PROFESSIONAL DEVELOPMENT
Building the best portfolio
for career progression
Craig Nesbitt
James McCaslin
Abstract
This article outlines the author’s recommendations on accomplishing
the best surgical portfolio to support successful career progression.
The key areas covered are research, education, quality improvement,
management skills, leadership development, clinical/operative experi-
ence and external interests. The article is intended to guide trainees
towards a more balanced portfolio and offers hints and tips on how
to enhance the key areas of the portfolio that often go undervalued.
Keywords ARCP; ISCP; Management and leadership; Quality
improvement; Research
Introduction
The portfolio has become the modern equivalent of a curriculum
vitae for a doctor in training. The portfolio is used to collect
appropriate evidence to demonstrate progress, competence and
reflective practice. Surgeons led the way with the development of
the Intercollegiate Surgical Curriculum Programme (ISCP) to
provide an online tool to store appropriate evidence in readiness
for the Annual Review of Competence Progression (ARCP).1
However, maintaining a high-quality portfolio is much more
than a tool to progress through training. It is key to being
shortlisted for higher training numbers or other senior positions.
Maintaining it is crucial to success. Here are our tips to having a
Portfolio which will impress. We have broken it down into six
areas (Figure 1) and will deal with each in turn.
Research
A major area of surgical practice in which can distinguish
yourself from the crowd is the research section of your portfolio.
All surgeons in training are required to have some participation
in research, but the level at which you have participated can be
the difference between getting shortlisted for a job or not. Case
reports or retrospective case series presented at local meetings
certainly have their place. However, publication of those results
will earn additional points for your efforts and should therefore
be the aim of any small project. Try to think of areas where
publication is likely before you start the hard work of data
collection and analysis. Aim for national presentation or publi-
cation from the outset to maximize your reward for the effort you
will need to apply. It is also important to follow through with
Craig Nesbitt MBChB FRCS MD is a Vascular ST8 in the Northern
Deanery, UK. Conflicts of interest: none declared.
James McCaslin MBBS FRCS MD is a Consultant Vascular Surgeon at
the Northern Vascular Unit, Freeman Hospital, Newcastle upon Tyne,
UK. Conflicts of interest: none declared.
SURGERY 36:9
projects and not let them fade into the background when other
activities come along. There are, for instance, open access jour-
nals which look for interesting cases or small cases series (i.e.
Foundation Years Journal, 123Doc) and Royal Colleges will
consider case series publications.
Undertaking a period of formal research, often in pursuit of a
higher degree, is a great way to enhance your portfolio. This can
be done as out of programme experience (i.e. undertaking a
Medical Doctorate during Higher Surgical Training) or by
applying for dedicated research training (i.e. Academic Clinical
Fellow or Academic Clinical Lecturer post). Additional time and
resources mean that research is generally of a better quality and
more likely to lead to (often multiple) publications and national/
international presentation. These all help bolster your portfolio,
but don’t underestimate the value of being in control of your own
time and the management skills this can teach you. These should
be highlighted and evidenced in the portfolio too. Any grants,
awards or prizes you earn along the way need to be highlighted.
Make sure they are understandable to doctors or surgeons
outside your direct interest, e.g. ‘Patey Prize Winner’ in itself
doesn’t put across that this is a national prize awarded by the
Society of Academic and Research Surgery at its annual meeting.
Just being shortlisted for these types of prizes is a distinction in
itself and should also be included.
Writing review articles for publication is another good way of
adding to your academic portfolio. The Cochrane Collaboration
produce structured reviews on defined topics and are a great way
to start off. They offer courses for beginners and support with
things such as literature searches and statistics along the way.
Often there are titles registered and not completed, so editors are
keen to find enthusiastic new authors to take on these dormant
projects. Otherwise, identifying an area of particular interest and
checking the title isn’t already registered is a great start. A word
of caution though; for your first Cochrane review, it is probably
best to avoid a title which has a huge evidence base with hun-
dreds of randomized controlled trials to go though. Choose a
more modest project for your first with perhaps a dozen or so
trials to include. Once you are a seasoned reviewer, then take on
those bigger articles!
We would advise exploring some of the collaborative groups
both in your region and around the country. There are now such
groups in existence for all of the major surgical specialties and
these are excellent ways of ticking the ‘national audit’ box on
your CV. The concept of these collaborates is that the trainee
network is used to collect data from multiple centres, improving
the recruitment to trials and ensuring their generalizability. The
national appendicectomy audit, which involved 95 centres, is a
recent example.2 A list of trainee research collaboratives is
available from the Ideal Collaboration website.3 Trainee research
networks will also participate in collaborative audits. Some
provide limited funding and support to help get research ideas off
the ground, such as ‘Dragon’s den’ style funding rounds at na-
tional meetings.
It is important to understand the UK regulatory framework for
research. Good Clinical Practice (GCP) is the international
ethical, scientific and practical standard to which all clinical
research is conducted. Compliance with GCP provides public
assurance that the rights, safety and wellbeing of research par-
ticipants are protected, and that research data are reliable. If you
478 Ó 2018 Published by Elsevier Ltd.
 PROFESSIONAL DEVELOPMENT

