Annals of the Royal College of Surgeons of England (1977) vol 59
POINTS OF VIEW
Some personal observations on the university department of surgery Roy Y Calne FRS MS FRCS Professor of Surgery in the University of Cambridge
Academic departments of surgery in the United Kingdom have emerged at different times throughout the country with structures that vary considerably as regards staffing, status, and co-ordination with other departments in the hospital, the university, and particularly the rest of the surgical staff not attached directly to the university department. Higher surgical training, undergraduate teaching, and surgical staffing of hospitals cannot be dissociated from each other, and the interrelationship to the university department is important for each of these. An academic department of surgery has three main functions. First and foremost to care for patients; it is impossible to run an academic department of surgery without at the same time practising surgery as a main professional commitment. The second function is teaching-both undergraduate and postgraduate. The third is the pursuance of research in an attempt to improve the understanding of disease and treatment of patients. It is often stated that all trainee surgeons should spend a period doing academic research. I believe that they should be exposed to experimental research, but since originality and aptitude for experimental work cannot be equated with intelligence or surgical ability, if a trainee surgeon is not interested in experimental research he should be encouraged to become involved in clinical investigation. The potential academic 'high-flyer' who aspires to a chair should spend I or 2 years in full-time research, either after senior house officer and before registrar or after registrar and before senior registrar. In this period he would discover if he really is dedicated to research and he should start work on a thesis. Prep-
aration of a thesis is an important exercise. It is the only time that an individual is compelled to go into his subject in full depth. Critical appraisal and analysis, not a mere history of previous work, is a most important part of the thesis. If the candidate adds something new to his subject this is a welcome bonus. Once the RCS Fellowship requirements have been fulfilled and the FRCS hurdle overcome the phase of higher surgical training begins and the Joint Committee requirements are helpful. The concept of a quota of senior registrar or lecturer/senior registrar posts geared to estimated consultant requirements seems sensible. I think the stipulated 2 years in a teaching hospital and 2 years in a district general hospital organized within the region achieves a reasonable balance of training, provided it has some latitude of room for manoeuvre. This period is concemed mainly with professional training and there is no important difference between academic and National Health Service requirements. At present there is the anomaly of up toi 6o applicants for senior registrar posts and often only two or three for lecturer posts of senior registrar status. Lecturer appointments have been criticized as 'backdoor' entry to consultant posts, since most lecturers become NHS consultants. It would seem to be reasonable for all surgeons undergoing their 4-year higher training to be of the same grade-part financed by the university and part by the NHS and appointed by joint university-NHS committees. In the course of his 2 years at a teaching hospital he would have the opportunity for experimental and/or clinical investigation in the university department and would have the academic duties of teaching
Some personal observations on the university department of surgery
undergraduate and postgraduate students. The number of lecturer/senior registrar posts would depend on the regional allocation. One of the 4 years could be outside the region, in the United Kingdom or abroiad, if suitable reciprocal locum arrangements could be made by the individual concerned. At the end of the 4 years the lecturer/senior registrar would be eligible to apply for consultant posts. I now come to the vexed question of senior lecturer/consultants. I have never seen this working as a suitable tenure position. One of the following alternatives is likely: i) Appointment to a chair of surgery. 2) Appointment to an NHS consultant post. 3) Some surgeons, however, are unable or unwilling to compete for either of these and remain in the university department, to the resigned acceptance of the current professor and the frustration and despair of a new one. A professorship of surgery is now an unenviable, underpaid post-overburdened by too many students, shortage of research funds, and excessive administration. The only advantage of being a professor is to be head of one's own department. To be lumbered for ever with a low-flying, stationary, or even crashed senior lecturer is quite unfair to the professor and the institution. I feel that senior lecturer/consultant posts should be of limited tenure for 4 years NOT renewable but with full consultant status in the hospital and consultant responsibilities for patient care in beds allocated to the university
I159
department. During this period there would be ample opportunity for the individual to flourish in research and surgical practice if he is able and become a professor oir consultant in a hospital olf his choice. If he cannot aspire to one of these he should be prepared to apply for and accept a consultant post in a hospital that is less attractive to him. If the senior lecturer/consultant post was clearly of limited tenure, then only those confident of obtaining a better permanent position would apply for such a post. The standard of applicant would be high and the university departments and hospitals would benefit. If it were felt that the unit was sufficiently large to have more than one permanent consultant, then this could be achieved by appointment of an ad hominem professor or reader or an NHS consultant in the university department. My own preference would be for an NHS consultant with academic sessions to help run the university department. He would have his own independent NHS beds but act as a senior lecturer in the university department under the professor in the organizing and pursuit of teaching and research. My proposals are not revolutionary but they would rectify certain anomalies that have caused much bitterness and discord in the past. With so many difficulties besetting our profession we must seek a friendly relationship between senior and junior academic and nonacademic surgeons and co-ordinate the structure and opportunities of surgical training.
