Postgraduate doctors typically spend several years in clinical and research roles accruing “points” required for selection into Surgical Education and Training (SET) in Australia and New Zealand. Entry remains highly competitive, with only 34% of applicants successful in 2024 1. Concerns about a bottleneck in surgical training were first formally identified in the 1988 Brennan Report 2, and despite subsequent reforms intended to align with its recommendations, the problem remains unresolved 3. This study was prompted by concern for the welfare and prospects of unaccredited surgical registrars (USRs), a substantial pre-vocational cohort operating outside formal RACS oversight. It aimed to explore their perceptions and experiences of the current pathway into SET. This exploratory study employed a mixed-method approach. A 21-item questionnaire was developed collaboratively with two USRs and refined through consultation with the Postgraduate Medical Council of Victoria, the Australian Medical Association, the Confederation of Postgraduate Medical Education Councils, and urology SET trainers. Demographic items were followed by questions regarding USR experience and an invitation to enter free-text comments. Participants were recruited through snowball sampling via social media from urology, orthopedic, ENT, plastic, and vascular surgery USRs in Australia over 6 months in 2023. Responses were anonymous. Quantitative descriptive analysis was performed using STATA. Free-text comments underwent framework analysis 4, with two researchers independently coding and reconciling themes. Ethics approval was from Eastern Health HREC (QA23-010-94 529). Eighty respondents completed the survey (Table 1). Gender distribution was 50% male, 49% female, and 1% nonbinary, with a median age of 31 years (IQR 29–34). All regions except the Northern Territory were represented. USRs preparing for application to Urology (31%) formed the largest group; vascular surgery (11%) the smallest. Postgraduate year (PGY) ranged from 2 to 13 (median PGY7), with specialty-specific medians ranging from 6 to 8. Eighty-four percent were PGY5 or above and 77% had completed two or more USR years. Forty-four percent held a higher degree; 53% had undertaken at least one full-time research year, and seven had completed three or more. Twenty-three percent relocated interstate for employment. Just over half (51%) had applied to SET at least once, with 10% having ≥ 3 attempts. Ninety-six percent had spent > 5000 on RACS-related courses and exams, and 39% had spent > 20 000. Travel costs followed similar patterns. Costs escalated with each unsuccessful application, with 67% of respondents with expenses > 40 000 having three or more applications. Informal commentary suggested some had accrued > 100 000 in total preparatory costs. Only 36% completed JDOCS. Formal supervisor feedback was rated helpful by 30%, clinical unit support received by 46%, and career guidance received by 60%. Only 4% believed RACS “looked after their interests. ” Forty-four respondents provided free-text comments. Framework analysis revealed three core themes: system issues, personal stressors, and culture (Table 2). No specialty-specific patterns were identified; however, cultural concerns were more common among women. “It seems that there is a serious bottleneck at the point of applying to training—many unaccredited registrars and very few training positions—ultra competitive. Very costly with required courses and exams prior to application with no guarantee of getting onto training—could all be for nothing if you're unsuccessful. ” (M) “Can feel like running a marathon. Then race day comes and you're not sure you can finish. But you try and find you don't have energy left to spare. And you've spent a lot of money and wondering what you've got to show for it. I entered surgical unaccredited training with so much excitement and drive. 5 years later in and I wonder where that all came from in the first place. ” (F) “Have moved yearly for last 5 years, including interstate. Spent > 90 000 and have a logbook comparable to a trainee in terms of primary operating proficiency for some years now. I have strong backing from previous consultant supervisors and yet continue to just fall short of a position. This will be my last allowed year of applying, as I have reached my application limit. The process is broken. ” (F) “Skills that are learnt over many years are nontransferable to any other specialties. Having spent more than 10 years to get myself in a position to apply for (specialty), I find that no other specialty will give me a look in, even for SRMO jobs as they see me as a (specialty) trainee, as such have limited other options. ” (M) “I've been told ‘I would love to give you this opportunity but you're a woman and we both know this place isn't going to like that’. ” (F) Requirement for formal support/guidance From RACS From others Costs associated with training applications