E25 Fellows On Fellowship

Listen to this podcast on SoundCloud

Chad Ball  0:00

Welcome to Cold Steel, the Canadian Journal of Surgery podcast with your hosts Ameer Farooq and Chad Ball. The goal of the CJS podcast is threefold. The first is to highlight the best research currently being completed by Canadian surgeons. Second is to offer educational topics for both surgeons and trainees alike and most importantly, the third goal is to inspire discussion, thoughts, creativity and career development in all Canadian surgeons. We hope you enjoy it.

Ameer Farooq  0:49

Surgical training is a series of tremendous transitions starting from the transition from medical school to residency, from junior to senior resident, and then the equally big step of going from residency to fellowship. In this episode we were lucky enough to be joined by two fantastic Calgary surgical fellows. Dr. Greg Knapp is a Calgary surgical oncology fellow and Dr. Salila Hashmi is the Calgary hepatobiliary fellow. We talk to them today about how to get the most out of your fellowship, making that mental mindshift from being a resident to being a fellow, as well as the complexities of applying to a fellowship, which reference letters to use and even get into the details of applying to a US fellowship if you’re a Canadian applicant. Check out the links below for more tips and tricks. Can you start us off by just telling us a little bit about where you guys both grew up and what your training pathway has been just so our listeners can learn a bit about both of you. And Greg, How about yourself? Where did you grow up in what what is your training pathway been?

Salila Hashmi  01:49

Okay, Ameer thank you, and thank you Dr. Ball for having us here. Um, so I’m originally from Pakistan. I lived in Karachi, which is the largest city of Foxconn, for first 24 years of my life, went to medical school there. And then as soon as I graduated, I came to the US spend two and a half years in the immunology lab at Emory in Atlanta, Georgia, worked under my great mentors, Dr. Alan Kirk, Dr. Chris Larson and Thomas Pearson. And after that I ended you know, did my surgery residency and critical care fellowship at Emory. And now I am here in Calgary pursuing hepatic artery surgery fellowship.

Greg Knapp  02:43

Again, I’ll echo Salila’s thoughts. Thanks for having me. My pathway is not nearly as exciting or as global as Salila. I grew up in southern Ontario, on the south side of the lake in town called Grimsby, which no one from Toronto knows where that is. But it’s about a 45 minute drive. And went to undergrad at McMaster and then did actually apply to medical school and a MAT and graduate school at the same time. And probably as a shock to most people, including myself, I got into both and was able to defer medical school to go to London to do a one year Master’s in international health policy at the London School of Economics. I then came back did medical school at Mac and then went went out to Halifax to do my general surgery training. Five years there, then I actually had a year in the community as a general surgeon in the small town of Woodstock, New Brunswick has kind of a gap year between residency and then my fellowship training in New York at Memorial Sloan Kettering and then here in Calgary and surgical oncology.

Chad Ball  04:12

Great, what prompted you to to pursue a fellowship in surgical oncology? And I’m curious, you know, especially given your tract how early did you make that decision along your pathway?

Greg Knapp  04:23

So I was definitely a late bloomer. I, you know, when I, I, I’ve thought about this a lot over the years. And I think one of the factors was, I think I did at least initially struggle to kind of find a real mentor that had that just really clicked with me and early in my training, and then kind of on top of that, I just had a real broad interest like I just seem to love everything like in general surgery was definitely the right fit, but slotting in to where did I want to live or what kind of practice that I want to have, you know what was going to be my niche was tough. And so I actually bounced around I did. I did a two month elective in Cape Town at Tygerberg and trauma. I then ended up doing senior electives in pediatric surgery. It was only after I came back from my peed my pediatric surgery electives, onto surgical oncology that I had that kind of like, Oh, yeah, this is the right fit. I don’t think I realized how much I didn’t like pediatric surgery until I came back to surgical oncology. So I didn’t I honestly didn’t really know until I was like, probably halfway through my fourth year, almost into my fifth year. And so that really, you know, that definitely created some challenges in terms of getting into my surgical oncology fellowship, ultimately. Because I didn’t have that kind of lead time. But we know that was my, that was my, that was my kind of my journey into it. What brought me you know, why surgical oncology, I think what really got me going was just, I liked, I liked the complexity of the kind of multi disciplinary decision making. I like the fact that, like, you had to be like, I admired the surgical oncologists that, you know, because they, they really had to be on top of kind of a rapidly advancing front of knowledge. And on top of that, the ones I worked with in Halifax were really amongst the most kind of technically comfortable in the abdomen in a wide range of scenarios. And so I also really, I found that appealing.

Salila Hashmi  06:45

So for me, it was switching gears a little bit too. I started when I started residency, I thought I wanted to transplant and you know, the two and a half years that I spent in the lab had sort of set the stage for that. But it wasn’t until my third year of residency that I decided I wanted to pursue hepatic artery surgery. And I think my mentor, Dr. Juan Sarmiento had a huge role to play in this, you know, both for my interest and my perseverance to pursue this. You know, the complexity of the patients, the disease processes that we see, the operative finesse that’s required for hepatic artery surgery, and the ability to take care of both the benign and malignant disease processes is what really drew me to this field. And that’s how I ended up here.

Ameer Farooq  07:33

The whole idea of this episode is really to try to explore a wide range of issues around pursuing fellowship, you know, everything from how to get into a fellowship, how to apply to one what drew drew drew to one, and I think one of the interesting things about fellowships is sometimes about timing. I think, Greg, you sort of had an interesting path for starting fellowship, in that you spent some time as a community surgeon prior to coming back and pursuing a fellowship. What, what made you want to come back and do a fellowship? And what was that transition? Like? And how do you think that year that you spent as a community surgeon changed your perspective and experience during your subsequent fellowships?

