Training to become a neurosurgeon is famously grueling: Years of long days and nights, multi-hour surgeries, and extreme responsibility. But in the UK, a miscalculation in the number of neurosurgery trainees going back years means that, while a six-figure salary is one outcome of all that work, another very real possibility is not getting a job at all.
That’s because there is a large and growing mismatch between the number of brain surgeons in the UK and the number of jobs for consultant neurosurgeons, the highest rank in the UKs National Health Service (NHS).
A 2020 report for the Society of British Neurological Surgeons (SBNS) found over 50 more neurosurgeons would have completed their training than there were full-time consultant posts by the summer of 2020. They predicted that number would keep rising, hitting a peak of 100 in 2029, before starting to decline. There are only 450 consultant neurosurgeons in the UK, a country with a population of 67 million.
Part of the problem is bureaucratic. Legal limits on doctors’ working hours, which were gradually phased in between 1998 and 2009, meant the NHS needed to recruit more doctors to fully staff hospitals. But the number of trainees recruited to each medical specialty is decided, not by the NHS specialty leaders, but by a government department. So while trainees are needed to do the daily work of long shifts, nights, and more routine operations, there isn’t enough money or capacity—support staff or operating theaters, for example—to create consultant posts for them to eventually reach. A June 2021 letter to the profession from the SBNS admitted that those unable to become consultants at the end of their training “may feel abandoned in a jobless wasteland.”
Arnab Ghosh, a neurosurgeon based in London, exemplifies that personal toll of the labor market mismatch. As a senior registrar who has been qualified for 17 years, he’s about to reach the level at which he can apply for consultant jobs, a moment he deferred for as long as possible by attaining a PhD and an extra neurosurgery qualification, because there are almost no jobs to apply for.
The problem, Ghosh explains, isn’t just that doctors feel “entitled” to the higher salary or status of a consultant position. He and others like him crave simple job security, a level of control over schedules, and a quality of life that isn’t possible as a “junior” doctor (the title that applies to everyone below consultant level.)
There is “a covenant when it comes to being a junior doctor, whereby you work your socks off…[and] you’ll not have an easy ride, but at least there’s some light at the end of the tunnel: You’ll have a normal life,” Ghosh said.
Right now, Ghosh says he’s paid for a 48-hour week but tends to work 60, seeing his young children one or two evenings a week, and working one night in eight—a schedule he says is gentle compared to many of his peers. Everyone in his position is essentially waiting for consultants to leave jobs in one of just 30 specialist units in the country. Their ultra-specific qualifications make international moves almost impossible. And given the depth of the obsession needed to get to this point, Ghosh says, most brain surgeons feel unable to move into another field of medicine—which would mean retraining “from scratch”—or to give up and do something else entirely. “It’s disheartening in a way that’s very difficult to explain… you live and breath [it] so entirely for so long,” he said.
A 2021 survey by the British Neurological Trainees’ Association confirmed that while “a large number of trainees felt an element of hopelessness,” very few were considering making a career change, primarily because of passion for, and investment in, their specialty. Once qualified as a doctor, becoming a brain surgeon takes a minimum of eight more years, with 10-12 years not uncommon.
Now, the SBNS has recommended, and the responsible government department temporarily adopted, stricter limits on how many graduates can pick neurosurgery. Many neurosurgeons in the system do additional training, fellowships, or PhDs, giving the job market some time to adjust. The SBNS letter even suggests that consultants cut back on pay or work, and that trainees think very hard about whether to switch tracks.
The 2020 pandemic, meanwhile, exacerbated the problem, delaying “non-essential” surgeries. Despite working for years, neurological trainees aren’t getting enough experience of complex surgeries.
The irony of the situation isn’t lost on doctors. The NHS is still undersupplied with the staff it needs, and Ghosh said all rotas have gaps compared to when he started, when that was very rare. But the surgeons who have yet to achieve consultant status are working what many would call unsustainably long hours, doing punishing night shifts, are on short-term contracts, or are constantly moving city in a way that’s incompatible with family life.
There are structural issues at play: The NHS, though an incredibly popular institution, is chronically underfunded, bureaucratic, and increasingly hard to run. But within that, maybe the balance of work between junior doctors and consultants needs a fundamental rethink.
There are also lessons relevant beyond UK medicine: The “reward” of a “normal life” shouldn’t be something doctors, or anyone else, works for 20 years to attain.