Attributes Influencing the Selection of Fellowship Programs by Pulmonary and Critical Care Applicants: A Pilot Study

To the Editor:

Recruitment of top-quality candidates is a high-stakes, high-cost, and high-effort aspect of every graduate medical education training program. Previous studies in internal medicine have estimated that training programs spend approximately $15,000 annually on recruitment activities for each matched position (1). For program leaders to efficiently use program resources and improve recruitment outcomes, it is essential to understand the program attributes that are most important to fellowship candidates.

Previous studies have examined the program attributes that residency candidates look for in emergency medicine and anesthesia training programs (2–4). The attributes that influence pulmonary and critical care fellowship candidates are largely unknown. Pulmonary and critical care applicants likely have distinct priorities when selecting fellowship programs, as the training involves unique clinical and procedural experiences. We therefore conducted a survey to determine the specific attributes influencing the selection of fellowship programs by pulmonary and critical care fellowship applicants interviewing at our institutions.

We surveyed fellowship candidates who were invited to interview for the Mayo Rochester Pulmonary and Critical Care Medicine (PCCM), Mayo Rochester Pulmonary Medicine, Mayo Rochester Critical Care-Internal Medicine (CCIM), Mayo Jacksonville PCCM, and Mayo Scottsdale Pulmonary Medicine training programs between 2014 and 2015. The Mayo Institutional Review Board approved this study.

All applicants who were offered an interview were invited to complete an electronic survey, using the Research Electronic Data Capture survey software, version 1.3.10 (Vanderbilt University, Nashville, TN). The survey was anonymous and distributed after each year’s fellowship match day.

The survey collected information on demographics and priorities in selecting a fellowship program based on the following attribute categories: clinical training, procedural training, program attributes, and career development (see the online supplement). The sources of information used to evaluate fellowship programs were also assessed. The primary aim of the investigation was to identify program attributes most important to applicants and, second, to assess the most influential sources of information used by applicants to evaluate fellowship programs.

The study investigators (J.H.S. and D.J.K.) collected and abstracted the survey responses anonymously. Descriptive analysis was conducted using JMP software (version 10; SAS Institute Inc., Cary, NC). The survey used a 7-point Likert scale to rank importance, using weighted averages.

The survey was sent to 162 applicants. We received 74 responses (46% response rate). Among the responders, 30 (41%) applicants were from the 2014 recruitment season and 44 (59%) were from 2015. A total of 35 (47%) interviewed at the Mayo Rochester PCCM program, 36 (49%) interviewed at the Mayo Rochester CCIM, 3 (4%) interviewed at the Pulmonary Medicine fellowship at Mayo Scottsdale, and 15 (20%) interviewed at the Mayo Jacksonville PCCM program (note that some applicants interviewed at several programs). Altogether, 50 applicants (68%) attended a non-U.S. or Canadian medical school, and 27% were from allopathic medical schools in the United States.

The survey results are summarized in Table 1. For the clinical training opportunities within a fellowship program, applicants reported the most important attributes were approachable faculty members, exposure to complex diagnoses or rare conditions, and autonomy in patient management. Call schedule was of less importance. With regard to procedural training, the number of intubations, bronchoscopies, and central line placement were most important, whereas pleural procedures were considered less essential.

Table 1.

