Reimagining Gastroenterology Fellowship Training – The Third Year of the Future

Introduction

In response to a changing healthcare landscape, medical education is increasingly being recognized as the “transformation needed to best address the workplace needs of our current and future health care system¹.” Capable physicians provide safe, equitable, and patient-centered care. They adjust to changing clinical practice climates, work and communicate professionally in teams, critically appraise their performance, and are able to receive constructive feedback and engage in self-reflection². Traditional models of gastroenterology (GI) fellowship create variation in skill and performance by providing the same learning framework to all trainees, which is often recognized at the time of fellowship graduation².

Competency-based education ultimately “translates the needs of contemporary society for improved health care into competencies that must be mastered” by physicians as they move through their training². It gives fellows who demonstrate early competence the opportunity to personalize and enrich their training during the third year of fellowship in ways that meaningfully contribute to their future goals as gastroenterologists and hepatologists.

In this review, we aim to summarize the perspectives presented at the “Third Year of the Future” session sponsored by the AGA Education & Training Committee and presented in symposium format at Digestive Diseases Week 2022. This integrated summary will present the consensus developed during the session.

The first two years of training will prepare the fellow for the third year

General GI training is prerequisite for individualized training and career paths. The first year of fellowship should focus on general clinical and research exposure, understanding that the “niche” identified by a resident starting fellowship may be a stronger reflection of mentorship available through their residency program as opposed to their true passion. To facilitate career development, first-year fellows should meet with potential mentors, gain broad exposure to available career paths, and explore their personal values and strengths.

The second year of fellowship should continue to focus on enhancing skill sets and overall subspecialty related clinical competence. During this time, program leadership should actively engage trainees in meaningful feedback and reflection, so that they are better able to identify areas of potential growth and work to develop their skills in these domains. Clinical competency committees should use Entrustable Professional Activities and/or milestones to guide decisions about competence; these decisions should be made collaboratively based on a fellow’s individual goals and the basic requirements for all graduating gastroenterology trainees.

Dedicated efforts to expose fellows to GI outside of clinical practice should be made. Possible areas of exposure include leadership skills, practice management and healthcare finance, quality improvement and patient safety, medical education, and diversity and health equity. Fellows should consider the impact of these interests on their professional identity development.

Throughout the first two years of fellowship, career developmental leadership should help trainees envision their futures by asking questions that allow them to think freely and without judgment (Figure 1). Based on these discussions, mentors and program directors can help fellows plan for optional specialized training pathways in the third year of fellowship based on their ultimate career goals. Potential career pathways are depicted in Figure 2.

Figure 1:

Model of career developmental leadership

Figure 2:

Potential career pathways for gastroenterologists

The third year will have clinical experiences that look and feel like a distinct year

Personalized training tracks offered in the third year should be available to fellows who have demonstrated competence in acquiring general gastroenterology skills in the preceding two years. These opportunities allow fellows to develop a niche, which may be clinical or non-clinical based on the goals of a specific trainee. Learning experiences may involve participation in subspecialty clinics, development of specific endoscopy skills, or engaging in scholarly projects aligned with the niche. Specialized endoscopy training can be acquired through simulation, hands-on workshops, observation at high-volume centers, industry-supported in-service sessions, and video-based learning. Some interests, such as Transplant Hepatology or Advanced Endoscopy, require a fourth year of clinical training at the conclusion of the traditional GI fellowship^{3, 4}. For example, a trainee seeking expertise in inflammatory bowel disease may engage in elective rotations in colorectal surgery, radiology, and visiting rotations sponsored by the Crohn’s and Colitis Foundation (CCFA). Potential specialized clinical training tracks are outlined in Figure 3.

Figure 3:

Examples of specialized clinical training

Some subspecialties have industry or organizational sponsored rotations that give fellows the opportunity to directly learn from experts outside their home institutions. Ideally, sponsored tracks will evolve to include non-traditional partnerships with non-profit public health services, insurers, or even government programs.

Regardless of clinical pathway, fellows who have demonstrated competence would benefit from graded supervision, in which they are granted increased autonomy based on their clinical competence⁵. “Promotion-in-place” has been shown to improve trainee self-assessment as well as program assessment of all trainees, not just those who perform below the expected standard⁵. Increased autonomy will more closely mimic the eventual practice environments of our graduates, which provides a safety net for trainees to troubleshoot independently in systems-based practice⁶.

The third year of the future will train fellows for the evolving healthcare landscape

Capable physicians possess skills and knowledge that extend beyond patient care. This includes an ability to identify the current health care context and improve patient care based on assessment of both systems and personal performance. In many ways, the needs of the health system are linked to the evolution of these competencies⁷. Examples of these needs are depicted in Figure 4.

Figure 4:

Current trends in the health care landscape

To be successful, fellows must be exposed to non-clinical activities that build knowledge and skill across a variety of domains, including emotional intelligence, change management, negotiation, and conflict resolution⁸. To achieve this, some trainees will pursue additional degrees during training, such as a graduate degree, certificate, or a specialized track that builds self-efficacy in these domains.

