Variability in Structure of University Pulmonary/Critical Care Fellowships and Retention of Fellows in Academic Medicine

Abstract

Introduction: Individual fellowship programs are challenged to find a format of training that not only meets the Accreditation Council for Graduate Medical Education requirements, but also grooms fellows to be trusted clinicians, and encourages them to enter academic careers. This study was undertaken as part of an internal effort to evaluate and revise the program structure of the pulmonary/critical care medicine fellowship at the Medical University of South Carolina. Our objectives were to characterize variation in the training structure and specifically research opportunities of university pulmonary/critical care medicine fellowship programs, and to identify factors associated with fellow retention in academic medicine and research.

Methods: A 30-item survey was developed through rigorous internal review and was administered via email. Descriptive statistics, Cronbach’s alpha, correlations, Wilcoxon sign-rank test, and ANOVA were carried out.

Results: We had a response rate of 52%. Program directors reported that, within the past 5 years, 38% of their fellows remained in academic medicine and 20% remained in academics with significant research focus. We found a statistically significant association between obtaining a master’s degree and remaining in academics (r = 0.559; P < 0.008). The survey also revealed statistically significant relationships between scholarly requirements (grant proposals, peer-reviewed original research projects) and the percent of fellows who graduated and remained in academics.

Conclusions: This survey offers some insights that may be useful to fellowship program directors. In particular, advanced education in research and maximizing scholarly activities might be associated with increased academic retention among fellowship trainees.

The past decade has witnessed tremendous change in graduate medical education based on mandates by the Accreditation Council for Graduate Medical Education (ACGME) (1–3). In addition to meeting ACGME requirements, pulmonary/critical care medicine (PCCM) fellowship programs must find a format that grooms fellows to be trusted clinicians and still encourages many to enter academic careers, including the possibility of a research career (4, 5). Although requirements exist for program structure and for amounts of clinical training time, there is significant leeway in how programs achieve these requirements (6). Little is known about program variability regarding research opportunities and the implications of different training strategies on the retention of fellows in academic medicine and research.

A pivotal decision point for all PCCM fellows is whether to pursue an academic career or private clinical practice. This decision is complex and, in most cases, involves financial, personal, and geographic factors (7). Other factors that may contribute, such as the structure of training programs and research exposure during training, are unclear. To date, no studies have addressed program structure with regard to research and what elements may or may not be associated with fellow selection of an academic career path among PCCM fellows.

This study was undertaken as part of our institution’s effort to evaluate and revise the program structure of the PCCM fellowship at the Medical University of South Carolina (MUSC). Our objectives were to characterize variation in the training structure and specifically research opportunities of university PCCM fellowship programs, and to identify factors associated with fellow retention in academic medicine and research. We plan to use our findings to inform revisions to MUSC’s PCCM fellowship program. To that end, we surveyed PCCM directors in major university centers across the United States.

Methods

Study Design

The present study was a prospective, observational, survey-based assessment of select PCCM fellowship program directors.

Outcomes of Interest

The proportion of fellows retained in academic medicine was our primary outcome. A secondary outcome was the proportion of fellows whose academic career was primarily research focused (i.e., academics with research).

Definitions

Academics for the purpose of our study was defined as fellows that took up positions in academic/university-based hospitals, and academics with research was defined as positions in which fellows pursued research majority of their time.

Survey Development

We hypothesized that variation in the distribution of clinical versus research time would be associated with variation in retaining fellows in academic medicine. Thus, we included questions regarding clinical training, including details, such as call structure and specific rotations. However, most of our questions were related to opportunities for research training, including the time allotted for research, presence of a mentoring committee, and mechanisms by which fellows are financially supported for a fourth year or advanced education/training in research. The rest of the questions were formulated to obtain information on fellowship tracks, scholarly requirements, and career choice of fellowship trainees from the perspective of program directors. The final survey instrument had 30 items.

Content Validity

To achieve consensus on the survey questions, a working group was convened in January of 2014. Membership was composed of eight independent pulmonologist and critical care physicians, one pediatric neonatologist, two physicians from the Department of Internal Medicine, and one current fellow in pulmonary and critical care. These physicians not only had clinical expertise, but all members also had significant experience in training and mentoring fellows and residents. In addition, several members were coauthors on prior publications of curricula in PCCM (8–11). The final survey was modified based on a consensus agreement among all members of the group. Data from the survey were then entered into REDCap, an electronic tool to administer a survey via e-mail (12).

