MRCS Examination Research Articles

Can MRCS exam performance predict surgical specialty destination?

INTRODUCTION Successful completion of the MRCS examination is mandatory for surgical trainees in the UK. The MRCS is attempted early in surgical training, before applying for competitive entry to specialty training posts. The aim of this study was to establish whether MRCS performance can predict future surgical specialty destination and whether those who perform well at the exam enter more competitive specialties. METHODS UK candidates who attempted the MRCS examination between 2007 and 2020 were matched to career outcomes data using the General Medical Council database (n=2,910). Specialty competition ratios were calculated from national recruitment between 2017 and 2019. Chi-squared tests determined associations with first-attempt MRCS performance. Multinomial regression models were developed to establish whether MRCS results can predict surgical specialty destination. RESULTS There was a statistically significant association between MRCS Part A first-attempt pass rates and training specialty (p=0.001) but not for Part B (p=0.655). Candidates who passed Part A at the first attempt were more likely to enter neurosurgical training (odds ratio [OR]: 1.75, 95% confidence interval [CI]: 1.18–2.61), cardiothoracic training (OR: 2.25, 95% CI: 1.30–3.90), plastic surgery training (OR: 1.75, 95% CI: 1.20–2.56), paediatric surgery training (OR: 2.01, 95% CI: 1.10–3.67) and general surgical training (OR: 1.48, 95% CI: 1.18–1.86) than trauma and orthopaedic training. MRCS Part B performance was not an independent predictor of surgical specialty. CONCLUSIONS Trainees who perform well at MRCS Part A are more likely to enter more competitive specialties. Further work is required to investigate the relationships between this finding, specialty application and selection patterns, and what surgical trainees value in their career decision making.

SP2.2.15MRCS performance predicts surgical career outcomes

Abstract Aims Successful completion of the MRCS examination is mandatory for progression into higher surgical (registrar) training in the UK. National selection for training programmes is a highly competitive process. Despite this, the ranking of applicants does not currently include MRCS performance scores. This offers a unique opportunity to compare two independent assessments of surgical trainees to establish whether MRCS performance can predict future surgical career outcomes and competitiveness in training. Methods All UK candidates who attempted MRCS between 2007-2020 were matched to career outcome data using the GMC list of registered medical practitioners and anonymised (n = 2910). Chi-squared tests determined associations with first attempt MRCS pass/fail outcomes. Multinomial regression models were developed to establish the predictive power of success at MRCS in determining surgical specialty and training deanery choices. Results There was statistically significant variability in MRCS Part A pass rates, ranging from 55.1%-76.7% between surgical specialties (P = 0.001) but no significant variability in Part B pass rates (P = 0.655). There was significant variability in Part A and Part B pass rates between training deaneries (P = 0.010 and P = 0.036 respectively). Pass rates ranged from 59.9%-77.7% for Part A and 70.1%-85.0% for Part B between training deaneries. Those in more competitive specialties and training deaneries performed better in MRCS in terms of first attempt pass rate, scores and number of attempts taken to pass. Conclusion MRCS performance is an early predictor of surgical career choice and competitiveness. Trainees who perform well at MRCS are more likely to enter competitive surgical specialties and training deaneries.

238 MRCS Performance Predicts Surgical Career Outcomes

Abstract Aim Successful completion of the MRCS examination is mandatory for progression into higher surgical (registrar) training in the UK. National selection for training programmes is a highly competitive process. Despite this, the ranking of applicants does not currently include MRCS performance scores. This offers a unique opportunity to compare two independent assessments of surgical trainees to establish whether MRCS performance can predict future surgical career outcomes and competitiveness in training. Method All UK candidates who attempted MRCS between 2007-2020 were matched to career outcome data using the GMC list of registered medical practitioners and anonymised (n = 2910). Chi-squared tests determined associations with first attempt MRCS pass/fail outcomes. Multinomial regression models were developed to establish the predictive power of success at MRCS in determining surgical specialty and training deanery choices. Results There was statistically significant variability in MRCS Part A pass rates, ranging from 55.1%-76.7% between surgical specialties (P=0.001) but no significant variability in Part B pass rates (P=0.655). There was significant variability in Part A and Part B pass rates between training deaneries (P=0.010 and P=0.036 respectively). Pass rates ranged from 59.9%-77.7% for Part A and 70.1%-85.0% for Part B between training deaneries. Those in more competitive specialties and training deaneries performed better in MRCS in terms of first attempt pass rate, scores and number of attempts taken to pass. Conclusions MRCS performance is an early predictor of surgical career choice and competitiveness. Trainees who perform well at MRCS are more likely to enter competitive surgical specialties and training deaneries.

