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1.  Fellow or foe: the impact of fellowship training programs on the education of Canadian urology residents 
Objective
Throughout North America, increasing emphasis is being placed on surgical fellowships. Surgical educators and trainees have raised concerns that the escalating focus on fellowships may threaten the educational mission of more novice trainees. Our objective was to collect opinions from multiple perspectives (faculty, fellows and residents) regarding fellowship structure, fellow selection and the impact of clinical fellowships on urology resident training.
Methods
We anonymously surveyed 52 members of a major academic urology training program (University of Toronto) with established fellowship training programs for their opinions regarding fellowship structure, fellow selection, and the impact on resident training and education.
Results
The overall response rate was 88%. We identified significant differences of opinion among faculty, fellows and residents regarding fellowship structure, fellow selection and the impact on resident education. Specifically, faculty and fellows supported the addition of more fellows, felt that certain complex cases should be designated as “fellow cases” and that residents' research opportunities were not restricted. Residents felt that fellows “steal” operative cases, that performing operations with the fellow is not equivalent to performing operations with faculty alone and that fellowship candidates should perform an operation with division faculty as part of the application process. There was agreement that fellowship programs add value to residents' overall education, that fellows should participate in the call schedule and that fellows' role in the operating room needs to be better defined with respect to case volume and selection. Proficiency in technical skills, clinical knowledge, teaching and teamwork were cited as the most attractive characteristics of an effective clinical fellow.
Conclusion
Residency and fellowship program directors must clearly define the role of the fellow and outline the limits of surgical practice, establish clear and consistent guidelines outlining responsibilities (operative, clinical and on-call), and open lines of communication to ensure that all opinions are recognized and addressed. Finally, they must select fellows with proficient technical skills, clinical knowledge, teaching ability and work ethic to ensure that they focus on “specialized” training.
PMCID: PMC2422895  PMID: 18542725
2.  The Radiology Fellowship Application and Selection Process in the United States: Experiences and Perceptions from Both Sides 
Objective. Our purpose was to investigate radiology fellowship directors' and recent fellows' experiences and perceptions with regard to the fellowship application and selection process and to compare these experiences and perceptions. Materials and Methods. Institutional review board approval was obtained. We conducted an online survey of the memberships of three radiology subspecialty societies between October 2009 and December 2009 to learn about radiologists' views regarding various aspects of radiology fellowships. Results. In the process of selecting fellows, program directors and recent fellows consider performance during the radiology residency and the quality or prestige of the residency program as the most important objective factors, and the personal interview, letters of recommendation, and personality as the most important subjective factors. 25% of the program directors were in the match, and 41% of the recent fellows were in the match. Most (48%) of program directors favored a match, but most (56%) of the recent fellows disfavored participating in a match. Both program directors and recent fellows expressed satisfaction with the fellowship application and selection process. Conclusion. There was no majority support for a fellowship match among program directors and recent fellows and less support among recent fellows. Recent fellows appear more satisfied with the current selection and application process than program directors.
doi:10.1155/2012/875083
PMCID: PMC3403493  PMID: 22848822
3.  Different tracks for pathology informatics fellowship training: Experiences of and input from trainees in a large multisite fellowship program 
Background:
Pathology Informatics is a new field; a field that is still defining itself even as it begins the formalization, accreditation, and board certification process. At the same time, Pathology itself is changing in a variety of ways that impact informatics, including subspecialization and an increased use of data analysis. In this paper, we examine how these changes impact both the structure of Pathology Informatics fellowship programs and the fellows’ goals within those programs.
Materials and Methods:
As part of our regular program review process, the fellows evaluated the value and effectiveness of our existing fellowship tracks (Research Informatics, Clinical Two-year Focused Informatics, Clinical One-year Focused Informatics, and Clinical 1 + 1 Subspecialty Pathology and Informatics). They compared their education, informatics background, and anticipated career paths and analyzed them for correlations between those parameters and the fellowship track chosen. All current and past fellows of the program were actively involved with the project.
Results:
Fellows’ anticipated career paths correlated very well with the specific tracks in the program. A small set of fellows (Clinical – one or two year – Focused Informatics tracks) anticipated clinical careers primarily focused in informatics (Director of Informatics). The majority of the fellows, however, anticipated a career practicing in a Pathology subspecialty, using their informatics training to enhance that practice (Clinical 1 + 1 Subspecialty Pathology and Informatics Track). Significantly, all fellows on this track reported they would not have considered a Clinical Two-year Focused Informatics track if it was the only track offered. The Research and the Clinical One-year Focused Informatics tracks each displayed unique value for different situations.
Conclusions:
It seems a “one size fits all” fellowship structure does not fit the needs of the majority of potential Pathology Informatics candidates. Increasingly, these fellowships must be able to accommodate the needs of candidates anticipating a wide range of Pathology Informatics career paths, be able to accommodate Pathology's increasingly subspecialized structure, and do this in a way that respects the multiple fellowships needed to become a subspecialty pathologist and informatician. This is further complicated as Pathology Informatics begins to look outward and takes its place in the growing, and still ill-defined, field of Clinical Informatics, a field that is not confined to just one medical specialty, to one way of practicing medicine, or to one way of providing patient care.
doi:10.4103/2153-3539.100362
PMCID: PMC3445299  PMID: 23024889
Clinical informatics training; clinical informatics; fellowship tracks; informatics fellowship training; informatics teaching; pathology informatics fellowship; pathology informatics training; pathology informatics
4.  Implementing the 2009 Institute of Medicine recommendations on resident physician work hours, supervision, and safety 
Long working hours and sleep deprivation have been a facet of physician training in the US since the advent of the modern residency system. However, the scientific evidence linking fatigue with deficits in human performance, accidents and errors in industries from aeronautics to medicine, nuclear power, and transportation has mounted over the last 40 years. This evidence has also spawned regulations to help ensure public safety across safety-sensitive industries, with the notable exception of medicine.
In late 2007, at the behest of the US Congress, the Institute of Medicine embarked on a year-long examination of the scientific evidence linking resident physician sleep deprivation with clinical performance deficits and medical errors. The Institute of Medicine’s report, entitled “Resident duty hours: Enhancing sleep, supervision and safety”, published in January 2009, recommended new limits on resident physician work hours and workload, increased supervision, a heightened focus on resident physician safety, training in structured handovers and quality improvement, more rigorous external oversight of work hours and other aspects of residency training, and the identification of expanded funding sources necessary to implement the recommended reforms successfully and protect the public and resident physicians themselves from preventable harm.
Given that resident physicians comprise almost a quarter of all physicians who work in hospitals, and that taxpayers, through Medicare and Medicaid, fund graduate medical education, the public has a deep investment in physician training. Patients expect to receive safe, high-quality care in the nation’s teaching hospitals. Because it is their safety that is at issue, their voices should be central in policy decisions affecting patient safety. It is likewise important to integrate the perspectives of resident physicians, policy makers, and other constituencies in designing new policies. However, since its release, discussion of the Institute of Medicine report has been largely confined to the medical education community, led by the Accreditation Council for Graduate Medical Education (ACGME).
