The Continuing Fellowship Conundrum

Introduction

The debate for a fair, equitable, and reasonable pathology fellowship application and selection process has been an ongoing issue with ebb and flow over approximately the past 10 years. The authors of this commentary have been closely involved with the fellowship issue over the past decade and have been part of the effort to achieve a workable solution with widespread support. Possible solutions to the concerns raised by various parties have included efforts to implement a uniform timeline, a formal match through the National Resident Matching Program (NRMP), a formal match through the San Francisco Matching Program, and most recently (and the focus of this commentary) a Code of Conduct (Honor Code) and application clearing house overseen by the Association of Pathology Chairs (APC). Table 1 summarizes these efforts and their outcomes to date.

Table 1.

Potential Solutions and Outcomes to the Pathology Fellowship Conundrum.

Possible Solutions

Outcomes to Date

Voluntary adherence by programs to a uniform application and offer time line Voluntary adherence by programs to not pressure applicants into making “snap” decisions Voluntary adherence by applicants to abide by commitments made to a fellowship program Formal fellowship match process (eg, NRMP or San Francisco Match) Voluntary adherence by programs and applicants to an honor code with data collected by the APC and made available to programs and residents

Compliance has not been uniform Compliance has not been uniform As noted in the text, last minute openings continue to be a problem Consensus among program directors and applicants have not supported a formal match process No data to date, has not been tried

Abbreviations: APC, Association of Pathology Chairs; NRMP, National Resident Matching Program.

Resident dissatisfaction with the fellowship application process seemed to peak in the mid-2000s when the College of American Pathologists (CAP) Resident Forum and its Executive Committee put forward its concerns and voiced support for, and approval of, a “unified” or “common” application form. The intent was that this common application would be accepted by training programs around the country. A suggested time line for the application process was also approved at that time.^1,2 This idea was examined and championed by the APC in the 2007 to 2010 time frame. Association of Pathology Chairs and Pathology Program Directors Section of the APC (PRODS) recognized the serious issues ingrained in the fellowship application process and dedicated resources to further explore these issues and concerns and to examine a possible move toward a match.²

Potential Solutions and the Fellowship Directors Ad Hoc Committee

Other medical subspecialties, when faced with similar fellowship application concerns, had successfully implemented a fellowship match through the NRMP. To evaluate the probability of a pathology fellowship match, the APC utilized surveys to identify subspecialties willing to be “first in line” for fellowship match implementation. It rapidly became apparent that the NRMP requirement for a time line more proximal to the fellowship matriculation date and the requirement for a high percentage of programs to agree to participate would be major hurdles. Only 2 subspecialties demonstrated a sufficient positive response to warrant pursuit of a match, and ultimately both felt that participation in a match would place them at a significant disadvantage relative to other subspecialties and nonparticipating programs. Discussion of the benefits and need for a match at the CAP Residents Forum also demonstrated that resident support for a match was not universally held. Many residents felt that being able to apply and accept positions outside the match helped them to accept multiple fellowships, to better plan for future moves, and to better support their lives outside of graduate medical education. Subsequently, surveys of residents completing their in-service examinations through the American Society of Clinical Pathology (ASCP) saw a drop in trainees’ interest for a formal match process,^3,4 even while interest in a uniform time line, common application, and a process that did not pressure applicants to immediately accept positions at the conclusion of their interviews was maintained. Needless to say, implementation of a matching process through the American Association of Medical Colleges and the NRMP did not succeed.

Both APC and PRODS continued to have serious concerns regarding the fellowship application process and to explore other means to effect change that might garner support and approval from all stakeholders (Table 1).^2,5 In the spring of 2013, the APC formed a Fellowship Directors Ad Hoc Committee (FDAHC) with representatives from each of the boarded pathology fellowship subspecialties (and including surgical pathology), with the intent that the members would work through their respective subspecialty societies to effect change in the fellowship application process. A move to investigate the San Francisco Matching Program was made, and due to its increased flexibility relative to the NRMP, it garnered some interest and traction, with the dermatopathology fellowship program directors planning to “take the plunge” no later than 2020. The future viability of the San Francisco Matching Program to be the vehicle for a “pan-pathology” match across all subspecialties is unclear at this point in time.

