Graduating residents are under contract until June 30 and may be assigned patient care responsibilities up until this date. However, those pursuing subspecialty training are often expected to begin fellowship on July 1, posing a significant hardship, especially for those who must relocate to another region. In addition, many programs require incoming fellows to attend institutional orientation while they are still residents.1  Thus, programs and trainees must make difficult decisions that potentially disregard contractual obligations, jeopardize patient care, and limit orientation, all adding to the stress of starting fellowship.2 

There is no requirement for fellowships to start on July 1. In fact, since the 1990s, orthopedic surgical fellowships have begun on August 1. Delaying the fellowship start date would provide time for trainees to relocate, reduce stress and improve wellness, and allow for a more comprehensive orientation to the new environment.

In 2013, the Council of Pediatric Subspecialties (CoPS) convened a multispecialty action team to examine the current July 1 start date for fellowships and to make recommendations to improve the residency to fellowship transition, thereby promoting trainee wellness. The action team was composed of individuals representing residency and fellowship program director (FPD) organizations from various specialties, designated institutional officials (DIOs), and representatives from various associations.1  In 2014, the action team conducted surveys of graduating pediatric residents entering fellowship and FPDs about delaying the fellowship start date.1  In the resident survey, >90% of trainees indicated a preference for a delayed date and reported that a one-week gap income was acceptable. FPDs were unaware of resident preferences, but when presented with the resident data in their survey, >80% indicated they would support a delayed start date.

On the basis of these data, the action team recommended that (1) beginning with the 2017 appointment year, pediatric fellowships start no earlier than July 7, (2) orientation for new fellows not be scheduled before July 5, and (3) an educational campaign be implemented to communicate the desires of the trainees to FPDs.

To determine compliance with these recommendations and obtain FPD and trainee opinions about the delay, all first-year pediatric fellows and FPDs from the 14 Accreditation Council for Graduate Medical Education–accredited subspecialties with American Board of Pediatrics (ABP) certification were surveyed. Only fellows who began training in June or July 2017 and entered fellowship within one-month post residency were included. Separate surveys were created for fellows and FPDs. These were developed by the authors and members of the action team and then reviewed by an ABP committee.

The surveys asked for the fellowship institution and subspecialty and included whether the fellowship began on or before July 1 (including orientation), the reporting dates for orientation, and the actual start of fellowship (aside from any required institutional orientation). Fellows who began fellowship after July 1 were asked additional questions related to gap in salary, health insurance, visas, and overall satisfaction with the delayed date. In both the fellow and FPD surveys, several questions allowed for open-ended responses. The surveys were conducted in the last quarter of 2017. Response rates for the fellow and FPD surveys were 37% (507 of 1364) and 57% (458 of 803), respectively. Characteristics of fellow responders were similar to those of nonresponders. To be included in the analysis, responses needed to include at least the institution, subspecialty, and start date.

Through pooled analysis, data were available for 527 of 804 (66%) of all pediatric fellowships, representing 119 institutions. Sixty-two percent of programs required their fellows to begin their training after July 1. Consistent with CoPS recommendations, most (84%; 263 of 315) programs that delayed their start date had orientation on July 5 or later and required fellows to begin their training July 7 or later (76%; 244 of 322). The start date was delayed in the majority of programs with a separate pediatric DIO (83%, 88 of 106) as well as those in which there was a single DIO overseeing all programs in the institution (60%; 174 of 292).

Most fellows (72%; 272 of 377) needed to move to a new place of residence for fellowship, with the majority (56%) moving with a partner or family member. Of fellows in programs in which the start date was not delayed, 92% would have preferred their program followed the CoPS recommendations and almost all provided comments (144 of 148). Comments were mostly related to relocation; fellows indicated they needed time to settle in and preferred not to use vacation time for moving. They thought that a gap between residency and fellowship would minimize the stress and frustration that accompanies moving (Table 1). Some indicated that they were unable to leave their residency before July 1 and were unable to attend orientation at the new institution.

