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Adult Reconstruction Fellowship: What is Important to the Applicants?

Open AccessPublished:August 23, 2022DOI:https://doi.org/10.1016/j.artd.2022.07.012

      Abstract

      Background

      Orthopaedic surgery trainees who aim to specialize in total joint arthroplasty commonly complete an additional year of fellowship training. Limited information regarding individual programs is readily available to potential applicants. The purpose of this study is to determine what information applicants value when considering an adult reconstruction fellowship program.

      Methods

      An anonymous survey was distributed to all 470 junior members of AAHKS. The 12-question survey gathered demographic information as well as average weighted scores (1-10) of various components regarding fellowship education, recruitment, and experiences. Subgroup analysis was performed on survey responses based on the following 3 different categories: Gender, year of training, and geographical location.

      Results

      A total of 135 respondents completed the survey (135 of 470, 28.7% response rate). Sixty-two (45.9%) participants held the position of postgraduate year 5, 43 (31.9%) participants held the position of postgraduate year 4. Exposure to operative techniques in revision surgery (9.62), exposure to operative techniques in primary surgery (9.51), and ability to obtain desired job opportunity after fellowship (8.89) were the 3 most considered components. Higher level trainees valued information regarding average number of hours worked relative to junior trainees (P = .046). Geographic differences were noted in the following 3 variables: the number of cases performed (P = .010), whether fellows had a dedicated clinic and/or operating room (P = .002), and the average number of hours worked (P = .020).

      Conclusions

      Amongst the 3 domains studied, applicants most valued educational components, such as exposure to various techniques surrounding total joint arthroplasty. There is a need for a centralized, comprehensive database that contains information applicants value most and this database should be customizable toward training level and location.

      Keywords

      Introduction

      The adult reconstruction fellowship match is one of the most competitive in orthopaedics [
      • Wera G.D.
      • Eisinger S.
      • Oreluk H.
      • Cannada L.K.
      Trends in the orthopaedic surgery fellowship match 2013 to 2017.
      ]. There exists a substantial need for a centralized database which reports on a standardized set of variables to provide applicants with a starting point for evaluating fellowship programs. There are currently 4 web-based directories that provide some information about various programs: the American Association of Hip and Knee Surgeons (AAHKS), San Francisco Match, Fellowship and Residency Electronic Interactive Database Access, and the American Academy of Orthopaedic Surgeons. These databases are incomplete and present nonstandardized information that is often outdated. Gu et al. [
      • Gu A.
      • Lehman J.D.
      • Sardana A.
      • Cohen J.S.
      • Richardson S.S.
      • Sculco P.K.
      Adult reconstruction hip and knee fellowship program content and accessibility.
      ] reviewed all programs identified through the AAHKS fellowship program directory in 2018 and found that only 3 of the 78 listed programs had functional links to program websites and that the database lacked key information on program structure, the application process and fellow education. In a recent query of adult reconstruction fellowship program websites available through AAHKS, San Francisco Match, American Academy of Orthopaedic Surgeons, and Google, Ahmed et al. [
      • Ahmed S.A.
      • Elnemer W.
      • Eltorai A.E.M.
      • Mariorenzi M.
      • Daniels A.H.
      • Cohen E.M.
      In-depth analysis of adult reconstruction fellowship websites.
      ] report that 19.8% of did not have a functioning website.
      The paucity of centralized data-sharing for applicants may provide certain applicants with an unfair advantage. Some applicants may benefit from conversations with mentors who are involved in the application process or may rely on advice from prior fellows. Additionally, informal means of data-sharing have emerged such as through on-line anonymous forums [].
      McEvoy et al. [
      • McEvoy C.M.
      • Brown S.M.
      • Miskimin C.
      • Mulcahey M.K.
      Orthopaedic sports medicine fellowship websites: information considered most important to fellowship applicants.
      ] surveyed applicants for orthopaedics sports medicine fellowship programs in order to characterize which aspects of program were most important to fellow applicants. Similarly, the purpose of the present study was to survey junior AAHKS members to characterize the demographic composition within the field of applicants and determine which variables applicants consider most pertinent to be included in a comprehensive catalog of fellowships in adult reconstruction.

