Creating and Sustaining a Successful Fellowship Program: Challenges and Solutions

Creating and Sustaining a Successful Fellowship Program: Challenges and Solutions

Current Problems in Diagnostic Radiology 46 (2017) 95–99 Current Problems in Diagnostic Radiology journal homepage: Creating and...

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Current Problems in Diagnostic Radiology 46 (2017) 95–99

Current Problems in Diagnostic Radiology journal homepage:

Creating and Sustaining a Successful Fellowship Program: Challenges and Solutions Keith D. Herr, MDa,n, Tarek N. Hanna, MDa, Bharti Khurana, MDb, Jamlik-Omari Johnson, MDa, Aaron D. Sodickson, MD, PhDb a b

Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA

Subspecialty expertise and fellowship training are two of the most desirable attributes in new radiology hires and, not surprisingly, the vast majority of diagnostic radiologists entering the job market today have had fellowship training. Fellowship training imparts not only expertise beyond that which is attainable during residency, but also a unique opportunity for professional maturation. In this article, we offer guidance in planning, building and sustaining a successful fellowship. The key steps in this process include strategic planning, development of a curriculum that can be customized to meet the educational goals of any individual fellow, professional development and trainee preparation for the marketplace, and approaches to ensure program longevity and success through local, regional and national fellow recruitment efforts. While many of the ideas presented are framed from the perspective of their integration into a newly formed fellowship program, they can also be adapted for use by existing fellowship programs as opportunities for program growth and improvement. & 2017 Elsevier Inc. All rights reserved.

Introduction Subspecialty expertise and fellowship training are 2 of the most desirable attributes in new radiology hires.1 A candidate with fellowship training has a competitive advantage over one without such training when commencing a job search. As such, graduating radiology residents and many employers consider “subspecialty expertise” and “fellowship training” to be one and the same. Not surprisingly, more than 90% of diagnostic radiologists entering the job market today have had fellowship training.2 The primary training objective of any fellowship is to impart advanced interpretive and interventional expertise beyond that which is attainable during residency. However, a fellowship also represents a unique opportunity for professional maturation, and successful ones facilitate a “metamorphosis” from supervised trainee to autonomous radiologist. For those entering academic careers, a successful fellowship should set the stage for becoming not only productive clinicians but also effective teachers and investigators. This article is intended to serve as a blueprint for what we believe to be the essential components of a successful fellowship program as well as a roadmap for effectively navigating the challenges faced in creating and sustaining one. The key steps in this process include strategic planning; development of a curriculum that can be customized to meet the educational goals of any n Reprint requests: Keith D. Herr, MD, Division of Emergency Radiology, Department of Radiology and Imaging Sciences, Emory University Midtown Hospital, 550 Peachtree Rd, Atlanta GA, 30308. E-mail address: [email protected] (K.D. Herr). 0363-0188/& 2017 Elsevier Inc. All rights reserved.

individual fellow; professional development and trainee preparation for the marketplace; and approaches to ensure program longevity and success through local, regional, and national fellow recruitment efforts (Fig). Many of the issues discussed later are framed from the perspective of their integration into a newly formed fellowship program. For those administering existing programs, these items should be critically assessed as potential areas for program improvement and growth.

Strategic Planning A critical first step in creating a fellowship is to assess your department’s readiness for a new training program. Without support from your institution’s administration and faculty members in other divisions, such an enterprise will ultimately fail. The institution’s Chair and Vice Chair of Education are pivotal in determining the feasibility of the project. Questions to anticipate from department leadership include: How will the presence of a fellowship further the departmental mission? What is the financial impact of this fellowship? What are the clinical coverage implications for residents, other fellows, and faculty? The clinical scope of a new fellowship may affect the workload and productivity of others, both within and outside the division, and it is important that all stakeholders are consulted before implementation. Valuable information regarding logistical considerations for creating or optimizing a fellowship can be gleaned from leaders of existing fellowships, both in the same and in different subspecialty areas. We advise reaching out to these fellowships early in the planning process for information related to day-to-day