Survey Distribution

Our target survey respondents were 40 pulmonary critical care fellowship program directors with e-mail addresses published in the ACGME directory of programs. Programs were chosen based on their tertiary care university base, size, and geographic distribution. Fellowship directors were targeted because they possess intimate knowledge of the content of the training curriculum and career pathways of fellows. Survey links were sent via email (n = 40) between March 2014 and April 2014. A reminder was sent to program directors who had not filled out the survey at the end of 2 weeks.

Statistical Analysis

Study data were collected and managed using REDCap. Descriptive statistics were calculated, including mean, SD, and proportions. Parametric statistical tests were used as appropriate. Pearson’s correlation and a one-way ANOVA were used to test for association between independent measures and our outcomes of interest. A Wilcoxon sign-rank test was conducted to analyze a subset of the data. Cronbach’s alpha was calculated to evaluate the survey’s construct validity. We defined significance as P less than 0.05. All data were analyzed in Statistical Package for the Social Sciences (SPSS) 22.0 (Armonk, NY).

Results

A total of 21 out of the 40 fellowship directors surveyed completed the survey (52% response rate). The survey had construct validity with a Cronbach’s alpha of 0.702. The mean scores, SDs, and percentages by item are reported in Table 1. With regard to our primary and secondary outcomes of interest, program directors reported that, within the past 5 years, 38% of their fellows remained in academics and 20% remained in research. The surveyed programs were all moderate in size, with a mean of 15 fellows in each program, along with 37 faculty members. With respect to the clinical training and fellow call schedule, we found that the average call (weekend, night, and in-house) decreased significantly from the first year to the third year of fellowship.

Table 1.

Responses of select survey items

Survey Item	Response
Number of ACGME fellows are in your program (mean ± SD)	14.86 ± 6.01
Number of full-time faculty members are in your division (mean ± SD)	36.95 ± 25.70
Do you receive hospital support for the fellowship director, % yes	66.6
Do you have different tracks for fellows, % yes	9.5
Call structure by fellowship year
First-year fellow (mean ± SD)
Weekend call	12.86 ± 8.64
Weeks of night call	8.10 ± 9.70
Weeks of in-house call	1.81 ± 3.29
Second-year fellow (mean ± SD)
Weekend call	7.19 ± 6.86
Weeks of night call	4.50 ± 4.66
Weeks of in-house call	1.67 ± 3.38
Third-year fellow (mean ± SD)
Weekend call	4.38 ± 0.4.27
Weeks of night call	2.05 ± 2.85
Weeks of in-house call	1.52 ± 3.29
Months of research time included in the fellowship (mean ± SD)	10.05 ± 6.52
Research month’s distribution (continuous), %	38.1
Salary source for research fellows, %*
Hospital	66.7
Department of medicine	9.5
Divisional	38.1
Training grants	33.3
Individual fellowship	19
Other	14.3
Percentage of fellows staying on for a fourth year of fellowship (mean ± SD)	28.57 ± 28.81
Mentoring committee for fellows, % yes	52.4
What percent of fellows obtain a master’s degree during their fellowship (mean ± SD)	16.52 ± 15.96
Funding Mechanism for the master’s program for fellows, %*
Hospital	6.7
Department of medicine	13.3
Divisional	60
Training grants	53.3
Individual fellowship	26.7
Other	20
Measure scholarship requirement, %*
Abstract presentation at national meetings	95.2
Book chapters	76.5
Reviews	85.7
Case reports	81
Peer-reviewed original research manuscript	90.5
Grant submission	57.1
In the past 5 yr, how many of your graduated fellows have remained in academics (mean ± SD)	37.71 ± 25.83
In the past 5 yr, how many of your graduated fellows have remained in research (mean ± SD)	19.86 ± 19.91

Definition of abbreviation: ACGME = Accreditation Council for Graduate Medical Education.

n = 21 program respondents.

^*Total is over 100, as respondents could chose multiple options.

The focus of our survey was availability of research opportunities, and we found that 28% of fellows remained in training for a fourth year of fellowship, and 17% of fellows pursued a master’s degree related to research. We found a statistically significant association between obtaining a master’s degree and remaining in academics (r = 0.515; P < 0.017); however, statistical significance was not achieved for pursuing an academic career conducting research and obtaining a master’s degree (r = 0.327; P < 0.148).

