Ready, SET, go for academic surgery?

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.