By Haseem Raja
FY2, Luton and Dunstable University Hospital

Trauma and Orthopaedics (T&O) is a competitive and popular surgical speciality in the United Kingdom (UK). Recently, however, application rates for surgical posts have been declining. This is a cause for concern, particularly as the demand for T&O surgeons is rising in line with an increase in the ageing population, prevalence of lifestyle diseases, and development of new surgical technologies. Changes to the pension tax regime have also exacerbated concerns regarding the future surgical workforce with many senior surgeons reducing their hours, declining extra sessions, and some even considering early retirement to avoid facing huge tax bills on their pensions. There is an urgent need, therefore, to understand the reasons for the recruitment shortfall in orthopaedics.

There are several challenges facing T&O recruitment, particularly in the undergraduate medical school setting. One of the major changes to medical school curricula recently has been the increased allocation for primary care and community placements. Surgical specialities such as orthopaedics have taken a back seat, occupying an even smaller percentage of the curriculum. The rationale behind this is to adapt and prepare students for a modern healthcare system whereby 90% of all patient contacts are happening in the community and hospital stays are becoming much shorter. The implications of these changes, however, on T&O are mutlifold. First, medical students are experiencing less T&O teaching than ever before. Second, opportunities for hands-on and practical exposure in theatre and clinics are being significantly reduced. Third, students will miss out on potential research projects that could enhance their academic skills and portfolios.

Lack of surgical exposure will mean students cannot make fully informed and honest choices about pursuing a career in T&O. It may also make them less likely to take the initiative and seek out further experiences in orthopaedics, such as a student-selected module, summer research post, or taster week during foundation training. The future of orthopaedics, however, is exciting and it is the responsibility of the profession to expose students and junior doctors to the full breadth of the speciality. Some initiatives for achieving this include: having an active involvement with undergraduate surgical societies to deliver lectures or courses, hosting open days or summer schools in T&O, and offering meaningful research projects that can result in presentations or publications.

It is also important to acknowledge that there has been a significant reduction in the proportion of junior doctors, following completion of their foundation training, who are entering speciality training directly. In 2018, this figure was only 37.7% – a stark contrast to 2011 when 71.3% entered speciality training straight away. This is reflective of the current NHS climate in which junior doctors are experiencing higher levels of dissatisfaction than ever before. Non-clinical factors such as work-life balance and lifestyle controllability are being increasingly prioritised over everything else, including prestige and financial remuneration, with many doctors choosing to pursue specialties with shorter training programmes or alternative careers.

In an effort to combat these issues and catalyse change, programme directors for T&O should make concerted efforts to design and structure placements to maximise interest in the field whilst offering ample learning opportunities for students and junior doctors. This includes dedicated time in emergency and elective theatres, as well as outpatient clinics. Rotation through different subspecialties, such as hand and knee, and supervised research activity during placements will allow individuals to better appreciate the breadth of the speciality. Liaising with programme and clinical leads, as well as rota co-ordinators, to accommodate for these changes is a vital step in this process. Failure to do so will risk losing those talented junior doctors who had or developed a genuine and keen interest for T&O; this is something that the profession can ill afford.

In addition, there are many factors that impact on junior doctors’ future career choices as they navigate through their training. It can be argued, however, that mentorship is one of the most important. Enthusiastic and supportive mentors can have a profound impact in developing students’ professionalism and personal growth, as well as their clinical knowledge and skills. This in turn can have a significant influence on speciality choice. The role of mentorship in T&O should, therefore, not be underestimated or overlooked but rather encouraged at every level of training.

Another key area to tackle in addressing the recruitment shortfall in orthopaedics is the under-representation of women. In 2018, it was reported that 11% of all higher trainees, specialist doctors, and consultants in T&O were female. This is striking given that women have represented around 50% of all graduating medical students in the UK for the last twenty-five years. Studies show that common assumptions contributing to females being discouraged from the speciality include: necessity of brute physical strength, poor work-life balance, and gender bias and stereotypes.

It is pleasing to see networking events and social media campaigns such as #WomenInSurgery raise the profile of female orthopods at various career grades whilst tackling the stigma that exists around the clinical perceptions and misperceptions of T&O. Promotion of such campaigns – both at a local and national level – should be actively championed as this will help redress the gender balance in orthopaedics and lead to more opportunities for women in the field.

In summary, attracting and retaining the very best doctors in T&O is essential for the delivery of high quality, effective care to patients. Active measures are needed both within medical education and the surgical profession to achieve this goal. There should be a greater focus towards challenging gender and speciality stereotypes, increasing surgical exposure during the formative years of medical training, offering flexible training programmes, and mentorship. In particular, orthopaedic trainers should seek to maximise learning from every situation and push their students and trainees to be the very best they can be. This will help inspire the next generation of T&O surgeons and ensure the profession keeps up with the projected surgical demands in the future.