Urological Fellowships – the unwritten but almost essential step to a future specialist consultant practice?
Preamble:
Training in urology in the UK, and indeed globally has seen significant changes in the last decade. This has mirrored the changing face of health care provision within and outside the NHS. For award of a Certificate of Completion of Training (CCT), the Joint Committee on Surgical Training (JCST) has recommended specific guideline criteria for different specialties, including urology. The current structure of urological training in the UK has evolved to prepare a trainee by the completion of training at bare minimum for a general urologist. However, depending on the training environment, trainers and trainee enthusiasm with an early focus of interest, many trainees achieve more than just this bare minimum by way of modular training, especially in their final years of training. Some will carry on with acquisition of specialist skills as junior consultants, but increasingly trainees are opting to go for fellowships in their area of specialist interest. This is almost becoming an unwritten essential step for getting a plum specialist post.
When to start?
Those trainees with a special interest in a particular area (and wish to pursue this after CCT) should start the thought process by the end of second year, and their initial groundwork to identify suitable fellowships by third year. Why the rush? Simple reason: the application time to the start of some fellowships typically lags by a year or more. For example, many North American institutional fellowships have application submission deadlines in January, followed by interviews in February-May, for a fellowship that will start in July the following year (18 month lag!). This rush is even more important if the fellowship is intended to be undertaken prior to end of training as an ‘out of programme experience’ or ‘out of programme training’, as the rules have recently changed as of April 2013 where some Local Education and Training Boards (LETBs), previously called ‘Deaneries’, under the Health Education England will not allow OOPE or OOPT in the final year of training. Refer to www.gmc-uk.org and www.hee.nhs.uk for more details on OOPT and OOPE.
When to go on fellowship?
The options are either doing your fellowship before completing training as an OOPE / OOPT or going on a post-CCT fellowship. When to go depends on your individual interest, personal circumstances, fellowship criteria, your choice and importantly the support of your programme director and local surgical training committee. The advantage of an OOPE/OOPT fellowship before CCT is that when you come back, you have your registrar job and salary to come back to. You also don’t lose your grace period at the end of CCT. The disadvantage is that you may come back specialised and ready for a consultant job, but since you haven’t yet completed your full training, you could miss some good job opportunities while you go back to being a registrar for a year. The advantage of a post-CCT fellowship is that you can start looking for jobs during your fellowship and ideally walk into a consultant (or locum consultant) job, but this requires diligently keeping in touch while you are away. The disadvantage is that you may not have anything to come back to, and you lose your grace period. Either way, it’s a gamble.
Where to go?
Traditionally, the two most popular destinations for fellowships are USA and Australia. Emerging spots include Canada, Europe and home-based UK fellowships. Each place has its pros and cons. Australian fellowships, usually for a year, are supposedly good hands-on experience with a fantastic salary package, proportional to frequency of calls. However they grossly lack research and formal learning opportunities. American and Canadian fellowships are usually 2 years with a year of research and a year of clinical/operative work. The research exposure as well as publishing, critical appraisal and exposure to knowledge is fantastic. For US fellowships, trainees have to sit the USMLE and be ECFMG certified. Canadian fellowships are becoming popular with British trainees as holding the FRCS (Urol) suffices, and there is no need to sit any other exams. They also offer a fine mix of research opportunities and hands-on operative experience. For oncology fellowships, visit www.suonet.org. Good financial planning is crucial, especially for North American fellowships.
Jaimin Bhatt
University of Toronto Health Network, Princess Margaret Hospital, Toronto, Canada
Post-CCT SUO Fellow in Urologic Oncology. Completed his urological training in the Oxford deanery (now called Health Education Thames Valley)
This is an excellent blog which throws the gauntlet down to trainees in the UK. To go abroad to train in a urological specialty, or to stay here in the UK? That is the question. Let’s hear some views from those who did, and those who did not. This is a great forum for debate on a key question which can materially effect your career.
Fellowships are interesting, because in the states, we have 2 types of applicants. One type is well trained, and desires to polish their skills in a specialty field. This type of fellow is very successful. Another type of fellow has been passed up in the system, despite technical deficiencies, and is sent to fellowship to correct them. That is too late. How can we objectively assess our trainees and isn’t that always prone to debate?
Sadly, the overseas fellowship is becoming a rarer event for Australian trainees. With a compulsory local fellowship and a much tighter consultant employment environment, we are seeing less of our own go abroad and bring back new skills. So much is to be gained by going abroad. Most of the procedures I currently perform were learned in the UK, but more importantly I had experiences and gained friendships I would have otherwise missed out on. Three years away completely changed my outlook on the specialty and got me out of the local “bubble”. One of the best things I ever did. Thanks to all at Lister and Guys.
A fellowship can be truly life changing. I wanted to learn a specific skill – namely robotic prostatectomy. I chose to go to Tony Costello in Melbourne Australia and gained huge exposure to the procedure such that I was fully proficient when I came home.