To begin gathering these perspectives and developing a plan to implement safer work hours for resident physicians, a conference entitled “Enhancing sleep, supervision and safety: What will it take to implement the Institute of Medicine recommendations?” was held at Harvard Medical School on June 17–18, 2010. This White Paper is a product of a diverse group of 26 representative stakeholders bringing relevant new information and innovative practices to bear on a critical patient safety problem. Given that our conference included experts from across disciplines with diverse perspectives and interests, not every recommendation was endorsed by each invited conference participant. However, every recommendation made here was endorsed by the majority of the group, and many were endorsed unanimously. Conference members participated in the process, reviewed the final product, and provided input before publication. Participants provided their individual perspectives, which do not necessarily represent the formal views of any organization.
In September 2010 the ACGME issued new rules to go into effect on July 1, 2011. Unfortunately, they stop considerably short of the Institute of Medicine’s recommendations and those endorsed by this conference. In particular, the ACGME only applied the limitation of 16 hours to first-year resident physicans. Thus, it is clear that policymakers, hospital administrators, and residency program directors who wish to implement safer health care systems must go far beyond what the ACGME will require. We hope this White Paper will serve as a guide and provide encouragement for that effort.
Resident physician workload and supervision
By the end of training, a resident physician should be able to practice independently. Yet much of resident physicians’ time is dominated by tasks with little educational value. The caseload can be so great that inadequate reflective time is left for learning based on clinical experiences. In addition, supervision is often vaguely defined and discontinuous. Medical malpractice data indicate that resident physicians are frequently named in lawsuits, most often for lack of supervision. The recommendations are: The ACGME should adjust resident physicians workload requirements to optimize educational value. Resident physicians as well as faculty should be involved in work redesign that eliminates nonessential and noneducational activity from resident physician dutiesMechanisms should be developed for identifying in real time when a resident physician’s workload is excessive, and processes developed to activate additional providersTeamwork should be actively encouraged in delivery of patient care. Historically, much of medical training has focused on individual knowledge, skills, and responsibility. As health care delivery has become more complex, it will be essential to train resident and attending physicians in effective teamwork that emphasizes collective responsibility for patient care and recognizes the signs, both individual and systemic, of a schedule and working conditions that are too demanding to be safeHospitals should embrace the opportunities that resident physician training redesign offers. Hospitals should recognize and act on the potential benefits of work redesign, eg, increased efficiency, reduced costs, improved quality of care, and resident physician and attending job satisfactionAttending physicians should supervise all hospital admissions. Resident physicians should directly discuss all admissions with attending physicians. Attending physicians should be both cognizant of and have input into the care patients are to receive upon admission to the hospitalInhouse supervision should be required for all critical care services, including emergency rooms, intensive care units, and trauma services. Resident physicians should not be left unsupervised to care for critically ill patients. In settings in which the acuity is high, physicians who have completed residency should provide direct supervision for resident physicians. Supervising physicians should always be physically in the hospital for supervision of resident physicians who care for critically ill patientsThe ACGME should explicitly define “good” supervision by specialty and by year of training. Explicit requirements for intensity and level of training for supervision of specific clinical scenarios should be providedCenters for Medicare and Medicaid Services (CMS) should use graduate medical education funding to provide incentives to programs with proven, effective levels of supervision. Although this action would require federal legislation, reimbursement rules would help to ensure that hospitals pay attention to the importance of good supervision and require it from their training programs
Resident physician work hours
Although the IOM “Sleep, supervision and safety” report provides a comprehensive review and discussion of all aspects of graduate medical education training, the report’s focal point is its recommendations regarding the hours that resident physicians are currently required to work. A considerable body of scientific evidence, much of it cited by the Institute of Medicine report, describes deteriorating performance in fatigued humans, as well as specific studies on resident physician fatigue and preventable medical errors.
The question before this conference was what work redesign and cultural changes are needed to reform work hours as recommended by the Institute of Medicine’s evidence-based report? Extensive scientific data demonstrate that shifts exceeding 12–16 hours without sleep are unsafe. Several principles should be followed in efforts to reduce consecutive hours below this level and achieve safer work schedules. The recommendations are: Limit resident physician work hours to 12–16 hour maximum shiftsA minimum of 10 hours off duty should be scheduled between shiftsResident physician input into work redesign should be actively solicitedSchedules should be designed that adhere to principles of sleep and circadian science; this includes careful consideration of the effects of multiple consecutive night shifts, and provision of adequate time off after night work, as specified in the IOM reportResident physicians should not be scheduled up to the maximum permissible limits; emergencies frequently occur that require resident physicians to stay longer than their scheduled shifts, and this should be anticipated in scheduling resident physicians’ work shiftsHospitals should anticipate the need for iterative improvement as new schedules are initiated; be prepared to learn from the initial phase-in, and change the plan as neededAs resident physician work hours are redesigned, attending physicians should also be considered; a potential consequence of resident physician work hour reduction and increased supervisory requirements may be an increase in work for attending physicians; this should be carefully monitored, and adjustments to attending physician work schedules made as needed to prevent unsafe work hours or working conditions for this group“Home call” should be brought under the overall limits of working hours; work load and hours should be monitored in each residency program to ensure that resident physicians and fellows on home call are getting sufficient sleepMedicare funding for graduate medical education in each hospital should be linked with adherence to the Institute of Medicine limits on resident physician work hours
Moonlighting by resident physicians
The Institute of Medicine report recommended including external as well as internal moonlighting in working hour limits. The recommendation is: All moonlighting work hours should be included in the ACGME working hour limits and actively monitored. Hospitals should formalize a moonlighting policy and establish systems for actively monitoring resident physician moonlighting
Safety of resident physicians
The “Sleep, supervision and safety” report also addresses fatigue-related harm done to resident physicians themselves. The report focuses on two main sources of physical injury to resident physicians impaired by fatigue, ie, needle-stick exposure to blood-borne pathogens and motor vehicle crashes. Providing safe transportation home for resident physicians is a logistical and financial challenge for hospitals. Educating physicians at all levels on the dangers of fatigue is clearly required to change driving behavior so that safe hospital-funded transport home is used effectively. Fatigue-related injury prevention (including not driving while drowsy) should be taught in medical school and during residency, and reinforced with attending physicians; hospitals and residency programs must be informed that resident physicians’ ability to judge their own level of impairment is impaired when they are sleep deprived; hence, leaving decisions about the capacity to drive to impaired resident physicians is not recommendedHospitals should provide transportation to all resident physicians who report feeling too tired to drive safely; in addition, although consecutive work should not exceed 16 hours, hospitals should provide transportation for all resident physicians who, because of unforeseen reasons or emergencies, work for longer than consecutive 24 hours; transportation under these circumstances should be automatically provided to house staff, and should not rely on self-identification or request
