Organising post CCT fellowships can be a tricky, but exciting, time. As an ST6 it can feel very early to be making final decisions about exactly what you want to sub-specialise in and likely where you want to work as a consultant. However if you want to apply internationally then many fellowships will ask you to apply at least 2 years in advance so this is likely to require applications way before you sit your FRCS exam. 

For some people the process seems very easy as they know exactly what they want to do and get  encouraged towards a suitable fellowship by their consultant mentors, for the rest of us the process can be a bit more daunting. In general it is recommended that you start thinking about the process and start to make enquiries enquiries early, perhaps as an ST6. The best place to start is often to speak to local consultants in your chosen subspecialty to see if they have any advice regarding good units and suitable fellowships for you. If you are attending  your chosen subspecialty conference then it may be a good time to try to meet current fellows and their fellowship trainers and ask around if people have any suggestions for you.

In the past it was more common to do just one year of fellowship training however increasingly trainees are doing two years, including one year of trauma. Trauma fellowship experience is usually necessary to work in a Major trauma centre and increasingly it is listed in the desirable criteria for DGH jobs.

Early Planning

In the first instance it is worth thinking carefully through the following questions to help guide you towards what your objectives are for your fellowship experience:

Elective

What is my consultant elective subspecialty practice going to look like?

What procedures or new technologies do I need additional specialist training in?

Do I need additional fellowship in any other elective areas that will make me more marketable as a consultant? e.g. arthroplasty

Are there any particular skills that you think the unit that you might want to work in would benefit from?

Trauma

Where do I see myself working – DGH or MTC?

Will my consultant job have a general trauma commitment? (Some hand or spines post may not)

Do I want to do a trauma fellowship?

If so should it include pelvis and acetabular surgery and frames or not?

General

Do I want to go abroad?

How will this work logistically with my family and home life?

Can I afford it?

Will there be a language issue?

How long do I want to spend on fellowship? What is the expected fellowship training of a consultant starting in my subspecialty?

Do I want to develop contacts and a reputation in a particular unit where I want to work in the longterm?

Am I interested in going to a particularly academic centre? If so, who are the major groups publishing in your subspecialty area currently?

Go abroad or stay at home?

Historically it was considered that there were certain areas of orthopaedics that were much better taught outside of the UK. However there are now excellent UK based fellowships covering most subspecialty interests. Clearly going abroad may allow you to gain exposure to completely different healthcare systems and also a different ethos to treatment in you chosen area. Clearly it is an opportunity for travel and broadening your horizons that may be sorely welcome after 6 years in one place. On the other hand you will need to be on the ball to organise international fellowships at least 2 years in advance for many of the Australian fellowships in the most popular subspecialties, although it can be possible to arrange things on a shorter timescale in some cases. 

It can be difficult to be sure what experience you are going to get without having access to previous fellows. Be aware that there are plenty of international pure assisting / observing research based fellowships for up to 12 months which may not be what you are looking for. Fellowships that include some or even all work in the private sector are fairly commonplace in Australia, do not assume that a fellowship working in the private sector equates to assisting only as it varies significantly.

Going abroad for fellowship is usually fairly expensive in terms of relocation costs for you and your family. Look out for fellowships that come with accommodation, especially in the big cities as that really helps, often it’s in a much nicer location that you would otherwise be able to afford. Fellowship wages can be very variable particularly in Australia where they can vary between £33-82,000 on recent inspection. The average for Australian fellowships is £45,000, North American fellowships tend to pay poorly. Some fellowship timetables schedule research time that can be used flexibly for both research and exploring. 

Be aware that nobody ever wants to admit that they did not have the greatest fellowship experience as it reflects poorly on their own training and skills so try to take information from as many sources as you can.

UK Fellowships

Most UK based fellowships are advertised via NHS jobs, however units vary widely in when they recruit. Some fellowships will hold a round of interview that recruits for the next 2.5 years all at once and others will not recruit until 3 months prior to the post. So if you have a particular fellowship in mind then it is definitely worth approaching the consultant team outside of the application process to enquire about the process. It is also worth ensuing that they are still planning to continue running the fellowship post as the constraints of consultant commitments, local trainee placements and funding may intervene. Ideally sign up early to NHS jobs and get email alerts for jobs that meet you chosen criteria so that you don’t miss out on units that recruit very early. If possible try to visit to a prospective unit prior to formal interviews. This is useful to get a flavour for the unit, speak to current fellows as well as meet consultants who might well be interviewing you soon.