354 Differential Attainment in Surgical Training

Abstract Introduction Differential attainment (DA), according to the General Medical Council (GMC), is the gap between attainment levels in different groups. Attainment measures should cover aspects that include academic performance and career progression. Two such areas in surgical training are the MRCS examinations and ARCPs, both of which are required for progression in a career in surgery. Our aim was to investigation whether socio-economic background was a significant factor for progression in surgical training. Method Data from the GMC for Core Surgical Trainees (CSTs) taking the MRCS examination between 2016 and 2019 and CST ARCP outcomes between 2017 and 2019 were obtained. Socio-economic background was assessed using the Index of Multiple Deprivation (IMD). ARCP and MRCS outcomes were assessed against IMD. Results Trainees from IMD Q1&2 (most deprived) had a significantly higher (p < 0.01) mean number of attempts (1.86) to pass MRCS examinations than trainees from IMD Q4&5 (least deprived) (1.54). IMD Q1&2 were significantly more likely to obtain unsatisfactory outcomes (24.4%) than trainees from IMD Q4&5 (14.2%) (p < 0.05). Conclusions There is clear evidence that differential attainment exists within Core Surgical Training. The reasons for this are likely to be complex and more work is needed to further investigate the relationship.

COVID-19 and anatomy: Stimulus and initial response.

The outbreak of COVID-19, resulting from widespread transmission of the SARS-CoV-2 virus, represents one of the foremost current challenges to societies across the globe, with few areas of life remaining untouched. Here, we detail the immediate impact that COVID-19 has had on the teaching and practice of anatomy, providing specific examples of the varied responses from several UK, Irish and German universities and medical schools. Alongside significant issues for, and suspension of, body donation programmes, the widespread closure of university campuses has led to challenges in delivering anatomy education via online methods, a particular problem for a practical, experience-based subject such as anatomy. We discuss the short-term consequences of COVID-19 for body donation programmes and anatomical education, and highlight issues and challenges that will need to be addressed in the medium to long term in order to restore anatomy education and practice throughout the world.