Training in effective handovers and quality improvement
Handover practice for resident physicians, attendings, and other health care providers has long been identified as a weak link in patient safety throughout health care settings. Policies to improve handovers of care must be tailored to fit the appropriate clinical scenario, recognizing that information overload can also be a problem. At the heart of improving handovers is the organizational effort to improve quality, an effort in which resident physicians have typically been insufficiently engaged. The recommendations are: Hospitals should train attending and resident physicians in effective handovers of careHospitals should create uniform processes for handovers that are tailored to meet each clinical setting; all handovers should be done verbally and face-to-face, but should also utilize written toolsWhen possible, hospitals should integrate hand-over tools into their electronic medical records (EMR) systems; these systems should be standardized to the extent possible across residency programs in a hospital, but may be tailored to the needs of specific programs and services; federal government should help subsidize adoption of electronic medical records by hospitals to improve signoutWhen feasible, handovers should be a team effort including nurses, patients, and familiesHospitals should include residents in their quality improvement and patient safety efforts; the ACGME should specify in their core competency requirements that resident physicians work on quality improvement projects; likewise, the Joint Commission should require that resident physicians be included in quality improvement and patient safety programs at teaching hospitals; hospital administrators and residency program directors should create opportunities for resident physicians to become involved in ongoing quality improvement projects and root cause analysis teams; feedback on successful quality improvement interventions should be shared with resident physicians and broadly disseminatedQuality improvement/patient safety concepts should be integral to the medical school curriculum; medical school deans should elevate the topics of patient safety, quality improvement, and teamwork; these concepts should be integrated throughout the medical school curriculum and reinforced throughout residency; mastery of these concepts by medical students should be tested on the United States Medical Licensing Examination (USMLE) stepsFederal government should support involvement of resident physicians in quality improvement efforts; initiatives to improve quality by including resident physicians in quality improvement projects should be financially supported by the Department of Health and Human Services
Monitoring and oversight of the ACGME
While the ACGME is a key stakeholder in residency training, external voices are essential to ensure that public interests are heard in the development and monitoring of standards. Consequently, the Institute of Medicine report recommended external oversight and monitoring through the Joint Commission and Centers for Medicare and Medicaid Services (CMS). The recommendations are: Make comprehensive fatigue management a Joint Commission National Patient Safety Goal; fatigue is a safety concern not only for resident physicians, but also for nurses, attending physicians, and other health care workers; the Joint Commission should seek to ensure that all health care workers, not just resident physicians, are working as safely as possibleFederal government, including the Centers for Medicare and Medicaid Services and the Agency for Healthcare Research and Quality, should encourage development of comprehensive fatigue management programs which all health systems would eventually be required to implementMake ACGME compliance with working hours a “ condition of participation” for reimbursement of direct and indirect graduate medical education costs; financial incentives will greatly increase the adoption of and compliance with ACGME standards
Future financial support for implementation
The Institute of Medicine’s report estimates that $1.7 billion (in 2008 dollars) would be needed to implement its recommendations. Twenty-five percent of that amount ($376 million) will be required just to bring hospitals into compliance with the existing 2003 ACGME rules. Downstream savings to the health care system could potentially result from safer care, but these benefits typically do not accrue to hospitals and residency programs, who have been asked historically to bear the burden of residency reform costs. The recommendations are: The Institute of Medicine should convene a panel of stakeholders, including private and public funders of health care and graduate medical education, to lay down the concrete steps necessary to identify and allocate the resources needed to implement the recommendations contained in the IOM “Resident duty hours: Enhancing sleep, supervision and safety” report. Conference participants suggested several approaches to engage public and private support for this initiativeEfforts to find additional funding to implement the Institute of Medicine recommendations should focus more broadly on patient safety and health care delivery reform; policy efforts focused narrowly upon resident physician work hours are less likely to succeed than broad patient safety initiatives that include residency redesign as a key componentHospitals should view the Institute of Medicine recommendations as an opportunity to begin resident physician work redesign projects as the core of a business model that embraces safety and ultimately saves resourcesBoth the Secretary of Health and Human Services and the Director of the Centers for Medicare and Medicaid Services should take the Institute of Medicine recommendations into consideration when promulgating rules for innovation grantsThe National Health Care Workforce Commission should consider the Institute of Medicine recommendations when analyzing the nation’s physician workforce needs
Recommendations for future research
Conference participants concurred that convening the stakeholders and agreeing on a research agenda was key. Some observed that some sectors within the medical education community have been reluctant to act on the data. Several logical funders for future research were identified. But above all agencies, Centers for Medicare and Medicaid Services is the only stakeholder that funds graduate medical education upstream and will reap savings downstream if preventable medical errors are reduced as a result of reform of resident physician work hours.
doi:10.2147/NSS.S19649
PMCID: PMC3630963  PMID: 23616719
resident; hospital; working hours; safety
5.  Fellows as teachers: a model to enhance pediatric resident education 
Medical Education Online  2011;16:10.3402/meo.v16i0.7205.
Objective
Pressures on academic faculty to perform beyond their role as educators has stimulated interest in complementary approaches in resident medical education. While fellows are often believed to detract from resident learning and experience, we describe our preliminary investigations utilizing clinical fellows as a positive force in pediatric resident education. Our objectives were to implement a practical approach to engage fellows in resident education, evaluate the impact of a fellow-led education program on pediatric resident and fellow experience, and investigate if growth of a fellowship program detracts from resident procedural experience.
Methods
This study was conducted in a neonatal intensive care unit (NICU) where fellows designed and implemented an education program consisting of daily didactic teaching sessions before morning clinical rounds. The impact of a fellow-led education program on resident satisfaction with their NICU experience was assessed via anonymous student evaluations. The potential value of the program for participating fellows was also evaluated using an anonymous survey.
Results
The online evaluation was completed by 105 residents. Scores were markedly higher after the program was implemented in areas of teaching excellence (4.44 out of 5 versus 4.67, p<0.05) and overall resident learning (3.60 out of 5 versus 4.61, p<0.001). Fellows rated the acquisition of teaching skills and enhanced knowledge of neonatal pathophysiology as the most valuable aspects of their participation in the education program. The anonymous survey revealed that 87.5% of participating residents believed that NICU fellows were very important to their overall training and education.
