Surgical fellowship after Training in Germany

[huss797]

Hi everyone,

Im a resident in a general surgery program in Germany. I am ECFMG certified, and I have some USCE as i was a student. I am interested in doing a fellowship upon finishing my training, and have found a few interesting programs on fellowship council.

- My first question is whether any IMGs around have had experiences with fellowship council?
- How tough is it generally to get into a surgical fellowship program as an IMG (im interested in various fields like colorectal, mic, surgical critical care and surgical oncology. I am aware of how difficult it is to get into a US residency program, as I myself tried once and it didnt work. I am also aware that without US residency, I cannot permenantly work in the US, as I wont be board certified.
- Are there any other application platforms other than fellowship council that I need to be aware of?
- What can I do to make my CV more attractive for a US fellowship? Is it possible to do the Absite from overseas? I already did step 3.

Thank you very much for your help.
Best regards

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[thedrjojo]

Hi everyone,

Im a resident in a general surgery program in Germany. I am ECFMG certified, and I have some USCE as i was a student. I am interested in doing a fellowship upon finishing my training, and have found a few interesting programs on fellowship council.

- My first question is whether any IMGs around have had experiences with fellowship council?
- How tough is it generally to get into a surgical fellowship program as an IMG (im interested in various fields like colorectal, mic, surgical critical care and surgical oncology. I am aware of how difficult it is to get into a US residency program, as I myself tried once and it didnt work. I am also aware that without US residency, I cannot permenantly work in the US, as I wont be board certified.
- Are there any other application platforms other than fellowship council that I need to be aware of?
- What can I do to make my CV more attractive for a US fellowship? Is it possible to do the Absite from overseas? I already did step 3.

Thank you very much for your help.
Best regards

You can probably cross Surg Onc off your list right away. US grads can't even match into Surg Onc fellowships, so there is 0 chance for an IMG to match.

Colorectal is also a competitive match, so that might be hard.

I assume you mean MIS (minimally invasive surgery). That and Surgical Critical Care aren't compettive per say, but that doesn't mean anything is easy.

Even transplant which seems very well geared towards IMG's have about a 50% match rate for IMG's, so your road is difficult ahead of you regardless.

 

[huss797]

You can probably cross Surg Onc off your list right away. US grads can't even match into Surg Onc fellowships, so there is 0 chance for an IMG to match.

Colorectal is also a competitive match, so that might be hard.

I assume you mean MIS (minimally invasive surgery). That and Surgical Critical Care aren't compettive per say, but that doesn't mean anything is easy.

Even transplant which seems very well geared towards IMG's have about a 50% match rate for IMG's, so your road is difficult ahead of you regardless.

Thanks for your reply thedrjojo,

Yes i meant MIS not mic. Are you aware of any other platforms other than fellowship council where I can submit my application?

Btw, my wife is an orthopedic resident in Germany and would also be interested in gaining further experience through a US fellowship. How do her chances look like and where do orthopods submit their applications?

Thanks

 

[ram006]

Slim chances all around. Just sat through a lecture about the ICD-10 implementation, "doc fix"and Obamacare. Why on earth would anyone want to practice medicine here anyway...

 

[thedrjojo]

Many fellowships have you submit the application directly to them, so you'd need to go to there websites

 

[thedrjojo]

Slim chances all around. Just sat through a lecture about the ICD-10 implementation, "doc fix"and Obamacare. Why on earth would anyone want to practice medicine here anyway...

Great for training still...

 

[huss797]

I understand your frustration. For me its about gaining some quality experience in a different country.

 

[ram006]

Great for training still...

Indeed. Understandable to want to train here but I don't agree with allowing FMGs to train in the states and leave. Personal opinion.

 

[thedrjojo]

Indeed. Understandable to want to train here but I don't agree with allowing FMGs to train in the states and leave. Personal opinion.

understandable, but usually FMG's get training spots that are otherwise unfilled. Look at transplant. No US grad that wants a transplant fellowship will go without one unless they have huge red flags, and even then most likely 1 program will give you a chance. And even with that, there are going to be 40-50 open fellowship spots. So these programs have to decide, do they take someone that wants to be there and wants to get the training (and is willing to be your "trainee"), or do you leave the spot unfilled and work without the fellow? Rare it will be that an FMG takes the spot of a US grad for fellowship, which is why I basically categorically told them surg onc and colorectal were nonstarters, and MIS may also be, but Surgical Critical Care, I'd think there might be some unfilled spots that would be willing to take on a person, although visa issues will be the biggest hold ups...