Last's Anatomy: Regional and Applied, 11th Edn

Last's Anatomy: Regional and Applied has long been a favourite with senior medical students and junior doctors studying for the MRCS examination. Most anatomy textbooks take the form of either large reference tomes or short books aimed at rapid pre-examination cramming. In contrast, Last's Anatomy is both comprehensive enough to satisfy postgraduate surgical expectations, and sufficiently focused to make it a realistic exam revision tool. Since its first appearance in 1954, Last's Anatomy has benefited from a relatively low turnover of single editors, all fellows of The Royal College of Surgeons of England. To this extent, the text has succeeded in staying true to its aims of providing a comprehensive, surgically oriented content, logically delivered and clinically relevant. In an academic climate, where anatomy is playing a progressively decreasing role, it is re-assuring to note that the content has remained descriptive and the format rigorously structured. For example, muscle groups continue to have clearly stated origins, insertions, actions, nerves and tests, whilst the course of blood vessels and nerves is fully described. The ‘Surgical Approach’ subsections add clinical relevance to the text by focusing on the anatomical basis of surgical practice (e.g. abdominal incisions on page 240 or Kocher's manoeuvre on page 279). These serve to bridge the gap between basic science and operative anatomy. Most chapters also contain sections on development, which provides a good basic science background for postgraduate surgical exams. Anatomy is par excellence a visual subject. An anatomy textbook with poor illustrations has been likened to a surgeon with poor hands – informative but of little practical relevance. The 11th edition represents a major step forward in the book's evolution. All the images have been coloured, a large number of clinical pictures have been added and new artwork has been used to enrich the text of past editions. Previously, complex images, such as the otic and pterygopalatine ganglia (page 354, 10th edn) have gained remarkable clarity in this edition (page 377) and illustrates the great benefit colour has brought to the visual appeal of the book. Similarly, new clinical photographs manage to integrate concepts of surgical anatomy, pathology and clinical relevance. One example is the identification of the parotid duct. This is achieved by depicting a malignant bloody discharge in a patient with a parotid duct tumour – a potent and memorable image. Also, new radiographic images add further clarity and meaning to the text (e.g. inferior mesenteric arteriogram on page 255). It is important to note, however, that with the exception of certain changes, the actual text of the book has remained very similar to that of the 10th edition even though its layout has been improved. In summary, Last's Anatomy is one of the only remaining descriptive surgically oriented anatomy texts. Its 11th edition has greatly added clarity due to the new colour scheme and updated images. Consequently, it will continue to be popular not only with postgraduates studying for the MRCS examinations but also with all those who appreciate the importance of sound anatomical knowledge in clinical practice.

Fundamentals of Surgical Practice (2nd edn)

The prospect of reviewing a text aimed at addressing the MRCS syllabus and examination has brought back many nightmares of the time I spent preparing to sit the examination myself. However, I have recently been asked by F2 and junior SHOs to recommend a text that they can use to prepare for the MRCS but have struggled to find one that addresses all of the issues in a relevant manner while providing enough depth. There are many texts available in the marketplace that are aimed at being study aids or texts to provide in-depth information of surgical practice, pathology, or anatomy. Few of these, though, truly focus on providing enough detailed information on all of the relevant topics for examination success. This book represents the new and expanded edition of a text addressing the first stages of the intercollegiate MRCS examination. It aims to mirror the examination syllabus and present trainees with a clear understanding of the core information required for success. It is edited by Professor Andrew Kingsnorth and Professor Aljafri A Majid, who are representatives of the Court of Examiners of The Royal College of Surgeons of England and panel of examiners of the Royal College of Surgeons of Edinburgh, respectively. Together they bring a wealth of publishing and examining experience in order to co-ordinate the contributions from many well-respected and extremely experienced chapter authors in a formal manner. The structure of the book takes the trainee through a variety of chapters covering all of the core issues required for the intercollegiate MRCS examination, with the emphasis being on addressing issues on a system-by-system basis with clearly defined goals for each chapter. Each chapter contains a wealth of information relating to relevant anatomy and individual clinical conditions. The information presented on clinical conditions covers essential epidemiology, clinical pathology, and clinical management. The delivery of the information is in the vast majority of chapters through large swathes of text. While it is appreciated that in certain circumstances this is unavoidable, the lack of use of tables or schematics makes the information difficult to digest. Certain chapters such as that on hernia management and vascular surgery make good use of illustrations, images and bulleted text to accentuate the written information. However, this is balanced by many chapters that are difficult to read due to the volume of text within them. The information presented in the chapters is detailed and accurate, covering a huge amount of ground but the style in which the information is presented often makes it difficult to extract. The provision of further and online reading resources at the end of each chapter is a useful pointer as to where to search for further information when more depth is required. The aim of this book to cover the core topics for the MRCS is achieved; however, I feel that the information could be aided in its delivery by reducing the amount of text within the chapters. Furthermore, we must also decide whether this is a book to aid in the preparation for the MCQ components of the examination or the viva and clinical components. The detail in the chapters may not provide enough information for this book to be used as a sole text for the MCQ components of the MRCS but I feel it is a valuable addition to the available texts as it provides a substantial proportion of the information required and acts as an accurate guide to the topics to be covered in exam preparation. I would have no hesitation in recommending this book to trainees at an early stage of their training in order to guide them effectively to the core syllabus topics and since it provides a substantial portion of the detail required for the MRCS. I would, however, advise that the trainee may require further detailed reading prior to sitting the MCQ components.

