Do or do not … there is no ‘try’?

Three trauma and orthopaedic surgeons illustrate through their personal experiences the benefits and pitfalls of postCCT pathways to a consultant position

HAROON REHMAN

ORTHOPAEDIC SURGEON, NATIONAL TREATMENT CENTRE, FIFE ORTHOPAEDICS

There are very good arguments for following the traditional route of obtaining CCT and then working a Fellowship or two prior to beginning consultant practice. Even if you have received exceptional basic and advanced training, a Fellowship is a well-recognised path to take.

Most established and traditional Fellowships will deliver a higher volume of cases than standard training schools. They run like well-oiled machines and, although some of the typical NHS challenges do creep in, they are often mitigated by an enthusiastic training Faculty and staff who appreciate training is part of the culture.

Surgery is a craft specialty. Complex cases require hands-on experience and most decent Fellowship centres will deliver the volume of disease to facilitate future specialist practice. Surgery is also a perishable skill and, in the current dry training environment, Fellowships providing a high-volume, low-complexity workload may also be right for some surgeons.

Fellowship centres are accustomed to supporting the growth of surgeons at this stage of their career. Alternate learning models are often used without the stresses of formal training assessments. Traditional units will provide mentorship and will work hard to develop your professional identity. Opportunities to engage with high-profile experts in your field may not present themselves to you in a similar fashion again.

In this sense Fellowships are invaluable in self development and professional networking, which will go on to benefit your patients, colleagues and trainees. Fellowship trainers are often exceptionally experienced individuals who have influenced surgical practice. Contemporary Fellows are peers who you may turn to if you experience difficulty in your own practice.

The specialist nature of Fellowship centres tends to mean that there are also opportunities to conduct top-level research. This will be of greater appeal to academic surgeons but is also useful in developing your CV for conventional roles.

I recommend Fellowships to surgeons finishing training. For me it was important this year wasn’t simply a repeat of training. My plan in my final years’ training was to develop surgical and decision-making skills in revision hip and knee surgery. Reduced operating opportunities due to COVID-19 limited exposure to this aspect of reconstructive surgery. This period of training can be a struggle socially and financially for a surgeon and their family. Yet any financial sacrifice made during this year can be compensated for quite quickly on starting a consultant post.

Unfortunately, most prestigious Fellowships are known only by word of mouth. I feel it is the duty of the profession to formally assess UK and international Fellowships and set benchmarks. Despite being a strong supporter of Fellowship training, I would add – as one of my mentors said to me – that the real learning does in fact start when you are a consultant.

THOMAS HOWARD CONSULTANT ORTHOPAEDIC SURGEON, NATIONAL TREATMENT CENTRE, FIFE ORTHOPAEDICS

A Fellowship in trauma or in the subspecialist area is usually a ‘desired’ rather than ‘required’ characteristic for the job application. How, then, might attending interview without a Fellowship penalise you, and might there be cases where there is advantage to going without?

I knew where I wanted to work.

I was lucky enough that there was a high-performing department with an excellent team with whom I had worked in my training years – and in the location where my family wanted to settle, the grass is pretty green here. Jobs were being advertised six months prior to my due CCT date. My post was based on a business case for a retiring senior colleague. In the current climate I couldn’t be 100% confident the business case would still exist on my return had I gone on a Fellowship. I have a wife, and young children that need schooling. Another year of travelling and being unsettled might have been good for my CV, but at what detriment to my family? You can obtain a forever job that you desire without a Fellowship – why pay the cost to family, children’s education, reduced salary and the expense of moving an extra time?

If I was not successful at interview, I’d have lost nothing: I would have gained interview experience and could go on a Fellowship at that point. The cost of not going for that interview, however, might emphasise the negatives of a Fellowship if unemployment is lined up afterwards.

A Fellow is an attractive colleague in a department as they have usually secured the job through a competitive application and have the skills to reflect this. They have completed training and can usually be left autonomously at consultant level.

The downside to having a Fellow, however, is the very same reason: they are attractive colleagues, another department may want them, and they may decide to cut their Fellowship short to start a career post.

COVID-19 has had a huge impact on orthopaedic delivery in the NHS. Some units have been affected more than others. Within the same units, elective and trauma work are sometimes disproportionately affected – the benefits of a Fellowship might not be so clear if you end up in a unit where clinical performance has been impacted by the pandemic.

In the end, what do you truly gain?

Is the Fellowship required for private practice? Where did your mentors say they learned the trade? It goes without saying that equipment and techniques used in routine practice aren’t necessarily those learned and used on a Fellowship. Surgeons unanimously agree that real experience is gained on the actual job as a consultant, rather than on a Fellowship.

THERE IS NO ‘TRY’

PHIL WALMSLEY

CONSULTANT ORTHOPAEDIC SURGEON, NATIONAL TREATMENT CENTRE, FIFE ORTHOPAEDICS; CHAIR, SCOTTISH ARTHROPLASTY PROJECT (SAP); ASSOCIATE POSTGRADUATE DEAN (QUALITY LEAD), NES; HONORARY SENIOR LECTURER, UNIVERSITY OF ST ANDREWS MEDICAL SCHOOL

Fellowships after the end of surgical training have become commonplace and might be viewed by some quarters as an orthopaedic ‘gap year’, which misses the original aims of undertaking a Fellowship. The word ‘Fellowship’ means sharing a community of interest, with the motivations and aims of trainees undertaking them naturally varying.

While for some subspecialist areas of practice Fellowships are a prerequisite, the skills required for broad consultant practice should be achieved within a specialist training programme and attainment of CCT.

The choice of whether to undertake a Fellowship will largely be determined by personal circumstances, financial position, career aspirations and opportunity.

Overseas Fellowships are perceived in some quarters to be more prestigious than those within the UK, but this is not necessarily the case. When I’m interviewing a prospective consultant colleague, if they have completed a Fellowship I am less interested by location and more in what knowledge and skills they gained.

It’s worth noting that unnecessary pressure for trainees to undertake a Fellowship isn’t helpful unless there are clear benefits in return for additional burden of doing so and appropriate support is available.

One issue for those seeking a Fellowship post is the lack of benchmarking, raising the question of whether units offering these posts should have regular external reviews of the quality of training provided.

There should now be multiple options for trainees to gain additional experience during the final stages of training. It is important that there is flexibility in how additional training is achieved during the final years of training and the immediate post-CCT period. Advice from mentors, training programme directors, specialty organisations and those who carry out an area of practice are all worth seeking.

I was fortunate to complete two Fellowships at the end of my specialist training: one within the UK and one overseas. While I enjoyed and benefitted from these posts, they wouldn’t automatically be good for every trainee. Fellowships can enhance training, but be clear on the aims and costs of undertaking one, as well as keeping in mind that there are multiple ways in which training could be achieved.