The results of our one-way ANOVA are provided in Table 2. We identified a statistically significant relationship between scholarship requirements (submitting grant proposals) and the primary outcome of remaining in academic careers (P < 0.042). Similarly, we identified a statistically significant relationship between fellows with peer-reviewed original research as part of their scholarship requirements and pursuing academic careers conducting research (P < 0.000). Finally, there was a statistically significant relationship between fellows being financially supported by individual extramural fellowship awards and pursuing careers in academics conducting research (P < 0.038).

Table 2.

Relationship between select variables and primary and secondary outcomes

Academics	Academics with Significant Research	P Value
Scholarship requirement (grant proposals)	—	<0.042
—	Funding (by individual fellowships grants)	<0.038
—	Scholarship requirement (peer-reviewed original research)	<0.000

In addition, we also performed subset analyses and grouped programs with greater than 40% retention in academics (nine programs) and less than 40% retention in academics (12 programs), and found statistically significant relationships between academic retention and scholarship requirements (peer-reviewed original research, grants) in both subsets. (>40% retention—Z = −2.675, P = 0.007; <40% retention—Z = −2.982, P = 0.003).

Discussion

An important finding from our survey is that obtaining a master’s degree was associated with increased academic retention. In addition, the measure that programs used to ascertain scholarship with respect to grants and peer-reviewed original research was associated with higher academic retention among fellows. On additional subset analyses, we also found that high scholarship expectation was associated with academic retention, irrespective of the subset chosen (> or <40% retention). However, we found no association between training structure (i.e., amount of dedicated research time) and fellow retention in academic medicine. Along the same lines, a study among gastroenterology fellows choosing academic careers identified a higher rate of prior graduate research training (13). We recognize that fellows who pursue master’s degrees related to research are self-selected, and thus may be “predestined” to pursue academic careers. However, many programs allocated substantial fellow time to research activities (up to 17 mo), which was not associated with retention in academic careers.

In the field of PCCM, a previous survey-based study evaluated factors predicting the initial career choices made by PCCM fellows and junior faculty, and found that alleviating financial pressures has only a modest benefit for retaining fellows in academics. However, in the same study, factors that proved to be vital in academic retention of fellows included mentors’ own academic training history, which, in turn, seemed to influence the preparation of their mentees. Both faculty and fellows who had mentors holding Ph.D. degrees had higher self-reported research skills and stayed on in academics (9). This brings into question the role of mentors and the trainees’ inherent qualities itself, which is beyond the scope of this survey. However, based on our survey, fellowship program directors and trainees should carefully consider allocation of time spent in clinical training, research training, and advanced educational opportunities in research.

Limitations

We acknowledge some important limitations to our study. First, we did not provide a standard operational definition for academics and academics with research, as we suspected that our survey respondents (fellowship program directors) would have similar insights into the question. We a priori selected fellowship programs based on potential similarities with MUSC. As a result, only 40 of the 155 U.S. programs were given the opportunity to respond; thus, our findings may not be generalizable. However, the sample selected represents PCCM programs in a variety of geographical distributions and sizes. Although our response rate was 52%, which is more than average, the results carry the risk of nonresponse bias. In addition, we did not survey fellows, and it is possible that the perspectives of program directors differ from their fellows. However, program directors would be in the best position to answer curricular questions and questions related to overall retention in academic medicine, which were our primary survey objectives. In our survey, we specifically differentiated between an academic career and an academic career with research involvement to glean more granular insight. However, we did not independently verify responses from program directors regarding the proportion of their graduates retained in academic medicine and/or research careers.

We specifically identified programs that had greater than 40% of retention in academics as “high” based on studies in the literature about other specialties (14, 15), but we believe that there could be significant differences in opinion on what constitutes high academic retention based on individual program characteristics. Finally, our surveys did not address questions such as, amount of research funding available, number of publications, impact factor of publications, and types of research, all of which may speak to the ability of a program to produce academically inclined fellows. This additional information may be valuable in assisting programs attempting to increase their retention of fellows in academic medicine, and should be evaluated in future studies.

Conclusions

In conclusion, although a fellow’s decision to prepare for and pursue an academic career has multiple determinants, this survey offers insights that may be useful to fellowship program directors desiring to increase retention of fellows in academic medicine. In particular, advanced education in research and high expectations for scholarly requirements might be associated with increased academic retention. Fellowship directors should provide careful consideration toward maximizing scholarly activities among fellowship trainees.