 

[ram006]

understandable, but usually FMG's get training spots that are otherwise unfilled. Look at transplant. No US grad that wants a transplant fellowship will go without one unless they have huge red flags, and even then most likely 1 program will give you a chance. And even with that, there are going to be 40-50 open fellowship spots. So these programs have to decide, do they take someone that wants to be there and wants to get the training (and is willing to be your "trainee"), or do you leave the spot unfilled and work without the fellow? Rare it will be that an FMG takes the spot of a US grad for fellowship, which is why I basically categorically told them surg onc and colorectal were nonstarters, and MIS may also be, but Surgical Critical Care, I'd think there might be some unfilled spots that would be willing to take on a person, although visa issues will be the biggest hold ups...

Right. I agree with 99% of your post, but my personal opinion is that, with the Medicare bubble about to burst and the proposed cuts to GME funding/loan forgiveness for US Grads, etc. , we should not be spending more money on positions American surgeons do not want. So I would say that given the two options, we should leave the spots unfilled and avoid utilizing resources that we essentially don't have to train someone who has no intention of providing service to the US.

Presumably, since there are PP transplant surgeons out there functioning independently, people could survive without fellows. Our budget crisis is real, it should take priority over physicians from other countries.

Sorry to the OP, little pessimistic after this mornings Grand Rounds. Nothing personal.

 

[thedrjojo]

Right. I agree with 99% of your post, but my personal opinion is that, with the Medicare bubble about to burst and the proposed cuts to GME funding/loan forgiveness for US Grads, etc. , we should not be spending more money on positions American surgeons do not want. So I would say that given the two options, we should leave the spots unfilled and avoid utilizing resources that we essentially don't have to train someone who has no intention of providing service to the US.

Presumably, since there are PP transplant surgeons out there functioning independently, people could survive without fellows. Our budget crisis is real, it should take priority over physicians from other countries.

Sorry to the OP, little pessimistic after this mornings Grand Rounds. Nothing personal.

The fellowships, most of them, if they lose their fellow, will shift that work onto attendings (meaning higher stress, more burnout, etc) or onto midlevel providers (which cost more than residents) or residents in the program (which may tax a residency, the residents, and could ultimately jeopardize patient outcomes). Most fellows are likely huge financial booms for the hospitals and programs that use them, probably even moreso than residents, because the massive amount of handholding training and formalized teaching structures are not present, often the billing of fellows (particularly non ACGME fellowships) is at Attending level, but the pay is at resident level. Yes, can they get by without the fellow? I'm sure all the programs would manage. Would that transisition cost the program, and cost it more than the FMG fellow would have cost? I think I made a strong case for that.

Residency you may have more of an agreement for not allowing FMG's into the system, but since that's entirely against the entire idea of land of opportunity, competition improving quality, and all that jazz, I still don't think I'd agree with you, but I'd at least entertain a proposal

 

[ram006]

The fellowships, most of them, if they lose their fellow, will shift that work onto attendings (meaning higher stress, more burnout, etc) or onto midlevel providers (which cost more than residents) or residents in the program (which may tax a residency, the residents, and could ultimately jeopardize patient outcomes). Most fellows are likely huge financial booms for the hospitals and programs that use them, probably even moreso than residents, because the massive amount of handholding training and formalized teaching structures are not present, often the billing of fellows (particularly non ACGME fellowships) is at Attending level, but the pay is at resident level. Yes, can they get by without the fellow? I'm sure all the programs would manage. Would that transisition cost the program, and cost it more than the FMG fellow would have cost? I think I made a strong case for that.

Residency you may have more of an agreement for not allowing FMG's into the system, but since that's entirely against the entire idea of land of opportunity, competition improving quality, and all that jazz, I still don't think I'd agree with you, but I'd at least entertain a proposal

I'm not arguing against fellows being profitable for hospitals per se, I'm arguing against using federal dollars to train someone who is never going to contribute to healthcare in America. And by contribute I mean take care of patients, not make money for hospital bc, I think we can all agree, the two are not always synonymous. Your argument is based on hospital profits which was not really what I was talking about. Regardless, if a fellowship has funding from a source other than the govt that's another matter. If they choose to take on a fellow to increase productivity that's up to them.

An FMG completing a residency in the US makes them more valuable since they can actually practice here. So I don't think they should be shut out of residency. A number of our graduates are FMGs that stick around to practice rural general surgery. They are sorely needed. Ironically, it seems like the visa issues make it harder for them to stay than to leave in many cases.

Completing a fellowship without a residency, however, is a separate matter as the OP mentioned.