      Material and methods

      Before distributing the survey, approval was obtained from the Institutional Review Board (IRB) at our institution. An anonymous survey was distributed to all 470 junior participants that are registered in the AAHKS database maintained by AAHKS administrators, which includes both members and nonmembers. Any resident with postgraduate year (PGY) 2 status through attendings in their first year of practice were surveyed. The survey was distributed to the e-mail addresses of registrants. The survey was distributed during the month of August 2021 with a 4-week response window and 1 additional reminder e-mail was sent 2 weeks prior to the survey due date. The 12-question survey, hosted on SurveyMonkey (San Mateo, CA), took an average of 5 minutes to complete and was aimed to gather information regarding applicant’s demographic information and components of a fellowship program website that were felt to be most pertinent.
      The demographic portion of the survey consisted of 6 questions aimed to obtain information including current academic position, age, gender, medical school training, and status as an internal medical graduate or military affiliation. Regional location of residency program was surveyed, as has been done in similar studies [
      • McEvoy C.M.
      • Brown S.M.
      • Miskimin C.
      • Mulcahey M.K.
      Orthopaedic sports medicine fellowship websites: information considered most important to fellowship applicants.
      ]. Additionally, the survey asked about 33 potential website offerings that were stratified into the following 3 components: Fellow education (15), fellow recruitment (8), and fellow experience (10). These components were identified from similar orthopaedic subspecialty websites and other surgical subspecialties [
      • McEvoy C.M.
      • Brown S.M.
      • Miskimin C.
      • Mulcahey M.K.
      Orthopaedic sports medicine fellowship websites: information considered most important to fellowship applicants.
      ,
      • Shiu B.
      • Petkovic D.
      • Levine W.N.
      • Ahmad C.S.
      Maximizing surgical skills during fellowship training.
      ,
      • Watson S.L.
      • Hollis R.H.
      • Oladeji L.
      • Xu S.
      • Porterfield J.R.
      • Ponce B.A.
      The burden of the fellowship interview process on general surgery residents and programs.
      ,
      • Yayac M.
      • Javandal M.
      • Mulcahey M.K.
      Accredited orthopaedic sports medicine fellowship websites: an updated assessment of accessibility and content.
      ]. Finally, a free response portion at the end of the survey permitted participants to include any additional pertinent information that was not addressed in the survey.

      Data analysis

      Descriptive statistics were utilized in data analysis. The average of each response to the 15 component questions was determined and further analyzed based on gender, application year and current position. Each response on the 10-point scale was given a weight ranging from 1 to 10: “Not important” corresponded to a rank of 1, “Moderately important” corresponded to a rank of 5, and “Highly important” corresponded to a rank of 10. These designations were used to calculate a weighted average to rank the important of various website components. The data were analyzed to determine whether there was a difference in responses within 3 different demographic subgroups of applicants: (1) training year, (2) geographic location (Fig. 1), and (3) those who were male or female. Wilcoxon rank sum test was used to determine whether there was a difference in responses between male and female; Kruskal-Wallis rank sum test was used to determine difference by training year and geographic location. The null hypothesis for Wilcoxon rank sum test and Kruskal-Wallis rank sum test was that the median value for website components was the same between sample subgroups. Analysis was completed using R v4.1.2 (Boston, MA). Figures and map were generated using Excel 2019 (Seattle, WA). The free response answers were reviewed and summarized.
      Figure thumbnail gr1
      Figure 1Survey respondents by geographic location.

      Results

      A total of 135 participants were involved in the research study, which occurred from August 16, 2021 to September 15, 2021. Four hundred seventy recipients were sent the survey, corresponding to a 28.7% response rate. Sixty-two (45.9%) participants held the position of PGY-5, 43 (31.9%) participants held the position of PGY-4, 15 were PGY-2 or PGY-3 level, and 9 (6.7%)were currents fellows. Six (4.4%) of the study participants indicated their position as other, clarifying that they are attending physicians (3), completing another fellowship (1), or hold board certification in another country (2). Demographic data are displayed in Table 1. The average number of applications submitted when applying to the San Francisco Match was 34.8 ± 23.4, with 24 (17.8%) participants submitting at least 50 applications (Table 1).
      Table 1Study demographics (N = 135).
      Current positionNPercentage
       PGY-210.74%
       PGY-31410.37%
       PGY-44331.85%
       PGY-56245.93%
       Adult reconstruction fellow96.67%
       Other (please specify)64.44%
      Gender
       Male11786.67%
       Female1712.59%
       Non-binary00.00%
       Prefer not to say10.74%
      Medical degree program0.00%
       Allopathic (M.D.)10174.81%
       Osteopathic (D.O)2115.56%
      International medical graduate
       Yes139.63%
       No12290.37%
      Active duty military75.19%
      Age, y
       <302014.81%
       30-3910980.74%
       40-4964.44%
       50+00.00%
      Match cycle
       2019-202021.48%
       2020-202153.70%
       2021-20226749.63%
       2022-20234835.56%
       2023-2024139.63%
      Total number of fellowship applications
       1-101914.07%
       11-202518.52%
       21-302820.74%
       31-402921.48%
       41-50107.41%
       51-1002417.78%
      PGY-2, postgraduate year 2; PGY-3, postgraduate year 3; PGY-4, postgraduate year 4; PGY-5, postgraduate year 5.

