Emily Newton-Dunn
Carving out a surgical niche that works for everyone
“If you want to stay somewhere, explore whether you can find a niche to step into. It’s no different to a consultant developing a sub-specialism. Look at the needs of the department you want to stay in and sell yourself to fill that gap.”
Miss Emily Newton-Dunne advocates the approach she took after stepping off the training pathway in plastic surgery. After a period as a locum, she became a locally employed (LE) ‘Trust Grade’ doctor in the plastic surgery department at the University Hospitals Plymouth NHS Trust. She went on to take a position as a Specialty Doctor and, in 2022, became a Specialist Doctor in Plastic Surgery, with an interest in skin cancer. Emily says: “The specialist doctor role is about having quite a narrow field. There was a desperate need around skin cancer in the South West, as the numbers of cases were shooting up. I work with dermatologists and with plastic surgeons. I run clinics, I operate, and I still can refer bigger things on to the consultants.”
Emily observes that some of the SAS doctors who are most satisfied with their careers have, like her, stepped into a niche field. This includes a SAS doctor in obstetrics and gynaecology with a special interest in fertility. “You’ve got to make yourself employable,” says Emily.
She had spent several years in training as a specialty registrar in plastic surgery in Plymouth. She had just returned from maternity leave when she was informed that in order to complete her training, her next rotation would be in Bristol. Emily did not want to leave Plymouth: her husband was a specialist doctor in the emergency department there, and she did not want to leave her young child. She decided to leave the training pathway and relinquished her training number.
Initially, Emily took locum jobs in plastic surgery and in the emergency department. Once her son started school, she wanted more regular hours and became a trust doctor, before being offered a specialty doctor contract. “I was lucky that when I wanted to do it, there was a desperate need for someone, and I could fill the slot. My manager said the income generated from the skin cancer activity would easily pay my salary uplift.”
Specialist expertise
In August 2022, Emily became a specialist doctor in plastic surgery. Like a consultant surgeon, Emily runs her own clinics, the patients she sees are under her care, and she has the same Supporting Professional Activities (SPA) time. She sees 40 to 60 new cases each week and is as able as her consultant colleagues when it comes to assessing skin lesions. “They actually ask me for advice, which is really nice…I think that comes from having such a niche area. The plastic surgeons do hand trauma and breast reconstruction, so they’ve got such a wide area in which they’ve got to keep their skills up.”
As far as patients are concerned, they are seeing a specialist in skin cancer. “I usually just say I’m one of the plastic surgery doctors because I think it’s very confusing to explain the different grades to patients,” says Emily.
Unlike her consultant colleagues, she does not currently have her own general anaesthetic theatre list; there are some procedures that she does not undertake, and she does not participate in the on-call rota. Emily recalls being asked by a senior surgeon why she did not wish to become a consultant or apply for CESR. “I’m happy to go home at the end of the day. I’m happy with what I do. I know what I’m doing is interesting,” responded Emily. “We need to get away from the idea that SAS doctors have not made it.”
Within the plastic surgery team, Emily is treated the same as the consultant surgeons. “I get invited to consultant meetings. I am really included.” She is aware that SAS doctors are not always integrated in this way. “Someone doing my job at another centre in the region doesn’t get invited to consultant meetings,” says Emily.
“I’ve had a lot of people say they are quite jealous of my job, because I haven’t had to move around, I’ve got a job that I like doing, and it fits with other aspects of my life”.
Supportive working environment
Emily describes the trust as a supportive environment for its approximately 90 SAS doctors. Consultants and directors are said to be familiar with having a cadre of highly skilled doctors who are not consultants. It also reflects efforts by SAS doctors to improve their terms and conditions. “I think it’s a really supportive environment, but I think people have fought for it to be like that,” says Emily.
The trust has a SAS Committee, chaired by an associate specialist, and SAS Tutor. There are plans in the pipeline to appoint a SAS Advocate. Dr Jamie Read, the first SAS Dean of a medical school, is a Plymouth SAS alumnus. Prior to the COVID-19 pandemic, SAS doctors met regularly as a group and efforts are underway to reinvigorate this.
Emily emphasises the need for SAS doctors to engage across the trust: “If they don’t engage, then we won’t get the support of the organisation.” She also acknowledges that the approach to SAS doctors can vary according to the specialty and that most are on the registrar rota, not the consultant rota. Many of the SAS doctors at Plymouth are female and Emily observes that many have become specialty doctors at a younger age than she did. She believes they should have access to a surgical mentor when they first start, who can also help them to foster connections with other SAS surgeons.