Distance Learning Improves Attainment of Professional Milestones in the Early Years of Surgical Training

To assess the impact of a surgical sciences e-learning programme in supporting the academic development of surgical trainees during their preparation for professional examination. In 2007, a 3-year online part-time Master of Surgical Sciences (MSc) degree programme was launched, utilizing an innovative platform with virtual case scenarios based on common surgical conditions addressed by the curriculum relating to the Membership Examination of the Royal Colleges of Surgeons (MRCS). Multiple-choice questions with feedback and discussion boards facilitated by expert clinical tutors provided formative assessment. Summative assessment comprised written examination at the end of each of the first 2 years (equivalent to MRCS level), culminating in submission of a research dissertation in year 3 toward an MSc. Students' age, gender, and level at entry to the programme were documented. Anonymized student feedback from 2008 to 2012 was examined using online questionnaires, and performance in the MSc programme was compared to MRCS examination outcomes for students who had consented to release of their results. A total of 517 surgical trainees from 40 countries were recruited over the 6-year period, and 116 MSc students have graduated to date. Of 368 students, 279 (76%) were foundation doctors (interns) and had not commenced formal surgical training on enrolling in the MSc programme. However, level at entry did not influence performance (P > 0.05 across all 3 years). Average pass rates since the programme launched, for those students completing all of the required assessments, were 84% ± 11% in year 1, 85% ± 10% in year 2, and 88% ± 7% in year 3 of the MSc programme. MSc students had significantly higher MRCS pass rates than nonenrolled trainees (67% vs 51%, P < 0.01, n = 352). There was a significant correlation between MRCS examination performance and overall performance in the MSc (R = 58%; P < 0.01, n = 37). Of 248 respondents, 202 (81%) considered that the MSc would improve their chances of gaining a surgical training post, and 224 (90%) would recommend the programme to their peers. The online MSc programme supports academic development of trainees in the early years of surgical training, is well received by students, and is associated with improved success in their professional examination.

Last’s anatomy: regional and applied, 12th edn

Last’s Anatomy was first published in 1954 and quickly became the mainstay for candidates studying for the primary FRCS examination. Today, it remains a mainstay for MRCS examination candidates. The author uses his vast experience of teaching anatomy to surgical trainees to ensure that the content is relevant to the clinical situation. The text is crisply written, packing a lot of information into as small an amount of text as possible, making the book both comprehensive and concise. In the 12th edition, the text has been reviewed and the anatomy of surgical procedures updated, especially in the light of the increase of laparoscopic surgery and minimal access procedures. New illustrations have been added depicting anatomy of clinical and endoscopic relevance, together with photographs of prosections. The only issue I have with this book relates to the illustrations. Some of the clinical illustrations are far from clear (eg Fig 2.18, Fig 5.59). There is also a lack of consistency in labelling of the computed tomography (CT) and magnetic resonance imaging (MRI). Some are not labelled (eg Fig 4.11, Fig 5.44), some have structures numbered directly on the image with the numbers referenced in the legends (eg Fig 5.39), while others are labelled clearly and appropriately with lead lines indicating the structures (eg Fig 4.17). There is also a problem with some of the x-rays. Fig 3.22 is of poor quality and unlabelled whereas Fig 3.39 is clear and labelled appropriately. However, the majority of illustrations in the book are clear and well labelled. It would have been appropriate to see some CT or MRI of the head, neck and spine in Chapter 6. The author states in the preface that the book will be of value to medical students, surgical trainees and practising surgeons. It will certainly continue to be extremely popular with surgical trainees studying for the MRCS and I would thoroughly recommend it to them. With curricular reforms, I am not certain that it will necessarily be a book of first choice for medical students although there is much in it for the motivated undergraduate who thirsts for knowledge.