Conclusions
While fellows are often believed to be a detracting factor to residency training, we found that pediatric resident attitudes toward the fellows were generally positive. In our experience, in the specialty of neonatology a fellow-led education program can positively contribute to both resident and fellow learning and satisfaction. Further investigation into the value of utilizing fellows as a positive force in resident education in other medical specialties appears warranted.
doi:10.3402/meo.v16i0.7205
PMCID: PMC3169169  PMID: 21912479
resident education; fellow teaching; pediatrics
6.  Robotic Surgery Training in Gynecologic Fellowship Programs in the United States 
Background and Objectives:
The increasing use and acceptance of robotic platforms calls for the need to train not only established surgeons but also residents and fellow trainees within the context of the traditional residency and fellowship program. Our study aimed to clarify the current status of robotic training in gynecologic fellowship programs in the United States.
Methods:
This was a Web-based survey of four gynecology fellowship programs in the United States from November 2010 to March 2011. Programs were selected based on their geographic areas. A questionnaire with 43 questions inquiring about robotic surgery performance and training was sent to the programs and either a fellow or the fellowship director was asked to complete. Participation was voluntary.
Results:
We had 102 responders (18% respond rate) with an almost equal response rate from all four gynecologic fellowships, with a median response rate of 25% (range 21–29%). Minimally Invasive Surgery (MIS) and Gynecologic Oncology (Gyn Onc) fellowships had the highest rate of robotic training in their fellowship curriculum—95% and 83%, respectively. Simulator training was used as a training tool in 74% of Female Pelvic Medicine and Reconstructive Surgery (FPMRS); however, just 22% of Reproductive Endocrinology and Infertility fellowships had simulator training. Eighty-seven percent of Gyn Onc fellows graduate with >50 robotic cases, but this was 0% for Reproductive Endocrinology Infertility fellows.
Conclusion:
Our study showed that the use of a robotic system was built into fellowship curriculum of >80% of MIS and Gyn Onc fellowship programs that were entered in our study. Simulator training has been used widely in Ob&Gyn fellowship programs as part of their robotic training curriculum.
doi:10.4293/JSLS.2014.00402
PMCID: PMC4154438  PMID: 25392648
Robotic surgery; Ob&Gyn; Fellowship; Training
7.  Current pediatric rheumatology fellowship training in the United States: what fellows actually do 
Background
Pediatric Rheumatology (PR) training in the US has existed since the 1970’s. In the early 1990’s, the training was formalized into a three year training program by the American College of Graduate Medical Education (ACGME) and American Board of Pediatrics (ABP). Programs have been evaluated every 5 years by the ACGME to remain credentialed and graduates had to pass a written exam to be certified. There has been no report yet that details not just what training fellows should receive in the 32 US PR training programs but what training the trainees are actually receiving.
Methods
After a literature search, a survey was constructed by the authors, then reviewed and revised with the help members of the Executive Committee of the Rheumatology Section of the American Academy of Pediatrics (AAP) using the Delphi technique. IRB approval was obtained from the AAP and Nationwide Children’s Hospital. The list of fellows was obtained from the ABP and the survey sent out to 81 current fellows or fellows just having finished. One repeat e-mail was sent out.
Results
Forty-seven fellows returned the survey by e-mail (58%) with the majority being 3rd year fellows or fellows who had completed their training. The demographics were as expected with females > males and Caucasians> > non-Caucasians. Training appeared quite appropriate in the number of ½ day continuity clinics per week (1–2, 71%), number of patients per clinic (4–5, 60%), inpatient exposure (2–4 inpatients per week, 40%; 5 or greater, 33%), and weekday/weekend call. Fellows attended more didactic activities than required, had ample time for research (54% 21-60/hours per week), and had multiple teaching opportunities. Seventy-seven percent of the trainees presented abstracts at national meetings, 41% had publication. Disease exposure was excellent and joint injection experience sufficient.
Conclusions
Most US PR training programs as a whole provide an appropriate training by current ACGME, American College of Rheumatology (ACR), and ABP standards in: 1) number of continuity clinics; 2) sufficient on-call activities for weekday nights and weekends; 3) joint interdisciplinary conferences; 4) electives 5) didactic activities; 6) scholarly activities; and 7) exposure to diverse rheumatology diseases. Areas of concern were uniformity & standardization of training, need for a customized PR training curriculum, more mentorship, free electives, training in musculoskeletal ultrasound, need for a hands-on OSCE certification exam and more exposure to ACGME competencies.
doi:10.1186/1546-0096-12-8
PMCID: PMC3922187  PMID: 24507769
8.  An evaluation of procedural training in Canadian respirology fellowship programs: Program directors’ and fellows’ perspectives 
BACKGROUND:
In recent years, there has been a rapid growth in diagnostic and therapeutic procedures performed by respirologists.
OBJECTIVES:
To assess the number and type of procedures performed in Canadian respirology training programs, for comparison with the American College of Chest Physicians minimum competency guidelines, and to assess fellow satisfaction with procedural training during their fellowships.
METHODS:
Internet-based surveys of Canadian respirology fellows and respirology fellowship program directors were conducted.
RESULTS:
Response rates for program director and respirology fellow surveys were 71% (10 of 14) and 62% (41 of 66), respectively. Thirty-eight per cent of respirology fellows reported the presence of an interventional pulmonologist at their institution. Flexible bronchoscopy was the only procedure reported by a large majority of respirology fellows (79.5%) to meet American College of Chest Physicians recommendations (100 procedures). As reported by respirology fellows, recommended numbers of procedures were met by 59.5% of fellows for tube thoracostomy, 21% for transbronchial needle aspiration and 5.4% for closed pleural biopsy. Respirology fellows in programs with an interventional pulmonologist were more likely to have completed some form of additional interventional bronchoscopy training (80% versus 32%; P=0.003), had increased exposure to and expressed improved satisfaction with training in advanced diagnostic and therapeutic procedures, but did not increase their likelihood of achieving recommended numbers for any procedures.
CONCLUSIONS:
Canadian respirology fellows perform lower numbers of basic respiratory procedures, other than flexible bronchoscopy, than that suggested by the American College of Chest Physicians guidelines. Exposure and training in advanced diagnostic and therapeutic procedures is minimal. A concerted effort to improve procedural training is required to improve these results.
PMCID: PMC2687562  PMID: 19399309
Bronchoscopy; Education; Needle biopsy; Pulmonary training; Respirology
9.  Women’s Health Training in Gastroenterology Fellowship: A National Survey of Fellows and Program Directors 
Digestive diseases and sciences  2011;56(3):751-760.
Background and Aims
The Gastroenterology Core Curriculum requires training in women’s digestive disorders; however, requirements do not necessarily produce knowledge and competence. Our study goals were: (1) to compare perceptions of education, fellow-reported levels of competence, and attitudes towards training in women’s gastrointestinal (GI) health issues during fellowship between gastroenterology fellows and program directors, and (2) to determine the barriers for meeting training requirements.
Methods
A national survey assessing four domains of training was conducted. All GI program directors in the United States (n = 153) and a random sample of gastroenterology fellows (n = 769) were mailed surveys. Mixed effects linear modeling was used to estimate all mean scores and to assess differences between the groups. Cronbach’s alpha was used to assess the consistency of the measures which make up the means.
