Geriatric medicine fellowship programs: a national study from the Association of Directors of Geriatric Academic Programs' Longitudinal Study of Training and Practice in Geriatric Medicine

This report documents the development and growth of geriatric medicine fellowship training in the United States through 2002. A cross-sectional survey of geriatric medicine fellowship programs was conducted in the fall 2001. All allopathic (119) and osteopathic (7) accredited geriatric medicine fellowship-training programs in the United States were involved. Data were collected using self-administered mailed and Web-based survey instruments. Longitudinal data from the American Medical Association (AMA) and the Association of American Medical Colleges' (AAMC) National Graduate Medical Education (GME) Census, the Accreditation Council for Graduate Medical Education (ACGME), and the American Osteopathic Association (AOA) were also analyzed. The survey instrument was designed to gather data about faculty, fellows, program curricula, and program directors (PDs). In addition, annual AMA/AAMC data from 1991 to the present was compiled to examine trends in the number of fellowship programs and the number of fellows. The overall survey response rate was 76% (96 of 126 PDs). Most (54%) of the PDs had been in their current position 4 or more years (range: <1-20 years), and 59% of PDs reported that they had completed formal geriatric medicine fellowship training. The number of fellowship programs and the number of fellows entering programs has slowly increased over the past decade. During 2001-02, 338 fellows were training in allopathic programs and seven in osteopathic programs (all years of training). Forty-six percent (n = 44) of responding programs offered only 1-year fellowship-training experiences. PDs reported that application rates for fellowship positions were stable during the academic years (AYs) 1999-2002, with the median number of applications per first year position available in AY 2000-01 being 10 (range: 1-77). In 2001-02, data from the AMA/AAMC National GME Census indicated a fill rate for first-year geriatric medicine fellowship positions of 69% (259 first-year fellows for 373 positions). During 2001-02, more than half of programs (53%) reported having two or fewer first-year fellows, whereas 31% had three or four first-year fellows. Thirty-three programs (36%) reported having no U.S. medical school graduate first-year fellows, and another 25 (28%) reported having only one. Of the 51 programs offering second-year fellowship training, PDs reported 61 post-first-year fellows (median 1, range: 0-7). During the past 10 years, 27 new allopathic geriatric medicine fellowship programs opened; there are now 119 programs. There are also seven osteopathic programs. The recruitment of high-quality U.S. medical school graduates into these programs remains a challenge for the discipline. Furthermore, the retention of first-year fellows for additional years of academic training has been difficult. Incentives will be needed to attract the best graduates of U.S. family practice and internal medicine training programs into academic careers in geriatric medicine.     

National Study of Internal Medicine Manpower: X. Internal medicine residency and fellowship training: 1985 update

The number of medical school graduates entering internal medicine residency training was at an all-time high in 1984-85. Although the number of first-year residents who were foreign-trained physicians did not differ greatly from the 1983-84 census, the number of first-year residents who were U.S. medical school graduates was much higher than the previous year largely because the number of graduates from U.S. medical schools increased substantially in 1984. The number of internal medicine fellowship programs and the number of fellows in 1984-85 were also at an all-time high. Foreign-trained physicians represent 22% of those in residency training and 20% of those in fellowship training. Of every 100 who completed residency training, 61 went on to a first year of subspecialty fellowship training, a number up slightly from the previous year. The increasing numbers of residents and fellows being trained in internal medicine, combined with the preference for subspecialization and the substantial proportion of foreign-trained physicians being trained, are discussed against the background of pending legislation to reduce federal assistance for graduate medical education.     

Factors influencing the selection of general internal medicine fellowship programs

Although criteria are available to guide the selection of general internal medicine (GIM) fellowship programs, the factors actually used in this process are unclear. Using a survey of current GIM fellows, we determined that most received information from their residency advisors, and many viewed them as the most important source of fellowship information. Program location was the top selection factor for fellows, followed by research opportunities, availability of a mentor, and the reputation of the program. This information may be useful to both fellowship candidates as an additional selection guide and to program directors seeking to best structure and market their fellowships.     