For hand surgery the UK has a number of formally recognised hand TIG posts for both plastics and orthopaedic trainees which has its own national recruitment selection process.

International Fellowships

The best way to find quality fellowships in your chosen subspecialty seems to be talking to colleagues. Quizzing recently qualified local consultants and people you meet subspecialty conferences as to where they went and what their experience was can be helpful. Your own consultant mentors in your chosen subspecialty will often have good connections both in the UK and abroad. Though be aware that this is a changing area; what was the best fellowship in the consultants day may longer be. Some UK specialist societies have a list of units that offer relevant fellowships.

Short traveling fellowships

Some trainees find useful to visit a specific unit abroad for a shorter time period e.g. 1-3 weeks to observe a particular procedure or area of practice without operating themselves.

Application Process

The fellowship application process can be very variable. Many international fellowships might start with a carefully drafted letter and cv as an initial enquiry followed by an informal Skype interview before appointment. Most UK applications are more formal and follow a competitive process like you might expect via NHS jobs and then a face to face interview. Understandably it is difficult for fellowship trainers to make their choice based on a 20-30 minute interview so be prepared that they are likely to have contacted at least one of your referees beforehand. Think carefully about who you put down as your referees, you want somebody enthusiastic who will go out of their way  to speak positively about you and help you get the job. Naturally it is also useful if they are well connected nationally in your chosen field or if they have previous worked with some of the fellowship trainers to lend extra weight to their assessment of you. You might also gently suggest a referee might drop any contacts they know in the centre a bell, to hopefully put a good word in for you!

Be prepared that this interview process is nothing like ST3 applications, there is unlikely to be a representative from HR or a standardised marking pro-forma; you will likely be just interviewed by the prospective consultant trainers. 

Attending Interview

At interview you should expect to mainly be asked questions about your career intentions, clinical and any research experience and motivation for applying for this fellowship. Think about what you can offer the department during your time there. There are likely to be a couple of questions that relate to difficult clinical or operative scenarios in your chosen subspecialty.

Make sure you know your logbook numbers, both as first surgeon and total seen, particularly for the core procedures of your subspecialty. Have an idea about what you are hoping to get out of the fellowship in terms of surgical experience.

You should take your up to date portfolio but be prepared that they may have little time to look at it. It may be useful to have a couple of printed copies of your cv at the front of your portfolio to give them.

As mentioned, the most useful thing that you can do beforehand is to speak to their current or previous fellow. This allows you to get the accurate inside information on the details of the operative and clinical experience that you are likely to get (and whether you actually want the job at all) and also what the consultant trainers are like.  What is the operating/ assisting balance; some antipodean fellowships have a fair amount of assisting in the private sector. Current fellows are also likely to remember some of the interview questions and be able to give you some tips about what is important to them as consultant clinicians.

Wherever possible try to attend interviews in person rather than via Skype as you will undoubtedly find it easier to make a positive impression and connection with them.

Funding

Many of the specialist societies and BOTA offer bursaries for both international fellowships and shorter travelling fellowships. Relocating to North America or Australia with your family is undeniably expensive however it is fair to say that you are unlikely to regret the experience on a personal or professional level.

Sources seem to suggest a starting budget of £10-15,000 to relocate your whole family to cover the costs of flights, medical registration fees, visa and document charges, indemnity, accommodation, car, private health insurance and school fees. The Australian Institute for Musculoskeletal Health offers an Australian fellowship application service where they organise all of your registration documentation for you for a fee. 

Be aware that it is likely you will be paid less as a fellow than as a registrar, in some cases significantly less. Uk fellowships with an on-call commitment are among some of the best paid and North American fellowships are at the other end of the spectrum.

Useful Resources

The following specialist society pages contain details of relevant fellowships.

BOFAS British Orthopaedic Foot and Ankle Society   

BSSH British Society for Surgery of the Hand  

BESS British Elbow and Shoulder Society 

BSCOS British Society for Children’s Orthopaedic Surgery 

BOOS British Orthopaedic Oncology Society 

Spines   

Australian Orthopaedic Association

Australian Institute for Musculoskeletal Health

 

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