Perceptions of the professional and personal impact of hybrid fellowship training: a qualitative study

ABSTRACT

Objectives: This study aimed to elucidate graduate perceptions of how fellowship training impacted their post-training professional and personal lives.

Methods: Interviews were conducted with 13 graduates of a hybrid (e.g. blended-learning) fellowship program. All participants were at least 1 year post completion of fellowship to limit recall bias and allow for post-training personal and professional development. Qualitative analysis was performed on interview transcriptions using directed content analysis with two coders other than the interviewers, followed by discussion until agreement was reached if there were disputes related to coding analysis. If needed, arbitration was provided from one of two interviewers.

Results: Analysis revealed three primary constructs of post-fellowship impact: practical, social, and personal. Practical subthemes were centric to care delivery. Social subthemes extended to intra, inter, and non-professional connections. Personal subthemes noted professional and cognitive evolution.

Discussion: Participants clearly described impact extending well beyond day-to-day practice suggesting that fellowship impacted the whole person versus sole practitioner. This study may impact program structure and content inclusion for fellowship programs as well as providing support for fellows in training.

Introduction

Beyond entry-level didactic and clinical training, clinicians can enhance specialization through board certification, residency training, and fellowship. Fellowships are considered the pinnacle of post-professional clinical training in the physical therapy profession as one is required to attain either board certification or residency training prior to admission to a fellowship [1]. The core goal of the extensive training is to enhance the development of advanced clinical reasoning and communication skills along with higher level application of evidence-based practice. This in-depth educational journey is believed to enhance personal practice standards as well as overall standards of the profession [2,3]. In the area of orthopedic manual physical therapy (OMPT), experiential, didactic, and reflective learning strategies are organized in a formal curriculum with a variety of structures. Under current guidelines, all programs are conducted under the direct guidance of fellowship mentors who have previously undergone similar training. As a result, knowledge and expertise are passed on to trainees with the goals of both providing patients with enhanced outcomes and passing on information and skills necessary for expert practice. Rodeghero et al. performed a data analysis to determine the impact of fellowship training on patient outcomes as compared to post-graduate residency or entry-level training alone [3]. The results revealed that fellows of the American Academy of Orthopedic Manual Physical Therapists (FAAOMPTs) delivered enhanced outcomes at a reduced cost, as noted by fewer visits needed to achieve superior outcomes. Although a true cost analysis was not performed, this research provides preliminary evidence that FAAOMPTs provide a greater per visit impact on outcomes than non-FAAOMPT providers. Unfortunately, the personal and professional impact of fellowship training on the actual Fellow-in-Training (FiT) has not been reported in the literature.

In the United States, fellowship training is delivered using two primary methodologies, the on-site, or in-residence, fellowship and a hybrid learning approach. The former is a traditional approach in which the FiT takes residence as a clinician within the fellowship organization. In contrast, the hybrid, or blended learning, design allows the FiT to maintain employment with their existing organization, with training provided through a blend of in-person and digital-based delivery methods. Both variants of US-based fellowships are subject to the International Federation of Orthopedic Manual Therapists’ and the American Academy of Orthopaedic Manual Physical Therapists’ standards [2,4], with accreditation overseen by the American Board of Physical Therapy Residency and Fellowship Education and the American Academy of Orthopaedic Manual Physical Therapists.

Regardless of design, fellowship is a rigorous process and noteworthy educational achievement, with many anecdotes of professional enhancement and reward upon completion of the process, but also associated with anecdotal reports of high levels of stress. Along with the relatively recent history of advanced fellowship program development [5], the intensity and time commitments are possible reasons for the low proportion of physical therapists completing fellowship training. In the United States, there are approximately 225,420 physical therapists, with nearly 53% self-described as an outpatient practitioner [6]. Yet, only a small portion of this number are fellowship trained (1327 active fellows—personal communication with AAOMPT staff), with only 468 graduated fellows between 1997 and 2015 [7]. It is surprising how few practitioners go on to this level of training. A possible reason for the comparatively low number of fellows may be associated with lack of incentive for higher reimbursement for care provided by individuals with this post-graduate training. It is uncertain, however, if alternative sources of revenue offset the impact of reimbursement models as fellows may assume administrative, teaching, course lecturer, or other roles that add income outside of their standard patient-care salary. As more fellowship programs are developed, it is important for program directors and potential FiTs to reflect on the personal and professional rewards and challenges associated with this intensive professional development pathway.