Are general surgery residents adequately prepared for hepatopancreatobiliary fellowships? A questionnaire‐based study

BackgroundThe present study was conducted to assess the preparedness of hepatopancreatobiliary (HPB) fellows upon entering fellowship, identify challenges encountered by HPB fellows during the initial part of their HPB training, and identify potential solutions to these challenges that can be applied during residency training.MethodsA questionnaire was distributed to all HPB fellows in accredited HPB fellowship programmes in two consecutive academic years (n = 42). Reponses were then analysed.ResultsA total of 19 (45%) fellows responded. Prior to their fellowship, 10 (53%) were in surgical residency and the rest were in other surgical fellowships or surgical practice. Thirteen (68%) were graduates of university‐based residency programmes. All fellows felt comfortable in performing basic laparoscopic procedures independently at the completion of residency and less comfortable in performing advanced laparoscopy. Eight (42%) fellows cited a combination of inadequate case volume and lack of autonomy during residency as the reasons for this lack of comfort. Thirteen (68%) identified inadequate preoperative workup and management as their biggest fear upon entering practice after general surgery training. A total of 17 (89%) fellows felt they were adequately prepared to enter HPB fellowship. Extra rotations in transplant, vascular or minimally invasive surgery were believed to be most helpful in preparing general surgery residents pursing HPB fellowships.ConclusionsOverall, HPB fellows felt themselves to be adequately prepared for fellowship. Advanced laparoscopic procedures and the perioperative management of complex patients are two of the challenges facing HPB fellows. General surgery residents who plan to pursue an HPB fellowship may benefit from spending extra rotations on certain subspecialties. Focus on perioperative workup and management should be an integral part of residency and fellowship training.     

Do general internal medicine fellows find jobs that match their training?

We surveyed employers of general internists at teaching hospitals to determine whether they prefer that new hires are graduates of general internal medicine (GIM) fellowships. We surveyed former GIM fellows who graduated between 1988 and 1994 to determine whether they found jobs with protected research time and whether the positions they found matched their expectations. Employers rated a GIM fellowship, among other criteria, as important for clinician-researchers, but not for clinician-educators. For graduates categorized as clinician-researchers (with more than 33% of their time protected for research), there was a good match between their actual time allocations for research and clinical work and what they recalled their expectations were when looking for a job. Clinician-educators had a marked discordance between actual time allocations for research and clinical work and their recollection of their expectations when looking for a job.     

National survey of geriatric medicine fellowship programs: comparing findings in 2006/07 and 2001/02 from the American Geriatrics Society and Association of Directors of Geriatric Academic Programs Geriatrics Workforce Policy Studies Center

This article documents the development of geriatric medicine fellowship training in the United States through 2009. Results from a national cross-sectional survey of all geriatric medicine fellowship training programs conducted in 2007 is compared with results from a similar survey in 2002. Secondary data sources were used to supplement the survey results. The 2007 survey response rate was 71%. Sixty-seven percent of responding programs directors have completed formal geriatric medicine fellowship training and are board certified in geriatrics, and 29% are board certified through the practice pathway. The number of Accreditation Council for Graduate Medical Education-accredited fellowship programs has slowly increased, from 120 (23 family medicine (FM) and 97 internal medicine (IM)) in 2001/02 to 145 in 2008/09 (40 FM and 105 IM), resulting in a 21% increase in fellowship programs and a 13% increase in the number of first-year fellows (259 to 293). In 2008/09, the growth in programs and first-year slots, combined with the weak demand for geriatrics training, resulted in more than one-third of first-year fellow positions being unfilled. The number of advanced fellows decreased slightly from 72 in 2001/00 to 65 in 2006/07. In 2006/07, 55% of the advanced fellows were enrolled at four training programs. In 2008/09, 66% of fellows were international medical school graduates. The small numbers of graduating geriatric medicine fellows are insufficient to care for the expanding population of older frail patients, train other disciples in the care of complex older adults, conduct research in aging, and be leaders in the field.     

