INTRODUCTION
For some graduating otolaryngology residents, the prospect of international subspecialty fellowship training may be intriguing.  Not only does an overseas fellowship offer the usual advantage of expanding one’s clinical knowledge base and surgical skill set, but it also affords the opportunity to gain perspective on healthcare delivery in another country while cultivating a network of international colleagues and experiencing the excitement of a foreign culture.  The United States does not have a monopoly on otolaryngology best-practice and an American travelling overseas is likely to encounter some techniques that are better than what they were taught as residents, some that are worse, and some that are just different.  However, exposure to different techniques and unfamiliar ways of thinking harbors the potential for tremendous professional enrichment. 

Speaking from a personal viewpoint, my experience several years ago as a fellow in otology & skull base surgery with Professor Marcus Atlas in Perth, Australia was overwhelmingly positive and I consider the time I spent “down under” as one of the most valuable assets in my career development.  In Australia I learned techniques that were both eclectic and outstanding while being exposed to a patient population wherein several otologic disease conditions were much more common than in the USA.  Overall, I feel confident that the surgical training I received in my fellowship was equal or better to training that I could have obtained as a fellow in the United States; however, overseas training experiences can vary and not every American that has traveled abroad for a fellowship would share my enthusiasm.  Thus, the adage “buyer beware” is appropriate for some international fellowship offerings. 

As an American, there are some important angles that should be considered when deciding whether or not to head abroad, and I will discuss these below.  I acknowledge upfront that most of the examples I will use apply to otology, but hopefully you can translate these illustrations to any subspecialty.  Also much of what I will discuss pertains to clinical training, so also keep in mind that research training may be a separate issue to consider depending on your career goals. 

WHAT IS MEANT BY THE TERM "FELLOW" IN THE POSITION YOU ARE CONSIDERING?
Be aware that what is meant by a “fellow” in some countries may not entirely be the same thing as what you are accustomed to and that this role can vary considerably from program to program—even within the same country.  For example, in some programs a fellow is actually a more exalted role as compared to fellows in the USA.  In my fellowship I assumed the position of a junior faculty member at a large public hospital overseeing the otology service with my own clinic and my own operating room time.  I was held personally liable for the care and follow up of patients and it was my responsibility to seek assistance from my fellowship director when needed.  Concurrently, I took more of an observational role in my mentor’s private practice so that I could see how he did things and then apply these lessons to my own patients.  Personally, I felt that this was an outstanding model for fellowship training that eventually led to me performing major ear and skull base procedures independently--having supervision only on “stand by.”

In contrast, some oversees fellows enjoy less autonomy than what is typical in the USA and some programs may in fact be observational, ranging from acting as a surgical assistant to not scrubbing for surgery at all.  An American applicant must be aware of this possibility when investigating overseas fellowship options and may only want to consider an observational fellowship if it is planned in addition to more hands on surgical training elsewhere and preferably beforehand.  That said, once you have achieved surgical competence it is possible to learn a tremendous amount of surgical wisdom by observing an expert, so it is not accurate to view such fellowships as valueless. 

Keep in mind that the surgical experience for otolaryngology trainees in other countries may be very different than what Americans may expect.  In some places like Australia and New Zealand, trainees enjoy an immense degree of surgical autonomy, graduating with a case log that compares favorably to the best American programs.  On the other hand, otolaryngology resident training in some European countries can be quite outstanding from a didactic perspective, but these training programs may be designed as part of larger system that intends to provide the bulk of its operative experience later in the form of mentored “on the job” training as a junior faculty member after completion of residency.  In this latter setting, a fellowship director may not have the expectation that a resident graduate has sufficient background experience to perform anything more than very basic procedures independently.  The European system of training otolaryngologists has an excellent track record and most of the prominent departments eventually produce highly competent ENT surgeons, but keep in mind that simply plugging an American residency graduate into this system may be complicated.  That said, outstanding European otolaryngology fellowship options for Americans certainly do exist. Insist to be put in touch with several recent fellows and get an impression of their experiences.  How was time allocated?  How much operative autonomy is given?  How heavily are fellows supervised?  What are the resident teaching expectations?  Was it enjoyable?  Worthwhile?  What does practice look like after graduation?