Greg Knapp  08:22

So, to address the first question, you know, what made me kind of come back, I think it’s important to kind of just state that, like, I ended up applying because of that lag time for my fellowship in my fifth year, so I knew, like I knew, at least by the by, by like, a year five, I want to do surgical oncology, we got to make this happen. And apply them. And then, you know, knew I had a spot by the, you know, kind of, say, June of my fifth year, so I knew I had this gap year, so I didn’t go into community being like, I want to be a committee, general surgeon, and then and then switch out. And I think, you know, I think that the people minor, because I’ve got a bit a taste of both. I think that that would be difficult. I think it’d be difficult if you were like, a community general surgeon for several years, certainly not impossible. And I’ve met some interesting people on the way who have done that, including one of my mentors in Halifax. So totally possible, but I think it’s quite difficult because you kind of get out of the kind of academic flow. But you know, so I think that that’s kind of, you know, point number one, I think point number two was, I thought that that year in the community was brilliant. I loved it, I thought like you, you work like a dog for five years. You know, the fifth year is a total grind. And then all of a sudden you kind of finish and then I had these like 12 months to a) decompress a little bit, but b) I was working in a rural hospital in kind of northern New Brunswick, there was just two surgeons, I was applying my kind of general general surgery skill set and knowledge base that I had just spent 12 years cramming the nuances, I got to apply that kind of right away. And so for me, I thought it was a great year, it was almost like, yeah, you know, in some countries where they have that kind of forced year of like military service. You know, it was like, I probably wouldn’t have chosen to do that. Had I, you know, crafted my ideal plan, but I thought it was a great year to just get out there, pick up some skills, apply the knowledge, make some mistakes, learn how to run an office, how to deal with, you know, interesting personalities in a small community. And so I took a huge amount of it in terms of the transition boy, like what a culture shock, like going from rural New Brunswick to Memorial Sloan Kettering, you know, that was an interesting transition, you know, from kind of flannel shirts to like silk ties. It was that it was neat. And that was, it was, you know, obviously, it was a transition, but it was one that, you know, at the end of the day, I still had, I still had, like a, I was still coming into it with like a pretty competent skill set. And so I think that, that, although I didn’t have maybe the pedigree of some of my colleagues, I certainly felt comfortable with with what I had to offer. And I knew why I was there, you know, to pick up that kind of nuanced. You know, oncology, training and management. So the transition actually wasn’t that bad. And it was actually a real thrill. And looking back on it now. It’s a really neat juxtaposition between two systems.

Chad Ball  12:00

In, as you’ve mentioned, a couple of times, you’re trained in the US for a period of time, and now you’re training in Canada. We’re, we’re curious, and you don’t have to hold back, I promise, despite most of the listeners being Canadian. What are some of the differences you notice? It can be at the fellowship level, but certainly at the resident level between the US and Canada, in terms of in terms of training in general?

Salila Hashmi  12:23

Yeah. That’s very interesting. You know, so one of the first things that I noticed, both for the residents and the fellows for, you know, being here in Canada was the autonomy. I think, both in terms of operative autonomy and clinical autonomy. I feel like the residents and fellows get way more than I had experienced and seen in the US, which certainly reminds me of my time that I spent at Grady, which is a county hospital that, you know, us as residents at Emory spent, probably if not half, you know, majority of our time, doing trauma and especially general surgery there. You know, in the academic centers, it’s, it’s a little difficult for both the clinical and operative autonomy because you have, you know, constraints like turnover times for the operating room. So there’s, it’s going to be hard for the attendings to give you, you know, from skin to skin sort of time to do those cases, because, you know, they’ll probably let you or you’ll decide on a part of the procedure that you really want to do, and they’ll let you take lead on it. Or they’ll let you start the case with a resident, but it’ll be you know, difficult for them to let you go ahead and, you know, take three or four hours at a case just because they’re constrained in the time that they can give you. Um, you know, and the second thing I would say is that the attendings are a little bit more approachable. You know, I’m pretty sure some of the US attendings may not agree to me with me on this, but I feel like the relationship between residents and fellows, for lack of a better word, I would say, it’s more on friendlier terms, then, you know, in the US, like, I would be scared to talk about some general things in the US which here, I can just bring it up, which could also be because now I’m a fellow, you know, I’m particularly more comfortable talking to attendings than I was when I was a resident for sure.

Chad Ball  14:17

Yeah, that’s interesting. You know, having a lot of us appears, you know, do our fellowships in the US and then often come back, not always, but but usually we do and there’s certainly something is there’s something to what to what you just said there’s a very different relationship and it’s a neat relationship between the fellow and the, and the faculty, I think, because to some extent, I experienced the same thing when I went both to Atlanta and Indianapolis and elsewhere as well. That relationship is is quite close. It’s quite neat. And it’s something you get to carry with your for really the rest of your of your career. A lot of us that have good experiences certainly certainly do. What about in terms of workload for the residents outlook, patient care, you know, individual responsibilities surrounding patients. Do you have any comments on differences with that regard?

Salila Hashmi  15:10

Um, you know, initially when I came, I thought, oh my god, the residents here not working as hard as they are in the US. But certainly that has changed over time. You know, I think we work equally hard here. As far as back home, you know, some of the differences were that our medical records are electronic. So, you know, by the time I finished rounds, here, all the notes are written, all the orders are done, which for an intern or a junior resident back home, that’s like the first hour of the day after you finish your rounds. And you really, you’re not allowed to be in the operating room until you finish that work. So you know, that takes a little bit away from the operative experience, but then it also teaches you, you know, time management that you have to finish your work in the first hour, you have to prioritize things, and then, you know, especially if you have to make it to the operating room, so I think both have their advantages. You know, one thing and I can only obviously speak about the residency at Emory, I think residents here certainly I love the fact that they have half day here where they have dedicated time, you know, gradually as the residents when I started, we only had one hour, you know, and that was just electric given by one of the attendings. And then, you know, we had, it’s gradually moved to two hours, but certainly having a half day to yourself. You know, I think it’s, it’s great for educational purposes, because it is very hard to find time during a grueling schedule to, you know, study and keep up with the academic work as well.

Chad Ball  16:46

The truth is, you know, both places I did my fellowship in the US, obviously, one was Emory like you, the other being any Indiana University, as well as lots of places I’ve visited, doing grand rounds and so on. And professorships, the reality is like an hour a week that’s protected is sort of pretty typical. And I think, you know, the residency is in Canada, you’re right there, they’re much better structured in terms of a lot more significant, protected educational time. So, you know, that’s something that we’re very lucky to have in Canada.

Ameer Farooq  17:20

I wanted to shift gears here a little bit, you know, start really getting into this idea of making that transition from being a resident to being a felon. And I’m trying to do this myself, as I head towards my own fellowship in colorectal in Vancouver, in July. You know, obviously, surgery is a very graduated process, and and training is a graduated process. And so how did, let’s maybe start with Salila, how did you approach making that transition mentally, from being a resident to being a fellow? And what do you think some of the key differences are? Just in terms of how you run your team? Or how you think about your role? Just overall, what how do you how do you think it’s different being a fellow versus being resident?