All that aside, transplant fellows being financial boons is debatable; certainly in their first year. I just don't see a fellow banging out a liver transplant 6 months in while the attending generates revenue elsewhere. The business model for transplant, like any surgery, is volume based but not to the same degree as knocking out gallbladders or hip replacements. There are a fixed number of available organs. Not all programs are doing so many transplants that they wouldn't be able to keep up were it not for the fellow. I think this reduces the potential for a fellow to have any real effect on generating revenue quite a bit as it's not uncommon for more than one attending to scrub on a liver (i.e. bill for 150%). There are usually multiple transplant surgeons at a hospital doing multiple things.

To me, it would seem that adding a fellow is not the difference between making hand over fist profits and scraping by. Admittedly I don't have any 'expert" knowledge of billing but I do have a working knowledge of how a transplant service at a university based program without fellows operates. No one is dying that shouldn't be and the number of cases going on is what it is, regardless of who's staffing them. If the organs come in, they come in. The fellow has nothing to do with that. If there are an abundance of open positions, you have to at least consider some of them may be unnecessary and, if funded by the government, are less than ideal.

 

[thedrjojo]

I'm not arguing against fellows being profitable for hospitals per se, I'm arguing against using federal dollars to train someone who is never going to contribute to healthcare in America. And by contribute I mean take care of patients, not make money for hospital bc, I think we can all agree, the two are not always synonymous. Your argument is based on hospital profits which was not really what I was talking about. Regardless, if a fellowship has funding from a source other than the govt that's another matter. If they choose to take on a fellow to increase productivity that's up to them.

An FMG completing a residency in the US makes them more valuable since they can actually practice here. So I don't think they should be shut out of residency. A number of our graduates are FMGs that stick around to practice rural general surgery. They are sorely needed. Ironically, it seems like the visa issues make it harder for them to stay than to leave in many cases.

Completing a fellowship without a residency, however, is a separate matter as the OP mentioned.

All that aside, transplant fellows being financial boons is debatable; certainly in their first year. I just don't see a fellow banging out a liver transplant 6 months in while the attending generates revenue elsewhere. The business model for transplant, like any surgery, is volume based but not to the same degree as knocking out gallbladders or hip replacements. There are a fixed number of available organs. Not all programs are doing so many transplants that they wouldn't be able to keep up were it not for the fellow. I think this reduces the potential for a fellow to have any real effect on generating revenue quite a bit as it's not uncommon for more than one attending to scrub on a liver (i.e. bill for 150%). There are usually multiple transplant surgeons at a hospital doing multiple things.

To me, it would seem that adding a fellow is not the difference between making hand over fist profits and scraping by. Admittedly I don't have any 'expert" knowledge of billing but I do have a working knowledge of how a transplant service at a university based program without fellows operates. No one is dying that shouldn't be and the number of cases going on is what it is, regardless of who's staffing them. If the organs come in, they come in. The fellow has nothing to do with that. If there are an abundance of open positions, you have to at least consider some of them may be unnecessary and, if funded by the government, are less than ideal.

Non ACGME fellowships are not funded by Medicare, and are funded by the department/hospital/whatever, typically supported by billing. If you are an MIS fellow, you are actually just a junior partner getting paid like a resident, since there is no regulatory body paying for that fellowship. Sure, they bill medicare and medicaid (ha, someone bills medicaid), but that is direct fee for service and not govment handouts. So, yes, my argument is that if a hospital is going to save money by hiring this fellow and is the one footing the bill.

6 months into the fellowship, who is going to the procurements in the middle of the night? While it varies, I can tell you a fellow is often the person on that flight. Attendings get to rest and be refreshed for the recipient. So, yes, in the procurement area, a fellow 6 months in will be helping there. Furthermore, Kidney's is where the money is in transplantation. Dialysis access you can be certain a fellow is doing with minimal supervision.

Plus, a fellow is cheaper than a PA 1st assistant...

 

[ram006]

Non ACGME fellowships are not funded by Medicare, and are funded by the department/hospital/whatever, typically supported by billing. If you are an MIS fellow, you are actually just a junior partner getting paid like a resident, since there is no regulatory body paying for that fellowship. Sure, they bill medicare and medicaid (ha, someone bills medicaid), but that is direct fee for service and not govment handouts. So, yes, my argument is that if a hospital is going to save money by hiring this fellow and is the one footing the bill.

6 months into the fellowship, who is going to the procurements in the middle of the night? While it varies, I can tell you a fellow is often the person on that flight. Attendings get to rest and be refreshed for the recipient. So, yes, in the procurement area, a fellow 6 months in will be helping there. Furthermore, Kidney's is where the money is in transplantation. Dialysis access you can be certain a fellow is doing with minimal supervision.

Plus, a fellow is cheaper than a PA 1st assistant...