POINTS OF VIEW
Some personal observations on the university department of surgery Roy Y Calne FRS MS FRCS Professor of Surgery in the University of Cambridge
Academic departments of surgery in the United Kingdom have emerged at different times throughout the country with structures that vary considerably as regards staffing, status, and co-ordination with other departments in the hospital, the university, and particularly the rest of the surgical staff not attached directly to the university department. Higher surgical training, undergraduate teaching, and surgical staffing of hospitals cannot be dissociated from each other, and the interrelationship to the university department is important for each of these. An academic department of surgery has three main functions. First and foremost to care for patients; it is impossible to run an academic department of surgery without at the same time practising surgery as a main professional commitment. The second function is teaching-both undergraduate and postgraduate. The third is the pursuance of research in an attempt to improve the understanding of disease and treatment of patients. It is often stated that all trainee surgeons should spend a period doing academic research. I believe that they should be exposed to experimental research, but since originality and aptitude for experimental work cannot be equated with intelligence or surgical ability, if a trainee surgeon is not interested in experimental research he should be encouraged to become involved in clinical investigation. The potential academic 'high-flyer' who aspires to a chair should spend I or 2 years in full-time research, either after senior house officer and before registrar or after registrar and before senior registrar. In this period he would discover if he really is dedicated to research and he should start work on a thesis. Prep-
aration of a thesis is an important exercise. It is the only time that an individual is compelled to go into his subject in full depth. Critical appraisal and analysis, not a mere history of previous work, is a most important part of the thesis. If the candidate adds something new to his subject this is a welcome bonus. Once the RCS Fellowship requirements have been fulfilled and the FRCS hurdle overcome the phase of higher surgical training begins and the Joint Committee requirements are helpful. The concept of a quota of senior registrar or lecturer/senior registrar posts geared to estimated consultant requirements seems sensible. I think the stipulated 2 years in a teaching hospital and 2 years in a district general hospital organized within the region achieves a reasonable balance of training, provided it has some latitude of room for manoeuvre. This period is concemed mainly with professional training and there is no important difference between academic and National Health Service requirements. At present there is the anomaly of up toi 6o applicants for senior registrar posts and often only two or three for lecturer posts of senior registrar status. Lecturer appointments have been criticized as 'backdoor' entry to consultant posts, since most lecturers become NHS consultants. It would seem to be reasonable for all surgeons undergoing their 4-year higher training to be of the same grade-part financed by the university and part by the NHS and appointed by joint university-NHS committees. In the course of his 2 years at a teaching hospital he would have the opportunity for experimental and/or clinical investigation in the university department and would have the academic duties of teaching
Some personal observations on the university department of surgery
undergraduate and postgraduate students. The number of lecturer/senior registrar posts would depend on the regional allocation. One of the 4 years could be outside the region, in the United Kingdom or abroiad, if suitable reciprocal locum arrangements could be made by the individual concerned. At the end of the 4 years the lecturer/senior registrar would be eligible to apply for consultant posts. I now come to the vexed question of senior lecturer/consultants. I have never seen this working as a suitable tenure position. One of the following alternatives is likely: i) Appointment to a chair of surgery. 2) Appointment to an NHS consultant post. 3) Some surgeons, however, are unable or unwilling to compete for either of these and remain in the university department, to the resigned acceptance of the current professor and the frustration and despair of a new one. A professorship of surgery is now an unenviable, underpaid post-overburdened by too many students, shortage of research funds, and excessive administration. The only advantage of being a professor is to be head of one's own department. To be lumbered for ever with a low-flying, stationary, or even crashed senior lecturer is quite unfair to the professor and the institution. I feel that senior lecturer/consultant posts should be of limited tenure for 4 years NOT renewable but with full consultant status in the hospital and consultant responsibilities for patient care in beds allocated to the university
I159
department. During this period there would be ample opportunity for the individual to flourish in research and surgical practice if he is able and become a professor oir consultant in a hospital olf his choice. If he cannot aspire to one of these he should be prepared to apply for and accept a consultant post in a hospital that is less attractive to him. If the senior lecturer/consultant post was clearly of limited tenure, then only those confident of obtaining a better permanent position would apply for such a post. The standard of applicant would be high and the university departments and hospitals would benefit. If it were felt that the unit was sufficiently large to have more than one permanent consultant, then this could be achieved by appointment of an ad hominem professor or reader or an NHS consultant in the university department. My own preference would be for an NHS consultant with academic sessions to help run the university department. He would have his own independent NHS beds but act as a senior lecturer in the university department under the professor in the organizing and pursuit of teaching and research. My proposals are not revolutionary but they would rectify certain anomalies that have caused much bitterness and discord in the past. With so many difficulties besetting our profession we must seek a friendly relationship between senior and junior academic and nonacademic surgeons and co-ordinate the structure and opportunities of surgical training.