However, the fellowship was much more than that. I learnt about living and working in a different country, the pros and cons of a different health care system. I was given the opportunity to manage clinical scenarios independently while still having extensive support to call on if required. This made the transition from being a registrar to being a consultant much easier when I came back home. In addition, I made some fantastic friendships which I hope will be lifelong.
Choosing where to go and arranging the fellowship place early on is essential however as the best fellowships are oversubscribed.
All in all it was a great life experience which I would highly recommend to everyone nearing the end of their training.
My fellowship with Prof Tony Costello in Melbourne was the best professional and personal year of my life.
I learnt new skills making me ready for consultant life in a way not currently offered in many UK centres. I learnt the good and bad points of another healthcare system. I learnt independence in emergency operating and how to run a service.
Additionally I became part of a fellowship family who will be my friends for life and got involved in academic and research projects which are still ongoing.
If I were to interview a consultant candidate I would be impressed by a fellowship on their CV and actively target employing these people.
An an American who did a fellowship overseas, I found it a valuable experience. I chose fellowship for the purpose of learning a new skill (robotic prostatectomy). I accomplished this and much more. The fellowship year was a great way to consolidate my skills as a urologist and learn additional techniques. I also developed lifelong friendships. It was one of the best decisions that I made.
(I hope that puts me into the first category described by Bhayani above)
[I worked with Prof. Tony Costello in Melbourne, Australia 2009-10]
As a Belgian urology trainee, I’m currently doing a one-year overseas fellowship with Prof. Tony Costello in Melbourne. This year is accredited as part of my urology training in Belgium (comparable to OOPT in UK).
The exposure to a different healthcare system and training culture has been a fantastic experience so far. I’m getting the opportunity to improve my surgical skills (good hands-on training attitude in Australia), learn specific techniques (robotic surgery) and take part in clinical research. This year’s experience has strongly influenced my clinical decision-making and even more my training attitude. Therefore this fellowship will not only be a valuable training year per se, but will also be beneficial for my future (final) year of training in Belgium.
The great working atmosphere, the warm community and the fantastic city of Melbourne (explaining the popularity of the Melbourne fellowship in this blog?) have made this fellowship an enormous pleasure and enrichment for my family and myself.
I strongly recommend a year of overseas training to all my fellow trainees, and I’m happy this fellowship year isn’t over yet!
I took a Fellowship year at Peter MacCallum Cancer Centre under Declan Murphy with a focus on Robotic and complex pelvic oncology. An overseas Fellowship has a number of benefits. For one, practices that may be taught as dogma in one environment may be better appreciated as idiosyncrasy when observed from a different environment. Fellowship jobs that have a relatively narrow focus and high volume of work provide the surgeon returning to a largely generalist job a wealth of experience that is impossible to acquire in a generalist position. As Fellowships are usually at academic centres, there is often casual access to prominent figures in the specialty, and a culture of hard work, creativity, and clear thinking. This happens in the context of knowing there is a limited time in the environment, creating a drive to “make hay while the sun shines”. There is also a fascinating variation in beer styles between countries. Increasingly, there are barriers to Fellowships. Some institutions, and indeed medical boards have become increasingly protectionist. Surgery has become more consultant driven over fears of inefficiency and litigation. Trainees may fear losing a future job if they leave their home environment for even a year. Perhaps the solution is an international Fellowship board to drive creation and maintenance of jobs, support trainees through the licensing process, and present the lasting value of Fellowship training.
I went from the Irish to the Australian healthcare systems to do my fellowship and I am currently working in Edinburgh. Irish trainees are expected to go abroad for fellowship training at the end of their SpR training scheme with equal numbers going to North America, UK, mainland Europe and Australia. I pursued a fellowship in Australia and this proved to be an excellent choice from a professional and family perspective.
The main strength of my fellowship was that I gained very subspecialised skills including robotics without deskilling in other areas. On the contrary I up-skilled using newer technologies and developing new techniques such as flexible urterorenoscopy, GLL prostatectomy, lap partial tran and retro nephrectomy and transperineal template biopsies. The focus in choosing a fellowship should be on the operating.
After reading the above comments I feel I should reiterate the overwhelming opinion of those urologist who have been lucky enough to spend a post CCT fellowship year abroad – it is an invaluable experience and has kick started many successful consultant careers particularly here in the UK. Furthermore it is a testament to the Melbourne fellowship program that it is responsible for training a considerable number of robotic surgeons currently working here in the UK. Many of us have had the privilege to go on to disseminate the skills we learnt during our fellowship program, training our colleagues back at home. We repay our gratitude to Tony and Declan by continuing to train the next generation of urologist.
I also had the opportunity to work with Professor Costello and Declan Murphy. Having trained in the US, this was an amazing opportunity to not only to learn and improve on robotics and laparoscopy but also a chance to practice medicine in a completely different healthcare system. If one can see the differences between technique and management between different surgeons at the same hospital and compare that with differences between surgeons at different hospitals, imagine the difference between those in different countries.
The other huge value of fellowship for me was the opportunity to meet the international “giants” of urology. The chance to meet with these urologists during meetings and hear their perspectives was fantastic.
