title: Systematic review with meta-analysis of the impact of surgical fellowship training on patient outcomes.
abstract: BACKGROUND
  The number of surgeons entering fellowship training before independent practice is increasing. This may have a negative impact on surgeons in training. The impact of fellowship training on patient outcomes is not yet known. This review aimed to investigate the impact of fellowship training in surgery on patient outcomes.
  
  
  METHODS
  A systematic review of the literature was conducted to identify studies exploring the structural and surgeon-specific characteristics of fellowship training on patient outcomes. Data from these studies were extracted, synthesized and reported qualitatively, or quantitatively through meta-analysis.
  
  
  RESULTS
  Twenty-three studies were included. The mortality rate for patients in centres with an affiliated fellowship programme was lower than that for centres without (odds ratio 0.86, 95 per cent c.i. 0.84 to 0.88), as was the rate of complications (odds ratio 0.90, 0.78 to 1.02). Surgeons without fellowship training converted more laparoscopic operations to open surgery than those with fellowship training (risk ratio (RR) 1.04, 95 per cent c.i. 1.03 to 1.05). Comparison of outcomes for senior surgeons versus current fellows showed no differences in rates of mortality (RR 1.00, 1.00 to 1.01), complications (RR 1.03, 0.98 to 1.08) or conversion to open surgery (RR 1.01, 1.00 to 1.01).
  
  
  CONCLUSIONS
  Fellowship training appears to have a positive impact on patient outcomes.
authors.affiliation: Patient Safety Translational Research Centre, Department of Surgery and Cancer, London, UK.
authors.forename: M J
authors.initials: MJ
authors.lastname: Johnston
authors.affiliation: Department of Surgery and Cancer, Imperial College London, London, UK.
authors.forename: P
authors.initials: P
authors.lastname: Singh
authors.affiliation: Department of Surgery and Cancer, Imperial College London, London, UK.
authors.forename: P H
authors.initials: PH
authors.lastname: Pucher
authors.affiliation: Department of General Surgery, Royal Free London, Barnet Hospital Campus, London, UK.
authors.forename: J E F
authors.initials: JE
authors.lastname: Fitzgerald
authors.affiliation: Department of Surgery, Faculty of Medicine, McGill University, Montreal, Quebec, Canada.
authors.forename: R
authors.initials: R
authors.lastname: Aggarwal
authors.affiliation: Patient Safety Translational Research Centre, Department of Surgery and Cancer, London, UK.
authors.forename: S
authors.initials: S
authors.lastname: Arora
authors.affiliation: Department of Surgery and Cancer, Imperial College London, London, UK.
authors.forename: A
authors.initials: A
authors.lastname: Darzi
mesh_terms: D002983:Clinical Competence; D004502:Education, Medical, Continuing / Q000379:methods*; D013502:General Surgery / Q000193:education*; D006801:Humans; D007396:Internship and Residency / Q000592:standards*; D063868:Patient Outcome Assessment; D013514:Surgical Procedures, Operative / Q000193:education*