Emily’s career journey
“SAS doctors will be around longer than trainees. Departments can train them up, know what they’re good at and what they are capable of”.
Changing the mindset
“I’m trying to think about the ways in the trust to actually promote the SAS route,” says Ms Jolita Zakaraite, consultant plastic surgeon and service line director for plastic surgery. Jolita has worked with Emily since they were trust grade registrars together. She came to the UK having completed her training abroad and became a consultant in 2014.
“Emily was very well regarded, very well liked in the department, but she was still doing a registrar-type job where she wasn’t independent in what she did…I felt like she wasn’t being used to her potential, from a service perspective,” says Jolita. “It’s a waste of resources having somebody with Emily’s experience in a consultant clinic doing the same work as someone who’s been trained for two years, when we have a massive gap in consultant workload.”
Jolita advocates the benefits of SAS posts in enabling doctors to develop as specialists within a defined field, without “the administrative hassles of a consultant.” She says: “It’s usually a narrow area because you have to go through the whole training pathway to have a broad practice.”
Jolita emphasises that it must be the right person: “I knew Emily was very conscientious and that she would ask questions if she was unsure.” For the first six months, Jolita was the named consultant for patients seen by Emily. After this time, patients came under Emily’s name, she ran her clinics independently, operated independently, and all activity was coded to her. “I honestly wouldn’t mind doing what Emily did. I constantly tell my manager that we will be looking out for people interested in skin cancer surgery because there is an extreme shortage of provision. It’s an area which easily could be picked up by SAS surgeons and doctors,” says Jolita. The kind of people she is looking out for are “surgically minded but who don’t want to go into very complex surgery.”
Jolita observes a change in the priorities of some doctors coming through training, with a greater reluctance to move geographical areas for rotations and more emphasis on achieving work-life balance. There are eight registrars in the plastic surgery department – four with a training number and four without. Over the last year, the department has introduced changes so that all registrars attend a quarterly interview to discuss their specific training needs, which the department tries to accommodate. Two of the registrars have decided not to apply for a training number because they do not wish to move their families, preferring to stay within the unit and apply for CESR instead. Jolita suspects quite a few would opt for SAS roles if these were promoted. Presently it is something of a step into the unknown, whereas the national training route is well established.
Jolita would like to develop an alternative pathway, where after foundation and core training, doctors could potentially choose to become a SAS doctor, supported by the trust, and become more senior and independent with time. “We get quite a few trainees who don’t really want to go through all the national training. I’m thinking maybe in the trust we should have a SAS route for these doctors… not everyone has to become a consultant” says Jolita.
In the meantime, Emily is a case study for the potential. “She’s excelled,” says Jolita and points out that Emily also undertakes teaching, consultant appraisals, mentoring and other leadership activities. Jolita says: “It doesn’t have to limit you: you can do training; you can be a coach and a mentor; you can do everything that everyone else does.”
What NHS organisations need to do
- Be open to drawing on the skills of SAS doctors: “SAS doctors need to push for opportunities, but organisations have to be open to how they will use the skills of these doctors,” says Emily. If the organisation has an SAS Committee, like Plymouth, it can help to facilitate development of this workforce.
- Increase awareness of SAS contracts: “Greater understanding amongst consultants and clinical leads of the potential of the specialist doctor contract (designed to replace the associate specialist) should increase these positions. Clinical leads should consider the advantages for their department of offering specialty doctor contracts to LE doctors or long-term locums.
Advice on identifying your niche
Emily’s tips for SAS or LE doctors wanting to get ahead within their unit:
- Be proactive: identify a gap that needs filling within your department and consider how you might fill it.
- Be prepared to push: let colleagues know what it is you’re interested in doing. “Let them know that you’re enthusiastic, and that you want to keep doing certain things and would like to do more of others.”
- Get past the stigma: don’t allow yourself to be diverted by any suggestion that you’ve chosen a second-rate career path – because you haven’t.
- Be persistent: if you meet the criteria for a specialty or specialist doctor role, be prepared to negotiate for this.
- Expect access to training opportunities: “you have to take the view that you are equal to trainees and take training opportunities without upsetting the department,” says Emily.
- Be reliable: demonstrate you are committed to your work and opportunities should follow.
- Speak with consultants: “If you want to stay in the department long-term, speak with consultants you get on with, to see how you could develop into a niche. The more it becomes a general conversation, the easier it is for consultants to train you up to fill that niche.”
- Appraisal: Use your annual appraisal as an opportunity to discuss your goals and identify the support you need to achieve them. Take that aspect of your appraisal into job planning discussions.