TABLE 1

Perspectives of Fellows and FPDs About the Delayed Start Date

ThemeRepresentative Quotes
Fellows in programs that did and did not delay the fellowship start date  
 Time to relocate “I had to take a week of vacation in residency to move across the country from the Midwest to California. So there was no time to move in and get settled or rest before fellowship started.” 
 “I had to move over 1000 miles, find an apartment, and get situated well enough to transition. This was extremely challenging. While this may be easy for some, I moved to a city with no family there. I didn’t have any time to even physically see my apartment before I secured it online due to the timing, limited funds (everything being used to move across country), and no vacation days left.” 
 Downtime and rest “Having worked through June 30th, I felt like I needed time to decompress, to get my life organized, and to get ready to start fellowship.” 
 “It is exhausting to wrap up residency and begin fellowship immediately, even just moving within the city was difficult because the quick transition.” 
 Gratitude for the delay “It was an incredible relief. A huge weight lifted to not have to start on July first. I extended many condolences to friends for starting on the first. I felt far more ready and prepared to tackle fellowship because of the delay.” 
 “Delaying the start day of fellowship was the best thing for me and my family. Not only we had time to pack and move after residency, but also to settle the family for a 3-year fellowship. It is extremely difficult to plan a move when you have to work up until 6/29 during residency and start on 7/1 in a different location.” 
 Wellness “It was much better for my mental health to have started fellowship later.” 
 “After 3 years of residency, it would be nice to have a mental break from training and to start fellowship fresh.” 
 Concerns about health insurance “[P]urchasing through COBRA is expensive and not an acceptable option during a time when you are dealing with costs of moving and the lapse in pay, on top of regular bills such as student loan payments. Additionally, our insurance didn’t take effect until 1 month after starting fellowship. Luckily, I had gotten married in June, so I was able to be covered under my husband’s plan; however, there were lots of my friends who were not able to get covered in an inexpensive way. Many went uninsured during the gap period.” 
 “Although our contract technically started on July 1 (so there was no gap in salary or insurance), we were given July 1–4 off as ‘working from home’ and started with institutional orientation on July 5. This was definitely a benefit, as I had time to move but did not lose any benefits or salary from a gap in employment.” 
FPDs in programs that did and did not delay the fellowship start date  
 Institutional reluctance “Our sponsoring and program’s institutions insist on an early start.” 
 “I would like to change to a start date later in July. Unfortunately, our department vice-chair for education and our institution’s DIO are not allowing it yet.” 
 Orientation “My institution has orientation for a large number of fellowship programs. This orientation is done as a single event, which the GME office schedules. I am not allowed to deviate from the plans for orientation or start dates, which are determined by our DIO.” 
 “Hospital orientation would make starting the first week of July impossible. A special hospital orientation is given for new physicians in training (interns, residents, fellows) mid-June.…” 
 “Our institution started mandatory hospital orientation on July 5th for all fellows.” 
 Not necessary “It was a nice gesture, but I’m not sure it materially changed the quality of life for our service’s trainees.” 
 “In our fellowship, we always have had an official start date of July 1 but allowed fellows to move/settle in and not start actual clinical duties until a week later. This way there is no interruption in pay or healthcare insurance but plenty of time to transition.…” 
 “I think I would give weightage to what the fellows have to say about this. It will be best when fellows who have started a fellowship with the delayed start date are the ones answering this question; sometimes problems surface after the fact.” 
 Need for clinical coverage “If fellows cannot start orientation until July 7, they cannot start clinical until at least July 10, usually later depending on when weekend falls. This poses a big problem for us getting clinical coverage from July 5–9.…” 
 “Our fellow coverage for the first week of July was decreased since there were only 2nd and 3rd year fellows available to work.” 
 Visa issues “Both of our fellows could not have any time off according to their visas. So they had to come and start on the 1st so that there was no break in their training.” 
 “J-1 visa holders cannot do COBRA.” 
 Concerns about health insurance “We were anxious that the trainees were without health insurance for the days between the end of their residency and the start of their official fellowship.” 
 “We were able to onboard our incoming fellows so that they had health insurance. COBRA exists but is very expensive, and if there is a significant event, they may not have the resources to pay for their COBRA.” 
 “I did not have any issues in my fellowship, but I oversee all fellowships as Super Fellowship Director, and I know we did face several challenges with J-1 and H-1B visa holders. We actually had to make their start date July 1 on ‘paper’ for our international office; they still started work with the other fellows, but we did have to do a ‘work around’ in order to make it work for them.” 