Results
Responses were received from 61% of program directors and 31% of fellows. Mean scores in perceived didactic education, clinical experiences, and competence in women’s GI health were low and significantly differed between the groups (P < 0.0001). Fellows’ attitudes towards women’s GI health issues were more positive compared to program directors’ (P = 0.004). Barriers to training were: continuity clinic at a Veteran’s Administration hospital, low number of pregnant patients treated, low number of referrals from obstetrics and gynecology, and lack of faculty interest in women’s health.
Conclusions
(1) Fellows more so than program directors perceive training in women’s GI health issues to be low. (2) Program directors more so than fellows rate fellows to be competent in women’s GI health. (3) Multiple barriers to women’s health training exist.
doi:10.1007/s10620-010-1532-7
PMCID: PMC3652315  PMID: 21267780
Women’s health; Gastroenterology fellowship; Training guidelines
10.  Prevalence and Cost of Full-Time Research Fellowships During General Surgery Residency – A National Survey 
Annals of surgery  2009;249(1):155-161.
Structured Abstract
Objective
To quantify the prevalence, outcomes, and cost of surgical resident research.
Summary Background Data
General surgery is unique among graduate medical education programs because a large percentage of residents interrupt their clinical training to spend 1-3 years performing full-time research. No comprehensive data exists on the scope of this practice.
Methods
Survey sent to all 239 program directors of general surgery residencies participating in the National Resident Matching Program.
Results
Response rate was 200/239 (84%). A total of 381 out of 1052 trainees (36%) interrupt residency to pursue full-time research. The mean research fellowship length is 1.7 years, with 72% of trainees performing basic science research. A significant association was found between fellowship length and post-residency activity, with a 14.7% increase in clinical fellowship training and a 15.2% decrease in private practice positions for each year of full-time research (p<0.0001). Program directors at 31% of programs reported increased clinical duties for research fellows as a result of ACGME work hour regulations for clinical residents, while a further 10% of programs are currently considering such changes. It costs $41.5 million to pay the 634 trainees who perform research fellowships each year, the majority of which is paid for by departmental funds (40%) and institutional training grants (24%).
Conclusions
Interrupting residency to perform a research fellowship is a common and costly practice among general surgery residents. While performing a research fellowship is associated with clinical fellowship training after residency, it is unclear to what extent this practice leads to the development of surgical investigators after post-graduate training.
doi:10.1097/SLA.0b013e3181929216
PMCID: PMC2678555  PMID: 19106692
11.  Fellowship training, workload, fatigue and physical stress: a prospective observational study 
Background
Fatigue in physician trainees may compromise patient safety and the well-being of the trainees and limit the educational opportunities provided by training programs. Anecdotal evidence suggests that the on-call workload and physical demands experienced by trainees are significant despite duty-hour regulation and support from nursing staff, other trainees and staff physicians.
Methods
We measured the workload and the level of fatigue and physical stress of 11 senior fellows during 35 shifts in the critical care unit at the Hospital for Sick Children in Toronto. We determined number of rostered hours, number of admissions and discharges, number and type of procedures, nurse:patient ratios and related measures of workload. Fellows self-reported the number of pages they received and the amount of time they slept. We estimated physical stress by using a commercially available pedometer to measure the distance walked, by using ambulatory electrocardiographic monitoring to determine arrhythmias and by determining urine specific gravity and ketone levels to estimate hydration.
Results
The number of rostered hours were within current Ontario guidelines. The mean shift duration was 25.5 hours (range 24–27 hours). The fellows worked on average 69 hours (range 55–106) per week. On average during a shift, the fellows received 41 pages, were on non-sleeping breaks for 1.2 hours, slept 1.9 hours and walked 6.3 km. Ketonuria was found in participants in 7 (21%) of the 33 shifts during which it was measured. Arrhythmia (1 atrial, 1 ventricular) or heart rate abnormalities occurred in all 6 participants. These fellows were the most senior in-house physician for a mean of 9.4 hours per shift and were responsible for performing invasive procedures in two-thirds of their shifts.
Interpretation
Established Canadian and proposed American guidelines expose trainees to significant on-call workload, physical stress and sleep deprivation.
doi:10.1503/cmaj.1030442
PMCID: PMC359430  PMID: 15023923
12.  The Current State of Fellowship Training in Pulmonary Artery Catheter Placement and Data Interpretation: A National Survey of Pulmonary & Critical Care Fellowship Program Directors 
Journal of critical care  2013;28(5):857-861.
Purpose
Given decreasing use of pulmonary artery (PA) catheterization, we sought to evaluate whether current pulmonary and critical care fellows have adequate opportunity to obtain proficiency in PA catheter placement and data interpretation.
Methods
All U.S. pulmonary and critical care program directors were invited to participate in an anonymous online survey regarding current training opportunities in PA catheterization.
Results
The response rate was 51% (69/136). 83% reported that the number of PA catheterizations performed by fellows within their program has decreased in the past decade. 54% estimated that their fellows currently participate in <10 supervised procedures during fellowship. The most frequently identified barriers to training were procedure volume and reluctance to place PA catheters in the medical intensive care unit. 43% of respondents agreed that training in PA catheter placement is currently adequate within their program and 55% agreed that training in data interpretation is adequate. Only 39% of respondents believe PA catheter placement should continue to be an ACGME training requirement.
Conclusions
Many current pulmonary and critical care fellows do not have the opportunity to gain proficiency in PA catheterization. Fellowship training programs should consider alternate means of training fellows in PA catheter data interpretation, such as simulation.
doi:10.1016/j.jcrc.2013.06.003
PMCID: PMC3770745  PMID: 23876703
Pulmonary Artery Catheterization; Medical Education; Critical Care; Pulmonary Hypertension
13.  Clinical fellowship training in pathology informatics: A program description 
Background:
In 2007, our healthcare system established a clinical fellowship program in pathology informatics. In 2011, the program benchmarked its structure and operations against a 2009 white paper “Program requirements for fellowship education in the subspecialty of clinical informatics”, endorsed by the Board of the American Medical Informatics Association (AMIA) that described a proposal for a general clinical informatics fellowship program.
Methods:
A group of program faculty members and fellows compared each of the proposed requirements in the white paper with the fellowship program's written charter and operations. The majority of white paper proposals aligned closely with the rules and activities in our program and comparison was straightforward. In some proposals, however, differences in terminology, approach, and philosophy made comparison less direct, and in those cases, the thinking of the group was recorded. After the initial evaluation, the remainder of the faculty reviewed the results and any disagreements were resolved.