Salila Hashmi  18:10

Yeah. So as you know, I’ll see that as a fellow You are the backbone of the team. Residents will come and go. So you know, you, you are going to be there for the year or for two years. So you have to set the precedent for everybody else on the team. You know, you want to be the team that every resident wants to come to and, you know, be a part of. So, you know, that’s, that’s on you how you set the mood and the tone and everything. Like you can’t be confused about a plan and expect the team to follow the plan. Like you have to have a clear thinking in your mind. If something’s not clear, and you have to run it by attendings. Just be upfront about it. Listen, this is something I’m going to talk to the attendings and I’m going to circle back and get back to you about a final plan. And, you know, whatever you have final plans, just go ahead and do those. The other thing is also I’ll say that, you know, Dr. Dolman, my program director always told us that when you’re preparing for cases, be prepared, that if the attending cannot make to the operating room, you should be able to do the case. And you know, it certainly holds true for fellowship, and not only being able to do the case, but also taking residents through the case. So you know, you’re not only that you’re learning you know, new techniques or you know, you’re you’re improving on your techniques, but you will also have to take a junior resident or a senior resident, even like, you know, through a case and you know, give them feedback, how they can do things better. So, like you how you expose something so that they can do better for you overall. You know, and then it’s just very more personal like every patient is your patient. Every complication is your complication. Every success story just feels a little bit more personal. You know, this is your family and you have to take care of it. Yeah, I mean, and but it’s, it’s, it’s fun, and it’s rewarding. And, you know, it’s great.

Greg Knapp  20:05

I think the I think the points that that Salila brought up are, are bang on, I think, you know, when I was looking thinking about, about some of the material for this for this podcast, I think that i think that that the the ownership component and to use that word, I think that’s really, for me what kind of separates, you know, the the resident fellow consultant, like transition, and as we already kind of alluded to, like, I kind of had this 12 months where, you know, it was just me, right, and there was nobody else. And, and I think that probably accelerated a little bit. That idea that, you know, as a fellow, you’re, you definitely, I think you not only feel a greater responsibility, but it is it is placed on you. And I think that that is, is a really key part of that transition through fellowship into a consultant post is both taking it on and then embracing that, because I think that is what differentiates, you know, ultimately kind of the trainee from the kind of from the ultimate provider, right. And there’s like, with that change in mindset, it, I think it subtly changes your approach to like how you see patients in clinic, all of a sudden, like, you’re not kind of missing things you’re like, Okay, like, in order to get the patient from like, this is the diagnosis and the workup to the operating room, there’s a whole bunch of other steps, right, all the logistics, all of the, you know, all of the stuff that you’re not really privy to in residency, where you’re just focused on saying, okay, like, this is the problem, this is what we’re going to do, and then all of a sudden fellowship, and then you know, the beginning of your career, you realize that, there’s all these other things that you got to do to get the person safely to the operating room to get them through the operation. And then like out the other side. And a lot of those aren’t like in textbooks, they’re not taught they are centered dependent. And in those, I think the little bit kind of wrapped up with a true ownership of that like scenario in that patient encounter. And I think that’s what kind of defines a big part of what’s different about a restaurant versus a fellow, kind of just in broad strokes.

Salila Hashmi  22:44

One comment I’ll make is also, like, involve the team and ask them for feedback. They may not like your style of leadership, and you may have to change gears and you know, do things a little differently. I hadn’t worked with Canadian residents before. So I don’t know what they’re used to as a fellow. So you know, I have to stop and ask them, is this working for you guys? Like, is this working for the team overall, like asked your attendings? Are you doing a good job so, and you know, you’ll be surprised that you will get some feedback that will certainly stop you from doing what you’re doing and make you think and you know, change some of the things and actually make you better. So  be prepared for that, too.

Ameer Farooq  23:24

I think that’s really, I’m gonna use that advice very, very closely. Hopefully, you’ve come July. So, I wanted to talk a little bit now about some specifics about pursuing a fellowship. And maybe first we’ve kind of touched on this a little bit with with you guys about actually figuring out what kind of fellowship you both pursued. Maybe, Greg, you can just talk maybe in broad strokes, you talked about what excited you about surgical oncology is what sort of things do you think residents should think about when trying to pursue a fellowship in a particular area, but also about where to pick a specific spot or a specific program to do fellowship? Because that’s also I think, a key aspect of doing a fellowship is really trying to figure out where to go and on where you really fit in.

Greg Knapp  24:27

Definitely. For me, the year at MSK you know, prior to coming to Calgary, I think kind of captures an interesting, you know, anecdote to share because this that fellowship was, was 12 months. It was it was a new fellowship in Global Oncology and I was actually the first fellow in this new stream where it’s kind of six months of clinical six months of research. And ,the only reason why I got there is because I ended up at the end of residency, you know, really realizing that, like, I was going into surgical oncology or that was my interest. And I was still cultivating all along, kind of a research portfolio in, you know, first global health, and then, you know, kind of global surgery. And then realizing that I was gonna have to find some way of marrying that with surgical oncology. And I hadn’t really found someone that had done that was doing that I didn’t have a mentor kind of in that space. And so I literally just spent, you know, several weeks kind of looking and reading and doing some research and found Peter Kingham at MSK (Memorial Sloan Kettering) and I just sent him a cold email, I just sent him an email out of the blue saying: Listen, like, this is my basically, this is my story, these are my interests, it looks like you guys are doing some research, and have this program in your global cancer disparities initiative, that totally jives with, with where I want to go, can we just chat, and that’s basically how, you know, we had a conversation, and then one thing led to another and he was like, You know what, we got something coming down the pipeline, that may be a perfect fit for you. And so that’s how I ended up in New York. And so I think it just, I think it speaks to, you may not have someone that is going to tell, you know, it may not be obvious, right? And where you’re going to do fellowship, and someone may not come to you and say, Greg, you know, you should go to Toronto for surgical oncology, or you should go to Calgary, you know, depending on your mentorship environment, you very much may need to, you know, take it into your own hands, think outside the box, think broadly. And kind of look for opportunities that aren’t necessarily advertised. Because I think that people respond really well to, you know, initiative and when you come to them with ideas and particularly when you come with them ideas that are kind of coupled with kind of solutions or a plan, you know, people are very responsive to that. And, and so, you know, that’s a little bit rambley and a little bit of an offshoot but, you know, my certainly my, my first fellowship at MSK was was not with that was not a textbook, you know, that was not an advertised, you know, kind of textbook year, you know, that kind of came about in a different way. But it was probably one of the most fundamental years of my training, and really will have a massive impact on my career trajectory, especially on the academic side. And, of course, you know, Calgary was very, very responsive to that, you know, when I came back to Calgary and said, Hey, I may I, you know, there may be an opportunity for me, you know, to do a year in New York, you know, what do you guys think about that? Could we make that work? You know, Dr. Mack in the Calgary group was super supportive. They’re like, yeah, of course, like we can we can we can make this work. But we can find a way of allowing you to do both, you know, well, you know, potentially keeping your spot here. And so there was a whole, you know, there was a lot of wiggle room that you didn’t really realize actually existed. If you came to people with a, with a plan.