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Fig. Conceptual diagram for creating and sustaining a successful fellowship.

operations, educational initiatives, and clinical programming. This initial discovery phase can highlight best practices that may be adapted to the existing infrastructure at your institution. Although conducting this inquiry, it is important to focus on differentiation: what makes your program unique? Capitalize on the strengths of your organization and emphasize them in your fellowship. An ongoing dialog with fellowship program directors (PDs) at other institutions is essential for exchanging new ideas and making sustained improvements in the fellowship program. In addition to an invested faculty, a fellowship program needs a committed PD, who has the necessary time and interest to devote to the program. The PD, working in conjunction with the program coordinator, should serve as the primary contact for prospective and current fellows. The PD needs to ensure efficient fellow credentialing, as trainees who are at an institution for only 1 or 2 years need to be integrated rapidly to maximize their training time. The PD should not attempt to accomplish fellow education single-handedly, but must rather serve as a facilitator in coordinating the educational efforts of divisional and extradivisional faculty members into a cohesive, time-limited program. The PD also serves as the official recruiter for the program. Along with other division faculty members, the PD should promote the fellowship at institutional, regional, and national conferences, and appear routinely at meet-and-greet functions with prospective applicants. Finally, the PD is the ultimate architect of the fellowship and is responsible for exploring new directions for the program and identifying ways to implement innovative changes. At the core of every successful fellowship program, there is a faculty member who is fully employed in the training of its fellows. In fact, a genuine interest in contributing to fellow training should be a prerequisite to joining the faculty program. Native teaching ability should be sought out during faculty recruitment, but existing talent can be fortified by offering resources to improve teaching skills, such as workshops and one-on-one mentoring by senior educators.3 Faculty members engagement in trainee education can be optimized if your department figures educational

aptitude and productivity into its performance incentive plan. Assembling a faculty group from diverse backgrounds with unique skillsets, who possess a full spectrum of clinical expertise, and who consider education a top priority, is important in ensuring a comprehensive educational program. The faculty members from referring departments within your organization can serve as a potentially overlooked educational resource for your fellowship. Cooperative and collegial crossdisciplinary interactions are essential to realizing these educational opportunities. In fact, multidisciplinary team participation is an established core feature of the American College of Radiology/ Society of Breast Imaging fellowship training curriculum for breast imaging.4 For an emergency radiology fellowship, for example, a collaborative relationship with the trauma surgery service in a high-volume trauma center is an appealing feature to fellowship applicants with a strong interest in trauma imaging and research. Similarly, regular participation in tumor board or morbidity and mortality conferences boosts the educational yield of virtually any radiology fellowship. We recommend developing written policies regarding clinical expectations, on-call frequency, vacation and academic time, fellow involvement in resident and medical student teaching, professional development activities and funding, and scholarship expectations. The process of delineating these policies encourages specificity in the details, and allows for guidance at times of difficult situations arise during the course of the fellowship. Mechanisms for an ongoing assessment of both fellow and fellowship performance should also be explicitly established. Trainee self-assessment accompanied by faculty members’ feedback should occur at regular intervals, as often as quarterly. Fellows should be given an opportunity to review faculty members’ evaluations with the PD at least twice a year to ensure that any deficiencies are identified early, constructive strategies can be implemented and appraised on a continuous basis. A 3601 evaluation from multiple sources, such as midlevel providers, nurses, technologists, and ancillary support staff, can supplement traditional faculty member assessment of clinical and professional skills