Attitudes and perceptions of internal medicine residents regarding pulmonary and critical care subspecialty training

STUDY OBJECTIVE: To evaluate the attitudes and perceptions of internal medicine residents regarding pulmonary and critical care medicine (PCCM) training. DESIGN: Prospective study. SETTING: Three university hospitals. METHODS: An eight-page survey was distributed and collected between March 1, 2002, and June 30, 2002. All internal medicine or internal medicine/pediatric residents training at the three institutions were eligible for the study. RESULTS: One hundred seventy-eight residents in internal medicine from an eligible pool of 297 residents returned the survey (61% response rate). PCCM accounted for only 3.4% of the career choices. Forty-one percent of the residents seriously considered a pulmonary and/or critical care fellowship during their residency. Of these residents, 23.5% found the combination of programs the more attractive option, while 2.8% found pulmonary alone and 14.5% found critical care alone more attractive. Key factors associated with a higher resident interest in PCCM subspecialty training included more weeks in the ICU (p = 0.008), more role models in PCCM (3.02 +/- 0.78 vs 3.45 +/- 0.78, p = 0.0004), and resident observations of a greater sense of satisfaction among PCCM faculty (3.07 +/- 0.82 vs 3.33 +/- 0.82, p = 0.04) and fellows (3.05 +/- 0.69 vs 3.31 +/- 0.86, p = 0.03) [mean +/- SD]. The five most commonly cited attributes of PCCM fellowship that would attract residents to the field included intellectual stimulation (69%), opportunities to manage critically ill patients (51%), application of complex physiologic principles (45%), number of procedures performed (31%), and academically challenging rounds (29%). The five most commonly cited attributes of PCCM that would dissuade residents from the field included overly demanding responsibilities with lack of leisure time (54%), stress among faculty and fellows (45%), management responsibilities for chronically ill patients (30%), poor match of career with resident personality (24%), and treatment of pulmonary diseases (16%). CONCLUSIONS: Internal medicine residents have serious reservations about PCCM as a career choice. Our survey demonstrated that a minority of US medical graduates actually would choose PCCM as a career, which suggests that efforts to expand PCCM training capacity might result in vacant fellowship slots. To promote greater interest in PCCM training, efforts are needed to improve the attractiveness of PCCM and address the negative lifestyle perceptions of residents.     

Teaching Geriatric Fellows How to Teach: A Needs Assessment Targeting Geriatrics Fellowship Program Directors

The entire healthcare workforce needs to be educated to better care for older adults. The purpose of this study was to determine whether fellows are being trained to teach, to assess the attitudes of fellowship directors toward training fellows to be teachers, and to understand how to facilitate this type of training for fellows. A nine‐question survey adapted from a 2001 survey issued to residency program directors inquiring about residents‐as‐teachers curricula was developed and administered. The survey was issued electronically and sent out three times over a 6‐week period. Of 144 ACGME‐accredited geriatric fellowship directors from geriatric, internal medicine, and family medicine departments who were e‐mailed the survey, 101 (70%) responded; 75% had an academic affiliation, 15% had a community affiliation, and 10% did not report. Academic and community programs required their fellows to teach, but just 55% of academic and 29% of community programs offered teaching skills instruction as part of their fellowship curriculum; 67% of academic programs and 79% of community programs felt that their fellows would benefit from more teaching skill instruction. Program directors listed fellow (39%) and faculty (46%) time constraints as obstacles to creation and implementation of a teaching curriculum. The majority of fellowship directors believe that it is important for geriatric fellows to become competent educators, but only approximately half of programs currently provide formal instruction in teaching skills. A reproducible, accessible curriculum on teaching to teach that includes a rigorous evaluation component should be created for geriatrics fellowship programs.     