Ameer Farooq  28:39

I think it’s so key in this whole thing is, yes, you need to find a fellowship program that you want to go to. But I think the key in this is that you really, also have to really understand what you want out of your fellowship and what your overall plan is, because I think people can help you move that plan forward. But if you don’t have a plan, then it’s hard. I think, for any group to really make that happen and to cultivate your interests. How about for you Salila? How did you decide on coming to Calgary and what were the specific things that you were looking for in a fellowship? And I know you did a fellowship prior to coming to Calgary as well.

Salila Hashmi  29:22

Yeah. So you know, when I was I wanted to do hip out of rotary and there are three essentially routes to do it. You can do transplant surgery and go to a program which has a high volume HPB service with transplant, you can do a surgical oncology fellowship, and, you know, potentially either do an extra year of HPB or make your surgical oncology fellowship such that you spend more time on HPB services, or you can just do a HPB fellowship. So, you know, again, you have to know what you want at the end of the day. And despite coming from a program, you know, Emory is very heavy on surge on training. I knew that I wanted to keep my general surgery and, you know, add a multitude of hepatic biliary surgery in addition to that. And so that’s why I went, you know, for the hepatic artery surgery route through the fellowship Council. It’s interesting when I tell people that I’m training at Calgary and you know, knowing my global history, they’re like, are you a Canadian? And I’m like, No, you know, it’s a great program. It’s one of the, you know, 14 programs that are in the match for the fellowship Council. And so you know, the expertise that are available here, the case volume, the variety, you know, and also the general feel that you get, once you interview, like, you know, these, this is going to be your family for a year or two, are you going to be happy here? Can you work with these people? Do you see them as your future mentors and like Dr. Ball mentioned, like, you know, this is going to be lifelong relationships for you. So all that, you know, plays a role in deciding where you want to go?

Chad Ball  31:02

That’s well said Salila. Maybe we’ll start with with Greg for the sort of next two part question. There’s no question. It depends, of course, you sort of alluded to it, who your mentors maybe have relationships with, but how do you how do you get in the door? Do you guys think of a given fellowship or fellowships if you don’t have any personal connections to it? You know, Greg, you talked a little bit about about your, your cold email. And I think that’s great advice. A lot of us have experienced that whether it’s residency electives or fellowships, for sure. You know, I’m curious what your thoughts are, I sort of I don’t know whether it’s right or wrong, but I usually give the residents when they come to me and ask that question, a two fold answer, I say, you can open all the doors in the world, based on in, like we said, connections with maybe your mentors to that sub specialty field or given institutions. Or you can simply make your CV and your application package on paper undeniable. So dropping a phonebook of publications in front of, you know, an applicant committee is hard to ignore. So I sort of think that there’s, there’s two ways to do it. And you certainly see on the receiving side on the on the faculty selection side, examples of both great, Greg, what do you think of that? That concept?

Greg Knapp  32:26

As I, as I was mentioning, earlier, that, you know, certainly I have definitely taken and have executed the one route, which is, which, you know, which is that kind of wisdom research, kind of reaching out and trying to cultivate something like denuvo. And I think just, you know, kind of really relying on putting yourself out there. And in making it, you know, really kind of presenting a case and then making it easy for someone to say yes. I think that there’s a lot of I think that there’s a lot to say about that. And that can be successful. I totally agree, though, that I think that’s probably not that, you know, a dependable route. And there’s absolutely no doubt as you know, when I think I was a little bit naive, until I went down to the US and, you know, that first couple of weeks at MSK and you realize, you know, what the other people in the room have accomplished in residency, what they’re bringing, from a research background, from a publication background, and then the skills that they’ve had to acquire and doing that, like, you know, the fact that they’ve pumped out 20 publications, you know, those aren’t just 20 publications to pad a CV, they’ve also had to work incredibly hard. And there’s a huge amount of subtle learning and skills that they’ve acquired along the way to get something to publication. And I think that is what is recognized. And, they are able to converse and move around in that they’re in a research world much more easily than someone who doesn’t have that same depth. And I think that that’s, you know, that certainly goes a very long way. And there’s no doubt that if you’re kind of coming from a Canadian program, if you are interested in fellowship opportunities that are either going to be a part of a North American wide match, or you’re competing against American applicants or want to go down to the US that you know, that is going to have to be a part of your game and that that is going to have to be a part of your process in order for you to be successful. So I totally agree. I I think that they’re kind of multiple approaches, I think combining, you know, I think in a perfect world, I would, you know, you would combine kind of my initial cold email, you know, cold call, looking for opportunities, creating opportunities, along with a undeniable CV, right? In one that really backs up, really backs up your interest and speaks for itself.

Chad Ball  35:24

I think your comments are dead on about research in particular, and not because you may have a career that’s heavy in research going forward. But you’re exactly right. It shows the faculty selectors are selection committee, that you can take a project or ideally, multiple projects from start to finish, meaning you’re a finisher, and you have insight into more than just the technique of a laparoscopic cholecystectomy, or a given procedure, you have that greater sort of wider view. And that’s clearly very, very powerful. And I’ll tell you that, again, on this side of the equation, it is a really strong predictor. For a successful fellow. It’s it’s not the only predictor. And it’s not always right. But in general, it’s quite a reliable measure. So you’re exactly right. And I do worry, you know, it’s particularly in Canada, less so in the US that are residences as they drift away from completing research projects, and it becomes less of a core tenant, that that’s going to hurt some of the applications, particularly to the US.