Results:
The most important finding of the study was how closely the white paper proposals for a general clinical informatics fellowship program aligned with the reality of our existing pathology informatics fellowship. The program charter and operations of the program were judged to be concordant with the great majority of specific white paper proposals. However, there were some areas of discrepancy and the reasons for the discrepancies are discussed in the manuscript.
Conclusions:
After the comparison, we conclude that the existing pathology informatics fellowship could easily meet all substantive proposals put forth in the 2009 clinical informatics program requirements white paper. There was also agreement on a number of philosophical issues, such as the advantages of multiple fellows, the need for core knowledge and skill sets, and the need to maintain clinical skills during informatics training. However, there were other issues, such as a requirement for a 2-year fellowship and for informatics fellowships to be done after primary board certification, that pathology should consider carefully as it moves toward a subspecialty status and board certification.
doi:10.4103/2153-3539.93893
PMCID: PMC3327041  PMID: 22530179
Pathology informatics fellowship; clinical informatics; clinical informatics fellowship; pathology informatics; pathology informatics teaching; clinical informatics teaching
14.  National study of continuity clinic satisfaction in pediatric fellowship training 
Background
A national online survey was conducted to evaluate pediatric subspecialty fellow satisfaction regarding continuity clinic experience.
Methods
An anonymous online survey (SurveyMonkey™) was developed to evaluate demographics of the program, clinic organization, and patient and preceptor characteristics, and to compare fellow satisfaction when fellows were the primary providers with faculty supervision versus attending-run clinics assisted by fellows or a combination of the two models. Pediatric subspecialty fellows in a 3-year Accreditation Council for Graduate Medical Education accredited program in the United States (excluding emergency medicine, neonatology, and critical care) were invited to participate.
Results
There were 644 respondents and nearly half (54%) of these had fellow-run clinics. Eighty-six percent of fellows responded that they would prefer to have their own continuity clinics. Higher satisfaction ratings on maintaining continuity of care, being perceived as the primary provider, and feeling that they had greater autonomy in patient management were associated with being part of a fellow-run clinic experience (all P < 0.001). Additionally, fellow-run clinics were associated with a feeling of increased involvement in designing a treatment plan based on their differential diagnosis (P < 0.001). There were no significant associations with patient or preceptor characteristics.
Conclusion
Fellow-run continuity clinics provide fellows with a greater sense of satisfaction and independence in management plans.
doi:10.2147/AMEP.S51069
PMCID: PMC3791542  PMID: 24101886
resident education/training; workforce; pediatric; patient-provider relationship; pediatric outpatient clinic
15.  Determinants of internal medicine residents' choice in the canadian R4 Fellowship Match: A qualitative study 
BMC Medical Education  2011;11:44.
Background
There is currently a discrepancy between Internal Medicine residents' decisions in the Canadian subspecialty fellowship match (known as the R4 match) and societal need. Some studies have been published examining factors that influence career choices. However, these were either demographic factors or factors pre-determined by the authors' opinion as possibly being important to incorporate into a survey.
Methods
A qualitative study was undertaken to identify factors that determine the residents choice in the subspecialty (R4) fellowship match using focus group discussions involving third and fourth year internal medicine residents
Results
Based on content analysis of the discussion data, we identified five themes:
1) Practice environment including acuity of practice, ability to do procedures, lifestyle, job prospects and income
2) Exposure in rotations and to role models
3) Interest in subspecialty's patient population and common diseases
4) Prestige and respect of subspecialty
5) Fellowship training environment including fellowship program resources and length of training
Conclusions
There are a variety of factors that contribute to Internal Medicine residents' fellowship choice in Canada, many of which have been identified in previous survey studies. However, we found additional factors such as the resources available in a fellowship program, the prestige and respect of a subspecialty/career, and the recent trend towards a two-year General Internal Medicine fellowship in our country.
doi:10.1186/1472-6920-11-44
PMCID: PMC3146947  PMID: 21714921
16.  Global health opportunities within pediatric subspecialty fellowship training programs: surveying the virtual landscape 
BMC Medical Education  2013;13:88.
Background
There is growing interest in global health among medical trainees. Medical schools and residencies are responding to this trend by offering global health opportunities within their programs. Among United States (US) graduating pediatric residents, 40% choose to subspecialize after residency training. There is limited data, however, regarding global health opportunities within traditional post-residency, subspecialty fellowship training programs. The objectives of this study were to explore the availability and type of global health opportunities within Accreditation Council for Graduate Medical Education (ACGME)-accredited pediatric subspecialty fellowship training programs, as noted by their online report, and to document change in these opportunities over time.
Methods
The authors performed a systematic online review of ACGME-accredited fellowship training programs within a convenience sample of six US pediatric subspecialties. Utilizing two data sources, the American Medical Association-Fellowship and Residency Electronic Interactive Database Access (AMA-FREIDA) and individual program websites, all programs were coded for global health opportunities and opportunity types were stratified into predefined categories. Comparisons were made between 2008 and 2011 using Fisher exact test. All analyses were conducted using SAS Software v. 9.3 (SAS Institute Inc., Cary, NC).
Results
Of the 355 and 360 programs reviewed in 2008 and 2011 respectively, there was an increase in total number of programs listing global health opportunities on AMA-FREIDA (16% to 23%, p=0.02) and on individual program websites (8% to 16%, p=0.004). Nearly all subspecialties had an increased percentage of programs offering global health opportunities on both data sources; although only critical care experienced a significant increase (p=0.04, AMA-FREIDA). The types of opportunities differed across all subspecialties.
Conclusions
Global health opportunities among ACGME-accredited pediatric subspecialty fellowship programs are limited, but increasing as noted by their online report. The availability and types of these opportunities differ by pediatric subspecialty.
doi:10.1186/1472-6920-13-88
PMCID: PMC3691626  PMID: 23787005
Global health; Pediatrics; Graduate medical education; Subspecialty; Fellowship training
17.  Developing Future Faculty: A Program Targeting Internal Medicine Fellows' Teaching Skills 
Introduction
The increased demand for clinician-educators in academic medicine necessitates additional training in educational skills to prepare potential candidates for these positions. Although many teaching skills training programs for residents exist, there is a lack of reports in the literature evaluating similar programs during fellowship training.
Aim
To describe the implementation and evaluation of a unique program aimed at enhancing educational knowledge and teaching skills for subspecialty medicine fellows and chief residents.
Setting
Fellows as Clinician-Educators (FACE) program is a 1-year program open to fellows (and chief residents) in the Department of Internal Medicine at the University of Iowa.
Program Description
The course involves interactive monthly meetings held throughout the academic year and has provided training to 48 participants across 11 different subspecialty fellowships between 2004 and 2009.
Program Evaluation
FACE participants completed a 3-station Objective Structured Teaching Examination using standardized learners, which assessed participants' skills in giving feedback, outpatient precepting, and giving a mini-lecture. Based on reviews of station performance by 2 independent raters, fellows demonstrated statistically significant improvement on overall scores for 2 of the 3 cases. Participants self-assessed their knowledge and teaching skills prior to starting and after completing the program. Analyses of participants' retrospective preassessments and postassessments showed improved perceptions of competence after training.