The lack of a meaningful, structured fellowship application process and time line continues, and anecdotally, the same ongoing issues continue to plague both residents and program directors.^1,2,5 The push for earlier and earlier decision-making by residents and fellowship programs continue, with decisions not infrequently occurring in the resident’s PGY1 or early PGY2 year of training. These early decisions preclude, in many cases, significant exposure to some of the subspecialty areas with the greatest need for a pipeline to bolster their pathologist workforce, for example, pediatric pathology, neuropathology, blood banking/transfusion medicine, and forensic pathology. Thus, it is not surprising that the current state manifests itself in increased numbers of programs with the dreaded “unexpected fellowship opening” for the upcoming academic year, and not uncommonly in the month or two before the fellowship program’s matriculation date. Data presented at the July 2017 APC Annual Meeting, based on a review of unexpected fellowship openings posted on the PRODS list serve, demonstrated that 70 discrete fellowship positions were posted in the 2016 calendar year, with 17 of those postings occurring between January and March 2016 and 9 of those postings occurring between April and June 2016 for a July 2016 matriculation date.⁶ Programs throughout the country were adversely impacted.

A Proposed Honor Code

In light of this history and the fact that little has changed (Table 1), and perhaps even worsened, the FDAHC of the APC has developed a voluntary Honor Code for fellowship applicants and program directors (available online under Supplemental Material). In addition, the FDAHC has also proposed the establishment of a “clearing house” for available and filled positions. The clearing house would be a current, updated listing with information input from the fellowship program directors and would be maintained by the APC. Clearing house data would be available to candidates and programs in a timely manner. A platform to accomplish this has already been developed by the APC. These proposed ideas have been presented to PRODS at APC, to the ASCP Residents Council, and to the CAP Residents Forum in 2017. The Honor Code would be applied to both applicants and programs and would be put into place for those looking for positions no sooner than 2019 (as many programs have already selected candidates under the current system). The intent is to gradually move toward a common time line.

The beauty of a formal match process, such as the NRMP program, is not only the speed in which the process is done, allowing for the programs to enroll new trainees months before matriculation rather than years, but in the fact that there are penalties associated with withdrawal. To date, such a process does not exist with pathology fellowships, and the lack of penalties is perceived to be a weakness inherent in the enforceability and wide adoption of the Honor Code and clearing house concepts, even though there are clear-cut benefits for their adoption from both the applicant and program perspectives.

Individual lives change, along with the needs of families, and geographic limitations are part of the complex nature of the fellowship decision-making process. With such a long time lag between selection and implementation of a contract, requiring someone to honor a contract after they have been exposed to a subspecialty they perceive as much more desirable or after their life circumstances have changed affecting their geographic and life style requirements is a recipe for disaster. Residents who feel forced to move to a location now deemed unattractive, or forced to complete a fellowship they now perceive as undesirable, cannot be expected to “do their best” and positively represent their training program. Therefore, a process which tightens (ie, shortens) the time line and allows individuals to experience all of the potential subspecialties through their PGY3 year of training in combined Anatomic and Clinical Pathology (AP/CP) or PGY2 year of training (AP- or CP-only) without forcing an early commitment is the one aspect of proposals for change in the fellowship application process that seems to be consistently supported^1,2,5 and which is potentially achievable with or without a formal match process, as long as fellowship programs across all subspecialties perceive the need and benefits such a change would provide. The proposed Honor Code reminds every one of their professional commitment to excellence and to the principles of honesty, integrity, and ethical behavior.¹ A central clearing house would allow residents and programs to track openings and acceptances. The institution of an honor code may seem to be a small step, but it is a step in the right direction that encourages all of us to be ethical, moral, and professional physicians, working toward a process where both applicants and programs can find the best possible match.