Factors influencing pulmonary critical care applicants’ ranking of program

Priorities in selecting a fellowship program	Ranking	Weighted averages of Likert scale (0–6)*
Clinical training	1. Faculty members who are approachable and work closely with fellows in clinical care	5.35
	2. Adequacy of the volume of tertiary care patients with complex diagnoses or rare conditions	4.69
	3. High level of autonomy in patient management	4.62
	4. Adequacy of the volume of “bread and butter” pulmonary and critical care patients (such as asthma and chronic obstructive pulmonary disease)	4.41
	5. Call schedule and rotation structure	3.36
Procedural training	1. Opportunity to manage the airway and perform intubations	5.18
	2. Overall number of bronchoscopies performed by fellows	4.99
	3. Opportunity to perform intensive care unit procedures (central line placement, paracentesis, thoracentesis)	4.89
	4. Number of pleural procedures (such as chest tube placement) carried out by fellows	4.79
Program attributes	1. Current fellows’ satisfaction with their program and morale	5.23
	2. General impression of the program at the interview day	5.11
	3. Prestige of the institution/ department/ faculty/program	4.58
	4. Geographic location (city) of fellowship program (includes spouse employment opportunities)	4.13
	5. Diversity of faculty and fellows	3.82
	6. Employment benefits (includes health insurance and presentation trip policy)	3.78
	7. Availability of elective rotations at other sites	3.12
	8. Availability of international electives	2.20
Career development	1. Mentoring and career guidance	5.15
	2. Opportunities to teach residents and medical students	4.69
	3. Opportunities to conduct clinical research during fellowship	4.59
	4. Employment opportunities and adequate preparation for private practice after training	4.32
	5. Program development of academic career (such as National Institutes of Health T32 grant opportunity)	3.69
	6. Opportunities to conduct basic science research during fellowship	2.73
Sources of information used to evaluate fellowship programs	1. Interview day: meeting and presentation by program director	5.12
	2. Interview day: discussion with current fellows	5.11
	3. Interview day: discussion with faculty during interviews	5
	4. Discussion with faculty at your current institution about other institutions and fellowship programs	4.54
	5. Official fellowship program website	4.46
	6. Interview day: tour of facilities	4.3
	7. Discussion with peers at your institution who are also applying for fellowship	4.16
	8. Handout materials and slides on interview day	3.74
	9. Preinterview dinner with current fellows	3.61
	10. Other websites or Internet message boards for medical trainees (such as Student Doctor Network forums)	2.99
	11. Social media: Twitter, Facebook	1.69

^*Weighted averages using the following Likert scale: not at all important = 0; low importance = 1; slightly important = 2; neutral = 3; moderately important = 4; very important = 5; extremely important = 6.

Current fellows’ satisfaction, the general impression of the program on interview day, and prestige were the top three key program attributes. The availability of elective rotation at other sites and international electives were the two lowest-ranked program attributes. Access to mentorship and career guidance opportunities, teaching medical students or residents, and clinical research opportunities were of highest importance with regard to professional development, whereas basic science research was the lowest.

Applicants identified that the interview day was of greatest importance in their evaluation of the program; specifically, our results found that the meeting and presentation by the program director, discussions with current fellows, and discussions with faculty during interviews were the highest ranked. Social media and websites or internet message boards such as the Student Doctor Network forums were considered least vital.

Discussion

Our survey is the first to assess the selection attributes influencing the pulmonary, CCIM, and PCIM fellowship program applicants in their selection of fellowship programs. Our findings highlight that approachable and engaged faculty members, procedural numbers, current fellows’ satisfaction, mentorship guidance, and the experience of the interview day are the most important program attributes, as ranked by the applicants.

Our survey interestingly found that social media and message boards do not seem to play a huge role. Overall, the atmosphere of the department, morale of the current fellows, and experience during the interview day appear to be of highest importance in selecting any program. Regarding procedural training, the applicants valued the ability to perform procedures, especially bronchoscopies, central lines, and intubations. The importance of procedures has also been shown in gastroenterology fellows applying for an advanced endoscopy fellowship (5).

Our key findings are similar to those of prior studies on residency program selection. Two studies on emergency medicine applicants found that the following attributes are essential in selecting a residency program: friendliness, environment, interview day, institutional reputation, hospital facilities, program director reputation, and spousal influence (3, 4). Another study highlighted the importance of a positive interview experience (5). Resident morale was also emphasized in various other studies (2, 6–9). Prior studies did not focus on the sources of information as an attribute.

Our study has several limitations. The main limitation is the limited generalizability of our findings to other programs that may offer different strengths. In addition, we were unable to stratify the results on the basis of the different program types and/or the program location because of the small sample size. Although the response rate for the Mayo Rochester program was reasonable, there is a potential for selection bias at the other sites because of the low response rate to our survey. The attributes were also not differentiated on the basis of sex (5). It is important to emphasize that this is a pilot study, and our preliminary findings underscore the need to conduct a larger study involving more programs at different locations and sizes.

Understanding the factors involved in the decision-making of pulmonary and critical care applicants on selecting certain types of fellowship programs can provide valuable information that will lead to a better match for both the applicants and the programs.