Personal Financial This study provides a contemporary account of unaccredited surgical registrars' experiences of surgical training selection in Australia. Many challenges identified decades ago remain unresolved and have intensified. The sustained bottleneck into SET, with only 35% acceptance 1, has entrenched prolonged periods in unaccredited registrar posts as the norm. Despite being PGY5+ and experienced, only half of survey respondents had applied for SET, consistent with a pattern of USRs delaying applications until confident of achieving a competitive CV score, adding to time and cost burdens. The survey captured responses from five of the nine RACS surgical specialties. Four of these have maximum application limits of three or four, while orthopedic surgery has unlimited attempts. This pattern is consistent with the other four RACS surgical specialties, with General surgery having unlimited attempts, and cardio-thoracic, pediatric, and neurosurgery all three or four maximum attempts 5. While there are specific differences in detail there is structural similarity in that all require RACS courses, examinations and specified clinical experience for eligibility, all use a points system to score curriculum vitae items, there is cross-specialty commonality with categories of curriculum vitae items, and there are minimum points required to progress in selection. Currently, only 4% of SET trainees are under 30 years and 51% are 30 to 34 years 1. Increasing postgraduate medical school entry and ongoing delayed SET application are likely to increase trainee age on entry to SET, disproportionately affecting women, minorities, and those with limited financial reserves. The delay to entering SET is regarded as inefficient, with workforce implications of subsequent limited career time as a specialist surgeon 3. Financial burden is substantial. Many incurred costs exceeding 20 000, with some surpassing 100 000. These accumulate before candidates reach an interview, creating socioeconomic barriers and widening inequity. The higher degree rate in our sample of 44%, at significant cost, is higher than previously reported for surgical trainees 6. Females reported greater cultural discomfort and disadvantage, consistent with the literature 7, 8 and published statistics for female representation in applications for SET 1, 9. While the proportion of successful female applicants has incrementally increased by 13% 2014 to 2024, the proportion of female applications has only increased by 4% 1, 9, suggesting that perceived barriers to women considering a career in surgery have not been addressed. Additionally, fear of repercussions was evident among respondents with reluctance to speak out. The relationship of USRs with RACS was found to be complex. Although RACS has no formal jurisdiction over USRs and no current membership category applies, they must nevertheless complete RACS courses and examinations to become competitive. These requirements entail significant expense and contribute to the financial burden and impacts identified in this study. Only 4% felt supported by RACS, and JDOCS uptake was low due to limited perceived utility, consistent with previously published findings 10. Health services rely heavily on USRs, with substantial variation in supervision and training value. Some posts provide valuable exposure; others involve a significant proportion of nights and relieving, with limited senior access or supervision. Many USRs also perform duties equivalent to accredited trainees without corresponding training entitlements, raising potential concerns under “equal pay for equal work” 11. Limitations for this study are acknowledged and include: the true number of USRs nationally is unknown, specialty representation was incomplete, participation voluntary, terminology may be variably understood by USRs, and responses were received from Australian USRs only. USRs form a large and essential part of the surgical workforce but face uncertainty, high financial burden, and limited support. Delayed SET entry disproportionately affects women, older graduates, and those without socioeconomic buffers. Coordinated system-level reform is required, and further research could inform policy and process reform. Caroline R. Dowling: formal analysis, visualization, writing – review and editing, writing – original draft. Ben O'Gorman: formal analysis, visualization, writing – review and editing, writing – original draft. Emily Schembri: statistical analysis. Jenepher Martin: formal analysis, visualization, writing – review and editing, writing – original draft. Shomik Sengupta: writing – review and editing. Open access publishing facilitated by Monash University, as part of the Wiley - Monash University agreement via the Council of Australasian University Librarians. The authors declare no conflicts of interest. The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.
Dowling et al. (Mon,) studied this question.