U.S. Scholar Ryan Ellis Visits the Royal College of Surgeons in Ireland

Many of the problems faced in surgical training, from trainee burnout to managing modern duty hour restrictions, are shared across the world. Efforts to foster international collaboration and exchange of ideas can facilitate more rapid and robust development of solutions. I was honored to be selected as the 2018 American College of Surgeons exchange fellow to the Royal College of Surgeons in Ireland (RCSI), where over a one-week visit I was tasked with learning about the Irish surgical training paradigm. While this was a daunting task for a short visit, the RCSI organized a thoughtful itinerary to maximize my time, including exposure to clinicians, trainees, and leaders in Irish surgical training. The visit culminated with the Millin Meeting, an annual conference focused on Irish surgical education named after the famous Irish urologist Terence Millin. Overall, I was able to gain an appreciation for both the differences and similarities between the two training systems.

Differences between the American and Irish training schemes are primarily structural. All surgical training in the country is performed directly by the RCSI, a stark contrast to the hundreds of independent training programs in the U.S. Premedical training contains two tracks—a six-year program beginning immediately after secondary school, and a four-year postgraduate program that closely resembles the American medical school paradigm. Following medical school, trainees spend two years that most closely resemble non-designated preliminary years in the United States. During that time trainees rotate heavily on both medical and surgical services, with opportunities to perform electives in their preferred surgical specialty. There is subsequently a competitive application into a four-year general training program. After general training, two additional training years similar to American fellowships are performed prior to independent practice. A significant number of Irish trainees subsequently spend additional years abroad in either Europe or North America to gain additional seasoning prior to embarking on a career as an independent surgeon.

Irish geography also leads to another major difference in training. The Republic of Ireland contains approximately 4.5 million people (similar to the greater San Francisco metropolitan area) with populations concentrated in Dublin in the East and Galway in the West. The rest of the island, which is about the size of the state of Indiana, has relatively sparse population. Because there is only one surgical training program in the country, trainees are free and often required to move about the island during training. Rotations are relatively long, and a change in rotation often means moving from one location to another. The same trainee may do part of their training in nearly every region of the country, gaining experience to both urban and rural medicine as well as cultural differences present throughout Ireland.

Despite the structural differences in training, what was most striking on my visit was how similar the issues faced in Irish surgical training are to those in the United States. Ireland, like America, sometimes struggles to appropriately staff rural hospitals, while pressures to regionalize complex surgical care have eroded the scope of practice for more rural surgeon. Trainee duty hour restrictions, in the form of the European Union Working Time Directive, have limited trainees to no more than 48 hours per week. Despite duty hour changes, significant concern about attrition and burnout in Irish trainees persist. Multiple lectures during Millin Day were dedicated to changes being made to the Irish system to maintain training integrity and optimize resident wellness in the modern surgical training environment. There were hours-long periods during the Millin Day conference when I could have easily been convinced that the topics being discussed were about our own training system in America, further cementing the role of increased international collaboration in addressing our common issues.

I am grateful to the American College of Surgeons for allowing me to participate in this program, and especially to the Royal College of Surgeons in Ireland for their hospitality and incredible introduction to their training system. The RCSI is truly a world leader in tackling the challenges of modern surgical training, and has demonstrated both flexibility and foresight in making changes to their training paradigm. I hope to use the experience and relationships made during the trip to foster continued dialogue and collaboration as both the United States and Ireland work towards improving modern surgical training.