      Fellowship education

      Nine components of fellowship education ranked above 7 (Fig. 2): The component that ranked highest was exposure to operative techniques in revision surgery (9.62), while the component that was ranked the lowest amongst participants was availability of basic science research (3.68). The comprehensive list of ranked components is presented in Figure 2.
      Figure thumbnail gr2
      Figure 2Fellowship education components ranked in order of importance. The weighted average score appears to the right of the bar graph.
      The Wilcoxon rank sum test could not reject the null hypothesis that responses regarding fellowship education components to be included in the website varied amongst males and females (P value >.05). The Kruskal-Wallis rank sum test did reject the null hypothesis for the number of cases performed to be included on the website based on geographic location: the number of cases performed was a more important component for those in the northeast (average ± standard deviation: 10.00 ± 1.25) and south region (10.00 ± 2.00) vs the midwest (average 8.00 ± 2.00, P = .010). The Kruskal-Wallis rank sum test did reject the null hypothesis for the component of program ACGME accreditation status to be included on fellowship websites. ACGME status was a more important component for younger trainees (PGY-2/-3) (9.00 ± 3.50) and less important for senior trainees (PGY-5 5.00 ± 4.50, P = .020).

      Fellowship recruitment

      The following 3 components of fellowship recruitment ranked above 7: ability to obtain desired job opportunity after fellowship (8.89), perception of lifelong network (8.43), and call burden (7.31). The component that was ranked the lowest amongst participants was diversity within the program (4.71). The compiled list of ranked recruitment components is presented in Figure 3.
      Figure thumbnail gr3
      Figure 3Fellowship recruitment components ranked in order of importance. The weighted average score appears to the right of the bar graph.
      Neither the Wilcoxon rank-sum test nor the Kruskal-Wallis rank sum test could reject the null hypothesis that responses regarding fellowship recruitment components to be included in the website varied amongst males and females, geographic location, or training year (P value > .05).

      Fellowship experience

      One component of fellowship experience ranked above 7: prestige of fellowship within field (7.13). The compiled list of ranked fellowship experience components is presented in Figure 4.
      Figure thumbnail gr4
      Figure 4Fellowship experience components ranked in order of importance. The weighted average score appears to the right of the bar graph.
      The Wilcoxon rank sum test could not reject the null hypothesis that responses regarding fellowship experience components to be included in the website varied amongst males and females (P value >.05). The Kruskal-Wallis rank sum test did reject the null hypothesis that training level did not affect the importance of average number of hours worked in fellowship. Fellows and attendings (7.00 ± 2.00) reported that this information was more important to include on a website as opposed to junior residents (PGY-2/-3) who felt that this information was not as important (5.00 ± 2.50) to include. The Kruskal-Wallis rank sum test did reject the null hypothesis for several components between geographic location. Information regarding a dedicated fellow clinic and/or operating room (OR) were felt to be more important to applicants outside of the United States (8.50 ± 1.25), while this was deemed to be less important to those in the midwest (6.00 ± 3.00) and west (6.00 ± 2.25, P < .002). The average number of hours worked per week was considered to be a more important component for those outside of the United States (8.50 ± 1.25) than those in the midwest (6.00 ± 3.00) and south (6.00 ± 2.25) (P = .01).