The trainee-led MRCS mock OSCE: a useful and inexpensive adjunct in exam preparation

The new MRCS examination was introduced in October 2008. One major change was the integration of viva voce, clinical and communication skills components into the Part B objective structured clinical examination (OSCE). This was partly in response to changes to surgical training resulting in 'earlier specialisation [and] less exposure to the range of surgical specialties'.

Preparing for the MRCS examination: a simple guide

Preparing for the MRCS examination: a simple guide

Regional variations in surgical examination performance across the UK: is there a postcode lottery in training?

The restrictions placed on training opportunities mean that good-quality teaching is of paramount importance to the modern surgical trainee. The authors of this month's article have constructed a league table of training regions based on success rates of candidates sitting the MRCS examination. They acknowledge that pass rate at examination is only one surrogate measure of training standards and that an objective assessment and ranking of rotations would need to take into account several other factors. Nevertheless, a relatively large variation in performance is evident, which highlights the need for more comprehensive, transparent assessments of the quality of training delivered.

OSCEs for the MRCS Part B

This book is written by registrars and aimed at trainees undertaking their MRCS exam. The MRCS examination has changed from short cases to OSCEs over the past couple of years and this book brings the trainees up to date with the process and expectations of the examination process. The book is divided into seven sections, relevant to the sections of the examinations including communication skills. Some sections refer to full-text reading within Bailey and Love, linking with the surgical textbook where further depth of knowledge may be required. As a revision book, the sections are laid out as bullet points, which may be useful in the run-up to the exam; however, the typeface and layout make the book rather difficult to read. Each page is made up of too many bullet points rather than any readable sections. The photographs are adequate but black and white, which limits their use. The diagrams are adequate and more useful. The information is good but the book is let down by its layout and presentation.

Applied basic surgical sciences for the IMRCS OSCE course

The Intercollegiate Basic Surgical Examinations Committee (representing the three royal colleges of surgeons in the United Kingdom) has recently made a very significant change to the format of the intercollegiate membership of the Royal College of Surgeons (IMRCS) examination. Parts 1 and 2 (applied basic sciences and clinical problem solving), which comprised the written component of the old format, have now been replaced by part A, which is made up of two papers—applied basic sciences and clinical surgery—to be done at the same sitting. The candidate is required to pass both papers individually and at the same sitting. Part 3 of the old format (comprising three separate components: oral examination followed by the clinicals and communication skills) has been replaced by the new part B objective structured clinical examination (OSCE). Although part 3 of the old MRCS examination is still available for those who have passed their written components under the old system, it is being phased out and will cease altogether in the autumn of 2010. In conforming to the altered format of the new examination, candidates will need to adopt a different approach when studying and preparing for the part B OSCE exams from that which might have been appropriate to the old part …

The new-style MRCS clinical exam: a candidate perspective

2008 saw the formulation of the new intercollegiate MRCS examination. The biggest change saw the old structured interview, best known as the 'viva,' and separate clinical exam scrapped and combined into an objective structured clinical examination (OSCE), the new part B. On successful completion of this examination you gain membership of the Royal College of Surgeons. Unlike the old system every candidate is allowed four attempts at passing the examination irrespective of time elapsed from successful completion of part A; however, if you are unlucky with your fourth attempt you are never able to enter any part of the MRCS examination again.

The new MRCS: changes from 2008

In the 1990s the MRCS examination succeeded the original FRCS examination because of changes in surgical training. Since then several factors have caused the surgical royal colleges to review the MRCS: the introduction of run-through and core surgical training instead of basic surgical training (BST); earlier specialisation; less exposure to the range of surgical specialties; and the development of the Intercollegiate Surgical Curriculum Programme (ISCP).

