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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)

 

Fellowships – a key ingredient or the ‘icing on the cake’?

What is the ultimate endpoint of a residency or speciality training program? Is it to complete 5 or 6 years of training in core urological procedures? Is it to produce safe, competent independent urologists? Is it to achieve FRSC (Urol) certification? In an ideal world it would be a marriage of all three; a safe, competent, independent, certified, practising urologist ready and eager to tackle any urological referral. In reality, we know that not to be the case.

Urology is a broad and advancing speciality encompassing patients of all ages and both sexes involving a complexity of benign and malignant pathologies. It is unrealistic to be an expert in all the sub-specialties and be able to offer the best and least invasive treatments to our patients. Furthermore, with a necessary emphasis on patient safety, transparency and proficiency, surgical training programs face significant barriers in affording trainees the opportunity to operate, specifically in the working time directive era.

Fellowships are usually undertaken at the completion of higher surgical training scheme often in a centre of excellence overseas. Fellowships offer trainees intensive experience in their niche area. On completion of a coveted fellowship, trainees hope to have acquired and polished the required skills to practice independently in their chosen field.

A recent pan European survey of 219 urological residents demonstrated laparoscopy and robotics were available in 74% and 17% of centres respectively [1]. Only 23% of trainees report their exposure as ‘satisfactory’. 68% have not completed a laparoscopic radical nephrectomy as first operator. Despite this 81% are considering fellowships in laparoscopy.

Buffi et al., have called for a validated and structured training curriculum in robotic surgery [2]. Trainees acknowledge the challenges in the acquisition of such skills but the modularisation of training is the best way to learn a procedure. Step by step trainees can piece together the operations. Hours spent on simulators and in dry and wet laboratories enhances these techniques. Furthermore, the dual consoles offer invaluable experience in robotics, however, are scarcely available.

The governing bodies have a responsibility to maintain standards of training as well as a duty towards patients. Proficiency in modern techniques such as laparoscopy and robotics are deficient in most training programs. Training programs need to encompass these techniques in a modular fashion from an early stage to develop the skills of tomorrows’ urologists [3]. Fellowships will undoubtedly foster and enhance these skills but a core knowledge and technical proficiency even in a simulator setting should be encouraged.

In truth, our learning and development never should never stop.

‘Live as if you were to die tomorrow. Learn as if you were to live forever’ Mahatma Gandhi

Mr Gregory Nason is a Specialist Registrar in Urology at the University Hospital Limerick, Ireland

References

  1. Furriel FTG, Laguna MP, Figueiredo AJ, Nunes PT, Rassweiler JJ. Training of European urology residents in laparoscopy: results of a pan-European survey. BJU Int 2013; 112: 1223–28.
  2. Buffi N, Van Der Poel H, Guazzoni G,  Mottrie A, on behalf of the Junior European Association of Urology (EAU) Robotic Urology Section with the collaboration of the EAU Young Academic Urologists Robotic Section. Methods and Priorities of Robotic Surgery Training Program. Eur Urol 2013; epub ahead of print.
  3. Lee JY, Mucksavage P, Sundaram CP, McDougall EM. Best practices for robotic surgery training and credentialing. J Urol 2011; 185: 1191-7.
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