Key areas of a successful portfolio

Research
• Higher degree
• Publications
• Presentations
• Grants/Awards
Education • Prizes
• Degrees
• Examiner
• Exams done Quality Improvement
• Faculty • Audit
• Courses run • Pathways
• Conference
attendance Portfolio

Management and
leadership
External • Committee positions
interests • Organizing courses
• Managing rotas
• Courses attended

Figure 1

wish to be active in research, you should complete this training Before you rotate to your next placement, contact the head of
(NIHR CRN GCP courses are available free of charge to the NHS). the department, express a keen interest to enhance your man-
Compliance with GCP training is mandated for trial Principle agement and leadership skills. There are many roles and posi-
Investigators (PIs).4 tions for trainees that rarely require an onerous commitment.
Offer to co-ordinate the trainee’s rota or organize and present at
Management and leadership their multidisciplinary (MDT) or mortality and morbidity (M&M)
meetings, which will likely already be established.
Leadership and management form an integral component of the
If you have the opportunity, try to attend a root cause analysis
ISCP Professional Behaviours and Leadership qualities of a sur-
(RCA) relating to an unexpected elective death, never event or
geon. As you progress towards your certificate of completion of
another serious clinical incident. Many NHS organizations run
training (CCT) the emphasis on this element of your portfolio
RCA training. Complete a critical incident form, write feedback to
becomes even more pertinent so it is good to make a start early.
a trainee or member of staff that has demonstrated exceptional
At the most basic level link relevant Workplace Based Assess-
practice or behaviour and as ever always reflect upon all of these
ments (WBA) to demonstrate your ability to: lead safe and
activities in your portfolio.
effective handover, maintain and update safe patient lists, and
Being a good manager includes understanding the structure of
your ability to deal with conflict resolution.
the NHS. There are several courses around the country specifically
Look to take on a role of responsibility, such as ‘rota co-
designed for this purpose. Although some are expensive, look
ordinator, explore your chosen specialties trainee societies
carefully as some are still running gratis! Another cheap and
locally and nationally. If your feeling more ambitious some of the
innovative way to enhance this element of your portfolio would be
national surgical training groups such as The Association of
to spend time shadowing managers to gain a broader insight into
Surgeons in Training (www.asit.org) and even the Royal Colleges
their roles; from the bed manager to the theatre matron, this
offer committee positions, but some will require a full-time
experience will enhance your appreciation of the various managers
commitment. Speciality societies may have a trainee group (i.e.
and their roles in the NHS and may also help you identify mean-
Rouleaux club in vascular surgery, Duke’s club in colorectal
ingful ways of improving service. The NHS annual report provides
surgery) and these societies may have representation on their
an overview of current NHS performance and future strategy.
speciality society’s council.