With exception of clinical outcomes from a single research paper [3], little is known about the outcomes of fellowship training at the personal or professional domain level. Furze et al. stated that research on residency and fellowship training has been focused on patient-centered outcomes and called for research targeting professional development and emerging clinical expertise [8]. Recently, a survey of graduates from a single hybrid fellowship program indicated fellowship ‘impacted’ respondents as a professional [9], with a reported significantly positive impact (average 10.7(0.7) out of 11 = ‘significant positive influence’ and 1 = ‘significant negative influence’). The purpose of this qualitative study was to build upon the existing research and survey results to elaborate on the impact of fellowship training from personal and professional perspectives.

Methods

Design

A qualitative approach using interviews and directed content analysis methods was used [10]. The general interview questions and topics were predetermined through discussion and agreement among the research team. To clarify and expand participant responses, the interviewers were allowed to follow-up questions on the responses to the initial questions and encourage discussion of unexpected topics initiated by the participants in a semi-structured format using open-ended questions [11]. The study was approved by South College IRB.

Subjects

Thirteen graduates of a single, hybrid fellowship program agreed to participate in web-based interviews using audio and/or video interfaces. Graduates who had completed the program at a minimum of 1-year prior were recruited to limit recall bias and allow for subsequent personal and professional life changes to occur. Qualified subjects were identified by the fellowship program director and contacted by an author who was not involved in the data collection and coding process. A total of 16 graduates were contacted with a final 13 prospective participants consenting to participate. Participant demographic data are provided in Table 1.

Table 1.

Subject demographic data.

Subject Number	Age	Gender	Number of Years Post Fellowship	Years of Practice	Practice Setting	Faculty Appointments
1	33	Male	2	7.5	Outpatient, Hospital	Entry-level DPT, Ranked Faculty
2	37	Male	3	13	Outpatient, Private Practice	Post-professional, Clinical Faculty; Mentor
3	43	Female	1	22	Outpatient, Private Practice	Post-professional, Clinical Faculty
4	34	Male	5	9	Outpatient, Private Practice	Entry-level DPT, Ranked Faculty; Post-professional, Program Director
5	33	Female	2	8	Outpatient, Private Practice	Entry-level DPT, Ranked Faculty
6	53	Female	2.5	31	Outpatient, Hospital	Post-professional, Clinical Faculty; Mentor
7	47	Male	5	23	Outpatient, Private Practice	Post-professional, Clinical Faculty; Mentor
8	38	Male	1	11	Outpatient, Hospital	Entry-level DPT, Adjunct Faculty; Mentor
9	34	Female	2	8	Outpatient, Private Practice	Entry-level DPT, Clinical Faculty; Post-professional, Program Director
10	36	Male	3	9	Outpatient, Private Practice	Entry-level DPT, Adjunct Faculty; Post-professional, Program Director
11	40	Male	3.5	15	Outpatient, Private Practice	Entry-level DPT, Adjunct Faculty; Post-professional, Clinical Faculty; Mentor
12	39	Male	<1	15	Outpatient, Hospital	Post-professional, Mentor
13	39	Male	<1	15	Outpatient, Private Practice	Post-professional, Mentor

Interviews

Study participants were scheduled for a 30-minute web-based interview with one of two authors. Both interviewers hold American Physical Therapy Association Certifications as Orthopedic Specialists, hold academic faculty positions, and have completed fellowship or residency training. One of the interviewers had contributed to the targeted fellowship program in the past but did not receive his training from this program. The other interviewer had no association with the fellowship to enhance trustworthiness and credibility of present study findings.