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and should be provided near the end of training. Fellow feedback of the training program is essential in ensuring that the program is meeting its stated educational objectives. Since the anonymity of fellow feedback cannot be guaranteed, the program must provide a permissive environment for honest feedback, safeguarding against deliberate or unconscious acts of retribution in the event of criticism. Finally, as most fellows will be soon entering the job market, flexibility around allotting time for job interviews with an early advance notice is important, and is a potential selling point for the program. For certain unanticipated situations, such as family medical or parental leave, the fellowship director can draw on existing departmental policies. When necessary, the policies should detail alternative fellow or resident scheduling and workflow when fellows need to be excused from clinical duty. Some institutions may consider seeking voluntary accreditation of their fellowship programs through the Accreditation Council for Graduate Medical Education (ACGME). There are, currently, 9 radiology subspecialties that are eligible for ACGME accreditation; however, these include clinical informatics, endovascular surgical neuroradiology, neuroradiology, abdominal radiology, interventional radiology, musculoskeletal radiology, nuclear radiology, pediatric radiology, and vascular and interventional radiology.5 The primary benefit of ACGME accreditation is an assurance to prospective program participants, potential employers, and the public that graduating fellows have been exposed to a learning environment that complies with an established standard of educational quality in preparation for independent professional practice.6 The ACGME accreditation process requires considerable logistical and institutional resources. Detailed subspecialtyspecific and common program requirements governing the eligibility for ACGME accreditation should be carefully evaluated before applying for accreditation.7 Most of these requirements, such as establishing formal mechanisms for fellow, faculty, and program evaluation, developing a comprehensive educational program and fellow involvement in scholarly activity, are within the reach of nearly all fellowship programs. However, some of these requirements, particularly those concerning duty-hour restrictions and levels of supervision, may preclude participation of ACGME accreditation for some programs.7

Developing a Curriculum It is beneficial for a new fellowship to conceptualize and elaborate a formal curriculum. Once established, existing fellowship programs should regularly assess their educational content for opportunities for growth and improvement, incorporating innovations in pedagogy, and evolving subspecialty curricular standards and feedback provided by graduating fellows. Many national subspecialty societies have detailed fellowship curricula that can be adapted for local use, depending on institutional resources and teaching orientation.4,8 Think critically, about how to offset any limitations of your own institution’s clinical offerings when creating or expanding your fellowship curriculum. For example, an abdominal imaging fellowship program with suboptimal body magnetic resonance (MR) imaging volume may consider a dedicated series of MR-focused lectures. Elective experiences in other subspecialty divisions can also be useful in supplementing the fellow’s skillset. If critical factors of subspecialty training are absent at your institution, consider collaborating with a neighboring institution with access to such exposure. Interpretative and Interventional Skills The fundamental objective of fellowship training is to acquire subspecialty expertise through clinical exposure. This experience


should be as comprehensive as possible, offering exposure to a breadth and complexity of pathology specific to the subspecialty. Ideally, the fellow should graduate from the program with expertise in a multitude of imaging modalities and techniques. Although it is important to ensure that clinical duties do not abridge nonclinical educational activities, sufficient clinical exposure is needed to promote efficiency and workload capacity in preparation for an independent practice beyond fellowship. Speed and accuracy are highly desired assets for private practice owing to a persistent growth in diagnostic volumes,9 but even in a recent survey of academic chairs, clinical productivity ranked fourth in importance when hiring faculty members behind subspecialty expertise; fellowship training; and the ability to work well with referring providers.1 Flexibility and customization are paramount in the creation of any individual fellow’s clinical program. When constructing a tailored clinical curriculum, ask fellows to identify their own perceived deficiencies and build these experiences into their program. Elective time can be employed to fill any gaps in clinical exposure, provide supplemental clinical experience, or prepare fellows for their intended postfellowship practice. This may require last-minute improvisation. For example, if an interventional radiology fellow accepts a position in a practice that requires breast biopsies, several weeks in the women’s imaging division at that institution may be valuable. Noninterpretive and Noninterventional Skills Noninterpretive and noninterventional skills receive less attention in curriculum development. These skills are arguably more challenging to teach than practical skills, but they should not be given short shrift. Some of these skills are acquired on clinical service. For example, fellows should demonstrate proficiency during their training in examination selection, protocoling, and modality-specific technique optimization tailored to patients’ varied clinical needs. Existing institutional resources should be accessed for fostering noninterpretive skills, and may include career-related workshops that emphasize professional networking, curriculum vitae (CV) optimization, and the business aspects of radiology. In emergency radiology, for example, a focus on teaching fellows about workflow processes and efficiency in the emergency department is stressed, as they may be called on in the future to implement or streamline processes involved in the imaging of the acutely ill or injured patient. Didactics Although many skills are best learned by doing, there is no doubt that a didactic component is essential to a fellow’s training experience. The educational focus should encourage critical thinking and decision-making rather than a simple reiteration of the latest facts and techniques. A formal didactic program can be challenging to create, manage, and maintain given the competing clinical and administrative responsibilities of faculty members. The fellowship should ideally provide regularly scheduled didactic activities covering the range of topics relevant to the subspecialty. Some national subspecialty professional societies offer model core lecture series for adaptation.4,10 Possible educational formats include traditional classroom lectures, interesting and follow-up case conferences, interdisciplinary conferences, journal clubs, and morbidity and mortality conferences. Engaging learner-centered activities or problem-based sessions may be more effective than traditional lectures.11 The flipped classroom has continued to gain popularity in medical education, especially with learners of the millennial generation. In this model, trainees can review online educational material during their nonclinical time and participate


