Fellow as a Resident Teacher - The Journey from Supervision to Supervisor

2016 - 1 February - Technological Game Changers
Heidi L. Frankel, MD, FCCM; Madiha Syed, MD; Ashish Khanna, MD, FCCP
In this articles the authors discuss the role of fellowship programs and the transitions from being supervised to being the supervisor.
 
The start of a fellowship is a tumultuous period during which one learns to juggle one’s new responsibilities. In essence, these responsibilities are a near-perfect combination of serving as productive clinicians, scientific investigators and effective teachers. Most of us feel competent in our clinical duties, but many of us have had no formal training in teaching and mentoring junior residents.(1) Also, ever present is the inherent conflict between the fellows’ and residents’ academic aspirations and the two groups split the experiences of patient management, leadership roles and procedural skills.
 
Multiple studies, especially in surgical specialties, have assessed the impacts of fellowship programs on resident teaching and procedure numbers.(2–5) Although these studies have cited a modest drop in resident case counts performed in some programs,(4) they were able to obtain and surpass the minimum American Council of Graduate Medical Education requirements. Importantly, establishment of fellowship programs had no impact on education as measured on in-service examination scores.(4)
 
Most programs have found fellows to be valuable resources who act as liaisons between faculty and residents. Moreover, fellows, by definition, have completed a basic residency program and function as junior faculty. They have more advanced training than residents and interns. Because they have an intense interest in their field, they provide advanced knowledge of specific complex disease processes and procedures. They help share academic responsibilities with faculty, who may be stretched thin among clinical, scholarly and administrative responsibilities. In addition, fellows split call responsibilities with senior residents, provide a high level of patient care and increase their departments’ academic output.
Incorporating fellows into departments’ educational missions has positive impacts not only on resident education but also on fellows’ attainment of teaching skills and their knowledge levels on the subject matter being taught.(6)
 
It comes as a surprise then that, despite the significant impact fellows have on sharing teaching and supervision responsibilities, very few programs have formal professional development training for fellows. A recent study at the University of Pittsburgh Medical Center shows that skills in medical education, administration and scientific research are considered an integral part of intensivists’ roles, but there is a large gap in imparting these skills to fellows.(7) In the study, the university introduced a curriculum focused on professional development of eight critical care medicine fellows, using pre- and post-course surveys. In the subsequent three-year follow-up, respondents had maintained their scores over the follow-up period and considered the course a significant part of their education. The study identified an unmet need in critical care curriculums, and found that introduction of professional development programs will allow easier transitions from fellow to attending physician status.
 
The need for more resources to improve physician knowledge about the wider scope of intensive care teaching and transitioning to the supervisor role has not gone unnoticed. The Society of Critical Care Medicine (SCCM) offers courses and educational materials directed at intensive care unit (ICU) management, from billing and coding to ICU design. SCCM’s In-Training Section recently played a vital role in identifying the difficult transition from residency to fellowship to staff. For the past four years, at SCCM’s annual Congress, the In-Training Section’s two-hour didactic educational session successfully identified issues and encouraged discussion with a panel of experts. Readers are referred to http://www.sccm.org/Member-Center/Sections/Pages/In-Training.aspx for more details. The section has also published data highlighting areas of concern as fellows’ transition to supervisor roles.(8) Also available are medical education programs that focus on teaching skills and the science of learning, although these may not be feasible for fellows just out of training who are seeking to establish themselves in practice. Cohen et al identified six programs in the United States in 2005. This number may have increased since then.(9) Tainter et al highlights innovative strategies in critical care education in a comprehensive review of resources and newer teaching methodologies.(10)
 
Another area in which critical care medicine fellows can gain further experience is their interaction with advanced practice providers (APPs). With an ongoing shortage of critical care specialists, APPs have been increasingly incorporated into the critical care team. Overall, their presence has been a welcome addition. A recent survey by Joffe et al on the impact of APPs on fellowship training showed that, in 25% of the programs, fellows had the opportunity to directly supervise APPs. Seventy-five APPs were satisfied with patient assignments made by either fellows (17%) or attending physicians (44%). Although the survey did not focus on educational interactions between APPs and fellows, program directors felt that they had a positive impact on fellow and resident education.(11) In the current environment, in which APPs are increasingly utilized in intensive care settings, it is important for fellows to interact with APPs in ways ranging from supervising to teaching.
 
