Understanding the Gap: Transition From Fellowship to Faculty

In 2013, pediatric common subspecialty entrustable professional activities (EPAs) were developed in alignment with efforts to transition toward Competency Based Medical Education, a system in which trainees’ advancement is based on skill level and does not passively mirror time spent in training.^1–3  In this competency-based system, pediatric fellowship program directors (FPDs) have been shown to graduate fellows who continue to require supervision in the common subspecialty EPAs.⁴  In this issue of Pediatrics, Weiss et al⁵  redemonstrate that FPDs graduate fellows who require ongoing supervision in the common subspecialty EPAs and newly establish that the degree of supervision required after graduation is more than FPDs would expect an attending physician subspecialist to need for safe and effective outcomes. These findings were consistent across subspecialities and bolstered by the study’s high survey response rate. Initial reactions to these findings may be concern, embarrassment, or frustration with current pediatric subspecialty fellowship training; after all, is not the point of fellowship training to develop competent fellows ready for independent practice?

We must closely consider whether the need for high levels of supervision after subspecialty fellowship is truly problematic or whether this finding may represent an opportunity to encourage growth and development in new fellowship graduates who have been trained to believe that lifelong learning is a key tenet of the medical profession. Recent research suggests that new residents and fellows require increased supervision, with new fellows requiring even more supervision than new residents in some cases, possibly related to the increased stakes of their work.⁶  The transition from fellow to faculty carries even more weight and would be an opportune time for new faculty to receive further support and direction.

To argue that high levels of supervision should be provided in every domain following fellowship graduation, however, would be to minimize the value of fellowship training itself. Fellowship graduates must be equipped to provide safe patient care. Reassuringly, Weiss et al found that clinical EPAs required relatively little postgraduate supervision, whereas nonclinical EPAs, such as those centered on scholarship, quality improvement, and leadership of the profession required the most postgraduate supervision.⁵  We believe these nonclinical EPAs to be particularly amenable to ongoing coaching and mentoring, with the goal of fostering recent graduates’ continued learning.

The logistics of implementing postfellowship supervision may be complex. Graduating fellows, their FPDs, and the division chiefs who hire them each share responsibility in ensuring that appropriate personnel, time, and resources have been dedicated toward recent fellowship graduates’ supervision. Fellows should work with their FPDs to ensure that they have clarity on their specific strengths and weaknesses globally and as they relate to each EPA specifically. For those EPAs that continue to require supervision, fellows should become accustomed to inquiring what specific data were used to inform the EPA designation and what areas for growth were uncovered. Most importantly, they should work with their FPDs to identify the tools needed to make continued progress. The principles learned may help not only with the EPA in question but also by equipping the fellow with strategies to address their future gaps in skills or knowledge.

Division chiefs must have a clear understanding of the areas in which recent fellowship graduates require supervision. Weiss et al propose the consideration of formalized learner handovers.⁵  Learner handovers have been shown to have benefits both for the supervisor and the supervisee,⁷  and we propose that FPDs review EPAs of graduating fellows with their hiring division chiefs. Ideally, this review would be completed before hiring, to ensure that necessary supervision resources can and will be available in time; however, the risk of bias from learner handovers has been described,⁸  and this approach may have undue influence on hiring decisions. FPDs may consider inviting the fellow to the learner handover, whenever it does occur, thereby recasting the need for supervision not as ongoing training but instead as an opportunity for continued development.

With their work, Weiss et al⁵  lay the foundation for partnerships among graduating fellows, their hiring division chiefs, and FPDs to ensure successful transitions for those beginning as new faculty. Ultimately, all parties must not think of EPAs as purely summative but rather formative, both for an individual trainee’s future career as well as for the quality of training provided by a fellowship training program.⁴  To address gaps in EPAs, FPDs must continuously review whether their programs are adequately training fellows in the clinical EPAs. Similarly, are there further mechanisms to increase fellow experience with nonclinical EPAs? Perhaps the learner handovers used to inform division chiefs about the progress of recent fellowship graduates may serve as a needs assessment for FPDs for areas requiring program improvement. The implementation of common subspecialty EPAs is in its early days; the findings by Weiss et al suggest that there is opportunity for growth at all stages.⁵ 

EPA

entrustable professional activity

FPD

fellowship program director