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in active discussion with peers and faculty members during conference times to enhance retention. To augment fellowspecific conferences, we encourage fellows to attend conferences offered to radiology residents or fellows in other subspecialties, as well as departmental grand rounds. Although clinical responsibilities may not permit perfect attendance, a special effort should be made to allow fellows to participate in as many nonclinical educational activities as possible.

Professional Development Aside from teaching subspecialty clinical expertise, a fellowship is an opportunity for professional transformation. Providing a nurturing environment and the necessary resources for professional maturation is one of the central challenges of administering a successful fellowship. Fostering Fellow Independence To evolve from trainee to attending radiologist during fellowship, a fellow must assume graduated degrees of responsibility and autonomy. For a diagnostic subspecialty fellowship, this progression can take the form of detailed readouts early on, advancing to independent or near-independent interpretations by the end of the fellowship year. It has been shown that decreased autonomy can negatively affect skills acquisition and confidence, and so even with 24-7 attending-level coverage, an effort should be made to afford fellows some degree of independence in providing interpretations or performing procedures.12 Internal or external moonlighting later in fellowship, with varying degrees of faculty backup, serves as an additional opportunity to prepare for future independent practice. Communication and Professionalism Effective communication skills and professionalism are of increasing importance in the practice of radiology, particularly in the contemporary environment of value-based health care delivery, in which collaboration with referring providers and patients is paramount. It is essential that faculty members model such effective communication with referrers, patients, technologists, and ancillary staff, if a fellow, is to follow suit. Problematic interactions with colleagues and other members of the health care team should be immediately identified and remediated, and an assessment of communication skills and professionalism should be an integral part of a fellow’s performance evaluation. The Academician A subset of fellows will be interested in pursuing careers in academic radiology, and providing mentoring and other resources for these individuals is important on a personal, local, and national scale.13,14 Fellowship programs have a responsibility to assist in the early career development of self-identified academicians and provide them with appropriate scholarly opportunities. Helping fellows to identify an area of research most exciting to them and to experience success in a small number of projects can be of great benefit in their future careers. In the first few weeks of the fellowship, consider providing fellows with a list of ongoing divisional or departmental research projects or focus areas. If a fellow expresses interest in any of these areas, introduction to the relevant investigators can easily be arranged. We encourage fellows to submit abstracts or educational exhibits to professional society meetings as an introduction to academic practice and an opportunity to network within the broader academic community.