The two interviewers met to discuss and determine interview questions to meet the overall research questions and ensure consistency and pilot tested the questions and interview process with another author prior to conducting the interviews separately. Subjects provided verbal informed consent and answered demographic questions prior to initiating the interview. Interview audio were transcribed verbatim and transcripts were checked by an independent reviewer for accuracy.

Coding

The coding process is illustrated in Figure 1. The consolidated criteria for reporting qualitative research (COREQ) were used when planning and executing this study [12].

Figure 1.

Thematic coding procedure.

Results

Three primary personal and professional growth themes emerged as constructs graduates perceived to be a result of the hybrid fellowship model: practice, social, and personal. Additionally, there were subthemes for the practice construct including time management and satisfaction with professional practice, subthemes for the social construct including improvements in connectedness, open and active listening, and family impact, and the personal construct subthemes including professional evolution, self-awareness, and metacognition that emerged. Please see Appendix A for specific exemplars and comments from subjects within each theme and/or subtheme.

Practice

Time management

The majority of participants (7 of 13) reported improvements in efficiency of clinical practice. The comments centered around speed, accuracy, and effectiveness of decision making, as well as basic organization both in clinical care and overall practice tasks.

Practice satisfaction

Twelve of the thirteen participants indicated higher satisfaction with practice. Examples focused on enhanced passion and a state of greater happiness with their professional practice since going through the fellowship. Often, increased professional satisfaction was attributed to being connected with similar individuals who helped facilitate a positive outlook and also to a feeling that they were contributing to the profession, another theme discussed later in this manuscript. Participants attributed this outcome to improvements in clinical reasoning ability, broader skill sets to help patients, and enhanced confidence, and two other identified themes/subthemes noted to be interrelated.

Social construct

Connectedness

Social connectedness was an identified theme across the participants with the exception of one person (12 of 13). Connections were identified within three general groups: (1) direct connections within cohort peers, faculty members, and one-to-one clinical mentors, (2) indirect connections with peers from non-overlapping program cohorts, and (3) indirect connections with identified leaders within the field of physical therapy, one-to-one mentors, and identified leaders within the general profession of physical therapy. Participants also discussed continual maintenance of connections through continued professional and social interactions.

Active and open listening

Several participants (9 of 13) in the present study indicated enhanced communication skills subsequent to training that centered on active listening, or ‘listening to understand’ [13]. This extended beyond just listening to patients to being more open to other viewpoints, being able to reflect on those viewpoints, and accepting feedback both in clinical practice and non-clinical situations.

Family impact

The impact of training on their families was discussed by 9 of the 13 subjects with high levels of family strain during training. However post-training, some also noted the relief of this strain after completion of the fellowship and a positive view of greater time for family, and some noted positive changes in family dynamics resulting from their growth as a person. It was also noted by some that post-graduate impacts of a continued rigorous professional activity schedule after graduation on the family dynamics could be considered negative.

Personal constructs

Professional evolution

The acceptance of new professional roles beyond previous daily clinical roles was perceived as positive for 11 of the 13 subjects. Common areas of positive professional evolution were as follows: (1) new roles in professional teaching, both entry-level and post-professionally, (2) new national and/or state association leadership roles, and (3) promotions or perceived beneficial changes in career not specifically associated with daily patient care. It should be noted these new opportunities and changes in career directions or roles were not always accompanied by increased income.

Not all reports could be perceived as positive in this subtheme. One subject (1 of 13) reported no change in professional status, and one subject (1 of 13) reported a self-imposed shift from a higher-paying administrative role to a lower-paying, but greater direct clinical practice role. The latter subject did, however subsequently assume an additional teaching role as a residency faculty member and fellowship program director, followed by taking on a full-time ranked faculty position at a university. The former discussed their previously high level of professional and personal attainment before training.

Self-awareness and metacognition

There were major changes perceived by the majority of subjects in their self-awareness and metacognition, noted by 12 of the 13 subjects. Interestingly, the changes in cognitive processing occurred both in the clinical and non-clinical settings, in that exchanges with family, friends, or non-professional social groups were often subjected to both reflection and thinking about how their thinking impacted events and interactions. At times, these changes were considered challenging as comments revealed perceptions of over-thinking simple situations. Overall, however the trend was for a positive perception of these cognitive skills and behaviors.