Salila Hashmi  36:33

As an applicant, you know, standing out, I completely agree with Dr. Ball, you know, there are two ways to do this. Again, if you have made up your mind early in your residency about, you know, wanting to do something particular, then plan for it, you know, if you’re going to go to a competitive fellowship, surgical oncology peds, even hepatobilliary now, you know, plan like, you could potentially take a year or two in the middle, to do some more research, you know, to build up your CV, I was reading an article, you know, preparing for this talk a little bit and looking at the surgical oncology match. And it seems like that the prgrams want, at least one first author, publication, published, and reputable journal, and, you know, at least five publications that you’re a part of, and, you know, I think with time, it’s just going to get even harder to, you know, get into these competitive fellowships, because everybody now wants to specialize, you know, especially in the US, like, out of the 10 surgery residents that we had, I think only one went into the community and the rest all are doing specialty fellowships. And so how are you going to decide between one person and the other specially to get through the door, like, you know, there are going to be cut offs for every program, you know, be it the number of publications, be it your scores, you know, we have the app site in the US and I’m sure there’s something similar here in Canada. So you know, plan ahead, put in the hard work, you know, talk to your mentors, if you don’t have a specific mentor in your program, talk to your mentors, they may know somebody, like if you, you know, like, we didn’t do peds surgery as an intern, and then as a fourth year. So if you know, you want to do that, you know, talk to your current general surgery, mentors, they may have friends from med school, or you know, somebody else who they can hook you up to, to be as mentors and you’ll be surprised like how small this world is. And there will be people who will help you out to get to what you want to do.

Ameer Farooq  38:38

I think we’ve all highlighted how important your CV is, and all this what do you what do you think electives fit into this equation Salila, how important are electives in securing a fellowship? And then when you’re on your electives, what do you what do you think are some key important things to do to stand out while you’re on elective?

Salila Hashmi  39:01

Yeah, so I think electives, I think of them as a double edged sword, honestly, you know, while you have a chance to go and show them how good you are, there’s also a chance they’re not going to like you, you know, they may potentially give you, you know, an invite saying that, okay, fine there, we’re here for, you know, an elective, but they may not like you. So, you know, 30 minutes is different from spending four weeks with them. So, you know, be careful about deciding to do electives, certainly for fellowships. You know, I think the letters, the scores, the work, you’ve put in, you know, speak volumes as well. So, if you’re really struggling deciding between places, you know, maybe doing an elective may be helpful, but I didn’t do an elective for HPB. You know, but I did spend my six months in my final year on the HPB service like I wanted to be ready when I start as HPB fellow You know, so I think it’s something very personal. It also depends. I don’t know if the Canadian residents do more, you know, electives, but certainly the US residents, it varies from program to program. As for doing, you know, but I’ll go back to my, like I said, I did three months of electives in, you know, medical school. And that’s how I decided I really want to come to US to train here. So it certainly set a pathway for me. So again, you know, you just have to be careful as about doing well in electives. You know, it’s it, I think, it just really boils down to small things, like, be on time, you know, be there available for anything and everything on the service, think of yourself as part of the team. You know, you want to be enthusiastic, but then there’s, you know, there’s a line that sometimes you cross and you’re like, essentially on the nerves for and I think we’ve all had students like that, certainly, you know, in our services, or some even residents where, you know, they’re overzealous, they want to do a lot, but then they don’t know when to keep quiet, or, you know, once the appropriate time to ask questions. You know, they’re not judging you on how good your skills are, because that can be taught, but they’re really looking as a person, like, you know, are you somebody that they can work for, like I said, for a year or two? Are you you know, are you somebody who they can stand for in the operating room? Like, you know, for six, eight hours? If you have a long case? Are they are they willing to do that? Are they going to trust you with their patients? You know, so those are the key things. So I think it really boils down to how you are and how you present yourself as a person more than you know, what skill set you take.

Ameer Farooq  41:45

I realize, you know, you two both are probably unique in terms of your fellowship path, and perhaps, you know, electives actually maybe didn’t play as much of a role for either of you and your fellowships. Greg, what are your thoughts on electives? And did you do any electives in surgical oncology, prior to your application? And how important do you think those are, in retrospect?

Greg Knapp  42:14

So I did not do. I did not do any surgical oncology electives. As I said, I was gonna I was late to the game. I did trauma, pediatric surgery electives had used up the time I had before I realized that surgical oncology was for me. So I think that highlights that electives are not essential to get a fellowship spot, right. Like, I don’t think I could be faulted for not, you know, for not doing for not doing electives. I just, you know, just did not realize that that was going to be my kind of ultimate kind of calling or pathway. And so, I think, yeah, I think it highlights that you don’t necessarily need to have electives. Are they helpful, I think, certainly, it definitely taps you into the community. So if you do, if you spend some time across the country, you know, you meet the players, you meet the people who are who are kind of leading the field, whether it’s in Canada or the US, you meet the other kind of the other applicants. And so I think it definitely gives you a much broader kind of understanding, it kind of certainly broadens your scope in terms of practice patterns. And so there’s a lot of benefit. And, and then you just, you’re also a familiar face. There are other ways of doing that, though. And you don’t need to do an elective to be a familiar face to have your name out there. Whether it’s through research, through committees, there are lots of ways that I think you can mirror some of those benefits. So I guess, in the end, I don’t think it’s essential, I think it’s certainly helpful for the applicant that kind of realizes that that’s an important part, or is a pathway early on. But for those who are late, you don’t need to beat yourself up. There’s nothing you can do about it. And there are other ways that you can generate the same opportunities that electives do.

Salila Hashmi  44:15

One more common I’ll make for electives is you know, a lot of times, at least for students, I’ve seen that for medical students. You know, when you’re going to an institution, make sure you make arrangements, you know, early on to make appointments to meet with the leadership there. So as a student, if you’re going on electrodes, make sure you’re meaning the program director, if you can, you know, go ahead and make an appointment with the probably Chief of Surgery as well. I would say if a resident you’re going there, make sure if you know you’re not directly working with the fellowship director do the same. Have exit interviews, you know, it just really shows how interested you are and certainly that feedback is going to help you later when you visit them for a second interview or you know, even for other interviews overall for fellowships.