National Study of Internal Medicine Manpower. XIV: Patterns of residency and fellowship over time, 1987 update

In response to concerns among internists following the 1987 internal medicine match, this report compares internal medicine trainees with those in other specialties since 1972, describes their paths through the internal medicine "pipeline," and documents their distribution and continuation rates in residency and subspecialty fellowship programs. It is based on the National Study of Internal Medicine Manpower, 1987-1988. Between 1972 and 1986 the number of trainees in internal medicine doubled, and the percentage of trainees in internal medicine grew from 20% to 25%, while the percentage in surgical specialties declined from 28% to 19%. The numbers of women and foreign medical school graduates training in internal medicine have continued to increase, but minority representation has stabilized. Women and minorities have lower continuation rates into fellowships, and distinctive patterns of subspecialization are found among women, minorities, and foreign medical school graduates.     

Indicators of early research productivity among primary care fellows

OBJECTIVE: Little is known about the impact of fellowship training in primary care on subsequent research productivity. Our goal was to identify characteristics of research fellows and their training associated with subsequent publications and research funding. DESIGN: Mail survey in 1998. SETTING AND PARTICIPANTS: 1988-1997 graduates of 25 National Research Service Award primary care research fellowships in the United States. OUTCOME MEASURES: 1) Publishing 1 or more papers per year since the beginning of fellowship, or 2) serving as principal investigator (PI) on a federal or non-federal grant. RESULTS: One hundred forty-six of two hundred fifteen program graduates (68%) completed the survey. The median age was 38 years, and 51% were male. Thirty-two percent had published 1 or more papers per year, and 44% were PIs. Male gender (odds ratio [OR], 3.6; 95% confidence interval [95% CI], 1.4 to 9.2), self-reported allocation of 40% or more of fellowship time to research (OR, 4.4; 95% CI, 1.8 to 11.2), and having an influential mentor during fellowship (OR, 5.0; 95% CI, 1.5 to 17.2) were independently associated with publishing 1 or more papers per year. Fellows with funding as a PI were also more likely to have an influential mentor (OR, 3.0; 95% CI, 1.3 to 7.2). CONCLUSION: Primary care fellows who had influential mentors were more productive in research early after fellowship. Awareness of the indicators of early research success can inform the policies of agencies that fund research training and the curricula of training programs themselves.     

Surviving and Thriving as Physicians in General Internal Medicine Fellowship in the Twenty-First Century

General internal medicine (GIM) fellowships play an important role in the development of physician scientists and clinical educators, as well as leaders in academic medicine. Nevertheless, the challenges of developing another novel aspect to one’s career, along with balancing coursework, research productivity, clinical duties, and personal life during fellowship, can be overwhelming. Similarly, successfully securing a job at the end of fellowship can be a daunting process. In this article, we discuss the foundational tenets and themes of the GIM fellowship. These themes include (1) finding your purpose and passion, with a focus on selecting research coursework and developing an area of study; (2) the role and importance of mentorship, including the various kinds of mentorship that fellows require (traditional and peer mentorship, sponsors, and coaches), as well as how to be an effective mentee; (3) securing research funding; (4) landing a job; (5) and protecting time to meet personal goals. There is an increased need for a vibrant, diverse, and successful generation of general internal medicine researchers to advance our understanding of complex issues in clinical medicine and healthcare delivery and to inform health policy. It is our hope that this piece helps to support that mission.KEY WORDS: general internal medicine, research, fellowship, mentoring     