Conclusion
The FACE program is a well-received intervention that objectively demonstrates improvement in participants' teaching skills. It offers a model approach to meeting important training skills needs of subspecialty medicine fellows and chief residents in a resource-effective manner.
doi:10.4300/JGME-D-10-00109.1
PMCID: PMC3179239  PMID: 22942953
18.  Are Pediatric Critical Care Medicine Fellowships Teaching and Evaluating Communication and Professionalism? 
Objective
To describe the teaching and evaluation modalities utilized by pediatric critical care medicine (PCCM) training programs in the areas of professionalism and communication.
Design
Cross sectional national survey.
Setting
PCCM fellowship programs.
Subjects
PCCM program directors.
Interventions
None.
Measurements and Main Results
Survey response rate was 67% of program directors in the United States, representing educators for 73% of current PCCM fellows. Respondents had a median of 4 years experience, with a median of 7 fellows and 12 teaching faculty in his/her program. Faculty role modeling or direct observation with feedback were the most common modalities used to teach communication. However, 6 of the 8 (75%) required elements of communication evaluated were not specifically taught by all programs. Faculty role modeling was the most commonly utilized technique to teach professionalism in 44% of the content areas evaluated, and didactics were the technique utilized in 44% of other professionalism content areas. Thirteen of the 16 required elements of professionalism (81%) were not taught by all programs. Evaluations by members of the healthcare team were used for assessment for both competencies. The use of a specific teaching technique was not related to program size, program director experience, or training in medical education.
Conclusions
A wide range of techniques are currently utilized within PCCM to teach communication and professionalism, but there are a number of required elements that are not specifically taught by fellowship programs. These areas of deficiency represent opportunities for future investigation and improved education in the important competencies of communication and professionalism.
doi:10.1097/PCC.0b013e31828a746c
PMCID: PMC4112058  PMID: 23867427
communication; professionalism; graduate medical education; fellowship training; evaluation; competency; pediatric
19.  Training satisfaction for subspecialty fellows in internal medicine: Findings from the Veterans Affairs (VA) Learners' Perceptions Survey 
BMC Medical Education  2011;11:21.
Background
Learner satisfaction assessment is critical in the design and improvement of training programs. However, little is known about what influences satisfaction and whether trainee specialty is correlated. A national comparison of satisfaction among internal medicine subspecialty fellows in the Department of Veterans Affairs (VA) provides a unique opportunity to examine educational factors associated with learner satisfaction. We compared satisfaction across internal medicine fellows by subspecialty and compared factors associated with satisfaction between procedural versus non-procedural subspecialty fellows, using data from the Learners' Perceptions Survey (LPS), a validated survey tool.
Methods
We surveyed 2,221 internal medicine subspecialty fellows rotating through VA between 2001 and 2008. Learners rated their overall training satisfaction on a 100-point scale, and on a five-point Likert scale ranked satisfaction with items within six educational domains: learning, clinical, working and physical environments; personal experience; and clinical faculty/preceptor.
Results
Procedural and non-procedural fellows reported similar overall satisfaction scores (81.2 and 81.6). Non-procedural fellows reported higher satisfaction with 79 of 81 items within the 6 domains and with the domain of physical environment (4.06 vs. 3.85, p <0.001). Satisfaction with clinical faculty/preceptor and personal experience had the strongest impact on overall satisfaction for both. Procedural fellows reported lower satisfaction with physical environment.
Conclusions
Internal medicine fellows are highly satisfied with their VA training. Nonprocedural fellows reported higher satisfaction with most items. For both procedural and non-procedural fellows, clinical faculty/preceptor and personal experience have the strongest impact on overall satisfaction.
doi:10.1186/1472-6920-11-21
PMCID: PMC3121724  PMID: 21575269
20.  Evaluation of a web-based portal to improve resident education by neonatology fellows 
Medical Education Online  2014;19:10.3402/meo.v19.24403.
Background
Integration of web-based educational tools into medical training has been shown to increase accessibility of resources and optimize teaching. We developed a web-based educational portal (WBEP) to support teaching of pediatric residents about newborn medicine by neonatology fellows.
Objectives
1) To compare residents’ attitudes about their fellow-led education in the NICU pre- and post-WBEP; including assessment of factors that impact their education and usefulness of teaching tools. 2) To compare fellow utilization of various teaching modalities pre- and post-WBEP.
Design/methods
We queried residents about their attitudes regarding fellow-led education efforts and various teaching modalities in the NICU and logistics potentially impacting effectiveness. Based on these data, we introduced the WBEP – a repository of teaching tools (e.g., mock code cases, board review questions, journal articles, case-based discussion scenarios) for use by fellows to supplement didactic sessions in a faculty-based curriculum. We surveyed residents about the effectiveness of fellow teaching pre- and post-WBEP implementation and the type of fellow-led teaching modalities that were used.
Results
After analysis of survey responses, we identified that residents cited fellow level of interest as the most important factor impacting their education. Post-implementation, residents described greater utilization of various teaching modalities by fellows, including an increase in use of mock codes (14% to 76%, p<0.0001) and journal articles (33% to 59%, p=0.02).
Conclusions
A web-based resource that supplements traditional curricula led to greater utilization of various teaching modalities by fellows and may encourage fellow involvement in resident teaching.
doi:10.3402/meo.v19.24403
PMCID: PMC4110380  PMID: 25059834
WBEP; NICU; resident education; fellow-led teaching
21.  Gaps in exposure to essential competencies in hand surgery fellowship training: a national survey of program directors 
Hand (New York, N.Y.)  2013;8(1):1-11.
Background
Graduate medical education has moved towards competency-based training. The aim of this study was to assess hand surgery program directors’ opinions of exposure gaps in core competencies rated as essential for hand surgery training.
Methods
We surveyed the 74 ACGME hand surgery fellowship program directors. Respondents rated their opinion of 9 general areas of practice, 97 knowledge topics, and 172 procedures into one of three categories: essential, exposure needed, or unnecessary. Program directors also rated trainee exposure of each component at their respective program. Moderate and large exposure gaps were respectively defined as presence of at least 25 and 50 % of programs rating trainees as not having proficiency in the component at the end of training.
Results
Sixty-two of 74 program directors (84 %) responded to the survey. For the 76 knowledge topics and 98 procedures rated as essential, a majority of the knowledge topics (61 %; n = 46) and procedures (72 %; n = 71) had at least a moderate exposure gap. In addition, 22 % (n = 17) of the essential knowledge topics and 26 % (n = 25) of the essential procedures had a large exposure gap.