We strongly recommend providing interested fellows with dedicated time away from clinical duties to engage in these academic pursuits. Involvement in academic work, however, should be evaluated on a regular basis, and only those fellows who demonstrate meaningful scholarly activity should be afforded ongoing academic time. Monitoring a research project through from start to finish can be challenging within the time allotted for fellowship training, and so we urge fellows to join existing projects of manageable scope rather than attempting to initiate projects that may end up abandoned at the end of the fellowship. Though involvement in research may be optional, all fellows, regardless of intended future practice, should be expected to participate in some activities, such as presenting case conferences or resident lectures. One of the challenges in making the transition from fellow to junior faculty is learning to effectively teach and supervise residents and medical students. Incorporating these functions into the fellowship curriculum can help these prospective academics assume this new role. Some fellowships allow fellows to final-sign later in the fellowship, whereas others (including all ACGMEaccredited fellowships) do not permit independent interpretations at any point in the fellowship. In either situation, it can be helpful to adjust workflow later in the fellowship year so that the fellow can directly supervise residents and medical students to become more comfortable in a supervisory role. The Launching Pad A fellowship is the ideal time to lay the groundwork for a successful career in radiology. Consider, encouraging fellows to attend national multispecialty and subspecialty society meetings during their fellowship and providing them with both the time and funding to do so. These conferences allow fellows to interact with members of the larger professional community and highlight the value of professional networking. Furthermore, consider offering fellows resources for their employment search. These may include reviewing their CVs, conveying employment opportunities as they become available, and providing career development resources, such as attendance at career fairs and CV workshops. Perhaps most importantly, flexibility around releasing fellows from clinical duty to attend job interviews is advisable. This is especially important for fellows seeking employment remote from the training location, as they may need extra travel time.

Candidate Recruitment Once an institution successfully establishes a fellowship, there is the need to attract high-quality fellowship applicants on a recurring basis. This is a challenge, for all but the most wellknown programs. There are several strategies to attract highcaliber applicants from within the sponsoring institution’s residency program and beyond. Internal Development At the home institution, the curricular scaffolding created to sustain the fellowship can be leveraged to target the residents and medical students, who represent a potential future applicant pool. Foundational clinical and research-oriented medical student electives, which provide junior and senior medical students dedicated time to work with subspecialty fellowship faculty members on clinical and scholarly projects, can stimulate interest in the subspecialty area and, potentially, the institution’s own fellowship. Increasing faculty participation in resident conferences and resident core and elective clinical rotations can likewise increase awareness of the existence and value of the institution’s

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fellowship. A positive experience on resident clinical rotations has been shown to influence fellowship selection, and such residents may be inspired to pursue local fellowship training.15 It can be anticipated that graduating residents entering fellowships or the workforce elsewhere, who were successfully engaged by the fellowship’s educational content during residency, will also be more likely to report positively on their subspecialty clinical experience to colleagues, junior trainees, and medical students, initiating a process of national name recognition in subspecialty training without the need for overt advertising. Accordingly, investing in faculty members and clinical resources to provide an enriching resident experience have the potential to pay dividends for sustaining the fellowship program. External Outreach In addition to local efforts to promote a fellowship program, it is essential to actively recruit applicants on a broader scale. To this end, fellowships should be publicized through relevant national and regional professional societies. This may entail listing the fellowship on the society’s website or advertising at society meetings. The association of program directors in radiology publishes an annual list of unfilled fellowship positions, which provides a valuable resource for both applicants and fellowship programs. Having faculty members from your fellowship speak on topics related to your subspecialty at other institutions (eg, invited resident lectures or grand rounds) or at professional meetings can have a substantial effect on expanding the applicant pool through name recognition. Do not be hesitant to engage in more traditional marketing activities, such as sending out mailers, posting on online radiology resident message boards, and using a variety of online employment tools to advertise open fellowship positions. Above all, do not be discouraged! It takes time and persistence to develop and grow a national reputation.

Conclusion Developing and maintaining a fellowship is a challenging but a rewarding enterprise. A fellowship serves as a critical catalyst in the transformation of an undifferentiated radiology residency graduate into a subspecialty expert, and the activities of the fellowship should work toward this goal. Recognizing that each fellow will enter fellowship training with a unique set of


expectations and goals, a successful fellowship training program strives to meet these individual needs by fine-tuning its curriculum accordingly. Although a fellow’s training may last only 1 or 2 years, a thriving fellowship program aims for continuous existence. The ultimate measure of success is the fellowship’s ability to sustain itself with new fellows drawn from a pool of exceptional applicants and to produce graduates who enter the workforce both highly skilled and in high demand.

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