Mr Husam Ebied describes himself as happy in his career as a consultant surgeon in benign Biliary Gastrointestinal (GI) and emergency surgery at Guy’s and St Thomas’ NHS Foundation Trust. However, his journey to reach this position was by no means easy.

Husam was always clear that he wanted to become a consultant surgeon, and he persevered for nearly a decade in NHS jobs to achieve this ambition (see Husam’s career pathway). Having qualified in Egypt and with seven years of surgical training under his belt, Husam began working in the NHS in 2007.

He was too senior to apply for training, so he turned his attention instead to applying for a Certificate of Eligibility for Specialist Registration (CESR).

Husam took a range of short-term contracts (lasting six to twelve months) as a locally employed (LE) surgeon. This included being a clinical attaché, a night fellow (working night shifts entirely), and several trust registrar positions. His determination to demonstrate the experience needed to meet the CESR requirements led Husam to undertake 15 different surgical posts in all.

Some posts were more valuable than others in contributing to his CESR journey. “There’s no way you can guarantee how much you will benefit from those six or twelve months. It’s unpredictable, unprotected, and you need to be very hard working and in the right place, at the right time, with the right people,” Husam says.

There were times when Husam was hesitant about moving on from a post, but he was determined to achieve the experience required to support his CESR application. For example, Husam described North Cumbria University Hospitals NHS Trust as having a “super ethos and very supportive” when he worked there for a year as a trust Registrar in vascular and colorectal surgery. He was reluctant to leave but needed more operating to support his skills development.

CESR application

Nothing about the CESR application route was easy. Husam had no support from a Director of Medical Education or from a tutor. He never had a formal educational supervisor, although some consultants were very supportive, and he was able to attend a CESR preparation course run by Guy’s and St Thomas’ Trust.

Husam emphasises the patience and tenacity required of anyone applying for CESR, which involves a great deal of box ticking and asking colleagues to sign his logbook. It also involved working long hours and taking posts hundreds of miles away from his family. Husam worked many Saturdays and relied on his wife to look after their two children. For a time, he only saw his family at weekends as he worked at a hospital in another region during the week. Husam believes this career path may not be achievable for doctors working less than full time or with family commitments, and says he was only able to undertake it “because my wife was very supportive.”

Husam also emphasises the need to have realistic expectations of the process and the time it takes. He submitted his application in June 2020 but it was in January 2022 that Husam was awarded a CESR. He advises any doctor considering the process to consider what they will gain. Being a senior SAS doctor is “a very valuable post”, he says, without the added stresses of being a consultant. “It depends on what you’re trying to achieve and your own idea of success. For me, it was being a consultant, as the career progression and opportunity to expand my wings is much greater,” says Husam.

Trust culture

“The key thing a SAS doctor needs is to be in an environment that can help them to evolve and progress. As a non-trainee you are often looked at as someone who is doing the stuff that others don’t want to do. This needs to change, which means changing the culture of the trust,” says Husam.

His journey gave him experiences across a range of trusts in England, from small hospitals in rural areas to specialist city centre teaching units, and different cultures with respect to the value attached to SAS and LE doctors. Some surgical colleagues supported his ambition by helping him to develop the skills he needed in specific areas. He described one consultant colorectal surgeon at The Royal London Hospital as “super supportive”.

Not all his experiences were so positive. Husam described surgical and nursing staff in some units as unsupportive and unkind, and he encountered racism. In many of the units, preference was given to doctors in training and there was no structured training, professional or career development for SAS or LE doctors.

These experiences gave Husam a keen sense of the culture and working environment he wanted to be part of. He found this at Guy’s and St Thomas’ NHS Foundation Trust, in 2013, when he joined as a clinical fellow in upper GI and endocrine surgery. He started on a six-month contract but stayed for two and a half years. “This was the best time of my career. I had enough surgical experience, so I focused on working on myself to get a consultant job.” He describes receiving “massive support” from his surgical colleagues, in terms of operating, teaching, helping to get his portfolio ready, evaluating his surgical skills, and finding a consultant post. “They’ve given me amazing support. They invested in me and in return, I did work very hard, developed my skills, and contributed to different aspects of service and training,” he says.

