Global exposure: The value and appeal of international Fellowships

Fellowships allow surgeons to seek expertise training while bonding with new mentors, being exposed to new techniques, expanding job opportunities and better-molding their budding careers. All want to maximize learning and skills acquisition in this carefully selected apprenticeship that can take place anywhere in the world.

Expert surgeons are defined as "experienced surgeons with consistently better outcomes." David Fisher, MB, BSc, embodies such a definition – equipped as he is with passion, talent and extensive international training and experience. His anatomically based cleft-lip repair technique has revolutionized the surgical approach to cleft lips.

The technique, published in 2005, has been widely adopted internationally.

Dr. Fisher is the medical director of the multidisciplinary Cleft Lip and Palate Program at the Hospital for Sick Children, Toronto, Ontario. He graciously agreed to discuss his career journey – and how his international fellowships shaped his practice.

Training journey

Dr. Fisher graduated medical school in Ireland. He completed residencies in General Surgery and Plastic Surgery in Grand Rapids, Mich., and his first fellowship took place in Paris alongside Daniel Marchac, MD. He pursued further training in Taipei, Taiwan, under the mentorship of Samuel Noordhoff, MD, and Yu-Ray Chen, MD. Dr. Fisher became a pediatric Fellow at the Hospital for Sick Children, Toronto, where he has established his practice.

PSR: When did your interest in craniofacial surgery and cleft lip and palate begin?

Dr. Fisher: You may not believe this, but it started when I was 12 years old. I saw a child opposite to me on the bus with a cleft. I remember specifically thinking to myself: "There has to be a better way." Later, my interest in clefts really started with embryology and grew from there.

PSR: What was the first Fellowship you decided to pursue?

Dr. Fisher: The first Fellowship I applied for was the craniofacial Fellowship with Dr. Marchac, while still being a general surgery resident (before even being accepted into a plastic surgery program). I knew the waiting list was four to five years, but I wanted to work with Dr. Marchac as he was an internationally recognized craniofacial expert and a pioneer in craniosynostosis surgery. The Fellowship was also based in Paris, and I knew I wanted to travel. In parallel, I needed to leave the United States for a period of two years, due to the limitations imposed by my visa.

My ultimate goal when planning the Fellowships was to have training and experience that would allow me to secure a job, be well-trained and, ideally, develop confidence to do the job I was seeking.

PSR: What was the next step in your Fellowship journey?

Dr. Fisher: I applied for the Sick Kids Hospital craniofacial Fellowship. There was now a six-month gap between Paris and Toronto. I had met Dr. Chen at The International Society of Craniofacial Surgery meeting in New York in 1986, and he offered me a Fellowship.

PSR: Did you face any linguistic or cultural challenges while abroad?

Dr. Fisher: Language was a problem, but the Fellowships were well-designed and expected a lack of fluency from the Fellows. I could not interact with the patients to the extent that I preferred, during both the France and Taiwan Fellowships. The advantage was that I was able write a research paper in English with the local teams – which they very much appreciated.

PSR: Did these Fellowships give you the confidence you were seeking?

Dr. Fisher: Absolutely. At the end of my residency, I really thought I knew a lot about clefts, since I had concentrated my efforts on that particular topic throughout the years. I'd even taken part in a mission and performed/assisted cleft surgeries as a resident. But when I was in Taiwan, Dr. Chen was about to leave me alone to do a cleft – and I knew I wasn't ready to be unsupervised. Clearly, I still had a lot to learn and confidence to build. Two years later, I started my practice and I performed my own repair on my first patient, so I obviously had gained more confidence by then.

Development of a new technique

PSR: What inspired you in the development of your cleft lip repair?

Dr. Fisher: When I left Taiwan, I was very confident with the Chang Gung repair, which is a modification of the Millard version. I believed that I would use this repair technique if I were to get a pediatric craniofacial cleft position. But I then trained with Hugh Thomson, MD, and saw a modified inferior-triangle technique. I thought of it as a wonderful repair. It became less clear which repair I was going to adopt for my own practice. Once I got the Sick Kids position, it was time to make a decision. I decided to use the best parts of each repair and combine them. I knew there was a way to put the scar where I wanted it to be.

PSR: How long was the development phase of your cleft-lip repair technique?

Dr. Fisher: It was pretty quick, probably over a few months. It was during my last Fellowship at Sick Kids. My first son was born then. I remember spending a lot of time thinking about what kind of a repair I would have liked him to have, had he been born with a cleft.

PSR: When did you first share technique idea?

Dr. Fisher: Before attempting my own repair on my first patient, I presented the technique to the pediatric plastic surgeons at weekly rounds when I was still a Fellow at Sick Kids. I didn't get any really concerning feedback. I knew it would work. However, I was extremely careful. Once on staff, I first attempted the repair on an incomplete cleft. Considering you always throw away the majority of the C flap, I knew I could convert the repair to a Chang Gung one if needed. But it worked.

I didn't publish the technique for the first five years. I performed 157 repairs first and wanted to obtain adequate outcomes data.

Words of wisdom

PSR: Do you have any recommendations for residents planning on completing international Fellowships?

Dr. Fisher: Plan ahead. Think about the Fellowships that interest you and make according arrangements. I had no expectations prior to completing my Fellowships, but I was confident that they were in great institutions and with exceptional surgeons to learn cleft surgery. I was ready to accept whatever challenge was to come my way. I definitely recommend highly international Fellowships. It's a time in your life when you can be the most selfish and get more education in an area of your choice, with really wonderful surgeons and teams.

While abroad, my favorite moments were definitely social ones. I was able to spend time and get to know surgeons who I'd only read about in books and admired. They generously allowed me to learn from their experiences and how they overcame challenges. You also make connections with individuals and teams that you stay in touch with over the years.

PSR: Any last words for future cleft surgeons?

Dr. Fisher: Most of us in medicine are used to delayed gratification. I see that some residents are anxious to complete training, make money and move on. But I think that delaying entry into a position by one or two years for further training will make you much richer on many levels in the long run...

Dr. Roy is PGY4 at the University of Toronto Division of Plastic and Reconstructive Surgery.