Actually now that you mention MIS, I remember hearing about one of our graduates being in the dog house bc he was having visa issues and couldn't bill as faculty. Either way, apples and oranges if you're not talking about federal money which is what I was referring to. I don't think federal money should be used to train non-American surgeons if they don't have some sort of obligation to provide care in the US.

Maybe things work different where you train, but like I said there isn't a constant flow of livers/kidneys/lungs etc. overwhelming most transplant centers. We don't have fellows and I've never seen a PA scrub as 1st assist. For livers it's an attending, chief and available attending hanging around in case things get dicey. Kidneys are usually an attending and a PGY2.

I did kind of forget about all the other HP, dialysis access and advanced lap stuff they do though outside of actual organ transplantation though...

 

[thedrjojo]

Actually now that you mention MIS, I remember hearing about one of our graduates being in the dog house bc he was having visa issues and couldn't bill as faculty. Either way, apples and oranges if you're not talking about federal money which is what I was referring to. I don't think federal money should be used to train non-American surgeons if they don't have some sort of obligation to provide care in the US.

Maybe things work different where you train, but like I said there isn't a constant flow of livers/kidneys/lungs etc. overwhelming most transplant centers. We don't have fellows and I've never seen a PA scrub as 1st assist. For livers it's an attending, chief and available attending hanging around in case things get dicey. Kidneys are usually an attending and a PGY2.

I did kind of forget about all the other HP, dialysis access and advanced lap stuff they do though outside of actual organ transplantation though...

Well, transplant centers that claim 150 kidneys a year do have the volume, but are not necessarily the centers filling with fellows. And if there is a fellow, is that second attending going to be wasting there time sniffing that case?

We have lost the forest for the trees, and while I could talk about transplant all day, tis not the issue or focus. I'm glad that in our already draconian system, your additional regulatory hurdle is not in place and programs can train whomever they feel is the best candidate for the job and not some USA quota

 

[ram006]

Well, transplant centers that claim 150 kidneys a year do have the volume, but are not necessarily the centers filling with fellows. And if there is a fellow, is that second attending going to be wasting there time sniffing that case?

We have lost the forest for the trees, and while I could talk about transplant all day, tis not the issue or focus. I'm glad that in our already draconian system, your additional regulatory hurdle is not in place and programs can train whomever they feel is the best candidate for the job and not some USA quota

That's one of my points.

150 kidneys a year is (obviously) on average one every 2-3 days. Adding a fellow doesn't bump that number up to 1 per day unless the fellow is somehow influencing how many organ donors there are out there. Point being the case load is not so excessive at every center it always requires a fellow to manage it as demonstrated by the fact that centers with unfilled positions do not cease to function.

Me saying federal dollars shouldn't be used to train foreign doctors who don't plan to ever practice in the US is not suggesting a "quota" or a regulatory hurdle. It's, what I think, is the appropriate use of GME funding so that we can continue to fund residencies and fellowships. Our medicare pool is limited, we shouldn't be giving it away.

 

[thedrjojo]

That's one of my points.

150 kidneys a year is (obviously) on average one every 2-3 days. Adding a fellow doesn't bump that number up to 1 per day unless the fellow is somehow influencing how many organ donors there are out there. Point being the case load is not so excessive at every center it always requires a fellow to manage it as demonstrated by the fact that centers with unfilled positions do not cease to function.

Me saying federal dollars shouldn't be used to train foreign doctors who don't plan to ever practice in the US is not suggesting a "quota" or a regulatory hurdle. It's, what I think, is the appropriate use of GME funding so that we can continue to fund residencies and fellowships. Our medicare pool is limited, we shouldn't be giving it away.

I would hardly call any fellowship giving it away...

One might argue the government probably has no business financing any post graduate medical education

 

[ram006]

I would hardly call any fellowship giving it away...

One might argue the government probably has no business financing any post graduate medical education

????

1.) I was talking about the money, not the fellowship itself
2.) ?????

 

[thedrjojo]

????

1.) I was talking about the money, not the fellowship itself
2.) ?????

You said our medicare pool is limited and we shouldn't be giving it away. Funding a fellow isn't giving it away, even if they aren't practicing in the us afterwards. It might not give the best return in investment.

And the second point, why should the government be paying for any of our residencies?

 

[ram006]

You said our medicare pool is limited and we shouldn't be giving it away. Funding a fellow isn't giving it away, even if they aren't practicing in the us afterwards. It might not give the best return in investment.

And the second point, why should the government be paying for any of our residencies?

Because they charge 6.8% interest on huge amounts of student debt...