Chad Ball  44:59

That’s Good point, Salila, I would echo what you said, Greg, and then and then maybe add to it. Sometimes the electives that we do, as residents are just like the your description of what we do as medical students, it can be more for us than then even, you know, the reverse. And my personal story is very much like that I figured out quite early, I wanted to trauma as part of my job within residency and I went down for 10 weeks to a very well known US trauma program, where some of my mentors to train previously and I realized quite quickly that, that probably it wasn’t as as good as I may be wanted or maybe I should say, it wasn’t the right fit for me. I wanted a higher volume experience and to be honest, if I hadn’t done that, I probably would have ended up there, I suspect, just based on where it was and the sort of lore that surrounded it. But certainly where I ended up at the end of the day, again, was a place I hadn’t done an elective, which was Emory and that was for sure an incredible, I would say that probably the best experience in the US. So you know, it’s a little bit of us interviewing them to as the applicant, there’s no doubt, I want to ask you guys specifically about asking or trying to figure out who should write your reference letters. And I’ll just say, again, from the other side of the equation, that the reality is, I don’t know, 95 or 99% of the letters are all great. Like they all say this, this candidate is superb, I support them 100%, they’re going to make a great surgical oncologist or, or breast surgeon or whatever that is. So on our side of the equation, they can be quite difficult to decipher there is certain code words for sure that some people will use, but in general, they’re all quite good. Do you guys have any advice about about who to ask and how to ask

Salila Hashmi  46:51

Like Dr. Ball said, all letters are going to be great. So you know, you, you have to make sure that your letters are exemplary, you know, or at least one of them stands out as being the best. A couple of things, you know, if you’re applying for a certain field, like, you know, I’ll take example, hepatobilliary and I don’t have a single letter from my hepatobilliary surgeon, that’s a red flag, you know, why is the department not supporting me, you know, in doing what I want to do, but that being said, doesn’t mean all three or four, depending on how many letters you’re using have to be from the all from hepatobillary surgeons, you know, a general surgery mentor, or my program director may know me better than one of the other surgeons who I haven’t worked with or don’t have that much of a personal relationship. And I think you just have to be upfront about it. I don’t think you know, there are going to be very few attendings who are going to refuse to write letters, but you can be upfront about it and tell them is this going to be a strong letter? And, you know, I think you can get a general sense that is this really going to be one of your strongest letters that you should use versus is this just going to be general run of the mill, you know, a good applicant, which, like Dr. Ball said, a lot of other people will have. So, you know, a few things to keep in mind.

Greg Knapp  48:16

And just to you know, just to add to that. I think for sure, like, for sure, for sure. You need to have like, you know, if there’s a couple all the letters are good, then, you know, common sense would dictate that, you know, make sure, like, if you don’t have the foresight to do it, to ensure that your letters are also good, right, then that will immediately disappear. And that will immediately disqualify you from the process. Right. So, you know, it’s that the letters are about, in many ways, identifying red flags. So make sure you don’t have any red flags, you know, to you totally, you’re 100%, you know, have to have the backing of your local subspecialty. You know, and I think that as soon as I said, like, that’s a must. Because otherwise, that is a subtle red flag. And I think we hear stories anecdotally of that happening. And that’s not an uncommon theme that I that I’ve come across in the past. And I guess the third thing is it does appear to me that, you know, there it’s a super small community and it definitely helps I think that, you know, I think it’s a, it’s probably actually quite important to realize, and I don’t like to use this word, but like, what is the pedigree of, you know, what is the what is the family tree of your mentor, your institution? Where do they have connections who were their mentors, because even though it’s a small community there is definitely a pole, there’s going to be a familiarity, there’s going to be a relationship that your mentors have with where, where they trained and that, you know, those letters, if it’s also someone who you’ve worked closely with and have a really good relationship with, those letters are going to mean something maybe a little bit more, I think and so, I think that’s important to keep in mind because letters that are tied to a history, both kind of academically and personally, I think probably kind of help them float to the top a little bit easier.

Ameer Farooq  50:39

I think that, in my own experience has been important. And you really do realize what a small world it is, and how much that personal touch in a reference letter really matters. When when it’s two people train at the same place are we knew each other from residency? How much that that makes a difference? I wanted to ask you both about the dreaded personal letter, and I certainly struggled writing my personal letters for fellowship, because it’s, you know, you sometimes feel like you have to write this award winning Pulitzer Prize essay and I’m not sure that that’s actually right, or that or that programs really feel the same way about writing a novel or an essay for for your personal letter. So what do you have any thoughts about how to write a good personal letter.

Salila Hashmi  51:34

You know, so I’ll say, you know, like you said, you want it to be shining, and you want it to be a great essay, but honestly, like, I think, just make it simple, just and have it and just, you know, interesting, honestly, it doesn’t have to be long, it should just tell a story about you, and why you are here, where you are, and what do you want to do. You know, I was reading this article in a journal of surgical oncology, where they said that the personal letters, you know, the least likely of the things to matter in the, you know, when they’re coming to decide, and choosing a candidate, but certainly, if they’re, if there’s a close competition, like, you know, especially for residency, if there were four or five people or for fellowship there, like two people they’re trying to decide, that may really make or break the game for you. So, you know, don’t underestimate the importance of it but like I said, you know, it doesn’t have to be fancy with like big words. You know, just make it simple. And like I said, it’d be good, personable and interesting. You know, it also serves as a platform sometimes for your interviews. So be ready to like, answer questions that you’ve written in there, like, you know, don’t write anything that you’re sensitive about, or are not comfortable discussing in your interview and certainly don’t lie about things, you know, like, this world today, everything is a click away, you mentioned something that you’ve done, and you actually haven’t, people are going to find out about it. So you know, just be authentic.

Greg Knapp  53:10

Having, you know, again, I think I have a limited experience with this. But certainly I read letters in the past, I’ve written many myself, and it seems like a key it is to understand that yeah, it’s probably, it’s probably not the most important thing in your package but again, it can identify red flags and so you know, just keep it simple, don’t write anything crazy, you know, and have someone else look at it, you know, have someone else outside  of medicine, perhaps have a look at it, because you’re just looking for kind of a genuine kind of letter of intent. And, you know, it seems like the people that kind of go on at tangents or weave these complex stories, you either a) get lost or b) gives you a weird vibe. You’re just trying to state your intent, and then get you in the front door to let the interview or your letters or your CV do the talking.

Ameer Farooq  54:13

I think my sense and my approach to it was talk about why you wanted to do your particular specialty, and then, you know, highlight a few things that make you stand out. But I think that’s so critical that you actually get someone to read it. And to keep it simple. You guys are both now approaching sort of the tail ends of your fellowship and I’m curious how you structured your time as a fellow, Greg, particularly, I know that there’s a huge breadth of knowledge to actually get through in addition to actually improving your technical skills in the operating room. How did you structure your time in terms of reading clinical activities? And do you have any advice for people who are about to start their fellowships as to get the most out of it.

