Job or Fellowship? Knowing When to Stop Training
Job or another fellowship? The rules that set the timing in the UK, US, Australia and Canada, what an extra year costs, and how to decide when to stop training.
By OrthoVellum Editorial TeamPublished Updated 8 min read
Educational content for clinicians, not medical advice. Editorial policy
Key points
- A second fellowship is uncommon. Of 9,776 US surgeons who applied for ABOS Part II between 2004 and 2016, 4.5% had done more than one.
- Regulations set the windows. UK trainees can be interviewed for consultant posts up to six months before CCT and can usually keep their training post for up to six months after it. JCST fellowships prefer surgeons within two years of certification.
- In the US, the ABOS Part II examination needs 17 consecutive months in practice, and fellowship time does not count. Every extra fellowship delays board certification.
- A US financial model found that spine fellowship training broke even after about five years, while hand, paediatric and foot and ankle fellowships never recovered the lost year of earnings. Money is rarely the deciding factor, but it is measurable.
- Take another fellowship when it teaches a defined skill that a specific job needs and you cannot learn it in post. Take the job when your gap is confidence rather than a missing procedure.
On this page7 sections
At the end of training, or at the end of a first fellowship, the question is whether to take a job now or do another fellowship. The answer depends on three things: what the extra year would teach you, what the rules in your system allow, and what the delay costs. Most surgeons stop after one fellowship. A second one is worth it when it teaches a defined skill that a specific job needs and that you cannot learn in post. This post sets out the regulations that fix the timing in the UK, US, Australia and Canada, the published numbers on cost and job prospects, and a way to decide. If you are still choosing a first fellowship, read the orthopaedic fellowship application guide first.
How many surgeons do a second fellowship?
Few. Of 9,776 applicants for the American Board of Orthopaedic Surgery (ABOS) Part II examination between 2004 and 2016, 444 (4.5%) had completed more than one fellowship (DePasse 2018). The most common additional fellowships were trauma (40.1% of those with more than one), sports medicine (38.7%) and joints (30.4%). The most common pairings were joints with sports medicine (10.6%) and foot and ankle with sports medicine (10.1%). The proportion did not increase over the 13 years, although paediatric orthopaedics combined with sports medicine became more common. We found no comparable figures for the UK or Australia.
What do the rules say about timing?
United Kingdom. Under the Gold Guide (opens in a new tab) (10th edition, paragraph 3.95), trainees must not be interviewed for a consultant post more than six calendar months before their anticipated CCT date. They should apply only if their last ARCP was an Outcome 1. Once you are on the specialist register, you can take a substantive, fixed-term or locum consultant post (paragraph 3.97). Higher specialty trainees can also use a period of grace. In Scotland, for example, the standard period is up to six calendar months after CCT (opens in a new tab). It is opt-in, you keep your national training number, and you cannot act up as a consultant during it. Visa holders can use it only if their sponsorship can be extended or they will have settled status by then. Employers, not the Gold Guide, set the terms, so check your own deanery's policy.
Formal post-CCT fellowships expect you soon after certification. JCST interface fellowships (opens in a new tab) in hand surgery, spinal surgery and major trauma require you to be on the specialist register, and "ideally within two years of achieving certification". Some unit fellowships set their own limit. The Edinburgh Trauma Fellowship, for example, asks for less than three years (opens in a new tab) since completing training. If you think you will want a fellowship, the window is the first two years after CCT.
United States. The ABOS rules and procedures (opens in a new tab) tie board certification to independent practice:
- To sit Part II, you must have started practice, with hospital admitting and surgical privileges, by 1 November. You then sit the examination two calendar years later.
- You must practise continuously in one location for at least 17 consecutive full calendar months, "other than as a resident or fellow". The practice must be in the US, its territories, Canada or a US service installation, apart from a humanitarian exception.
- After passing Part I, you have five years to pass Part II. Fellowship time after Part I does not count towards those five years, and each fellowship must last at least six months.
A second fellowship therefore moves your Part II date back by a year without using up your board-eligible time. The ABOS subspecialty certificates in hand surgery and sports medicine can be examined after an ACGME-accredited fellowship, but they are awarded only after primary certification (opens in a new tab).
International fellows in US programmes face a separate constraint. J-1 physicians are subject to a two-year home-country physical presence requirement (opens in a new tab) before they become eligible for certain other US visas. A US job straight after a J-1 fellowship is not simple.
Australia and New Zealand. AOA-accredited fellowships are short-term supervised subspecialty posts taken after training, and AOA notes (opens in a new tab) that they are not formal surgical training. The Australian Hand Surgery Society's PFET programme is a defined two-year exception. International surgeons on the Medical Board's Short-term training pathway (opens in a new tab) can train for up to 24 months. The pathway is open to qualified specialists and to trainees within two years of finishing, and it does not lead to specialist registration.
Canada. In Ontario, a clinical fellowship is a one- to three-year "topping off" (opens in a new tab) that does not lead to Royal College certification and is not on its own a route to permanent practice.
What does another year cost?
The direct cost is a year at fellow's pay rather than consultant pay, plus a later start to your pension and to building a referral base. One published model puts numbers on this, and it is American. Using US physician compensation surveys, Mead et al (2020) estimated the return on one fellowship compared with general orthopaedic practice over a working career:
| Fellowship | Estimated return (US model, Mead 2020) |
|---|---|
| Spine | Highest return; broke even after about 5 years |
| Adult reconstruction | Positive, but no advantage once adjusted for hours worked |
| Sports medicine, trauma | Neutral; negative once adjusted for hours worked |
| Hand, paediatrics, foot and ankle | Never recovered the earnings lost in the fellowship year |
The model compares one fellowship with none. A second fellowship adds another year of lost earnings to whatever the first one cost. Most surgeons do not choose a subspecialty for money, but if a second fellowship is meant to increase earnings, these figures do not support that assumption outside a few fields.