ThemeRepresentative Quotes
Fellows in programs that did and did not delay the fellowship start date  
 Time to relocate “I had to take a week of vacation in residency to move across the country from the Midwest to California. So there was no time to move in and get settled or rest before fellowship started.” 
 “I had to move over 1000 miles, find an apartment, and get situated well enough to transition. This was extremely challenging. While this may be easy for some, I moved to a city with no family there. I didn’t have any time to even physically see my apartment before I secured it online due to the timing, limited funds (everything being used to move across country), and no vacation days left.” 
 Downtime and rest “Having worked through June 30th, I felt like I needed time to decompress, to get my life organized, and to get ready to start fellowship.” 
 “It is exhausting to wrap up residency and begin fellowship immediately, even just moving within the city was difficult because the quick transition.” 
 Gratitude for the delay “It was an incredible relief. A huge weight lifted to not have to start on July first. I extended many condolences to friends for starting on the first. I felt far more ready and prepared to tackle fellowship because of the delay.” 
 “Delaying the start day of fellowship was the best thing for me and my family. Not only we had time to pack and move after residency, but also to settle the family for a 3-year fellowship. It is extremely difficult to plan a move when you have to work up until 6/29 during residency and start on 7/1 in a different location.” 
 Wellness “It was much better for my mental health to have started fellowship later.” 
 “After 3 years of residency, it would be nice to have a mental break from training and to start fellowship fresh.” 
 Concerns about health insurance “[P]urchasing through COBRA is expensive and not an acceptable option during a time when you are dealing with costs of moving and the lapse in pay, on top of regular bills such as student loan payments. Additionally, our insurance didn’t take effect until 1 month after starting fellowship. Luckily, I had gotten married in June, so I was able to be covered under my husband’s plan; however, there were lots of my friends who were not able to get covered in an inexpensive way. Many went uninsured during the gap period.” 
 “Although our contract technically started on July 1 (so there was no gap in salary or insurance), we were given July 1–4 off as ‘working from home’ and started with institutional orientation on July 5. This was definitely a benefit, as I had time to move but did not lose any benefits or salary from a gap in employment.” 
FPDs in programs that did and did not delay the fellowship start date  
 Institutional reluctance “Our sponsoring and program’s institutions insist on an early start.” 
 “I would like to change to a start date later in July. Unfortunately, our department vice-chair for education and our institution’s DIO are not allowing it yet.” 
 Orientation “My institution has orientation for a large number of fellowship programs. This orientation is done as a single event, which the GME office schedules. I am not allowed to deviate from the plans for orientation or start dates, which are determined by our DIO.” 
 “Hospital orientation would make starting the first week of July impossible. A special hospital orientation is given for new physicians in training (interns, residents, fellows) mid-June.…” 
 “Our institution started mandatory hospital orientation on July 5th for all fellows.” 
 Not necessary “It was a nice gesture, but I’m not sure it materially changed the quality of life for our service’s trainees.” 
 “In our fellowship, we always have had an official start date of July 1 but allowed fellows to move/settle in and not start actual clinical duties until a week later. This way there is no interruption in pay or healthcare insurance but plenty of time to transition.…” 
 “I think I would give weightage to what the fellows have to say about this. It will be best when fellows who have started a fellowship with the delayed start date are the ones answering this question; sometimes problems surface after the fact.” 
 Need for clinical coverage “If fellows cannot start orientation until July 7, they cannot start clinical until at least July 10, usually later depending on when weekend falls. This poses a big problem for us getting clinical coverage from July 5–9.…” 
 “Our fellow coverage for the first week of July was decreased since there were only 2nd and 3rd year fellows available to work.” 
 Visa issues “Both of our fellows could not have any time off according to their visas. So they had to come and start on the 1st so that there was no break in their training.” 
 “J-1 visa holders cannot do COBRA.” 
 Concerns about health insurance “We were anxious that the trainees were without health insurance for the days between the end of their residency and the start of their official fellowship.” 
 “We were able to onboard our incoming fellows so that they had health insurance. COBRA exists but is very expensive, and if there is a significant event, they may not have the resources to pay for their COBRA.” 
 “I did not have any issues in my fellowship, but I oversee all fellowships as Super Fellowship Director, and I know we did face several challenges with J-1 and H-1B visa holders. We actually had to make their start date July 1 on ‘paper’ for our international office; they still started work with the other fellows, but we did have to do a ‘work around’ in order to make it work for them.” 