Discussion

This study aimed to expand and provide a deeper picture of the impact of fellowship training at a personal and professional level using qualitative methods, a need identified by Robertson and Tichenor [3,5]. The results above support the previously noted programmatic evaluation survey findings that graduates of the hybrid model are impacted by training with strong personal and professional benefits [9]. The present study revealed multiple positive impacts reported by graduates in clinical practice, social, and personal arenas. This study provides support for the benefits and challenges of post-graduate fellowship training. Furthermore, the study provides a glimpse into the impact on the lives of individuals who have completed fellowship training. The impact on practice was expected as this is a goal of training, and will be only partially explored here. The social and personal constructs, however, have not been discussed elsewhere and warrant greater depth.

Practice constructs

Practice satisfaction and enhanced time management were primary themes related to greater mastery of clinical practice and improved outcomes of patient care. Participants reported enhancing the speed of clinical judgments as well as improved analysis of the patient presentations. In essence, practice was perceived to improve through the acquisition of systematic processes provided by training. Actual improvement is supported by previous quantitative research [3].

Social constructs

Social constructs found in this study were the sense of enhanced connectedness and enhanced communication skills. Synonymous with connectedness is the term ‘social integration’. Rockinson-Szapkiw et al. discussed social and academic constructs related to the completion of online doctoral degrees [14]. Although not a direct comparison, hybrid-model fellowship training shares similar perceived hardships and challenges including, but not limited to, demographic isolation of students, academic rigor, and risk of attrition. Their research suggested that social integration with the faculty was more predictive of degree completion than integration with peers. As noted by subjects, the target hybrid program does specifically endeavor to facilitate faculty, student, and graduate integration through several in-person mechanisms, including conference and course associated social events. Subjects also reported integration maintenance through non-instructional web-based means, for example, FaceBook groups.

Additionally, Tan identified three factors leading to improved online social interactions between learners: (1) a shared academic goal, (2) knowledge of technologies, and (3) existing knowledge of course content partially explained how online learners establish social interactions with other students [15]. Indeed, FiTs have a shared goal of enhancing knowledge through training, must competently utilize technology in the hybrid model, and practice in orthopedic specialty prior to fellowship training. Further explaining inter-cohort connections might be the programmatic process by which FiTs transition from learners to teaching assistants for subsequent FiTs. To further extrapolate to post-training connectedness, these FAAOMPTs reported lifelong knowledge acquisition goals and desire to seek out those with more knowledge that resulted in connectedness to professional leaders.

Furthermore, subjects reported improved active listening and communication skills that crossed from the practice to personal settings. In their seminal work, Rogers and Roethlisberger described active listening as ‘listen(ing) with understanding… seeing the expressed idea and attitude from the other person’s point of view, sensing how it feels to the person, achieving his or her frame of reference…’ [12]. This description is in agreement with previous work by Jensen et al. finding that expert physical therapists treat patients as valued and trusted sources of knowledge and that collaboration was central to the therapeutic relationship [16]. In the present study, participants did not appear to reserve this behavior to clinical care as listening to understand crossed both professional and familial communication. This skill set is of frank desire as Furze and colleagues call out communication skills as one of the proposed common competencies for residency and fellowship training [7].

Notably, the theme of family impact appeared to revolve around work-life balance and/or work-life conflict. Sirgy and Lee specifically describe individuals achieving balance when they are actively engaged in both work and non-work roles [17]. They further note that conflict arises when resources are limited or denied with one role to the benefit of the other. Comments from the present study reveal the in situ burden of training on this balance, but also noted are both benefit and continued strain subsequent to training depending on continued evolution of graduates’ professional endeavors. Work–life ratio is therefore of great importance to program directors and potential FiTs to consider. The former should consider this balance during curriculum development, and the latter should consider the risk to benefit balance both during and after training, in light of their long term professional goals.