Assessing the Accessibility of Content for Geriatric Fellowship Programs

The information available on program websites concerning geriatric fellowships in internal medicine and family medicine is a crucial factor in generating applicants' interest in individual programs. Our study aimed to quantify the accessibility and quality of information available on accredited geriatric (family medicine and internal medicine) fellowship program websites and further analyze the implications of the results obtained. A list of geriatric (family medicine and internal medicine) fellowship programs was analyzed through quantified measures after being verified for accreditation. Certain criteria were evaluated for each of these programs, such as website accessibility and whether critical information was available on online program websites. These criteria were centered on academic, administrative, and application-based factors. Hundred and fifty eight Family Medicine and Internal Medicine geriatric fellowship programs were identified in total, of which only 150 were accredited by the Accreditation Council for Graduate Medical Education and considered for analysis. Of these, 20 (13.33%) programs had website links that were nonfunctional and only 145 programs had websites at all. On programs' websites, information regarding aspects such as contact information—including phone number or email for the program—were lacking. Other information regarding past and current fellows, research, and curriculum were also generally lacking. Geriatric Fellowship websites in Family Medicine and Internal Medicine can gain better traction from those interested in applying for their programs by updating information more often and providing more and better information concerning critical aspects of the programs themselves online.     

Creating a geriatric medicine fellowship program in 10 "easy" steps

The aging of the U.S. population poses one of the greatest future challenges for family medicine and internal medicine residency training. One important barrier to providing quality education and training in geriatric medicine to residents is a serious and growing shortage of practicing geriatricians and geriatrics faculty. The Accreditation Council for Graduate Medical Education currently accredits 45 family medicine-based and 107 internal medicine-based geriatric medicine fellowships in the United States. There are 13 American Osteopathic Association-certified geriatric medicine fellowship programs. In this article, the authors examine the rationale for the development of additional geriatric medicine fellowship programs and offer some practical suggestions and pointers for those interested in developing their own geriatric medicine fellowships. The authors write from the perspective of their own recent experiences with the development and accreditation of a family medicine residency-affiliated fellowship in geriatrics. Other residencies may find this article useful in determining the feasibility of developing a geriatric medicine fellowship for their programs and communities and will find practical guidance for beginning the process.     

Recovering Physicians in Addiction Psychiatry Fellowships

In this report, the authors describe the characteristics and experiences of recovering fellows in a university addiction subspecialty fellowship. Four stages of adjustment were identified: 1) initial adjustment, 2) role conflict, 3) role integration, and 4) graduation. From a faculty viewpoint, it is particularly important to separate clinical from educational responsibilities in dealing with recovering fellows. Despite some continuing conflict about treatment models, most fellows achieved their training goals and were able to successfully adapt to post-training practice. However, some fellows were unable to integrate personal recovery and professional roles.     

Geriatrics training in general internal medicine fellowship programs: current practice, barriers, and strategies for improvement

To ensure its growth and prosperity, general internal medicine will need to embrace care of the elderly, research on aging, and geriatrics education as components of its core mission. Experts agree that general internal medicine fellows could benefit from increased opportunities in research on aging and geriatrics education; however, important barriers will hamper efforts to integrate geriatrics training into general internal medicine fellowship programs. This article reviews the barriers to integration and proposes solutions for overcoming those barriers. As a result of interviews and meetings with a broad representation of general internists, geriatricians, funding agencies, and policymakers, we propose 2 interventions: 1) the development of institutional program grants to foster collaboration between general internal medicine and geriatrics faculty in the training of general internal medicine fellows and 2) the creation of a 3-year fellowship program combining general internal medicine and geriatrics. This article discusses the importance of evaluating these and other programs intended to increase the geriatrics experience of general internal medicine fellows, and it describes the potential implications of these changes for a broad array of stakeholder institutions.     

Training the Next Generation’s Nephrology Workforce

The subspecialty of nephrology faces several critical challenges, including declining interest among medical students and internal medicine residents and worrisome declines in the number of applicants for nephrology fellowships. There is an urgent need to more clearly define the subspecialty and its scope of practice, reinvigorate meaningful research training and activities among trainees, and ensure that fellows who complete training and enter the practice of nephrology are experts in the broad scope of nephrology. This need requires a critical look at fellowship training programs and training requirements. A new workforce analysis is also needed that is not focused on primarily meeting estimated future clinical needs but rather, ensuring that there is alignment of supply and demand for nephrology trainees, which will ensure that those entering nephrology fellowships are highly qualified and capable of becoming outstanding nephrologists and that there are desirable employment opportunities for them when they complete their training.     