      Free response

      There was a final section where participants were able to enter “free text” about any additional information that they felt should be included in a fellowship website. There were 4 responses to this question: (1) Program adjustments due to COVID-19 pandemic (Virtual or in person interviews, hospital policies if another outbreak were to occur); (2) Ability to contact previous fellows for information; (3) Willingness of program to accept international graduates; and (4) Access to the direct anterior hip approach.

      Discussion

      Applicants to adult reconstruction fellowship programs expressed that 9 components of fellowship education (exposure to operative techniques in revision surgery, exposure to operative techniques in primary surgery, breakdown of revision to primary cases, number of cases performed, availability and participation of faculty in fellowship, clinical independence, clinic-to-OR ratio, didactics, and research infrastructure), 3 components of fellowship recruitment (ability to obtain desired job opportunity after fellowship, perception of lifelong network, and call burden), and a single component of fellowship experience (prestige of fellowship within the field) were of the highest importance to include on fellowship program websites. Information about applicant preferences and desired information will help inform a comprehensive database of programs that is readily available to all applicants.

      Demographics

      Gender diversity seems to be improving amongst current adult reconstruction fellows and applicants. In the present survey, 12.6% of respondents are women. Cannada et al. [
      • Cannada L.K.
      Women in orthopaedic fellowships: what is their match rate, and what specialties do they choose?.
      ] reported that 6% of applicants in 2014 were women. While the present study is not designed to determine incidence of various demographic variables, these results should be seen as encouraging and prompt further research investigating current demographic trends in adult reconstruction fellowship. While nearly 24% of the respondents identified as non-White race, there were only 3 respondents who identified as Black and 6 (4.4%) participants who identified as Hispanic. International medical graduates represented nearly 10% of the survey participants. The results of this survey demonstrate that there is still a significant amount of work to be done in order to increase access and desirability to all eligible applicants. A comprehensive website that allows for quick assimilation of information will help improve access to all applicants and hopefully allow for more diversity within the field.

      Competition

      The average number of applications being submitted currently is at an all-time high. Participants in the survey applied to or anticipate applying to approximately 35 programs. This represents a 24.3% increase in the average number of applications from 2017, in which Wera et al. [
      • Wera G.D.
      • Eisinger S.
      • Oreluk H.
      • Cannada L.K.
      Trends in the orthopaedic surgery fellowship match 2013 to 2017.
      ] reported that the average number of applications submitted was 28. The 2021 cost of submitting each additional application after the first 10 applications is $35 per program []. This represents a significant cost increase for applicants. A comprehensive website may allow applicants to narrow the list of appropriate programs based on desired traits of specific programs and reduce overall application fees, further increasing access.

      Fellowship education

      Nine components of fellowship education were considered highly important. Exposure to techniques in revision and primary surgeries was first and second, respectively. This trend is consistent amongst other subspecialties and surgical fellowships [
      • McEvoy C.M.
      • Brown S.M.
      • Miskimin C.
      • Mulcahey M.K.
      Orthopaedic sports medicine fellowship websites: information considered most important to fellowship applicants.
      ]. Applicants in neurosurgery, otolaryngology, and sports medicine have been similarly surveyed and reported that “Exposure to advanced operative techniques” and “Complexity of cases” are most prioritized amongst applicants [
      • McEvoy C.M.
      • Brown S.M.
      • Miskimin C.
      • Mulcahey M.K.
      Orthopaedic sports medicine fellowship websites: information considered most important to fellowship applicants.
      ,
      • Judge P.D.
      • Alvi S.A.
      • Tawfik K.O.
      Priorities in the neurotology fellowship match: a survey study of program directors and fellows.
      ,
      • Yung K.C.
      • Courey M.S.
      Factors important in laryngology fellow and laryngology fellowship selection.
      ]. There is a strong interest in faculty participation and mentorship for adult reconstruction applicants. Birch et al. [
      • Birch D.W.
      • Asiri A.H.
      • de Gara C.J.
      The impact of a formal mentoring program for minimally invasive surgery on surgeon practice and patient outcomes.
      ] report on the successful adoption of minimally invasive surgical practices after the introduction of a formal mentorship program. A website should contain information about the various physicians that the fellow will be interacting with throughout the year with some comment on their mentorship abilities. Additionally, applicants reported that didactics were highly important and should be mentioned on the website. Shive et al. [
      • Shive M.
      • Zachary C.
      • Lee P.
      Virtual didactics exchanges to enhance trainee education.
      ] describe a didactic experience that emerged in dermatology fellowship as a result of coronavirus disease 2019 which allowed for extramural faculty to be involved in fellow education and satisfaction with didactics increased from a mean of 3.2 to 4.9 on a 5-point scale. In the contemporary setting of postpandemic education in which virtual meetings are ubiquitous, didactics have the potential to bridge gaps in education and standardize fellow education.
      Geographic differences were seen in the desire to be informed about number of cases performed during fellowship, with the northeast and south regions considering this to be very important. While those in the idwest did not consider this as important, the weighted average was 8.0, signifying that this was still deemed important. The regional difference may be attributed to the amount of exposure afforded in residency programs. ACGME status was more important to include on a fellowship website for younger residents, while this was not as important for senior trainees. This may represent a misunderstanding by junior residents that ACGME status is correlated with the quality of the fellowship. A fellowship website may expand on ACGME accreditation status and how that individually affects the fellows’ experience.