 

[ram006]

I actually can't believe someone would be ok with paying the asinine amount of interest on loans to the fed to become a doctor only to have them turn around and tell us to go figure it out on our own during residency. You must not have much debt...

 

[thedrjojo]

I actually can't believe someone would be ok with paying the asinine amount of interest on loans to the fed to become a doctor only to have them turn around and tell us to go figure it out on our own during residency. You must not have much debt...

I have 200k in debt. Which paid for my degree, and when I can make beyond a resident salary I'll be able to pay back. But, residency has never been intended to be retribution for the gawd awful debt we have accumulated. You think residents would only make 40-50k in the open market, being able to bill for our services, etc?

Graduate medical education is just another of those messed up/broken things with this system...

 

[thedrjojo]

Because they charge 6.8% interest on huge amounts of student debt...

They charge all students that, yet don't get involve in the post graduate employment of any of them

 

[thedrjojo]

I would like to apologize to the op for contributing to this thread hijacking. This sidebar on what should happen has no bearing on what does happen, or what you can do to achieve your goal

 

[ram006]

They charge all students that, yet don't get involve in the post graduate employment of any of them

They actually do not charge all students that, but I'm ready to tap out if you are.

 

[thedrjojo]

They actually do not charge all students that, but I'm ready to tap out if you are.

Yeah, we see things a bit differently, and I'm not feeling continuing. Agree to disagree it is. Well done, not many people wear me down on sdn (as is evidence by my unruly number of posts)

 

[ram006]

Yeah, we see things a bit differently, and I'm not feeling continuing. Agree to disagree it is. Well done, not many people wear me down on sdn (as is evidence by my unruly number of posts)

Agreed. I need a cigarette.

 

[thedrjojo]

Actually now that you mention MIS, I remember hearing about one of our graduates being in the dog house bc he was having visa issues and couldn't bill as faculty. Either way, apples and oranges if you're not talking about federal money which is what I was referring to. I don't think federal money should be used to train non-American surgeons if they don't have some sort of obligation to provide care in the US.

Maybe things work different where you train, but like I said there isn't a constant flow of livers/kidneys/lungs etc. overwhelming most transplant centers. We don't have fellows and I've never seen a PA scrub as 1st assist. For livers it's an attending, chief and available attending hanging around in case things get dicey. Kidneys are usually an attending and a PGY2.

I did kind of forget about all the other HP, dialysis access and advanced lap stuff they do though outside of actual organ transplantation though...

From another of your posts, I realized I'm doing research with your transplant department on several studies. Small world. Your surgeons are fast on their livers...

 

[ram006]

Ya man. Pretty impressive faculty. Dr. Halff I believe either started or had some key role in starting the program at NYU before he came to us. Awesome teachers in that division, it was hands down my favorite rotation as a PGY2. We get to do it again as a chief with no fellow, I'm looking forward to it. Are you headed to a transplant fellowship in the future?

 

[thedrjojo]

Ya man. Pretty impressive faculty. Dr. Halff I believe either started or had some key role in starting the program at NYU before he came to us. Awesome teachers in that division, it was hands down my favorite rotation as a PGY2. We get to do it again as a chief with no fellow, I'm looking forward to it. Are you headed to a transplant fellowship in the future?

That's the plan. Washburn is the PI we are working with. I met him at the ATC (American transplant congress), nice guy.

 

[Mad Jack]

I thought that with the changes in fellowship eligibility requirements, only those that completed an ACGME residency could apply for ACGME fellowships, which leaves only unaccredited fellowships available to FMGs that have not completed ACGME residencies. I mean, even DOs with AOA residencies were banned from ACGME fellowships so I can't imagine they'd just let somebody from Germany waltz right in.

 

[illixir]

This is obviously just anecdotal evidence but on one of my outside rotations, I saw that the surg onc fellow at one of the big 4 hospitals in nyc is an FMG who did surgery residency in his country, he's doing MIS next year and then going back to his home country. The surg onc fellowship is not SSO accredited though, I'm sure he doesn't care.

 

[thedrjojo]

This is obviously just anecdotal evidence but on one of my outside rotations, I saw that the surg onc fellow at one of the big 4 hospitals in nyc is an FMG who did surgery residency in his country, he's doing MIS next year and then going back to his home country. The surg onc fellowship is not SSO accredited though, I'm sure he doesn't care.

The fact that program is not sso is the only reason why they have an FMG. For surg onc, that makes a huge deal in the us.

 

[illixir]

OP indicated in his post he knows he won't eventually practice in the US after his fellowship, so this should be right up his alley if he wants to pursue this. It's harder to find these programs because you just have to search the web and apply directly to them but some exist in most fields. I would think he should focus on applications outside the match in all fields of interest.