MRCS Picture Questions: Book 1

Preparing for an examination is not only a question of having a suitable knowledge bank but also involves having some experience and rehearsal in answering questions and organising knowledge. This book, which is the first of a series, provides that experience in the form of a picture quiz; although primarily aimed at the MRCS examination, it would be a suitable basis for anyone studying surgery including undergraduates. It is divided into five sections: lumps and bumps, upper gastrointestinal with hepatobiliary and pancreatic surgery, vascular, head and neck, and neurosurgery. Each section has a series of clinical pictures focused around a topic together with a list of questions similar to those encountered in the MRCS examination. The answers are provided on the other side of the page. The breadth of questions is such that, while this would not be a substitute for a standard text, it does nevertheless provide a very comprehensive overview of most topics, which acts as a checklist to the main features with a prompt to the salient points. As the authors point out, with changes in junior hours and working practice it may prove difficult for trainees to see every condition, particularly the more obscure ones. This book fills that gap very well and reminds trainees of their existence and importance. It would be a useful purchase for both surgical trainees and undergraduates. There is little one can fault in it.

Get Through MRCS: Anatomy Vivas

Simon Overstall's revision aid, Get Through MRCS: Anatomy Vivas, is aimed at candidates preparing for the oral section of the intercollegiate MRCS examination. It is part of the renowned Get Through series of books published by the Royal Society of Medicine Press. Although the author is a registrar in plastic surgery in Australia, he recently obtained the MRCS and appreciates that the anatomy examination is often the most feared component of the viva voce examination for this qualification. It focuses purely on the anatomy component of the oral examination by covering the head and neck, upper and lower limbs, thorax, abdomen and pelvis and the back. It contains specimen questions based on actual anatomy orals, using colour photographs of prosections, diagrams, X-rays and scans and is supplemented with model answers and explanations to aid the learning process. It also provides some useful advice on how to behave during the oral examination. This book will instil more confidence in the candidate who is preparing to tackle the anatomy oral. This superb book is highly recommended to those candidates preparing for the intercollegiate MRCS diploma. It skilfully fulfils the need for a book dedicated to the anatomy oral.

The eSTEP™ Website: A Good Model for Online Surgical Training?

eSTEPTM: http://www.rcseng.ac.uk/education/estep/home_html BeST online: https://www.intumed.com/ Online learning is not a new concept and this is certainly true in surgery. With online textbooks, basic skills videos and interactive tutorials, the World Wide Web should be the surgical trainees’ oyster. Yet few of these resources are comprehensive enough or of sufficient quality to be the ideal surgical training tool. Perhaps recognising this deficit, The Royal College of Surgeons of England (RCSE) launched eSTEPTM in 2001 – a comprehensive online learning resource aimed at surgical trainees. eSTEPTM complements the printed modules in the Surgeons in Training Education Programme (STEPTM), a distance learning programme introduced in 1994. STEPTM is firmly aimed at the surgical trainee working towards the MRCS examinations. A wide breadth of information is presented on the eSTEPTM website including case discussions, anatomy teaching videos, GMED Limited’s ‘Multimedia Course in Minor Surgery’, self-test questions and discussion boards – much of what the surgical trainee is seeking online. The website is quick, convenient to access and easy-to-navigate, if a little bland. The study modules are divided into 12 components reflecting the STEPTM printed modules – six core modules covering areas common to all branches of surgery and six system-specific modules – with each containing a variable number of case studies and multiple choice questions. The case studies are well written and are illustrated using realistic examples from every-day practise. A large compilation of clinical cases is supplemented on a weekly basis and explores the study modules in depth. Trainees are encouraged to participate in online discussion – commenting, answering questions and clarifying areas of uncertainty – facilitated by an online moderator. Thought-provoking exchanges result, promoting self-directed learning rather than the classical ‘spoon-feeding’ mode of knowledge acquisition. Some cases are supplemented with convenient anatomical videos – useful given the limited anatomy teaching resources available to postgraduate trainees. The minor surgery course uses images, videos and animation to prepare the surgical trainee embarking on their first minor operations list. A large bank of multiple choice and extended matching questions are of good quality and are written in a format similar to the MRCS examination making them suitable for exam preparation. So far, eSTEPTM sounds like the answer to a surgical trainee’s prayer – a high-quality learning resource aimed at supporting the trainee through their early surgical training years and their MRCS examinations – what more could a trainee ask for? If so, why are all trainees not subscribing to STEPTM so they can make use of the eSTEPTM website? One potential reason is financial – £1370 (or £1420 via direct debit) for a 24-month subscription will seem pretty hefty to the average junior surgical trainee. Subscription is limited to one option (24 months) which some will find restrictive. Many may only wish to use certain aspects of the website, while some will complete the MRCS examinations in less than 24 months – more flexible subscription periods would certainly be attractive. It is important to bear in mind that subscription includes the 12 STEPTM printed modules, 24-months’ access to the eSTEPTM website, 24-months’ subscription to the Surgery journal, discounts on books and RCSE courses, access to a College Day which includes an introduction to eSTEPTM, an overview of the Intercollegiate doi 10.1308/003588408X301190