The final thing to understand is that not all overseas fellowships are dedicated exclusively to a single subspecialty, so you may find a fellowship listing for something like “otology and endoscopic sinus surgery.”  This is because in many countries, fellowship-trained ENT surgeons will enter practice and continue to see general otolaryngology patients throughout their entire careers.   For example, a fellowship-trained neurotologist may remove tonsils, perform endoscopic sinus surgery, or complete a neck dissection.  Although this may seem odd in the United States, where we have become very compartmentalized, international otolaryngologists often take great pride in being able to handle just about anything that walks into the clinic.  As such, it may be expected that a “fellow” will scrub and assist in cases outside the intended subspecialty scope of their fellowship.  In fact, it is actually quite common for overseas trained otolaryngologists to complete multiple fellowships in several different subspecialties or to complete multiple fellowships in a single subspecialty at several different locations.  As such, it may not actually be the intent of a particular fellowship program to act as a comprehensive subspecialty training experience.

WHAT ARE THE PRACTICAL IMPLICATIONS INVOLVED WITH INTERNATIONAL FELLOWSHIP TRAINING?
There is no simple answer since the prerequisites, application process, and paperwork involved will vary tremendously from country to country.  For example, in some instances fellows may be selected without a personal interview or letters of recommendation.  Foreign language competency is usually required for any paid position that involves direct patient care. You’ll have a better experience if there is no language barrier. 

Each country will have its own unique licensure requirements, credentialing process, and visa application.  For established fellowships that have a history of hosting many international fellows there is likely to be a well-defined process in place.  However, it is not unheard of for a program to offer a spot and then expect the incoming fellow to “figure it out.”  Many foreign fellowships come into being as custom-made apprenticeships. Being a trailblazer in such a program is extremely risky, as uncharted logistical territory could stall your clinical experience. Learn whether Americans have filled the post in the past and if there were any barriers to obtaining a medical license. 

As a general rule, Americans wanting to go overseas should expect a time-consuming process that is much more burdensome than pursuing a domestic fellowship.  Given this reality and the fact that some overseas fellowships do not share common start dates with the American training calendar, it may be necessary to have a waiting period lasting for up to a year after completion of residency before being able to begin an international fellowship. Thus, having contingency plans such as moonlighting or research is a good idea.

One must also consider the financial implications of heading overseas.  In short, beware that an international fellowship may be an expensive proposition.  For example, some fellowships do not offer a salary since they expect that competitive fellowship applicants should be “funded” with financial support from the government of their home nation or from their future place of employment.  Of the funded fellowship positions, most will offer a salary on par with what their own otolaryngology trainees are earning and this is typically at least as high as fellows are paid in the USA.  In the best-case scenario, if a fellow has faculty status, he/she may be highly compensated at the level of a junior attending physician. 

Another thing to keep in mind is that in other countries one’s employer does not provide medical insurance coverage and you may not qualify for free public health care.  Thus, you may need to obtain your own overseas health insurance coverage from an independent provider and it may be a requirement to provide proof of coverage before a visa is granted.  Additional financial obligations may include:  fees for obtaining a medical license, cost of malpractice insurance (not nearly as expensive as in the USA), visa application fees, cost of international airfare, cost of setting up overseas mobile phone coverage, minimum deposit required to open an overseas bank account, and cost of international relocation. Finally, do not forget to inquire about CME coverage and vacation. This is a difficult question to ask in an interview setting, but is another source of wide differentiation between fellowships. As many as 6 weeks of vacation and $16,000 of CME expense are possible.    

Once convinced into pursuing a particular fellowship, getting face time with the program director is your best application.  Although much advancement in medical education relies on what you know, this is certainly a step that relies on WHO you know. Some posts have over a hundred applicants.  Gaining visibility among that cohort requires more than a long CV.  Make efforts to track down faculty at meetings – either stateside or abroad – and get to know them socially.  Not only will this increase your odds of landing the position, but will also be informative regarding personality fit.

HOW DOES AN INTERNATIONAL FELLOWSHIP IMPACT MY JOB PROSPECTS?
This is another difficult question to answer since there is so much diversity in the scope and quality of the fellowships available.  The answer to this question will also vary depending on the type of career you desire.  My main advice is to rely heavily upon the counsel of your mentors within your residency program and the input you are receiving from any potential future employers.  In some instances, such as in neurotology (and possibly pediatric otolaryngology in the future), an overseas fellowship will not fulfill the ACGME-accredited fellowship requirement needed to be eligible to sit for the subspecialty certificate examination.  Does this lack of eligibility really matter?  Maybe.  I have no doubt that lack of board eligibility in neurotology has the potential to prevent an applicant from being considered for some jobs (competence in neurotology aside).  However, if, for example your fellowship provides a unique skill set in caring for conditions such as vestibular disorders or tinnitus or it affords expertise in something like complex electrophysiology that is typically not very popular among American trainees, an internationally trained fellow could find himself/herself in high demand.  