GME, graduate medical education.

For fellows in programs in which the start date was delayed, 94% (207 of 221) were satisfied or very satisfied with the delay. Many fellows expressed gratitude for delaying the start of fellowship, and others noted how the start date affected their well-being (Table 1). For example, one fellow reported the following:

I had to save 1 week of vacation in residency for the last week of June for relocation purposes. How am I supposed to move to a new city and be able to attend orientation in June when technically my residency does not end until June 30th?… A start date of July 1st and orientation prior to that gives us no personal time and no work life balance.

Most fellows (81%; 183 of 225) indicated that the lack of salary during the gap in training had little or no impact. However, only 53% had health insurance during the gap, and 27% of fellows were unaware about continuation of health coverage through the Consolidated Omnibus Budget Reconciliation Act (COBRA). Health insurance was provided by various sources. Only 5 of 121 (4%) fellows purchased COBRA, although some indicated they would have purchased it retroactively if necessary. Twenty-six (12%) fellows were training on a visa, and most did not have an issue with their visa related to the gap. Nonetheless, some FPDs had misconceptions about COBRA eligibility for those training on a visa (Table 1).

The vast majority of FPDs (301 of 385) thought that delaying the start date improved the transition from residency to fellowship. Institutional factors were cited as the most common reason for not delaying, including the graduate medical education office not allowing the change and/or the need to have a single hospital-wide orientation. FPDs from programs in which the start date was not delayed cited concerns about clinical coverage, visas, and/or trainee health insurance (Table 1).

Voluntary compliance with CoPS recommendations was good, with nearly two-thirds of fellowships delaying their start date. Incoming fellows overwhelmingly support a break between residency and fellowship. Many categorical programs schedule vacation at the end of residency for trainees pursing fellowship to provide time for moving. Although this does allow trainees to report by July 1, fellows commented that vacation should be used for rest rather than relocation.

Nonetheless, to improve compliance, a few issues still need to be addressed. Although almost all FPDs (132 of 142) from programs that did not delay the start date were aware of CoPS recommendations, 27% still did not consider a delay, and ∼25% thought the current system was satisfactory, so no change was needed. In contrast to fellows’ concerns about wellness, only 5 FPDs commented that delaying the fellowship start date would affect wellness; of these, 3 indicated it would have little impact. Thus, additional education about trainees’ desires is still needed.

Both fellows and FPDs had concerns about health insurance. Only a few fellows purchased coverage through COBRA, and many trainees were unaware that this was even an option.3  The cost of COBRA is high, so it would be beneficial to examine other ways to provide gap health insurance. Perhaps fellowships or institutions could subsidize the fee.