Personal constructs

Personal constructs found in this study are the sense of evolution within the profession and the sense of enhanced self-awareness and metacognition.

Professional evolution was seen across nearly all subjects, with the exception of one, suggesting fellowship training in the hybrid model does impact the transformative behavior of graduates. Admittedly however, fellowship training may not be the sole driving force behind continued post-training professional evolution or achievement. It has been shown that a person’s motives for wanting to perform may be more important than their actual performance goal or level of self-efficacy [18]. Therefore, a FiT’s inherent motives to achieve may be more important than the actual achievements, although this is merely speculative within the present study with only one subject speaking directly to this. Interestingly, the one subject who did not report post-fellowship professional advancement was previously active in teaching and scientific writing, and had practiced for a substantial period of time with many prior professional achievements. The findings therefore would benefit from further research to determine trait versus state characteristics of graduates to elucidate this construct.

Expectedly, subjects in the current study generally reported developments of self-awareness and meta-cognitive skills that were not restricted to clinical practice. Evolutions in metacognition and self-awareness related to clinical reasoning, differential diagnosis, intervention choices, and outcome evaluation are well established learning outcomes of fellowship training facilitated by the time and intensive practice with feedback to develop these higher level attributes [2]. Enhancement of these higher level cognitive skills may be attributed to extensive synchronous and asynchronous interactive clinical reasoning coursework and cognitive apprenticeship, whereby the fellowship instructors explicitly describe their methods and decisions utilized in complex clinical applications allowing learners deep insight into reasoning. The students are then expected to demonstrate these integrated complex processes in follow-on clinical cases and during one-to-one clinical mentorship [19]. Of interest, the changes in reflective and metacognitive skills set were noted by participants to cross into seemingly unrelated non-clinical circumstances. It is therefore possible that some of the similarities in non-clinical psychosocial interactions (such as non-verbal and other communication strategies) are triggered in all circumstances and the activation of reasoning processes becomes engrained and crosses over in all contexts [20].

Limitations

The use of graduates from a single, hybrid fellowship program limits generalizability of the findings; however, qualitative methods are intended to provide a rich picture of a few individuals. The study does provide a platform for further inquiry into different fellowships and educational models. The personal and professional impact on those that did not complete training may have been different. Although the experiences of others may be different, saturation of content themes was strongly supported in almost all areas suggesting that the thematic findings of the study are of interest and could be expanded in future studies using survey methods.

Implications for fellowships/future fellows

The finding of connectedness within the hybrid model of fellowship training suggests that this remote pedagogical methodology facilitated strong peer and mentor connections. This supports the notion that hybrid fellowship models provide meaningful social connections similar to traditional in-residence models. Utilizing technology and social platforms allows for multiple modes of communication to help build fellow culture and connectedness. In addition, it is important for prospective FiTs and for program directors to acknowledge the perceived benefits that occur beyond the professional arena where fellowship training can potentially positively affect one’s personal life. Further, prospective FiTs can anticipate potential family life stress or strain, and perhaps can strategize and plan with family and/or significant others to attempt to mitigate these stressors. Program directors should also be aware of this potential impact on each fellow-in-training’s personal life, and he/she should be prepared to support the fellow as able with strategies such as adjustments of the plan of study, temporary hold status, and additional social support.

Conclusion

Qualitative analysis revealed perceived impacts across social, personal, and practice constructs for graduates from a single hybrid fellowship program. Participants reported strong positive benefits including satisfaction with outcomes, improved social connectedness and professional evolution, enhanced active listening, and self-awareness. Half the participants reported improved time management. The impact on family life during the training was discussed, with both challenges and rewards noted, indicating that graduates are impacted by training on multiple dimensions. Further study across different models of fellowship training and using larger survey-based methods is needed. Fellowship training programs may benefit from explicit attention to these constructs to further enhance the real and/or perceived benefits as well as the challenges of fellowship training at the social, personal, and practice levels.