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 PROFESSIONAL DEVELOPMENT

We recommend that you try and attend at least one multi- Teaching
agency conference during your surgical training. The UK surgi-
Explore the option of becoming a tutor, lecturer or examiner for
cal and medical colleges run several such events and many of the
your local medical school. Engage with the universities surgical
independent education, training, safety and human factors con-
societies who are always on the lookout for trainees to support
ferences bring together allied health professionals. These meet-
their various worthwhile educational endeavours.
ings can provide a refreshing look at pertinent issues affecting
The Royal College of Surgeons of England runs a ‘Training the
healthcare.
Trainers Course: Delivering Teaching Skills’ that is suitable for
The NHS Leadership Academy Programmes provide devel-
trainees from Foundation to Speciality level, as well as Consul-
opment for doctors wanting to progress further in management
tants and SAS grades. All surgical colleagues provide the op-
and leadership roles. The Edward Jenner programme is the
portunity to become faculty on courses. There is likely for
foundation course in leadership skills. The launch and founda-
example to be a basic surgical skills course run close to where
tion modules are free to access and available online.
you live. Make contact with the course organizer and ask if you
can observe or participate.
Education
We would strongly encourage you to consider setting up and
Exams are a necessary evil. Some trainees will seemingly breeze running your own course. In 2012 we set up the UK Endovas-
through without drama, whereas others will endure a more tur- cular Trainees (www.ukets.org), our aim was very simple, but
bulent path. The key is endurance and maximizing preparation the idea quickly took off. Try running a taster course for medical
time. Written components are now well supported with written students, or even targeting local high schools; recruitment into
and online material. The clinical and vivas require a different surgical specialties has dwindled over the years and such en-
approach and we advise preparing in small groups for both deavours are likely to be met with enthusiasm by local candi-
practical and psychological support around what can be a very dates and faculty. Overall don’t be afraid to try, the results can be
challenging time. Speak to your programme director; it can be richly rewarding and add that extra level onto your CV and will
beneficial to co-ordinate your exams with quieter placements, score highly in the education section of the portfolio station at
don’t forget a long commute can become a valuable time to interview.
revise with audio podcasts.
Attending courses can be a costly affair,5 obviously some are Health care quality improvement
mandatory but standing out from the crowd requires a little
Clinical audit is obligatory; engage the process as early as you
extra. An educational programme running courses and practical
can in your training. The key to successful audit is to carefully
workshops now accompanies most major national and interna-
select a relevant topic with a clear standard of care where you
tional conferences. With careful planning you can target such
suspect a deficiency lies and for which you already have a pro-
meetings with your abstract submissions e attend, present and
posed plan to improve things. Don’t omit to register your audit
complete a course and kill three birds with one stone!
with your Trusts quality and audit department. Work in groups
Regularly attending conferences is highly recommended. Co-
to collect the data in a timely fashion and work to a pre-planned
ordinate your study leave approach by setting out your study
date for your data presentation. If you’re struggling for a project
leave so as not to impact too greatly on your clinical re-
contact your hospitals audit department, they may have projects
sponsibilities. Ensure you combine local meetings, national and
just waiting to go! Don’t forget a good quality audit can get
international meetings. If you’re clever you can tick the inter-
you national presentation at a surgical meeting as well as a
national box when the meetings are scheduled in the UK thus
local departmental presentation. Most general surgical rotations
cutting down on travel costs. Another tip is to approach local
are 6e12 months and this is not always conducive to completing
company representatives who hold an educational budget and
the audit cycle, yet this is arguably the most important step. Task
might sponsor your attendance.
the re-audit cycle to your incoming colleagues, if you’re very
In years gone by additional degrees were almost mandatory
organized you can perhaps swap projects and thus complete two
for progression in surgery, although this is no longer the case,
audit cycles.
when appropriate we would advocate exploring this option.
Quality improvement is based on evaluating the outcome of
Speciality applications give points for a post-graduate qualifica-
one or more interventions to improve patient outcomes or
tion. There are so many advantages to a higher degree, a chance
experience using an appropriate tool. Unlike clinical audit there
to step away from the rigours of clinical training and firmly
does not need to be an agreed practice standard (Table 1). One
embellish the research and educational components of your
example of change methodology is ‘Lean’ which is derived from
portfolio, not least the opportunity to focus on a new challenge.
a method used by Japanese car manufacturers. This methodol-
We would recommend speaking to those consultants with a
ogy maps out the steps in a clinical pathway and looks to remove
strong track record of success and involve your programme di-
those that are unnecessary and re-design those that result in
rectors early as possible in your decision making, as moving out
delay. The PDSA changes model uses continual improvement,
of programme requires careful and sensitive co-ordination. If full
with small cycles of planning, doing, studying and acting to effect
time research isn’t your thing, you can apply for one of the many
change. These changes methodologies have the advantage over
certificates/diplomas or master’s degrees, which it is possible to
audit cycles of achieving more rapid results.
complete alongside full-time training. Before taking on such
Trainee research collaboratives both in your region and
commitments think carefully about how much time it will take
around the country often support audit and quality improvement
up.
projects in addition to research. One final way of generating audit

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 PROFESSIONAL DEVELOPMENT

Understanding the difference between clinical audit, quality improvement and research
Clinical audit Quality improvement Research
Audit in healthcare is a process used by health Better patient experience and outcomes Research studies are designed to provide
professionals to assess, evaluate and improve achieved through changing provider behaviour information on health or disease.
care of patients in a systematic way. Clinical and organization through using a systematic C Epidemiological
audit measures current practice against a change method and strategies.6 The aim is to C Clinical observational studies and trials
defined (desired) standard. After changes are achieve change more quickly and effectively C Basic science
made the audit is repeated to complete an than by audit cycles.
audit cycle.

Table 1

outcome is to become an audit facilitator. Create a list of simple
audit titles and when you next rotate meet with your juniors,
establish which of them is interested in an audit project and then
give them a clear outline for your project, facilitate any issues
they might have, with any luck you could complete multiple
projects in a short space of time.
Another way of generating quality improvement work is by
formulating and writing guidelines or pathways for your
department (Table 2). These are often delegated to senior
trainees and need to be evidence based, so can take a deal of
work, but are excellent examples of genuine change in practice.
Furthermore, the experience you gain in service development is
invaluable for your career going forwards as these projects will
need to be faced throughout your time as a surgeon.
The Health Foundation and NHS Improvement have co-
founded the ‘Q community’ to bring together people with an
interest in health quality improvement. Their website is a useful
resource before embarking on quality improvement activity
(www.health.org.uk). BMJ Open Quality, part of the BMJ Quality
Improvement Programme, publishes peer reviewed health quality
improvement papers and provides information on healthcare
quality improvement.7
Clinical and operative experience
It is only too common for clinical and operative experience to
consume the surgical trainee. Although arguably one of the most
important attributes of a surgeon, times have changed, and the
focus of training should be to maintain a healthy balance across
all of the spheres we have outlined in this article. The ISCP cur-
riculum provides clear guidance on indicative numbers of key
operations the trainee should achieve.1 We would advise keeping
a personal spread sheet of those operations deemed mandatory for
progression into your chosen specialty, update it regularly and
alert your clinical and education supervisors at the earliest op-
portunity if you feel you are not on track. Negotiate fairly with
your fellow trainees to share out those cases most essential to
your progression, conduct dual trainee operating when feasible
thus maximizing the training opportunity of these key operations.
Operative numbers are only half of the story when it comes to
proving evidence of your competence. There is increasing
recognition that numbers alone do not indicate cognitive and
technical competence. There is an increasing emphasis on the
development of clinical decision making and leadership within
the operative environment. You should consider attending
Deanery or National courses to develop these skills as important
as another day in theatre. Your development as a surgeon should
in addition encompass preparation for surgery, including patient
selection, and postoperative care. Involvement with enhanced
recovery programmes, if in place in your speciality, is one op-
portunity to develop your skills. Simulation training, both tech-
nical and team based, has been referred to already and is another
excellent opportunity to develop your operative skills and gain
experience that can go into your CV and portfolio.
The Postgraduate Medical Education Board (PMETB) and
Modernising Medical Careers (MMC) introduced work-based
assessments (WBAs) for competency assessment.8,9 These were
introduced as part of competency-based approach to training,
aiming to go beyond the simplistic concept of operative numbers.
Within surgical curriculums there are levels of competence
defined for different procedures. Don’t forget to gather the
necessary level 4 work-based assessments (WBA’s) before
reaching the final stages of your training.

Understanding clinical guidelines and clinical pathways

Clinical guidelines
A guideline is a document that recommends how healthcare
professionals should care for people with a specific condition. They
should be based on pre-existing valid guidelines and draw on available
evidence. Their successful implementation requires enthusiasm!
The National Institute for Health and Care Excellence (NICE) provide
evidence-based guidance for the NHS
Clinical pathways
A clinical pathway, also termed (integrated) care pathway or care map is
designed to reduce variation in healthcare delivery, and therefore
improve outcomes. A single clinical pathway might refer to one or more
clinical guidelines
Pathways are multidisciplinary and best suited to patients with a
predictable clinical course (i.e. acute appendicitis or cholecystitis

Table 2

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 PROFESSIONAL DEVELOPMENT
External interests
Vascular surgeon, and former president of the Vascular Society,
Mr Wyatt, is famous for reminding his trainees ‘surgery is a
marathon and not a sprint’. As the age of retirement rises, amidst
proliferating therapeutic surgical options for older more complex
patients with escalating expectations, stress within our high-risk
industry will also intensify. We must future proof ourselves with
a sustainable lifestyle to endure the rigours of our rewarding, but
admittedly stressful profession. Surgeons all need to develop
psychological resilience to cope with a crisis and return quickly.
It is essential that you maintain interests that give you a ‘mental
break’ be it time with friends or family, sport or a hobby.
Having interests away from the operating room is imperative
to maintaining a healthy work life balance. Genuine time and
emphasis should be placed on building a healthy support
network away from hospital. From your hospital intranet you
will find links to joining clubs to suit all variety of interests and
hobbies. If you’re savvy, you can combine such activities with
positions of leadership to further enhance your portfolio.
Conclusion
Your portfolio is your chance to shine and to a certain extent show-
off your progress, abilities and achievements. Use it correctly to give
appraisers, future employers and supervisors a good overview of
your training to date, not forgetting the areas outside of clinical
practice which are so important to life as a consultant. Keep on top
of your portfolio to avoid missing essential detail and making it into
a huge task just before ARCP e it needn’t be! Finally, don’t forget
SURGERY 36:9
that just like medical note keeping e ‘If it’s not written down, it
didn’t happen’. Make sure you record all your hard work in the
portfolio as evidence of your progress. A
REFERENCES
1 https://www.iscp.ac.uk (Accessed 25 June 2018).
2 BJS 2013; 100: 1240.
3 http://www.ideal-collaboration.net/trainee-research-
collaboratives/.
4 https://www.nihr.ac.uk/our-faculty/clinical-research-staff/
learning-and-development/national-directory/good-clinical-
practice/.
5 Jaques H. Junior doctors spend £17 114 on postgraduate training.
BMJ 2011; 343: d6446.
6 Øvretveit J. Does improving quality save money? A review of the
evidence of which improvements to quality reduce costs to health
service providers. London: Health Foundation, 2009.
7 https://bmjopenquality.bmj.com.
8 Lammy S. Core surgical training applications: making the cut. Ann
R Coll Surg Engl (Suppl) 2014; 96: 26e7.
9 Rahbour G, Hogben K. How to succeed in ST3 general surgery
national recruitment. BMJ 2014; 348: g1551.
FURTHER READING
Core surgical training applications: Making the cut8.
How to succeed in ST3 general surgery national recruitment9.
ISCP and JCST (www.jcst.org) websites have some information about
surgical portfolios.
482 Ó 2018 Published by Elsevier Ltd.