When clinical teachers were surveyed, they responded that the factors that made them effective teachers were their intuition and judgment (62% respondents) and the way they were taught (43% respondents). Also, more than 60% of respondents had not attended a workshop or conference on teaching, and 90% had not read evidence-based literature on teaching.(12) In order to improve fellows’ teaching aptitude, there should be an intensified focus on creating professional development programs that allow access to teaching improvement workshops, peer coaching, mentorship programs and leadership development. Another important aspect of fellows acting as teachers is feedback from residents, medical students and other members of the care team. A study conducted over five-and-a-half years by Baker et al demonstrated that a combination of feedback and evaluation focusing on areas in which improvement was needed led to improvement in teaching scores.(13)
 
Physicians enter fellowships seeking to enhance their knowledge of a subspecialty, enhance their career prospects and become experts in their field. This should be seen as an opportunity not only for personal professional development but also for mentorship of the next generation, an idea that is better expressed in George Steiner’s quote on the call to teach: “There is no craft more privileged. To awaken in another human being powers, dreams beyond one’s own; to induce in others a love for that which one loves; to make of one’s inward present their future; that is a threefold adventure like no other.”
 
References:
1. Wilkerson L, Irby DM. Strategies for improving teaching practices: a comprehensive approach to faculty development. Acad Med. 1998 Apr;73(4):387-396.
2. Dinan KA, Davis JW, Wolfe MM, Sue LP, Cagle KM. An acute care surgery fellowship benefits a general surgical residency. J Trauma Acute Care Surg. 2014 Aug;77(2):209-212.
3. Carroll MI, Downes K, Miladinovic B, et al. A single-institution experience: the integrated vascular surgery residency’s effect on fellowship and general surgery resident case volume and diversity. Ann Vasc Surg. 2014 Jan;28(1):253-259.
4. Duffy JW 3rd, Thomas JC, Makari JH, et al. The impact of a fellowship on resident training in an academic pediatric urology practice. J Urol. 2008 Feb;179(2):720-723; discussion 723.
5. Zyromski NJ, Torbeck L, Canal DF, Lillemoe KD, Pitt HA. Incorporating an HPB fellowship does not diminish surgical residents’ HPB experience in a high-volume training centre. HPB (Oxford). 2010 Mar;12(2):123-128.
6. Backes CH, Reber KM, Trittmann JK, et al. Fellows as teachers: a model to enhance pediatric resident education. Med Educ Online. 2011;16. doi: 10.3402/meo.v16i0.7205.
7. Moore JE, Pinsky MR. Faculty development for fellows: developing and evaluating a broad-based career development course for critical care medicine trainees. J Crit Care. 2015 Jun 10. doi: 10.1016/j.jcrc.2015.05.032.
8. Sreedharan R, Bhalala U, Khanna A, Goodman D, Tisherman S, Lee S, Hunt E, Nadkarni V. “My biggest concern…": transitioning from fellow to faculty. Crit Care Med. 2015 Dec;43(12 Suppl 1):166.
9. Cohen R, Murnaghan L, Collins J, Pratt D. An update on master’s degrees in medical education. Med Teach. 2005 Dec;27(8):686-692.
10. Tainter CR, Wong NL, Bittner EA. Innovative strategies in critical care education. J Crit Care. 2015 Jun;30(3):550-556.
11. Joffe AM, Pastores SM, Maerz LL, Mathur P, Lisco SJ. Utilization and impact on fellowship training of non-physician advanced practice providers in intensive care units of academic medical centers: a survey of critical care program directors. J Crit Care. 2014 Feb;29(1):112-115.
12. Jason H, Westberg J. Teachers and Teaching in U.S. Medical Schools. Norwalk, CT: Appleton-Century-Crofts; 1982:71-83.
13. Baker K. Clinical teaching improves with resident evaluation and feedback. Anesthesiology. 2010 Sep;113(3):693-703.