The eSTEP™ Website: A Response

As the STEP™ Tutor, I would like to thank Kaur and Harrison for their review of a component of The Royal College of Surgeons of England (RCSE) – Surgeons in Training Education Programme (STEP™), and also take this opportunity to clarify the development of this programme. STEP™ was initially launched in 1994 as a distance learning programme for surgical trainees. This was revised in 1997 (STEP™ MRCS CsiG version) and once again in 2000 to keep up to date with the requirements of the MRCS examination. We are revising this again to reflect the new surgical training and Intercollegiate Surgical Curriculum Project (ISCP) . The key change in the 2000 edition of STEP™ was the introduction of the eSTEP™ website; this was introduced to complement the printed version of STEP™ and provide a ‘blended’ learning programme. This allowed the principles expounded by the STEP™ team of W Ribbans, M Larvin and J Masih – namely that the programme would have a greater emphasis on self-directed work by trainees, there would be a larger component of interactivity with less didactic teaching and also introduce a community function for the distance learning programme. By 2005, STEP™ had been taken up by 7500 trainees in the UK; however, it was also clear that there were going to be some major changes in training with the introduction of the Foundation years ( ) and the surgical curriculum. The STEP™ team at the RCSE have undertaken an extensive market research (Larvin M, Haine L, Kamal T. STEP™ survey: what trainees want from a distance learning programme. Bull R Soc Surg Engl 2006; 88: 230–1) of the trainees' requirements and also reviewed the surgical curriculum as it was being developed. Several issues have been identified: The majority of trainees responded that they still wanted printed material as a resource although the material required revision in content and presentation. The eSTEP™ website was also integrated closely with STEP™ hence achieving a true ‘blended’ learning resource. The team are also aware that technology has changed dramatically since the early eSTEP™ site was developed. From the first item above, the survey demonstrates that trainees prefer a blended learning approach where they can learn didactic material from printed material and can take self-assessments online. Unlike BeST Online (Basic electronic Surgical Training) which is wholly online, STEP™ combines printed modules with online support via the eSTEP™ website and also provides additional benefits including: (i) Surgery journal subscription (24 months); (ii) discounts on textbooks via Blackwell's online bookshop; (iii) an event at the RCSE (STEP™ College Day); and (iv) discounts on the RCSE's Intercollegiate MRCS examination preparatory courses. Bearing in mind the results of the survey, the team is actively involved in producing a new edition of STEP™ (including an updated version of the eSTEP™ website) for release later in 2008. STEP™ will provide the surgical trainee with a distance learning resource combining the didactic elements as well as a complementary interactive website. The latter will allow peer-led discussions as well as a conduit for rapid responses to changes in the surgical trainees' environment. With this programme, the surgical trainee will have access to an up-to-date resource that will be responsive to the inevitable changes in surgical training. Computers are incredibly fast, accurate, and stupid. Human beings are incredibly slow, inaccurate, and brilliant. Together they are powerful beyond imagination. Albert Einstein, 1879–1955