Working with Fellows

Colorectal fellows are a general surgeons who have completed the years of residency, are about to take the general surgical board examinations which will permit practice as a general surgeon, but who have such an interest in colorectal surgery that they will delay their careers by a year in the cause of acquiring specialist training in colorectal surgery. They apply to (usually) several board-certified Fellowship programs, go through series of interviews, and enter a matching system where they grade the programs, and the programs grade them. The whole process is a little like looking for a college. The Fellows generally want a good and comprehensive training experience which allows them to be exposed to the full variety of colorectal diseases and colorectal procedures. In ranking the training programs, they have an eye towards their future career. Technical instruction in robotics and minimally invasive techniques are important to some, while others want to train in advanced endoscopy. Some fellows are inclined to research and intend an academic career. Others plan a lifetime of private practice and want to learn how to operate safely. The reputation of a Fellowship program and of the staff working there are often factors in the applicants’ final choice, especially if they will be applying for a competitive job after the fellowship. Finally, the location of the program may be a factor. Cleveland winters can be tough. From the point of view of the Fellowship program, the best fellows must be bright, hard-working and personable. In-service examination grades and career awards are nice to see and the number of papers in a CV can be impressive, but we really like to read the letters of recommendation. If they are glowing, and written by someone we know, this is a step up. We also place a great deal of weight on the interview. Here is where we look behind the nerves and the suits to see the person inside and to determine if they would be a good fit for our program.

It is a privilege to work with a fellow, a privilege and a responsibility. The fellow is on my service to learn, and every opportunity to teach must be taken. This is not spoon-feeding as the fellow is already a general surgeon. They should already know how to operate and know the basics of colorectal surgery. However, the degree to which this is true can vary widely. Our initial few days with a fellow is a time of evaluation: they evaluate me and I evaluate them. I send them a written account of my thoughts about the fellowship, what I expect from them, and what they can expect from me. Their experience with me comes in the clinic, where they see me talking to patients and learn how to interview a patient, how to examine, how to diagnose and how to strategize management. In the operating room they learn my approach and my methods, but it is in the clinic is where the results of treatment of seen. It is critical that fellows are there.

The daily care of in patients is a job for the fellows with supervision from me. The operating room is the fellows’ domain, where they get to be involved with cases of their choice. During the cases they are taught the practical elements of the procedure at hand, the alternatives, the ways of handling and preventing complications. For fellows to obtain the maximum benefit from these cases they need to read about the patient and the disease prior to showing up in the OR.

Several years ago, I made the decision that my fellows would not be personally involved in my colonoscopy practice. I have much that I can teach them, but it has to be by them observing me and us discussing the procedure. Having a fellow involved in the examination is not possible given the boutique nature of my practice.

Using the “James” technique of putting yourself in the “other person’s” place is useful when interacting with fellows. Initially they can be nervous, slightly withdrawn and a little defensive. They are “checking you out”. They may have heard rumors about you or perhaps they are just shy. It is essential that you set expectations on day one as they cannot fulfil requirements of which they are unaware. Correct missteps gently. There is no need to shout. You are both professionals so explain what should or should not have been done and help them understand the reasons for the request. Offer praise when things go well. Positive reinforcement is just as important as negative. Expand their knowledge by testing its limits and then pushing out into the unknown. Find out their opinions and philosophies. Ask about their families, their dreams, and aspirations. In other words, be a friend. Soon they will join the small but very friendly family of colorectal surgeons of America. They will be your colleagues, but more than that they will be representatives of your institution. And they will be your legacy.