Greg Knapp  55:02

I think in an ideal world, you would know where you’re going to end up after your fellowship and I think that how you structure your fellowship is to a certain degree, I think it should be, I think it’s designed to be kind of tailored to the additional skills that you want to acquire, both from a technical and from a decision making point of view, that will allow you to excel, you know, where you see yourself ending up, you know, so in the environment in the niche, or in the community, filling, you know, a particular role. And so, I think an early understanding that you’ll be able to tailor you’ll be better able to tailor your training if you have an idea and if you’re working towards a particular job. Now, that’s easier said than done. That whole finding a job bit is just as nebulous and could be another podcast but I think that’s important. If you have something in mind thinking about that early working towards that, because I think it will really help it really helped me narrow your focus and, and allow you to really get the absolute most out of your fellowship. On top, you know, I guess on top of that, I would say that you have to know coming in what your weaknesses are. So regardless of where you think you might end up, if there is a, if there’s something that you’ve come out of residency with not a huge amount of exposure and I think that’s part of being kind of a reflective resident or reflective surgeon, what are your weaknesses, you know, and then addressing those head on because this is kind of your last opportunity as a full time trainee to just devote time to that, right and it’s precious opportunity and then I think finally, when it comes to reading and teaching, I personally find that if you can’t teach it, you probably don’t know it, right and so I like the idea of trying to do as much teaching as possible, both from a selfish point of view, because if you find yourself kind of stumbling or kind of, you know, fluffing over a certain topic, then all sudden, you’re like, Oh, yeah, I don’t really have that down cold, right. And so, constant teaching on the ward on the whiteboard, it helps me, it helps me reflect on what I need to what additional knowledge I need to pick up and I think it also helps just keep it regular. Just like in residency, I think, a slow steady accumulation is always better than been cramming and for me that’s about either trying to have a regular schedule of some questions or some reading, work or teaching, as I said, I guess just one last point on that, where you have perhaps a little bit more flexibility as a fellow than you do a resident. I found a particularly useful strategy for me. I’m certain that on certain rotations in my fellowship has been actually doing a better job of prepping for clinic. And that’s kind of allowed me to then take that clinic visit kind to the next level, especially if there’s some kind of complex new patients. It’s a really I find it’s been really helpful to kind of have a look at that list and really kind of dig into that patient before the clinical encounter, you know, where time allows.

Ameer Farooq  58:46

I’ve certainly, you know, in talking with the teaching, I’ve certainly benefited from your 6:30am fully white coated, tied up teaching sessions on the 10th floor of the Foothills hospital so I’ll say that it I’ve certainly benefited as a resident. So what advice do you have about in terms of structuring your time as a fellow and in focusing your learning during fellowship?

Salila Hashmi  59:14

Yeah, I mean, one thing I would say is, you know, this is not easy. There is a lot of behind the scenes work that needs to be done when you’re a fellow which you probably don’t appreciate as a resident, which is, you know, the sort of same thing that you don’t appreciate as a medical student, what you know, for the residents. But I think the key thing is to be organized, you know, make sure you have a weekly or a monthly planner, like know what cases you’re going to have for the next few weeks. Like you know, if you don’t have much information about the recent literature in terms of management or the disease process itself that you’re not familiar with, give yourself some time to come up with that. Read about that and don’t underestimate like Greg said, Don’t underestimate the importance of clinic, you know, this is the time where, where you’re going to be deciding not only about the patients that you’re going to be operating on, but you know, deciding not when not to operate on patients. And I think sometimes as a resident, you don’t appreciate that, but in a few months time, you will be in those shoes where you have to make that decision. There’s, you know, you can maybe call your mentors, but you know, it’s going to be hard and you are going to be in those tough shoes and so the more you do that, the more patients you see, the better you’re going to get and the more comfortable you’re going to get for sure. I think that’s what I would say, and like Greg said, obviously, if you’ve gone to something, you don’t know it well, be honest about it. If I don’t know the answer to something, and I think Greg was on service, and we had, you know, quite a few discussions and, you know, there were things that I didn’t know the answer to, and I, you know, we were like, okay, let’s look it up, you’ll look this up, and I’ll look this up and, you know, it certainly helps and you will be surprised how sometimes, you know, question from a resident or even a medical student, or sometimes even nursing staff on the floor, can certainly just lead you down and track where you really need to read up a lot on a certain topic, which you thought you knew well.

Ameer Farooq  1:01:20

Just to drill down a little bit more about the reading side of this. Did you guys both,  Greg, maybe to start, did you pick a particular text and sort of make a regular reading schedule? Or did you, as you say, read around certain cases or topics that, you thought were important as you went through?

Greg Knapp  1:01:46

When I started fellowship, I was mostly just reading around, reading around the cases and the clinics for sure. And I was using that as the kind of regular entry point into the literature and then on top of that, as kind of mentioned, you know, the kind of fairly regular Wednesday morning, teaching rounds, that kind of kept me on a fairly predictable schedule. Certainly, now, as you know, we’re kind of coming to, you know, a bit of a close the last six months, we have an exam, at the end, I certainly have made a schedule, just to make sure that I am, you know, identifying what I need to kind of, you know, now there’s a timeline, making sure I’m covering the material, I need to with the with a particular endpoint, that being an exam at the end, as kind of a hard as kind of a hard hurdle, or, like, a physical hurdle to, to jump with regards to textbook or, you know, in surgical oncology in a lot of fields, right, like, it’s moving so quickly, by time, it’s in a textbook, you know, people say, it’s already outdated. I think that’s not necessarily true. There is still a huge amount and certainly, all of my old mentors have said and have loved to remind you that, there is publications from before,  2010 or there are publications from before 2000, there’s, you know, there obviously is a huge body of background literature that has got us to the point where we are in is still super relevant. And I do find that textbooks like in surgical oncology, we have Morita, is the lead author on a kind of general complex surgical oncology textbook. It was published in 2017 and it’s still very useful because it brings you up to 2017. Right? And if synthesized, it’s condensed, the reference list is fantastic, right? And then yeah, you have to supplement that 100%. Right. But it does provide a nice format, I think, for me for my learning style, and it does provide a nice summary, to kind of bring you up to speed in areas that you may be a little bit more deficient.

