understanding concepts of generalism and specialism amongst medical students at a research-intensive London medical school. BMC Med Educ 22, 291 (2022). https://doi.org/10.1186/s12909-022-03355-1

[8] Dolea C. Increasing access to health workers in remote and rural areas through improved retention: global policy recommendations. World Health Organization. 2010. ISBN 978-92-4-156401-4.

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