      Fellowship recruitment

      There were 3 components that were considered to be very important to applicants in respect to recruitment. The highest average weighted components include ability to obtain desired job opportunity after fellowship (8.89), and the perception of creating a lifelong network (8.43), and call burden (7.31). No differences were seen between various subgroups, suggesting that there is agreement amongst those surveyed about which variables in regards to fellowship recruitment are most important to include on a website. A website could include a list of positions that previous fellows take upon completion of fellowship to provide a better idea of the practice type and region. Additionally, a website could include contact information of previous fellows in order to foster a network among previous fellows and applicants.

      Fellowship experience

      The most important factor of fellowship experience for applicants was prestige of the fellowship amongst peers. Conversely, the U.S. News and World report ranking of the affiliated hospital was considered least important (4.26), suggesting that the applicants are concerned primarily with the status of the adult reconstruction fellowship as opposed to the partner hospital system. Information on the website could focus on the academic and clinical reputation of the fellowship as it relates to other adult reconstruction fellowship programs. Geographic location (6.79) and work-life balance (6.46) were considered moderately important to those surveyed. Work-life balance and location may not be considered as important given the short chronicity of this training position.
      The average number of hours worked in fellowship was considered to be pertinent information for a fellowship website for senior residents and current fellows/attendings; however, this was less important for junior residents. This may be a reflection of the current work hours imposed on junior residents, which begins to taper as residents become more senior. This could also reflect the importance of social obligations that arise in fellowships when residents are older and more likely to have family obligations which preclude a heavy fellowship schedule. A dedicated fellow clinic and/or OR was felt to be more important to applicants outside of the United States than those who trained in the United States. This may reflect differences in training and the desire to have some autonomy in clinic and/or OR as a resident who trained outside the United States. In order to increase access to international applicants as well as improve the rate of successful match for international graduates, it is pertinent that websites include information which they deem to be important when researching fellowship programs.

      Limitations

      There are several limitations to the present study. The survey itself may introduce some bias as to how the questions were asked and what topics were queried. The survey was dispersed through the AAHKS membership list, which may be limited in its scope of future arthroplasty fellowship applicants. Participants who were not a current member of AAHKS would not have been surveyed, potentially introducing some selection bias. Past applicants may have been less likely to participate in the survey. Finally, as with most surveys, there was a low response rate of 28.7%, although this rate was higher than in similar studies (13.2%) [
      • McEvoy C.M.
      • Brown S.M.
      • Miskimin C.
      • Mulcahey M.K.
      Orthopaedic sports medicine fellowship websites: information considered most important to fellowship applicants.
      ]. Furthermore, our survey design may have underrepresented certain topics that may have had altered rates of importance to survey respondents had they been include. From free-text responses, it is plausible that the inclusion of “access to learn the anterior approach to the hip” would have been rated of higher importance if listed.

      Conclusions

      Competition for adult reconstruction fellowship applications is at an all-time high. As we move toward an increasingly diverse and competitive field, it is important that we develop resources which may provide all applicants with reliable information. This information should help inform applicants about programs in areas they are most interested in. This in the hopes that diversity in applications continues to increase and applicants apply to a well-curated list of programs to avoid the inefficiencies of application for educational purposes. A comprehensive website with the components identified above would be an integral first step toward improving access and information to all applicants.