Conclusion
This study illuminates the discrepancies between what is believed to be important for practicing hand surgeons and graduates’ proficiency as perceived by program directors. The field of hand surgery must work to determine if program directors have unrealistic expectations for what is essential for practicing hand surgeons or if reforms are needed to improve exposure to essential skills in hand surgery training.
doi:10.1007/s11552-012-9482-5
PMCID: PMC3574485  PMID: 24426886
Competencies; Competency-based training; Hand surgery fellowship; Hand surgery training; Medical knowledge; Patient care
22.  Global Health Fellowships: A National, Cross-Disciplinary Survey of US Training Opportunities 
Introduction
Medical trainee interest and participation in global health programs have been growing at unprecedented rates, and the response has been increasing opportunities for medical students and residents. However, at the fellowship level, the number and types of global health training opportunities across specialties have not previously been characterized.
Methods
A cross-sectional survey was conducted between November and December 2010 among all identified global health fellowship programs in the United States. Programs were identified through review of academic and institutional websites, peer-reviewed literature, web-based search engines, and epidemiologic snowball sampling. Identified global health fellowship programs were invited through e-mail invitation and follow-up telephone calls to participate in the web-based survey questionnaire.
Results
The survey identified 80 global health fellowship programs: 31 in emergency medicine, 14 in family medicine, 11 in internal medicine, 10 in pediatrics, 8 interdisciplinary programs, 3 in surgery, and 3 in women's health. Of these, 46 of the programs (57.5%) responded to the survey. Fellowship programs were most commonly between 19 and 24 months in duration and were nearly equally divided among 2 models: (1) fellowship integrated into residency, and (2) fellowship following completion of residency. Respondents also provided information on selection criteria for fellows, fellowship training activities, and graduates' career choices. Nearly half of fellowship programs surveyed were recently established and had not graduated fellows at the time of the study.
Conclusion
Institutions across the nation have established a significant, diverse collection of global health fellowship opportunities. A public online database (www.globalhealthfellowships.org), developed from the results of this study, will serve as an ongoing resource on global health fellowships and best practices.
doi:10.4300/JGME-D-11-00214.1
PMCID: PMC3399610  PMID: 23730439
23.  Resident selection of Hand Surgery Fellowships: a survey of the 2011, 2012, and 2013 Hand Fellowship graduates 
Hand (New York, N.Y.)  2013;8(2):164-171.
Background
We desired information from the recent, current, and future matched hand surgery fellows regarding their residency training, number of interviews, position matched, cost of interviewing, influences, opinions on future hand training models, and post-fellowship job information.
Methods
Institutional review board approval was obtained from our institution to submit an online survey. An email was sent to the coordinators of all US Hand Fellowships to be forwarded to their fellows with graduation years 2011, 2012, and 2013, as well as directly to the fellows if their email addresses were provided. Data on the application process, relative importance of program attributes, and opinions regarding optimal training of a hand surgeon were collected. Statistical analysis was performed with respect to the training background and graduation year of the respondent.
Results
The survey was completed by 137 hand surgery fellows. Seventy-one percent of the survey responders were from an orthopedic residency background, 20 % from plastic, and 7 % from general surgery. Forty-four percent of all of the respondents matched into their first choice. The type of operative cases performed by the current fellows was most often selected as very important when making their rank list. Seventy-seven percent of the respondents reflected their personal preference in fellowship model to be a 1-year fellowship program.
Conclusions
The field of hand surgery is unique in that it has residents from multiple training backgrounds who all apply to one fellowship. The current fellowship model allows for diversity of training and the possibility of obtaining a second fellowship if desired.
Electronic supplementary material
The online version of this article (doi:10.1007/s11552-013-9504-y) contains supplementary material, which is available to authorized users.
doi:10.1007/s11552-013-9504-y
PMCID: PMC3652997  PMID: 24426913
Fellowship; Hand; Residency; Survey; Training
24.  Why Not Nephrology? A Survey of US Internal Medicine Subspecialty Fellows 
Background
There is a decreased interest in nephrology such that the number of trainees likely will not meet the upcoming workforce demands posed by the projected number of patients with kidney disease. We conducted a survey of US internal medicine subspecialty fellows in fields other than nephrology to determine why they did not choose nephrology.
Methods
A web-based survey with multiple choice, yes/no, and open-ended questions was sent in summer 2011 to trainees reached through internal medicine subspecialty program directors.
Results
714 fellows responded to the survey (11% response rate). All non-nephrology internal medicine subspecialties were represented, and 90% of respondents were from university-based programs. Of the respondents, 31% indicated that nephrology was the most difficult physiology course taught in medical school, and 26% had considered nephrology as a career choice. Nearly one-fourth of the respondents said they would have considered nephrology if the field had higher income or the subject were taught well during medical school and residency training. The top reasons for not choosing nephrology were the belief that patients with end-stage renal disease were too complicated, the lack of a mentor, and that there were insufficient procedures in nephrology.
Conclusions
Most non-nephrology internal medicine subspecialty fellows never considered nephrology as a career choice. A significant proportion were dissuaded by factors such as the challenges of the patient population, lack of role models, lack of procedures, and perceived difficulty of the subject matter. Addressing these factors will require the concerted effort of nephrologists throughout the training community.
doi:10.1053/j.ajkd.2012.10.025
PMCID: PMC4164433  PMID: 23332603
Non-renal fellows survey; nephrology education; mentors; perception of nephrology; internal medicine fellows; nephrology workforce
25.  Building Faculty Community: Fellowship in Graduate Medical Education Administration 
Introduction
The Department of Graduate Medical Education at Stanford Hospital and Clinics has developed a professional training program for program directors. This paper outlines the goals, structure, and expected outcomes for the one-year Fellowship in Graduate Medical Education Administration program.
Background
The skills necessary for leading a successful Accreditation Council for Graduate Medical Education (ACGME) training program require an increased level of curricular and administrative expertise. To meet the ACGME Outcome Project goals, program directors must demonstrate not only sophisticated understanding of curricular design but also competency-based performance assessment, resource management, and employment law. Few faculty-development efforts adequately address the complexities of educational administration. As part of an institutional-needs assessment, 41% of Stanford program directors indicated that they wanted more training from the Department of Graduate Medical Education.
Intervention
To address this need, the Fellowship in Graduate Medical Education Administration program will provide a curriculum that includes (1) readings and discussions in 9 topic areas, (2) regular mentoring by the director of Graduate Medical Education (GME), (3) completion of a service project that helps improve GME across the institution, and (4) completion of an individual scholarly project that focuses on education.
Results
The first fellow was accepted during the 2008–2009 academic year. Outcomes for the project include presentation of a project at a national meeting, internal workshops geared towards disseminating learning to peer program directors, and the completion of a GME service project. The paper also discusses lessons learned for improving the program.
doi:10.4300/01.01.0024
PMCID: PMC2931184  PMID: 21975722

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