General thoracic surgery has evolved towards a highly specialized technically demanding surgical specialty. Fellowship positions in leading units are therefore becoming more and more important (1). As a European ESTS trainee member from Belgium, I had just finished my training and was also looking for fellowships to add to my postgraduate training.
During the ESTS postgraduate course 2015 in Lisbon, the 1st ESTS-AME prize was awarded for the best overall performance by a trainee member. The award included an expenses-paid attachment to a leading thoracic surgery unit in China for one month. I had the chance to win this award and since I had never been in Asia before, I couldn’t even imagine what expectations to have in the First Affiliated Hospital of the Medical University of Guangzhou with professor He as the president of the hospital and the director of the department of Thoracic Surgery (Figures 1,2).
Famous thoracic surgeons as Toni Lerut and Diego Gonzales-Rivas told me that it is important to leave your comfort zone, before you can really experience new things in surgery and in life. So that is exactly what I did, adapting to a new culture, chopsticks (which I saw as a part of my VATS training), food I’ve never eaten before and a language of which I don’t understand a word (Figure 3). I left all prejudices home and was ready for the journey.
From the start of the experience, I was overwhelmed by the incredible technicity of the surgeons and their use of the last new technologies. But in a fellowship abroad one needs at least one month to have an idea of a culture, the structure of a health care system and how surgeons adapt to it (Figure 4). After a while I learned that in China basic health care is not very well organized, distances to radiotherapy units are long and reimbursement of chemotherapeutic agents can be difficult. This makes surgery by far the first option for lung and oesophageal pathology in China. And these are the same reasons why surgeons are focusing on quality of life, more than trying to win one percent in long term survival of these patients.
In Guangzhou I saw surgical procedures I have never seen before: the experience with spontaneous breathing anaesthesia is probably the largest in the world, once starting with lung biopsies and wedge resections, over lung volume reduction surgery, mediastinal resections and anatomical lung resections, to even sleeve resections and tracheal resections nowadays (2). Almost every surgery is done by video assisted thoracic surgery, with the least amount of ports possible (Figure 5A,B). Also fast track protocols, with patients really walking from the post anaesthesia unit to the ward, are feasible. The so called tubeless protocol, without or with as less tubes and catheters as possible is safe and contributes to the comfort of the patient.
The philosophy is to keep the perioperative event as simple as possible for the patient, but there is also a lot of effort to keep it as simple as possible for the surgeon: 3D monitor systems and even “glassesfree” 3D thoracoscopic monitor systems are frequently used (Figure 6).
The training centre is recognized by the Royal College of Surgeons and staff surgeons and anaesthesiologists are willing to learn any details although difficulties due to the language barrier.
During a course and a conference in that same month, I had the opportunity to talk with general thoracic surgeons and trainees from other centres in China (Figure 7). Their high hospital volumes improve technical skills and the use of specific technology reducing complications and health care costs. The Chinese surgeons I have met are very ambitious: they are looking for the best possible and least invasive surgical strategies for their patients, residents have a high quality training, new journals are being published and courses about the latest technologies are given. They even collaborate in general health care promotion (Figure 8).
The fellowship not only gave me the opportunity to learn about new techniques, technologies and protocols. It is also a chance to learn to know so many new people, not only from China, but from over the whole world. This fellowship was the ideal period for networking and hopefully for longstanding collaborations in the future. As W. Churchill said: “This was not the beginning of the end, but only the end of the beginning.” I realised my training is not finished, but actually just started.
I learned a lot for myself and to bring home, but I felt I had to do something in return to show at least my gratitude for this experience. I hope that I was of some help in writing, discussing and translating surgical papers together with the local team.
To every thoracic surgical trainee, I can recommend a clinical fellowship abroad as it broadens your horizon and gives you new perspectives for the future. I would especially like to encourage Western trainees to come to China, since they are often not aware of the possibilities and new techniques available there.
I would like to thank the ESTS and publishing company AME for giving me the opportunity to experience this unforgettable journey. My special thanks to professor Jianxing He and his entire team. Their hospitality is enormous. I will never forget the expression “If you can think of a solution, there is always a way to accomplish it”.
Conflicts of Interest: The ESTS-AME prize included an expenses-paid attachment to the First Affiliated Hospital of the Medical University of Guangzhou, China for one month, sponsored by AME publishing company. The author has no conflicts of interest to declare.
- Fitzgerald JE, Milburn JA, Khera G, et al. Clinical fellowships in surgical training: analysis of a national pan-specialty workforce survey. World J Surg 2013;37:945-52. [Crossref] [PubMed]
- Liu J, Cui F, He J. Non-intubated video-assisted thoracoscopic surgery anatomical resections: a new perspective for treatment of lung cancer. Ann Transl Med 2015;3:102. [PubMed]
- Sihoe AD. The AME Special Competition 2015: 4 rounds, 27 contestants, countless lessons learned about China. J Thorac Dis 2015;7:E139-47. [PubMed]