Biographies

Kevin MacPherson is a Clinical Lecturer for the University of Florida Department of Physical Therapy’s entry-level clinical doctorate program and adjunct faculty for the Bellin College Orthopaedic Manual Physical Therapy Fellowship Program. He is a Board-Certified Orthopaedic Specialist and Fellow of the American Academy of Orthopaedic Manual Physical Therapists. In addition to his teaching responsibilities, Dr MacPherson owns a small private practice, AthletePRX.

Mark Shepherd is a physical therapist who holds a Doctorate of Physical Therapy (DPT) and is both board certified in orthopaedics (OCS) and is fellowship trained in orthopaedic manual physical therapy (FAAOMPT). He holds academic appointments at South College Physical Therapy Program, Bellin College, and Rasmussen College and teaches with Evidence in Motion and the International Spine and Pain Institute. Dr. Shepherd has published several peer reviewed articles and presented at both state and national conferences. He continues to practice in clinical care in the state of Maryland.

Jamie Childs Everett is a Doctorate of Physical Therapy and holds the Board-Certified Orthopedic Clinical Specialist recognition and is a Fellow of the American Academy of Orthopedic Manual Physical Therapy. She owns her own private practice in Cheyenne, Wyoming and currently sits as the Component President for the Wyoming Physical Therapy Association. She recently presented at the AAOMPT conference and serves as a lab assistant for the Institute of Clinical Excellence, a post-professional continuing education program for physical therapists.

Adam J Fritsch is a staff physical therapist at Athletico Physical Therapy. Board certified in Orthopedics and current Fellow in Training with Evidence in Motion.

Julie M Whitman is the Director of Bellin College’s Doctorate of Science in Physical Therapy Program and the Orthopedic Manual Physical Therapy Fellowship Program, as well as the Evidence in Motion Post-Professional DPT in Musculoskeletal Management. She is board certified in Orthopaedic Physical Therapy and is a Fellow of the American Academy of Orthopaedic Manual Physical Therapists (AAOMPT). Dr Whitman is widely published, including educational CD-ROMs, e-books, and texts on Orthopaedic and Manual Physical Therapy. She has 40+ peer-reviewed manuscripts, and over 30 published abstracts in the areas of orthopaedics and manual physical therapy. She has been either the primary author or co-author on research grants from the Foundation for Physical Therapy, the Orthopaedic Section of the APTA, and the AAOMPT, and served on the Steering Committee for Physical Therapy Journal. She has presented research both nationally and internationally at professional conferences, and awards include: AAOMPT’s Kaltenborn “Teach I Must” Award, Section on Geriatrics Excellence in Research Award, JOSPT George J. Davies - James A. Gould Excellence in Clinical Inquiry Award, AAOMPT Outstanding Research Award, Discovery Health Clinical Excellence Award in Back Care at the International Federation of Orthopaedic Manipulative Therapists Conference, Outstanding Clinical Educator in the State of Texas, the Jack Walker Award, and Steven J. Rose Excellence in Research Award.

Kim Dunleavy is a Clinical Associate Professor and the Director of Community Engagement and Professional Education at the University of Florida in the Physical Therapy Department. She is an APTA Orthopaedic Board Certified Specialist, completed a Masters in Orthopaedic Manipulative Therapy through the Ola Grimsby Institute, a Masters in Sports Physical Therapy from the University of Central Arkansas and a PhD in Instructional Technology from Wayne State University. She is a Fellow of the National Academies of Practice and represents the American Council for Academic Physical Therapy Education on the Global Forum for Innovation in Health Professions Education - a component of the National Academies of Science, Engineering and Medicine. She teaches entry-level and continuing professional education courses on the management of musculoskeletal diagnoses. Her scholarship spans interprofessional and global educational models and methods as well as evaluation and management of chronic musculoskeletal conditions, particularly using exercise for chronic cervical pain. She is the author of a textbook on Therapeutic Exercise Prescription. Her current research has two directions; participatory ergonomic approaches to manage chronic low back pain in seafood workers and interprofessional education methods.

Appendix. Appendix A

Theme frequency examples.