Finally, as others have mentioned, the friendships and contacts you develop during this time made this one of the best decisions I’ve ever made (not only because I met my wife in Australia).
In Singapore, all urologists go abroad for fellowship training prior to assuming consultant positions. This gives every department a very global viewpoint, with everyone contributing their experiences in various centers of excellence.
I have benefited greatly under the tutelage of Tony and Declan, gaining not only technical expertise but clinical wisdom. The exposure to a different healthcare system and culture certainly broadens ones horizons, and makes me a better clinician.
There is no doubt that Fellowship-trained surgeons have a huge advantage compared to others when competing for consultant positions. It is not just the specialist skills which are acquired, but the experience and maturity which a post-training specialist year (preferably in another country), confers upon those who choose to pursue such positions. Fellowship-trained surgeons stand out during interviews for substantive positions when compared to their peers who have not had the same experience – they look different/walk different/talk different, and they invariably prevail over are those who have not been away from their training rotation.
However, there are challenges in undertaking these types of positions. There are social and family challenges in uprooting and moving to a new environment for a year (but this can also be a wonderful aspect of such a year); positions are often not well remunerated (if at all); licensing and visa paperwork is tedious etc. Also, with increasing competition for such places, it is often very difficult to secure a good Fellowship position. For the Melbourne Uro-oncology Training Program, myself and Prof Tony Costello receive over 200 applications per year and typically have confirmed positions 3 to 4 years in advance.
My tips for success are first,to plan far in advance – 3 to 4 years minimum for the best Fellowships. Second, use personal contacts if at all possible to express an interest in a particular program. Your existing trainers/mentors will often have connections to various big centres and this is very important in opening doors. Third, keep your CV ticking over with publications and presentations. These do not have to be of Nobel prize-winning standard but you must be able to demonstrate productivity. Fourth, ensure your clinical and operative competencies are on track. We typically confirm candidates when they are relatively early on in their training on the assumption that they will be asked an appropriate level when they start their Fellowship training. However it is less important for us to know that you are already an accomplished surgeon, and more important for us to know you have basic skills, good clinical sense, and most importantly, that we will get on with you during your time with us. Personality counts.
Finally, pick a location and program which is likely to be a happy place for you and your family to spend a year. As mentioned previously, it is not so much the technical skills acquired, but the overall experience and maturity of a Fellowship year which creates the value to make you more competitive and a better doctor.
The BAUS Office of Education (and Sections) are currently working on revising the subspeciality training curricula to make them fit for purpose. I have been working in consultation with many colleagues on the 3 oncology curricula, comprising pelvic (prostate and bladder) cancer, upper tract with testis cancers and penile cancer. These fellowships should be undertaken in “approved” UK centres, they should run for 12 months minimum and recommend a minimum surgical experience for each relevant procedure either as principal surgeon or surgeon under supervision. I believe the UK can provide trainees with the necessary experience, although I would never dissuade a trainee from seeking this in the right place overseas.
I am currently half way through my fellowship year in Melbourne under the tutelage of Prof Costello and Declan Murphy. This has has been a fantastic experience both from a professional and personal standpoint. I trained in the US at Penn and came to Melbourne to advance my robotic skills. Most trainees in the States spend all of their urology years at one institution. Gaining an outside perspective on how to manage patients and practice urology is an invaluable experience which has been practice changing for myself. In addition, exposure to a completely different healthcare system as well as urologists from around the world has further advanced and refined the way I view certain aspects of urology. My training here as a robotic surgeon has been exceptional. However, I feel fortunate that my training as a Urologist has continued to advance as well. The opportunity to manage complex patients in a public health system has further allowed me to hone my intraoperative and clinical decision making skills as I prepare to start my future practice. I feel very fortunate to have had the opportunity to spend this year in Melbourne and would highly recommend a fellowship year abroad to any trainee.
M currently working as urology specialist in Qatar
I did my Ms urology from pakistan in 2008
M interested to do any urology fellowship programme
Can some body guide and help me in that regard
Myself currently working as a second year urology resident in india. I have done my MBBS and ms from india. For getting a fellowship in australia how should i prepare? and what kind of exams? Can someone guide me about this
As a urologist trained in Nigeria I was opportuned to be in Singapore General Hosp under the tutelage of Prof Chris Chen and Mr Tan.
It was a wonderful oppurtunity, learning new skills which I largely did not do during my training. I made wonderful friends and the skills I learnt significantly transformed my practice back home. I strongly recommend this for any post CCT fellow
I had great opportunity working with Prof. Tony Costello, Justin Peters, Peter Mortensen, Gerry Joyce, Damien Bolton, and Jeremy Goad as a fellow in urology in Australia at St. Vincent”s Hospital Melbourne. The Fellowship program was still in its infancy, but the knowledge, skill and the attitude that you acquired had a great impact in my professional career when i came back to the Philippines. It was one of the best personal and professional years of my life. It is the best opportunity to develop lifelong friendship with this guys.More power to Prof Tony Costello, Declan Murphy and his staff. Many thanks for the wonderful opportunity