Salila Hashmi  1:04:09

I would say that I do have a textbook, which is, you know, Blumgart’s but that doesn’t mean I pick it up every day, which I probably should and even if I read one page a day, but you know, just have one textbook that you can refer to and one thing I would say that I have recently noticed is that my you know, husband, who’s a surgery resident was always on my back to actually join Twitter and I always held back saying that, no, I don’t want to and, you know, I’ve done this recently where I have actually joined Twitter and then, you know, just following because all these, you know, surgery journals have their own pages or like your mentors are the big names in the field, you’ll be surprised all of them are on Twitter and if you follow them, you know, sometimes they will have really valuable advice. They will highlight, some of the journal articles that you may not have noticed that have come out recently and so this is something that I have recently started doing and I think it’s worth doing, you know, maybe spending five minutes don’t do it socially and, you know, making social friends, but certainly for professional things, I think it’s a good addition where sometimes, because I cannot certainly go through like 10 different search, you know, surgery journals, but certainly having the right people to follow and then highlighting the appropriate journals or the articles has, I think we’re in a good reason, fine, you know, look into it, you may, you may be surprised,

Ameer Farooq  1:05:40

I’m very biased, because you guys probably both know that I’d love Twitter. I think it’s the best thing ever and I love reading and probably spent too much time on Twitter but I would echo what you said that Twitter is a very valuable resource. In closing, and thank you guys both, again, for for giving your time and I think this is going to be very useful for anyone who’s looking into doing a fellowship. So that maybe I could ask you, if you had to go back and do anything differently, I know, you’re not completely done but if you had to do anything differently, during your fellowship, knowing what you know, now, what would that have been? And why?

Salila Hashmi  1:06:18

Yeah, I mean, you know, again, I would say, one thing would be, you know, and it’s, I think that that’s going to stay forever, like, you know, reading more, I always thought that that I could do a better job of that during residency and I still feel I could have done a better job in fellowship. The other thing I would say is, you know, like, start early, like, I picked up some of the research projects a little bit late in the game, and I, you know, I’m sure I’ll be able to still finish it, but, you know, certainly for taking things on to, you know, a little bit next level, like, I started working on a randomized control trial with Dr. Ball just recently, and, you know, just with every, all the situation going on right now, and that’s been on a hole. So, you know, had I started working on that earlier in the fellowship, maybe, you know, things may be a little bit different, we would probably have some, you know, early data. So, you know, that’s what I would say, the other thing I would say is, you know, like, it’s a, it’s a difficult, you know, like, we had talked about the transition, being a resident and a fellow, the work will get done, you know, don’t try to do everything yourself, like, learn to delegate, you need to make time for yourself, be it for reading, be it for your wellness, be it for going home doing 10 minutes a workout. So just just make sure that you use your team well, I think, initially I had a hard time of letting go, like, I have to look into the charts again, and check on numbers again, if not before leaving at night, things will get done, there are people who are going to take care of those things. So, you know, I think trusting a little bit more than I initially used to that now I do, I think if I did that early on, maybe would have given me a little bit more time to spend in doing other things than you know, just being in the hospital.

Greg Knapp  1:08:16

I thought about this question before the podcast and before the recording, I think the one thing that jumped out is one you really have to be honest. Be honest with yourself about what you need from the fellowship and I think, if I was to do one thing differently, you know, through both, it’s just being even, there’s always a room for better communication, and better feedback and if you’re not, you know, it is a short period of time, it’s a brilliant opportunity and it goes by quickly, you know, it goes by in a flash, especially when you’re busy, and trying to juggle a couple different balls. So you really have to be honest with yourself, you know, and there’s always there’s always room for better communication about what about what you need, you know, to to maximize your fellowship opportunity, right so that’s about communicating that with your preceptors with the services that you’re on, and I think that there’s, I’ve always found that when that is communicated, people are very receptive to that right. By this point, you are a fellow, you are a general surgeon, you have something to you have something to bring to the table. Right? And when you come to people and say what, I’m not getting this and this is how I want to get more exposure or this is what I want to do differently and you come to them with a kind of a plan again, I guess that’s a theme I keep coming back to people are really receptive and I certainly probably, you know, I definitely could have done a better job at various points in my fellowship doing that, expressing that, to just, you know, to milk out even more from the opportunity. That would be kind of my only last advice.

Ameer Farooq  1:10:38

Just before we close out, I forgot to ask this earlier and particularly Greg, I think this would be a question for you, for Canadian residents looking to go to the US. Do you have any suggestions regarding visas, USML, all that kind of, you know, administrative stuff that does sometimes become important when trying to go down to the US?

Greg Knapp  1:11:05

Yeah, for sure. I definitely I’ve come across this numerous times. There’s a ton of like,  misinformation and I think, you know, number one, do your own research, you know, there’s a lot of anecdote and you’ll hear other residents or people tell you all you need to have the USMLE for every program. It’s just not true, right? Like, it is very state dependent, it is hospital dependent, you know, are you at a private hospital, a public facility is it a private Cancer Center, is it you really got to look at the individual program, and then reach out, they all have huge departments of people that deal with bringing in foreign talents, right? They all have human resource departments, they’re a simple email away, and they will clarify exactly what you need, right? I even found some of the blogs, you know, there’s a lot of, there’s a lot of general information that is actually not that useful and so you got to identify what are the programs you’re interested in and then actually go to their website and take it a step further. If you’re really interested in talk to either past fellows, sure, but just go straight to their HR department and be like, Hey, I’m a Canadian fellow, right? board certified, you know, what do I need from you guys? Or what do I need to to have the appropriate license at your facility? And everyone’s going to be different? And so I think it’s, if there’s one take home message is, it’s kind of like believe no one, do your own research and it’s, it seems like it’s very staid and institution specific.

Salila Hashmi  1:13:01

Ameer, I’ll just make one more comment. I’ve met a lot of US applicants who will be hesitant to apply to Canadian programs, especially for fellowships thinking that there is a lot of paperwork that goes into it. Honestly, yes, it did span over a few months and the only thing that took me the longest was getting my background check from FBI from the US. The rest was as smooth as it can be. So you know, don’t be hesitant for the US applicants to apply to Canadian programs. I’ve totally enjoyed my time here and you know, wouldn’t change my decision if I had to go back so certainly happy to answer anybody’s questions, if they had any.

Greg Knapp  1:13:42

I would say same thing. Like in New York, it was actually surprisingly easy. I did not need USMLE. The visa was relatively straightforward. It was actually a lot more difficult to get my two month elective in Cape Town than it was to go to New York.

Ameer Farooq  1:13:57

So great Greg, thank you guys so much for coming in Cold Steel. Absolutely fantastic. You’ve been listening to Cold Steel, the official podcast of the Canadian Journal of Surgery. If you’ve liked what you’ve been listening to, please leave us a review on iTunes. We’d love to hear your comments and feedback. So, feel free to email us at podcast.cjs@gmail.com, or connect with us on Twitter @CanJSurg. Thanks again.