Theme	Subtheme	Frequency	Example(s)
Practice	Time Management	7/13	‘… it has certainly improved my reasoning abilities, my abilities to capture data, to see things and assimilate more quickly… As I have gone through this journey, I look at it from a patient care perspective. I’m able to more effectively and efficiently narrow down a differential diagnosis and get the patient moving in a more positive direction. I am more quickly able to change course if we are not getting outcomes we are looking for…’ – Subj 8 ‘It tends to force you to be better at time management in that regard, I’m much better at organizing life and getting things done in a more efficient manner.’ – Subj 12
	Satisfaction	12/13	‘I’m definitely happier with the profession and what I do.’-Subj 2 ‘… I find myself reflecting on things more and that makes me happy. If I, I don’t know if happy is the right word, I feel satisfied when I can reflect on things and look back on it and whether it is a good or bad experience is irrelevant really, just the fact that I’m now reflecting on things that I never used to..’-Subj 3 The increased professional satisfaction was attributed to being with similar individuals who helped facilitate a positive outlook and also to a feeling that they were contributing to the profession: ‘I think it really helped solidify my foundation and man fellowship really ignited the passion behind it all. I am not quite sure I ever would have found it if it wasn’t for fellowship and being with like-minded individuals, to really help prosper this outlook and this motivation to really make change not just within the physical therapy profession but within the medical profession as a whole.’-Subj 1 ‘… I think it’s given me a better appreciation of my profession and knowing that I’m enjoying what I’m doing and that I think I’m doing something worthwhile.’ -Subj 7 Participants attributed this outcome to improvements in clinical reasoning ability, broader skill sets to help patients and confidence: ‘I would say that it really changed the enjoyment of my job. … pre-fellowship, my clinical reasoning was in so its infancy that a lot of patients frustrated me, not the people, but the presentation… So from the perspective of enhancing my clinical reasoning to improve my job satisfaction, that has been a quantum leap. I enjoy being a physical therapist much more because there are many fewer patients nowadays where I really feel stumped and I’m not sure what to tell them.’-Subj 10 ‘I’m a lot more satisfied. I’m a lot more confident and satisfied with what professional and personally of who I am and how I do things…’-Subj 13
Social	Connectedness	12/13	Direct connections ‘through fellowship I was able to grow the network both with faculty and my peers to a point where I feel I have a strong network of very knowledgeable therapist that I can reach out to and vice versa and have discussions with.’ Subj 3 Indirect connections ‘… a Facebook page that has been wonderful and connecting with current and past fellowship graduates from their program’ – Subj 8 Indirect Connections to Leaders After naming 2 prominent non-faculty researchers, ‘Now those are my day to day circles of these individuals that are advancing our profession nationally and internationally. So, it’s been a complete 180 from having a small local network to having a gigantic national, international network that I can leverage at any given time to help move myself forward more, but more importantly our profession and patients for forward so that that’s just gigantic’ – Subj 10
	Open and active listening	9/13	‘… I am more investigative about things. I may be looking for more support for what people say, whether it’s actual evidence or even just their opinion for why they say things. I am more curious about why people say things. I am more open to hearing the other side of things. I find myself a little less judgmental of people views before I’ve heard both sides or heard their reasoning. I may come to conclusions less quickly than I used to. I may gather more information before I make decisions’ – Subj 3 ‘… really allowed me to recognize the need to listen actively, actively and engaging in deeper conversation with other individuals, to appreciate their perspective on whatever the topic of conversation is at that point of time, and not being so quick to close off on ideas, because the ability for me to recognize that I have bias all the time even not just within my clinical thinking but bias within my daily thinking and outside clinical practice thinking.’ – Subj 1 ‘… really appreciate different things from different camps from different schools of thought. So, in that regard I think it made me much better in my professional interactions… to communicate with those who either share my views, or may have a different point of view, and see what can be gained from that’ – Subj 4 ‘I think that’s what ultimately kind of took my practice to the next level. And not just that we can all read the textbooks in the journal, article and the evidence… getting good feedback and criticism and on how you’re speaking to patients and your body language and tailoring them to every single patient front of you. I think that is what’s changed with the fellowship.’ – Subj 5
