To the Editor: The recent article on the review of the University of Sydney Medical Program (USydMP)1 by Goulston and Oates included a lengthy list of “changes made or planned in accordance with key recommendations”.2 Regrettably, and to the despair of many, the most needed change will not take place.

It is reported in the review that the average age of future USydMP graduates will be 29–30 years, as it has been for the past decade.1 From 2008, those who aspire to be surgeons will competitively enter the new Surgical Education and Training (SET) program of the Royal Australasian College of Surgeons (RACS) after completing “at least their second postgraduate year”.3 The SET program is for 5–6 years, depending on the specialty. Most trainees subsequently take a subspecialty fellowship for 1–2 years, either in Australia or overseas, by which time our hapless graduates will be 40 years old. A woman may have to have leave of absence for a pregnancy. A postgraduate degree is now a prerequisite for an academic career and this involves an additional 2–3 years of full-time research. Finally, it takes in the order of 5 years to establish a referral specialist practice in most branches of medicine.

In the review document, Goulston and Oates nihilistically state “There is no opportunity for streaming within the USydMP”.1 There is no mention of undergraduate education in Australia, let alone the streaming of such education, in the article from the RACS outlining the SET program.4 However, strangely enough, it is noted therein: “North American students must make their long-term career choice in the final year of their medical school and are streamed accordingly”. One wonders if there is any purposeful communication between the RACS and our universities. There certainly should be.

It is imperative in this day and age that undergraduate and postgraduate medical education be considered as a continuum so that we can begin to rid ourselves of the absurdly long and manifestly inefficient process outlined above. The historian and journalist Paul Johnson put his astute finger on the problem in writing a column about universities generally: “. . . a visitor from another planet, unfamiliar with the history of the institution, would think it odd that our ablest boys and girls, at a time when their mental and physical powers are at their highest, are withdrawn from the service of society and kept in comparative idleness . . .”5

One can but conclude that, at least for future surgeons, the wrong people are at the helm at the RACS and at the University of Sydney’s Faculty of Medicine.

In reply: Taylor raises several issues that the Royal Australasian College of Surgeons (RACS) has carefully considered. The new Surgical Education and Training (SET) program commenced this year.1 The acronym SET could equally mean Shorter Efficient Training.

In the previous program, 2–5 years of basic surgical training was followed by 4–6 years of advanced training, resulting in surgeons entering specialist practice an average of 10 years after graduating with their medical degrees. We responded to societal and regulatory factors, including the older age of medical (compared with other) graduates, sex, work–life balance, safe-hours requirements, workforce pressures and competition from other specialties. Our new system aims to streamline training by early selection directly into one of nine surgical specialties and completion of training by Postgraduate Year 7 or 8 in most cases.

It is not only shorter, but more comprehensive than previously. It is much more than an apprenticeship, where training occurs by random clinical exposure. We are covering defined curriculum objectives for every trainee by offering training in metropolitan and regional hospitals, synthetic laboratories and the private sector. We are moving away from reliance on the number of years of training and numbers of operations as measures of experience. We are focusing on the development of a range of surgical competencies encompassing professionalism, communication, collaboration, clinical decision making, scholarship, leadership and health advocacy, as well as essential medical and technical expertise. These competencies are regularly monitored by performance assessment throughout training.

At the completion of training and the RACS fellowship examination, a surgeon is competent to commence practice as a specialist. Additional formal training experience is optional. Of course, the RACS promotes the concept of lifelong learning.

The RACS and universities are communicating. Common concerns are the compromised state of basic science education and the limited exposure of medical students to a range of surgical specialties. The College has had discussions with many universities and health authorities about the possibility of “streaming” in the later years of medical school and in Postgraduate Years 1 and 2. It is worth noting that the University of Sydney has plans for the final 2 years of its course to be integrated, with increased emphasis on critical care and surgery.2

In reply: We are in sympathy with Taylor’s concerns about the length of medical training and point out that a more careful reading of our review of the University of Sydney Medical Program1 contained the following comments (on page 203):

This is followed by three recommendations on page 204: