The Intercollegiate Membership of Royal College of Surgeons (MRCS) examination is considered a key ‘gatekeeper’ to the surgical profession in the UK, as passing the examination remains a prerequisite for entry to higher specialty training (HST) [1]. MRCS examination fees are expensive, creating a barrier to progression in surgical careers for many aspiring trainees [2]. However the additional hidden costs of this mandatory gatekeeping assessment remain largely unknown. In order for surgical training to be equitable and accessible to all, it is vital that the socioeconomic impact of this examination is investigated.

There are already a number of well-documented barriers for trainees into surgery but financial burden is often cited as one of the key limiting factors to entering specialty training [3]. It is known that individuals from low socioeconomic group backgrounds were less likely to choose a career in surgery [4] and this group also had significantly lower pass rates at MRCS exams [5].

MRCS examination fees currently totals £1625 (£578 for Part A and £1047 for Part B or ENT OSCE (Objective Structed Clinical Examination)) [6]. One report estimated the mean cost of reaching the minimum essential criteria for entry into HST to be £3,360 [7], which is 19%, 52% and 41% higher than medicine, anaesthetics and acute care common stem respectively [7]. Moreover a surgical trainee will spend an estimated £4185 on exams alone by the end of training [8]. These figures are, however, a gross underestimation as they do not factor in the other hidden costs of sitting high-stakes assessments such as study resources and revision courses. In addition, this examination is taken early in a surgeon's career, therefore these costs are likely significant in comparison to the salaries of newly-qualified doctors.

We hypothesised that in order to pay for examination fees and study resources, early-career surgeons would have to routinely undertake shifts in addition to their rostered hours. If so, this would greatly add to the burden faced by trainees who are already experiencing increasing levels of work-related burnout. One systematic review suggests burnout affects up to 80.5% of clinicians [9], a sentiment of which is echoed by a recent GMC survey [10]. This inevitably leads to job dissatisfaction, lower productivity, attrition, and ultimately worse patient care.

To address this important gap in the literature, this study aims to quantify the burden of the MRCS examination on a cohort of surgical trainees by establishing its financial impact on trainees’ lives. Furthermore, this study aims to identify whether there is an association between money spent on revision resources and the likelihood of success at the examination to better inform the actions of prospective examination candidates and future study budget policies.