	Family Impact	9/13	‘It’s changed me, which I guess by default would change the (family) relationship.’- Subj 3 ‘I just think it has given me opportunities to do things I really enjoy, and when you’re doing what you like, I think that makes your personal life better, makes your family life a lot better’ – Subj 7 ‘I became a better communicator with (family) people.’ – Subj 9 However, the impacts of the rigorous schedule and requirements during and after the training on family commitments were also acknowledged: ‘… to the detriment sometimes of my relationship with my wife and my children, you know, they can sometimes take a backseat to professional endeavors which is not such a good thing, but I also try to explain to them the greater good of what I’m trying to accomplish here.’ – Subj 2 ‘Obviously sacrifices at times in terms of family time, when there’s an assignment due or whatever, you know, since graduating fellowship yeah you have a much more balanced lifestyle in terms of balancing family versus work versus, you know, the stuff you’re doing outside of your clinical practice… it’s much more balanced now’: – Subj 12 ‘It really was tough and took a bit of a toll. I believe that we (family) are stronger because of it’ – Subj 8
Personal	Professional Evolution	12/13	Professional Teaching ‘But the biggest one would be my new position as assistant professor, and I being a faculty member in the in academia was never on my radar. It wasn’t in my plan.’ Subj 5 National/State Level Association ‘…I have become more active with the … Association Chapter. We have a couple of fronts that we are working on to change the laws and regulations of the practice of manual therapy in the state … I am a member of the task force with the spinal manipulation … and I am currently working more with other forms of manual therapy advancements in the regulations to practice in the physical therapy field.’ – Subj 13 Promotions/Career Changes ‘So, it did open the door for me to get involved with my company’s own in-house residency program as faculty there. We later developed an in-house fellowship program which I eventually became the director of. That wouldn’t have been possible without fellowship’ – Subj 4 These new opportunities, changes in career directions or roles did not always accompany increased income. ‘I didn’t get a raise from it, didn’t really change anything that way’ – Subj 6 One subject, however reported no change in professional status, and one subject, reported a self-imposed shift from an administrative role to greater direct clinical practice and a teaching role as a residency faculty member and fellowship program director, followed by taking on a full-time faculty position at a University. ‘After demoting myself from clinical director and essentially becoming staff clinician, I also realized that my (administrative) sphere of influence was diminished a little bit too and I couldn’t share this new great stuff with others. So that’s really when I started to look towards education again to where, yes I still treat some patients on the side, we have a faculty practice and all that but then I’m able to pass on information on to (students). ’ – Subj 4
	Metacognition & Self-awareness	12/13	‘I have learned to stop and question or rationalize about life events that happen both in the personal and professional spheres. I did change quite a bit in the fellowship, in regards, anywhere from a range of confidence and humbleness… I have a more sense of criticism of actions. I rationalize a lot more before taking a step or making a move both professionally and personally.’ – Subj 13 ‘You know it has certainly improved my reasoning abilities, my abilities to capture data, to see things and assimilate more quickly. So that has carried over into other aspects of life, … my wife was actively engaged in opening a charter school… And I was able to be a sounding board for her as she was bringing ideas to the table and problems solve … but I felt that through fellowship training especially the grounding of communication and interpersonal relationships that I developed, … (I) was able to be of assistance to her. And the success that they had in opening a new school’ – Subj 8 ‘I’ve been able to apply (reasoning) beyond just my clinical world to my home setting and interactions with people outside of, you know, PT practice, the hospital setting, you know, dealings with people in the public and that kind of thing’ – Subj 12 ‘…I think it tightened up my mind, my pursuit of quality. I mean I think (fellowship) gave me another barometer for how well I can do everything in my life’ – Subj 10 At times these changes were considered challenging: ‘…But it almost causes you to think too much sometimes. I could have a harder time just accepting some things at face value. So, it made you more introspective. At the same time, it kind of made you question all that you knew, and also opened your eyes to how much you didn’t know.’ – Subj 4

Disclosure statement

No potential conflict of interest was reported by the authors.