Examples of this needs-driven evolution include advocacy, diversity, health systems science, and leadership. The increasing complexity of reimbursement, rising insurance premiums, and the emergence of telehealth have highlighted the need for advocacy in our field. Special attention to diversity, equity, and inclusion, as it pertains to both patient care and our physician workforce, has rapidly emerged as an unmet need within GI⁹. Lastly, the importance of resonant health care leadership has grown as physician well-being and prevention of burnout are more regularly prioritized⁸.

The third year of the future will be personalized

Successful individualized training is rooted in strong self-assessment and mentorship. The goal of a reimagined fellowship is not only to meet the needs of the changing health system, but also to cultivate trainees with a greater sense of their professional identity at the time of graduation. Professional identity development begins with the trainee’s vision for their future self – both personally and professionally.

Programs should make routine use of individualized learning plans (ILPs) that are updated and shared with a mentor at least annually. ILPs give fellows the chance to prioritize their short- and long-term goals in accordance with their overarching vision¹⁰. Continued reference to ILPs and course readjustment based on stated goals provides fellows with the foundational skills required for self-assessment. ILPs also help mentors guide fellows in choosing which opportunities are best aligned with their goals¹⁰.

These opportunities could include formal teaching activities with medical students/residents, informatics training, or exposure to palliative care. Procedural training in the third year can also be adapted to meet the specific needs of each fellow, depending on their chosen clinical practice. For example, if a fellow is joining a practice that lacks anorectal motility expertise, then she may train to competence in anorectal manometry and do additional anorectal clinics.

It is our responsibility to recognize that our fellows may be served by teachers and mentors outside our divisions when considering these topics, and we should foster interdisciplinary relationships across our institutions to meet these evolving needs. Program directors should be prepared to identify divisional and institutional stakeholders in key non-clinical areas that can serve as mentors to their trainees. Moreover, they can refer fellows to opportunities within professional societies; examples include AGA’s Connections Corner or Career Compass, quality improvement training through the Institute for Healthcare Improvement, and national society-based committee service to build skills and network¹¹.

Change is required to reimagine fellowship

In order to implement the third year of the future, programs and institutions will need to commit to creating a schedule that is inherently flexible in the third year of training. Although this transition will not be easy, it is essential to training the physicians we require as the health care system evolves to better meet the needs of our patients². Increased flexibility in clinical training programs is often not feasible due to the clinical demands placed on the fellows. We must acknowledge this reality and work with our institutions to create programs and solutions that better serve both our immediate and future needs. In addition, new clinical experiences will need to be incorporated. The current focus tends to be on inpatient consult services; however, the physician of the future may benefit from a greater emphasis on outpatient experiences, endoscopy in ambulatory surgical centers, and the use of telemedicine.

New models of supervision should be explored. In an ideal training program, once a fellow is deemed competent with a particular component of practice, they would be allowed to practice with indirect or no supervision⁶. These decisions are governed by educational policy, faculty comfort, hospital regulations, billing requirements, and the physical clinic or endoscopy space available. Changes would require discussions with multiple stakeholders.

Professional societies could serve as forums for sharing expertise and mentorship in both clinical and non-clinical domains. They may also convene working groups of interested educators, fellows, and program leadership at national meetings to envision what this future should look like and set an agenda for programs interested in adopting this change.

Opportunities for advanced degrees in clinical research, which has traditionally been at the heart of many academic divisions, already exists at many programs. As we increasingly recognize the importance of other pathways in academic medicine, this existing pathway for advanced training could be a starting point that is modified to fit the needs of the reimagined fellowship.

Change will benefit our programs and our society

A personalized third year will make our fellowship programs more marketable to applicants. Of the 22 trainees in attendance at this session who were surveyed, nine responded that they would be much more likely to choose a program with specialized tracks (four responded they would be a little more likely and only one said it would not influence their decision). Respondents indicated that they would pursue a specialized track to make themselves more marketable for an academic position, to potentially be more involved in their future institution’s administration, and because they are interested in a career with a broad impact on population health. The most popular tracks were leadership and specialized clinical training (Table 1). The most common concerns they listed regarding specialized tracks were the potential to be distracted from acquiring and fine tuning “core” GI skills, time commitments required, and limited faculty expertise to provide said training.

Table 1:

Interest in specialized training tracks reported by trainees at the 2022 E&T CSS at DDW

Summary

A career that fits a person’s strengths and passions, allows for autonomy, and enables the person to engage in diverse efforts is most likely to promote vitality and reduce burnout, especially if that person is embedded in an institution that supports their interests and development¹². By building these skills and habits early in training, we may be able to enhance career satisfaction and retain talented physicians in academic medicine.

Developing gastroenterologists with diverse skill sets will likely better meet the current and future needs of society. Traditional research and academic focused pathways have helped develop physician-scientists that ensure the continued generation of new knowledge for the field. However, we also need physicians who will make sure that knowledge translates to excellent, evidence-based, equitable clinical care within well-led healthcare systems. This goal requires discrete non-clinical skill sets that are not part of the current standard training curriculum. Some of these current gaps and potential solutions have been highlighted in this review.

In many ways, we are at a crossroads. Traditional fellowship training is siloed, with learning occurring in discrete blocks of predetermined periods of time that may or may not make sense in terms of an individual trainee’s future career and practice. We should endeavor to provide fellows with the training opportunities that make the most sense for them: this is what fellows want! A reimagined fellowship could transform the experience of our fellows and improve their readiness for clinical practice – while ensuring they become competency-based physicians for life.