CLINICAL RHEUMATOLOGY TRAINING IN AN UNCERTAIN FUTURE. Opinions of Recent and Current Rheumatology Fellows About an Extended Fellowship in Musculoskeletal Medicine

Objective. To estimate among recent and current rheumatology fellows the appeal of a 3-year rheumatology fellowship emphasizing musculoskeletal medicine. Methods. A survey of 348 trainee members of the American College of Rheumatology during 1990–1993, by mailed questionnaire. Results. The response rate was 77.8% (n = 271). Both recent and current fellows indicated that they desired more experience in musculoskeletal medicine. Most notably, 50% of current fellows, and a significantly higher proportion of recent fellows (70%; P < 0.005), indicated that they would have opted for a 3-year fellowship in musculoskeletal medicine had one been available to them at the completion of their residency. Conclusion. Expertise in musculoskeletal medicine is desired by a sufficient proportion of recent and current rheumatology fellows to warrant the investment in another year of training.     

The Impact of Health Care Reform on Gastroenterology Fellows: Are Training Programs Preparing Them for the Future?

Objective : Health care reform is dramatically changing the practice and delivery of medical care. The goal of this investigation was to examine gastroenterology trainees' outlook on the impact of health care reform on training programs. Methods : A 24-question survey was mailed in February 1996 to 780 GI fellows obtained from the comprehensive American College of Gastroenterology (ACG) database. Results : A total of 362 fellows responded (46%): 85% were male, 57% Caucasian, 75% married, and 86% were university-based. Ninety-six percent of fellows believed that health care reform is adversely affecting the quality of health care and 94.1% felt that it was adversely affecting fellowship training. Eighty-eight percent expressed concern over the impact of health care reform on practice opportunities. Only 9% of fellows reported that their training program had established a specific educational program addressing health care reform. where 83% of fellows felt that their program should do so. Conclusion : Gastroenterology fellows are concerned about the impact of health care reform on the quality of care and the quality of their fellowship training. Trainees believe that programs are not providing sufficient education to help them respond to the changes in health care.     

Can U.S. GI fellowship programs meet American Society for Gastrointestinal Endoscopy recommendations for training in EUS? A survey of U.S. GI fellowship program directors

BACKGROUND: American Society for Gastrointestinal Endoscopy (ASGE) EUS training and credentialing guidelines exist, but the capability of U.S. GI fellowships to meet these guidelines has not been assessed. OBJECTIVE: To ascertain the capability of U.S. GI fellowship programs to meet ASGE guidelines for EUS training in the context of 3-year and advanced GI fellowships. METHODS: U.S. GI fellowship programs were surveyed for the presence or the absence, type, and extent of EUS training. Demographics regarding the programs and the program directors were obtained. MAIN OUTCOME MEASUREMENTS: Data on the annual total EUS volume and data on EUS performed by 3-year and/or advanced-year fellows were collected and analyzed. RESULTS: Ninety-one of 142 contactable GI programs responded (64%); 72% of programs performed >200 EUS/y and thus could train >or=1 EUS trainee/y. For 3-year GI fellows, 55% received less than 3 months of training, with 43% not receiving actual "hands-on" EUS experience, and 61% not learning EUS-guided FNA. The median EUS performed by 3-year fellows was 50 (0-350). Programs that offer advanced endoscopy fellowship had a median advanced-trainee EUS volume of 200 procedures (range, 50-1100 procedures). Of advanced fellows, 20% failed to receive "hands-on" training and 52% performed <200 procedures. We observed a significant difference in the median EUS volume performed by 3-year versus advanced-year fellows (P<.001). Program director variables did not correlate with training EUS volumes. CONCLUSIONS: The majority of U.S. GI fellowship programs have established the EUS volume to train at least 1 EUS fellow, per ASGE guidelines; however, most 3-year and many advanced fellows are currently receiving insufficient EUS training.