To the Editor: The recent editorial by Waxman1 implies that early streaming of students during medical school training is to become the norm for admission to the Royal Australasian College of Surgeons’ Surgical Education and Training (SET) program. We would like to draw attention to the disturbing nature of this development for medical students and junior doctors alike.

Waxman described the imperative for students to now decide upon a career in surgery “usually as undergraduate medical students”.1 He stated that some universities have proposed early streaming of students into specific surgical modules in later years of their medical programs. While early streaming may appear to be the answer to the growing conflict between the time constraints of undergraduate medical programs and the expanding body of medical knowledge, there are a number of significant pitfalls to this approach that are yet to be explored.

First, early streaming may jeopardise the quality of the generalist education offered at medical schools. International experience from McGill University in Canada, which implemented an early-streaming program in the late 1970s, supports this notion.2 The cohorts from McGill’s early-streaming program had poorer overall performance than their predecessors in the non-streamed program on the Medical Council of Canada’s national licensing examination, which was attributed in part to their reduced opportunity for generalist training.

Second, the notion that well resourced university surgical departments could provide an early-streaming package for undergraduate students that “[gives] their students an advantage and an almost guaranteed pathway into SET”1 creates gross inequity in access to surgical training. This system would disproportionately disadvantage students from both graduate-entry programs, which have a shorter course duration, and newer universities, which lack the resources to provide advanced surgical training modules.

Third, the program disadvantages students who have not formed firm career intentions by the later years of their medical program. With data from the United Kingdom showing that more than a quarter of junior doctors change their career intentions in the 3 years after graduation,3,4 a significant proportion of medical graduates will gain no appreciable benefit from early streaming, and may in fact be disadvantaged by it.

We strongly discourage the introduction of early-streaming programs in medical schools. All schools should graduate “pluripotent” undifferentiated doctors with a strong generalist background.

To the Editor: The editorial by Waxman1 on the Royal Australasian College of Surgeons’ new Surgical Education and Training (SET) program contains some factual errors that have led to anxiety among potential applicants. We wish to give the formal position of the College and to correct any misunderstandings. The SET program2 is evolutionary, builds on the strengths of the previously available program, and is based on an educationally sound framework and group of principles.

Registering an interest in training with the College does not in itself confer an advantage but will enable those registered to receive up-to-date information and College publications. The College website also provides up-to-date, relevant information for potential applicants. Completion of the Australian and New Zealand Surgical Skills Education and Training (ASSET) course is not compulsory before selection into SET, but it must be completed by the end of the first 2 years of the SET program.

The College and the specialist surgical associations and societies involved in the delivery of the SET program will rely on robust workplace-based assessment to monitor trainees’ progress and provide career advice. New in-training assessment tools are necessary to achieve this, and their implementation requires support, including courses for surgeons who undertake this vital work.

Those contemplating a career in surgery will not have to decide on their career choices at an earlier stage than previously. In the previous program, graduates could apply during their internship but now must wait until their second year after graduation. The College is committed to a broad-based period of preparation for surgical training but does not wish to deny the opportunity to those in their second year after graduation who are certain of their career aspirations. Applications will also be accepted from those who delay their career decisions for whatever reason.

Streaming medical students for vocational careers is an attractive educational philosophy, provided it does not interfere with the generalist experience required for all graduates. Furthermore, streaming is predicated on the medical colleges recognising this prior learning in their programs. Until this is resolved, the question of its implementation remains some way off. The current practice of undertaking electives in an area of interest is strongly supported.

The College is committed to working with the universities for a more integrated approach across the continuum of learning and seeks to build on the meaningful and collaborative partnerships already established. The key interface is the practising surgeon in an academic position who understands the requirements of the College and the university, as well as the needs of the community.

Selection into surgical training is through a national merit-based process. The curriculum vitae (CV) and its components of academic achievement, other accomplishments and clinical experience will each be scored and given appropriate weighting. The lower percentage overall for CVs (15%–25%) takes into account that many candidates will apply very early in their careers.2 While we laud the suggestion of university surgery departments providing a package for potential trainees, “giving their students an advantage and an almost guaranteed pathway into SET”1 does not necessarily follow, given the competitive nature of selection.