Before implementation of the delayed start date, CoPS worked with the Educational Commission for Foreign Medical Graduates to permit a gap in training for J-1 visa trainees. In pediatrics, the Educational Commission for Foreign Medical Graduates requires that the visa holder submit a form for approval, but no fee is associated with this process.4  A change to immigration regulations before implementation allowed a gap in training for those possessing an H-1B visa.5,6  Nonetheless, some FPDs were unaware of these changes or had misconceptions, so communicating these changes to the community is still necessary.

Actual data from trainees, rather than assumptions, were instrumental in formulating the CoPS recommendations and convincing programs to delay their start date. Issues related to J-1 and H-1B visas were addressed well before implementation. There was communication with the pediatric community, which, although not perfect, helped to disseminate the recommendations and trainee desires.

Fellows prefer a gap in training, and it is possible to delay the fellowship start date even without a mandate to do so. However, not all fellowships elected to comply, suggesting that data about fellow preferences still need to be disseminated. Clear, readily available information regarding health insurance and visa requirements provided to trainees and FPDs would help to address misinformation. Fellowships that have not yet delayed their start date could enhance wellness of entering fellows by complying with CoPS recommendations. Moreover, other specialties could replicate the process used in pediatrics to delay their start date.

We thank Alma Ramirez, BS, for helping to compile the data and the ABP Education and Training Committee for supporting this work. We also acknowledge the continued efforts of the members of the action team for continuing to advocate for a delayed start date in other specialties.

The content is solely the responsibility of the authors and does not necessarily represent the official views of the American Board of Pediatrics or the American Board of Pediatrics Foundation.

Dr Mink conceptualized and designed the study, developed the survey instruments, coordinated and supervised data collection, analyzed the data presented, and wrote the initial manuscript; Drs Wininger and Muchmore conceptualized and designed the study, developed the survey instruments, analyzed the data presented, and wrote the initial manuscript; Drs Leslie, Hofkosh and McGuinness conceptualized and designed the study, developed the survey instruments, and analyzed the data presented; Mr Turner conceptualized and designed the study, developed the survey instruments, supervised data collection, and analyzed the data presented; Dr Balmer conceptualized and designed the study, supervised and helped with data organization, coding, and analysis, and interpreted the data presented; and all authors critically reviewed and revised the manuscript and approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: Funded, in part, by the American Board of Pediatrics Foundation.

ABP

American Board of Pediatrics

COBRA

Consolidated Omnibus Budget Reconciliation Act

CoPS

Council of Pediatric Subspecialties

DIO

designated institutional official

FPD

fellowship program director

1
Mink
R
,
Caputo
G
,
Fried
E
, et al
.
Delaying the pediatric fellowship start date to improve trainee well-being
.
J Pediatr
.
2015
;
167
(
2
):
222
223
2
Nagata
JM
.
A trainee’s perspective: delay the fellowship start date
.
Acad Med
.
2017
;
92
(
7
):
897
3
US Department of Labor
.
Continuation of health coverage (COBRA)
. Available at: https://www.dol.gov/general/topic/health-plans/cobra. Accessed October 27, 2019
4
Educational Commission for Foreign Medical Graduates
.
Application involving brief gap between pediatrics residency and fellowship.
Available at: https://www.ecfmg.org/evsp/gap-pediatrics-residency-fellowship.pdf. Accessed October 27, 2019
5
US Department of Labor, Wage and Hour Division
. Fact sheet #62W: what is “portability” and to whom does it apply? Available at: https://www.dol.gov/whd/regs/compliance/FactSheet62/whdfs62W.pdf. Accessed October 27, 2019
6
Council of Pediatric Subspecialties
.
Important changes to the H-1B visa program
. Available at: https://www.pedsubs.org/important-changes-to-the-h1-b-visa-program/. Accessed October 27, 2019

Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.