The body of evidence supporting specialist fellowship training programs is considerable; demonstrating a significant impact on surgical proficiencies and patient care outcomes [27–33]. Other research also points towards a consistent increase in the number of applicants pursuing surgical sub-specialities [34–36]. matched by an increase in available centres offering advanced surgical fellowship training [37]. The factors contributing to these trends are multiple and complex. They include the current structure of graduate surgical training programs, evolving healthcare systems, and rapid advances in surgical practice. When considering Surgical travelling fellowships in general, the picture is mixed. A subset of Travelling surgical and colorectal fellowships exhibit a similar structure and framework to the training programs stated above and their validity could, therefore, be considered within the same context. The remaining TSF, however, varies considerably in duration, structure, experience, and level of immersive involvement. For the latter, this level of heterogeneity has, perhaps, contributed to the lack of scientific evidence on its impact and validity. Nonetheless, general figures published on websites belonging to sponsoring colleges of surgery, surgical associations, and societies showed a pattern of increase, in the annual number of fellows from the year 2000 consistent with other specialist training programs.
In this study, we have provided a quantitative analysis of trends in the number of fellows in TSF and CTF and their most sought-after surgical themes in colorectal surgery. We have also provided a qualitative assessment of the values, experiences, and impacts expressed by traveling from developed and developing countries.
Our results demonstrate a pre-COVID-19 pandemic showing an increase in the annual number of combined TSF and CTF averaging 26% since the year 2000. The time-series analysis predicts a continued uptrend beyond the latest available data points in 2019. The data also shows the distribution of host countries for both TSF and CTF. They are, aligned, and in order of volume, North America, Western Europe, The U.K., Australasia, Japan, and South Korea. Recently, the COVID 19 pandemic has affected education at all levels. Surgical fellows have faced irreplaceable challenges also. Nicholas et al., (2021) have reviewed aspects of Canadian surgical fellowships that have been affected by this pandemic, and proposed solutions including varying the mix of cases to meet objectives, pursuing alternative finance structures and leveraging technology for both research and advancing surgical technique [38].
The incentives to peruse a traveling fellowship, highlighted in this study, are multifactorial. The pursuit of technical surgical knowledge is key. This is demonstrated in the result of our annual distribution of theme analysis, where a correlation was found between the timely emergence, or popularization, of a novel surgical technique, and the year of travel in which it was first recorded as a theme interest. Other incentives include the powerful perception of the value of the TSF/ CTF award itself, as an opportunity to advance one’s career.
Additional factors include the opportunity to present completed or ongoing work of research or simply to attend conferences and forums and the ability to connect with master surgeons.
The values obtained in this review are multiple. The most sought-after theme-interests were, consistently, shown to be: minimally invasive surgery (laparoscopy, robotic surgery, and TaTME), the organization of healthcare, surgical training and mentoring, multidisciplinary management of challenging colorectal cases and new approaches to the pelvic floor and proctological conditions. Less quantifiable, but non the less frequently expressed were the powerful values of building a lasting mentor-mentee relationship, advancing surgical knowledge, gaining operative insight, embracing the opportunity to reflect and question, the ability to compare and contrast, and finally to represent one’s establishment in a public relation exercise. For international traveling surgical fellows (ITF) from low- and middle-income countries, their experiences, highlighted in this review, reveal a palpable impact on surgeons’ attitudes, their institutional workflow in managing complex colorectal cases, and on community-based initiatives such as screening programs.
The COVID-19 pandemic had a significant impact on surgical education, including how selection process for ITF is conducted also. It’s observed that the virtual enrolment has the potential for cost savings, by transitioning fellowship interviews to virtual platforms, each ITF candidate saved about a $6,000 in interview travel expenses, and the fellows required less time off from their residency programs. However, these ITF candidates missed some of the live aspects of interviewing, and training programs when they switched their interviews to virtual formats [39].
The disruption caused by the COVID-19 pandemic effectively resulted in the suspension of TSF/CTF for two years. Candidates have instead explored the possibilities offered by internet-based platforms. These technologies have enabled borderless and synchronous communications, permitting a broad spectrum of virtual interaction. Substantive evidence has since emerged on their efficacy, validity, cost efficiency and broader reach [14–17, 39, 40]. It now continues to be adopted by many institutions in mainstream technical and non-technical surgical training [41]. The lasting impact of covid and these technological advancements on the course of TSF/CTF is yet to be seen. Recent advertisements and figures published by the ECP and ASCRS suggest continued support for CTF [42]. But the future may be shaped by other important factors such as cost and carbon foot printing.
This review has highlighted the many merits of traveling fellowships, their importance to individual candidates, and their deep professional impact. New technological and online interactions are unlikely to be, in the short and intermediate term, disruptive to this tradition. However, shortly a hybrid approach is likely to be synergistic.
This review has limitation as it is a retrospective, heterogenous, and positively- biased statements expressed in post-fellowship reports. In addition, current findings may be undermined by the lack of limited or unpublished information from a significant number of surgical organizations. Future prospective standardized feedback will be needed to validate our findings and could help guide and inform the standard of practice. Furthermore, the benefits and impacts of inviting host surgeons and institutions need to be investigated and are likely to be of significant value.
“In an increasingly digital, distance-learning, homogenous, one-size-fits-all era, the James IV Travelling Fellowship captures the essence of this immersive method of exchanging surgical knowledge and keeps it very much alive. There are some things you just can’t Google” [43]. Mr. Euan J Dickson, James IV Association of Surgeons Traveller 2019 British Isles & Rest of the World Group