The indirect costs are personal: another move, a partner's career on hold, visas tied to training posts, and children changing school. Write them down alongside the clinical case.
Will another year improve your job prospects?
Sometimes, but not in every field. An analysis of 466 US job adverts in 2019 compared each subspecialty's matched fellows with its advertised posts (Chan 2020). There were 1.1 fellows per advertised job in foot and ankle, 2.0 in adult reconstruction and 2.1 in trauma, against 6.3 in sports medicine, 5.8 in shoulder and elbow and 5.7 in oncology. Generalist posts were more available than posts in any subspecialty. A second fellowship in a crowded field adds a line to your CV but does not change the ratio.
What changes your prospects is a fit with a specific post. If a department is recruiting for a role that combines two skills, such as trauma with complex arthroplasty, and tells you in writing that it will wait a year, a targeted second fellowship can secure it. "Fellowship-trained" with no job in view is a weaker reason.
How to decide: a working table
| Your situation | Lean towards |
|---|---|
| A specific job needs a skill you lack, and the employer will hold the post | Fellowship, with the employer's requirement and timing in writing |
| You can do the operations but feel unready to make every decision alone | The job, with a mentor and shared lists for the first year |
| The fellowship on offer repeats your first one in a different city | The job |
| You want a defined combination for a tertiary or academic role | A targeted second fellowship, for 6 to 12 months |
| Your registration, visa or period of grace is about to run out | Decide on those dates, not on the ideal plan |
| You have a good job offer and only a vague fellowship plan | The job |
The quality of each option matters more than the label. A well-supervised fellowship in a busy unit can be worth more than a poorly supported consultant post, and a strong consultant post with a good department is worth more than a fellowship spent assisting.
What to ask before you decide
- What exactly will the fellowship teach that I cannot learn in my first two years in post? If you cannot name procedures, the answer is probably nothing.
- Will the job I want still be there in a year? Ask the department directly.
- What will the department do to support a new consultant? Ask about joint operating, a named mentor and how complex cases are shared.
- What do surgeons three to five years ahead of me wish they had done? Ask some who took the job and some who did a second fellowship. Ask what surprised them, not what they achieved.
- Which dates are fixed? Note your CCT date, the end of any period of grace, visa expiry, the ABOS 1 November start date and the fellowship start month.
If you take the job
Plan the learning you would have done in a fellowship. Ask for joint lists with a senior colleague for complex cases, keep a personal outcomes log from the first case, and agree a mentor before you start. Surviving your first year as a consultant and the emotional transition to consultant cover the first year. How to choose between job offers and how to land your first consultant job cover getting there.
Frequently asked questions
Is it worth doing a second orthopaedic fellowship?
Only for a defined reason, such as a combination that a specific job requires or a procedure your first fellowship did not cover. In US data, 4.5% of surgeons applying for board certification had done more than one fellowship, most often adding trauma, sports medicine or joints. A second year delays board certification in the US and consultant earnings everywhere, so get the target job's requirement in writing first.
How long after CCT can I do a UK fellowship?
No single rule sets a limit. However, JCST interface fellowships require you to be on the specialist register and prefer candidates within two years of certification. Some unit fellowships, such as the Edinburgh Trauma Fellowship, ask for less than three years since completing training. Higher specialty trainees can also use a period of grace of up to six months after CCT, keeping their training post while they look for a consultant job.
Does a fellowship delay ABOS board certification?
Yes. Part II requires 17 consecutive full calendar months of practice in one location, starting by 1 November, and time as a resident or fellow does not count. Fellowship time taken after passing Part I does not count against the five-year board-eligible limit, and each fellowship must last at least six months. A second fellowship therefore moves your Part II date back by a year.
Should I take a consultant job if I do not feel ready?
Feeling unready is common and is not by itself a reason for another fellowship. Ask whether the gap is a specific procedure you have not been trained in, or confidence in decisions you have already been trained to make. A fellowship fixes the first. A job with senior colleagues, joint lists and a mentor usually fixes the second faster.
References
- DePasse JM, Daniels AH, Durand W, et al. Completion of multiple fellowships by orthopedic surgeons: analysis of the American Board of Orthopaedic Surgery certification database. Orthopedics 2018;41(1):e33-e37. DOI (opens in a new tab)
- Mead M, Atkinson T, Srivastava A, Walter N. The return on investment of orthopaedic fellowship training: a ten-year update. J Am Acad Orthop Surg 2020;28(12):e524-e531. DOI (opens in a new tab)
- Chan JY, Charlton TP, Thordarson DB. Analysis of orthopaedic job availability in the United States based on subspecialty. J Am Acad Orthop Surg Glob Res Rev 2020;4(11):e20.00195. DOI (opens in a new tab)
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OrthoVellum Editorial Team. Job or Fellowship? Knowing When to Stop Training [Internet]. OrthoVellum; 2025 Oct 14 [updated 2026 Oct 2; cited 2026 Oct 29]. Available from: https://www.orthovellum.com/blog/job-or-fellowship-when-to-stop-training
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Prepared by the OrthoVellum Editorial Team from cited sources, under our editorial policy.
For education and exam preparation; not medical advice or a substitute for clinical judgement and local guidance.
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