      Conflicts of interest

      The authors declare there are no conflicts of interest.
      For full disclosure statements refer to https://doi.org/10.1016/j.artd.2022.07.012.

      Acknowledgments

      We would like to acknowledged the American Association of Hip and Knee Surgeons Education Committee for their help with the dissemination of the survey and guidance with manuscript preparation.

      Appendix A. Supplementary data

      Appendix A

      Tabled 1
      Question #Questions and answer choices
      1What is your current position?
      PGY1
      PGY2
      PGY3
      PGY4
      PGY5
      In Fellowship
      Other
      2How to do you identify your gender?
      Male
      Female
      Non-Binary
      Prefer not to say
      Other
      3Which of the following best describes your ethnicity?
      Asian or Pacific Islander
      Black or African American
      Hispanic or Latino
      Native American or Alaska Native
      White or Caucasian
      Multiracial or Biracial
      Other
      4What is your age range?
      20-29
      30-39
      40-49
      50-59
      60-69
      Other:
      5[Select all that apply] Are you:
      International Medical Graduate (IMG)
      Osteopathic Graduate
      Active Military
      None of the above
      6Which Match Cycle will you/did you participate in?
      2019 Match for 2020 Training
      2020 Match for 2021 Training
      2021 Match for 2022 Training
      2022 Match for 2023 Training
      2023 Match for 2024 Training
      Other:
      7How may fellowships do you hope to/did you apply to?
      8How many interviews do you hope to/did you complete?
      9what region are you from presently? Please reference the map when making selection
      Pacific - AK, CA, HI, OR, WA
      Mountain - AZ, CO, ID, MT, NM, NV, UT, WY
      West North Central - IA, KS, MN, MO, NE, ND, SD
      East North Central - IL, IN, MI, OH, WI
      Middle Atlantic - NJ, NY, PA
      New England - CT, MA, ME, NH, RI, VT
      West South Central - AR, LA, OK, TX
      East South Central - AL, KY, MS, TN
      South Atlantic - FL, GA, DC, DE, MD, NC, SC, VA, WV
      Canada
      Other:
      10What region do you intend/hope to end up in? Please reference the map when making selection
      Pacific - AK, CA, HI, OR, WA
      Mountain - AZ, CO, ID, MT, NM, NV, UT, WY
      West North Central - IA, KS, MN, MO, NE, ND, SD
      East North Central - IL, IN, MI, OH, WI
      Middle Atlantic - NJ, NY, PA
      New England - CT, MA, ME, NH, RI, VT
      West South Central - AR, LA, OK, TX
      East South Central - AL, KY, MS, TN
      South Atlantic - FL, GA, DC, DE, MD, NC, SC, VA, WV
      Canada
      Doesn’t matter
      Other:
      11What information pertaining to fellowship should be included in a comprehensive website? On a scale from 1-10, 10 being extremely important and 1 being not at all important
      Exposure to operative techniques in primary surgery (approaches, robotics, minimally invasive surgery etc)
      Exposure to operative techniques in revision surgery
      Number of cases performed
      Breakdown of revisions to primaries
      Clinic to OR ratio
      Didactics (quality and breadth)
      Diversity of program
      Allowance for national conference attendance
      Call burden
      Call pay/moonlighting opportunities
      Clinical Independence
      Rounding, note writing, other “service” responsibilities
      Research opportunities/requirements
      Prestige of faculty
      Availability and participation of faculty in fellowship
      Resident teaching opportunities
      Prestige of fellowship within field
      US News and World Report of hospital affiliated
      Salary and cost of living considerations
      Number of fellows per year
      Geographic location of program
      Employee benefits
      Dedicated fellow clinic/OR
      Average of hours worked per week
      Overall work-life balance
      Perception of life long network
      Presence of non-clinical education (business of medicine, medical-legal, ambulatory surgery center, grant writing, dealing with industry, contract negotiation)
      Burden of research (how much help, or are fellows mining charts)
      Availability of basic science research
      Ability to obtain desired job opportunity after fellowship
      Ability to get involved in society, academy etc through fellowship
      Geography of work post fellowship (do fellows stick around or go, non-compete etc)
      Program ACGME accreditation status
      Other (please specify)
      12Is there anything else that you think the Education Committee should take into consideration when creating a comprehensive fellowship website?

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