Making the job his own

After this contract ended Husam began work as a locum consultant at another London trust. Keen to get back to Guy’s and St Thomas’, he kept in contact with the team there. When a consultant emergency surgeon position came up, Husam went for it, even though it did not reflect his upper GI specialty interest. He knew the trust had the culture, colleagues and working environment he sought. After two years, he moved to a hybrid role reflecting the trust’s need for more elective activity to be undertaken. He now provides less emergency work and more elective surgery. While he does not undertake upper GI cancer work, he does a lot of benign biliary work, which he enjoys. He is one of the founding members of the trust’s advanced abdominal reconstruction and advanced hernia practice.

Katie Adams, Clinical Lead for GI surgery and consultant colorectal and emergency general surgeon, describes Husam as “patient-focused and great on-call, very approachable and hard working.” She emphasises his willingness to pick up extra lists, as well as his commitment to developing his “high-efficiency skills” – Husam’s high-intensity lists were covered by the BBC, says Katie. She says: “He moved from being an emergency surgeon as a locum to being a locum upper GI surgeon, to being a substantive upper GI surgeon – so that’s three steps. He’s had to go through three consultant interviews and it’s really rare that someone goes from being an emergency surgeon to a specialty surgeon.” By developing a sub-specialism – open abdominal wall reconstruction – Husam has an area of specialised work and has developed a team to support this. “He’s really receptive to taking opportunities that come his way and runs with it,” says Katie.

Simon Atkinson, consultant pancreaticobiliary surgeon and general surgeon, similarly emphasises Husam’s work ethic and personal characteristics. “Husam does the work, he’s supportive and good at it. He does research and he certainly contributes to the running of the NHS service aspect and he’s doing extra work,” he says. He advises trusts to set clear expectations at the outset when offering doctors senior clinical fellow contracts, with emphasis on the time-limited nature of these jobs.

Department support for LE doctors

Regarding the working environment, Katie describes the department as having a flat hierarchy, comprised of consultants, training registrars and clinical fellows, and senior house officers. Katie says that the department does not distinguish between trainees and those who are not part of the national training programme. “It’s about the value of each person,” she says. “Overall for a surgical department we are quite inclusive and we do try and break down some of those old hierarchies.”

Many of the clinical fellows have qualified abroad and some are already on the specialist register or post CCT. Every clinical fellow has a named consultant. Some undertake independent practice; others are not suited to this. Many leave the unit for consultant jobs or return to positions abroad. Katie sits down with each clinical fellow when they first start to ask what their goal is and what they need to achieve it. Most want to become a consultant.

The trust runs a CESR webinar and group sessions, and staff are experienced both at completing the paperwork and accommodating training on operating lists to meet CESR requirements.

Advice on working towards CESR

Husam’s tips for SAS or LE doctors wanting to apply for CESR:

• Be clear with yourself, and others, whether you want to go down this path. “Don’t waste time deliberating over whether to go for it. Decide and have a clear plan,” says Husam.
• Spend time looking at the GMC guidance for doctors on applying for CESR.
• Talk to someone who has been through the pathway recently.
• Don’t be scared of asking for what you need to support your CESR application, or of moving out of your comfort zone.
• Think through the practicalities of gathering evidence – “I used two laptops to do this and got through many printers. My competencies were signed off on paper and had to be scanned, uploaded and filed,” says Husam.
• Plan for the costs. Husam spent £4,500 on training courses and exams, including ATLS (Advanced Trauma Life Support) and courses in leadership and research.
• Be prepared for the timeframe – once you open an application with the GMC you have 12 months to submit your evidence. Once your application is submitted, it can take between three and six months to process. It goes through initial checks before being assigned to an adviser, who highlights any additional evidence needed to strengthen the application. Samples of evidence go through a verification process, before the application is finalised. It is then evaluated by the relevant royal college, faculty or associate, and a recommendation is made to the GMC. The final decision rests with the GMC. For Husam, the whole process took approximately 18 months.
• Use the waiting time well. Husam knew when he submitted his evidence that he was light on publications, so worked on achieving two extra papers whilst waiting to hear back from the GMC adviser.
• Try not to destroy your work-life balance through the process!