Taking a bite of the Big Apple: doing a fellowship in New York
Authors: Arundathi Mahendran
Publication date: 02 Nov 2012
Arundathi Mahendran found her transplant surgery fellowship in Manhattan daunting but rewarding
I recently returned from Manhattan, New York, after a two year surgical fellowship in abdominal transplantation (kidney, liver, and pancreas). I clocked up 691 working days, doing on average 90 hours a week, with a total of just under 9000 training hours. In that time as primary surgeon I did 123 kidney transplantations, 42 liver transplantations, and 12 pancreas transplantations, not to mention the various reoperations for complications and emergency surgeries. To say I was exhausted and frazzled by the end would be an understatement. However, I returned home content and confident that I could now call myself a transplant surgeon.
Seeking new training opportunities
I knew early in my medical career that I wanted to be a transplant surgeon. However, the Medical Training Application Service debacle of 2007 made it clear to me that I would need to target and organise my own training to get ahead on this career path. My mentor suggested that I investigate alternative training routes, so I started looking at programmes in the United States.
I was amazed by how organised the training programmes are in the US—they have large case volumes and an opportunity to develop a broad skill base as well as highly specialised and advanced surgical techniques. Training in New York would give me unparalleled operating time, a breadth of clinical cases, and experience of using sophisticated surgical technology.
When I was a clinical fellow I applied for, but didn’t get, a place on the specialty training year 3 transplant programme, so I sent my CV to a number of places across the US. I was particularly keen to work at Columbia University/New York Presbyterian Hospital, with an opportunity to be trained by Lloyd Ratner, the transplant surgeon who pioneered laparoscopic donor nephrectomies.
Running the bureaucratic gauntlet to obtain a licence to practise in the state of New York was the next step, followed by the US medical licensing examinations, which were painful, because I last studied basic medical sciences years ago at medical school.
I knew no one in New York, so finding somewhere to live while still living in London was a challenge. However, the opportunity to live and work in Manhattan is the stuff that dreams are made of, so I persevered and found an apartment in historic Harlem, the home of jazz.
Practising abroad
Everything about training in the US felt new: from the laboratory values and vocabulary to the way in which people spoke and represented themselves. Gone was, “Take this patient to theatre!” to be replaced by, “This man needs to go to the OR stat!”
The average day during my fellowship moved quickly and was packed with ward rounds and non-stop operating. When I arrived, the programme director greeted me with the following declaration (imagine a Brooklyn accent): “Rest up Arundi, coz from Monday . . . your ass is mine . . . for two years.” From the day I started to the last time I walked through the hospital corridors, I was on call 24 hours a day, seven days a week. Each fellow is given a Blackberry, which goes off constantly, to the point that different consultant and team members were given their own ringtones so that when a phone went off in the middle of surgery we could tell whom it was for and the level of urgency with which the call should be dealt.
I missed the emphasis on welfare of juniors that we have in the United Kingdom through the hours restriction of the European Working Time Directive. No one in New York monitored my hours or showed much concern; I was perennially exhausted, and my diet suffered. There was also little free time to do anything other than operate.
I remember flying to North Carolina to procure organs and bring them back to New York to transplant, arriving there, and seeing only the four walls of the operating theatre before being driven back to the airport to fly home with the goods. That was the extent of my travel in the US.
It was a hard life, but you come out of it “bomb proof”: little fazes you, and you are confident in your skills and aware of your limitations in looking after the sickest people.
Benefit back home
At my fellowship graduation I was awarded a certificate by the American Society of Transplant Surgeons to say that I was a credentialed specialist in liver, kidney, and pancreas transplantation. In the UK you are unlikely to train in three organs and usually spend your higher specialty year training in either kidney or liver transplantation. Not only did I earn this certification through my fellowship, but afterwards I knew without a doubt that I had more than the required skills, experience, and knowledge to be a competent and safe transplant surgeon anywhere in the world.
Buoyant with the skills and experience I gained in New York, I’m ready to plough that back into our “socialised medicine” model (the description my US consultants gave the NHS). I enjoyed my time in New York, but I missed the values and beliefs that our battered old NHS still champions—comprehensive healthcare is a human right, and as a society we hold that principle close to our hearts.
Competing interests: None declared.
Arundathi Mahendran PhD student in surgical education
Goldsmiths College, University of London, UK
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