In theory, international training and lack of board eligibility may also create obstacles when trying to obtain hospital credentials for certain procedures (in the case of neurotology, the main issue is typically with intradural surgery performed without a neurosurgeon); however, my own personal experience has been that if you have a documented caseload worthy of credentialing it should not be a problem.  For subspecialties without board-eligibility issues such as rhinology, head & neck, facial plastics, or laryngology, there should be less concern about professional certification and credentialing issues.

Completion of a fellowship with an undisputed international expert ought to bolster a person’s employability and most internationally prominent otolaryngologists will have some degree of clout and a network of colleagues within the United States.  That said, even the most respected international mentor is unlikely to provide job-seeking advantages equivalent to the alumni network and inside track provided by a well regarded domestic fellowship.  Some surgeons that undertake excellent international fellowships will find themselves frustrated by the lack of familiarity or respect with which their fellowship is viewed by some “American-centric” colleagues—especially if these same colleagues are in competition for patients. 

On the other hand, I have found that most Americans are reasonably open-minded and many realize that international training can afford a unique perspective.  One major advantage of completing an overseas fellowship is the potential to develop an international network of otolaryngology colleagues and some employers will recognize that hiring a fellow with these connections may provide an opportunity to expand the visibility and prominence of their own department beyond the borders of the United States. 

FINAL IMPORTANT CONSIDERATIONS
Because of the uncertainties, hassle, and cost, it’s fair to say that you have to be very motivated to go overseas for a fellowship.  Without question the most important aspect in deciding whether or not the benefit is worth these efforts is honesty about one’s professional goals and training needs. 

• What are you trying to accomplish during your fellowship? 
• Would you rather be invited to serve on an influential committee within the AAO-HNS (more likely with a domestic fellowship) or invited to speak at a surgical training course in another country (more likely with an international fellowship)?
• Do you just need surgical training and a fellowship certificate to hang on your wall or do you also need to bolster your academic profile? 
• What were the strengths and weaknesses of your residency training background and are they well matched with the proposed fellowship? 
• Are you generally comfortable operating in your planned subspecialty realm and just wanting to broaden horizons or are you intending to remediate for experience that you lacked as a resident? 
• Do you already have a job lined up or are you prepared to engage in a career search from abroad? 
• Are you capable of humbling yourself sufficiently to assume a different role than to what you may be accustomed as an American trainee?
• Are your personal finances sufficient to support pursuing an international fellowship?

IF YOU CHOOSE TO ACCEPT AN INTERNATIONAL FELLOWSHIP, HERE ARE A FEW "DO'S and DON'TS"

DO:

• Proceed humbly with an open mind; you don’t know as much as a graduating resident as you think you do.
• Study the way in which patients are cared for in other countries beyond just the role of the doctor.
• Engage and respect the culture of the host nation inside and outside of the hospital.
• Delay the start time of fellowship if needed to save up enough money beforehand to assure living comfort and the ability to go sightseeing.
• Cultivate international contacts, as this may be one of the greatest advantages to overseas training.
• Welcome exposure to clinical and surgical duties outside of your subspecialty area of focus.

DON'T:

• Assume that anyone is going to “bow down” and respect that you are an American-trained otolaryngologist.  Be aware that some countries actually view our system of training as inferior.
• Go overseas for a fellowship just so you can have an extended international holiday.  If you are not serious about the program, you may very well be asked to leave.
• Take for granted that a fellow in another country may not be the same role as a fellow in the USA.
• Enter a training program with the intent that you are going to teach foreign doctors the “proper” way to operate.
• Assume that your mentor will have predetermined confidence in or an accurate sense of your surgical abilities coming out of residency.
• Get upset after you return home and find that many Americans are not familiar with your fellowship.
• Drink the water, ever.

IN SUMMARY...
In the end, a good international fellowship offers a highly valuable training experience.  Gaining perspective on healthcare delivery in a different system will increase your versatility and help you contribute to a rapidly evolving American medical landscape.  Learning entirely new approaches to disease will equip you with skills that facilitate challenging situations borne of previous stateside management.  Finally, international training can be a rich life experience, offering friendships with a worldwide network of contemporaries and mentors.

Authors:
Michael B. Gluth, MD
The University of Chicago Medicine

William R. Schmitt, MD
Surgical Specialists of Spokane, Washington