Clinical Investigations

Survey of Current Practices in Fellowship Orientation
Maria R. Lucarelli^a, Catherine R. Lucey^b, John G. Mastronarde<sup>a

a</sup>Division of Pulmonary and Critical Care Medicine and
^bDepartment of Internal Medicine, The Ohio State University Medical Center, Columbus, Ohio, USA

Address of Corresponding Author

Respiration 2007;74:382-386 (DOI: 10.1159/000092546)

 Outline

• Key Words
• Abstract
• Introduction
• Methods
• National Survey of Pulmonary/Critical Care Fellowship Training Programs
• Data Analysis
• Results
• Formal Orientation Programs
• Didactic Sessions
• Wet Labs
• Simulators
• Discussion
• Conclusion
• References

• Author Contacts
• Article Information
• Publication Details
• Drug Dosage / Copyright

  Key Words

• Medical education
• Endoscopy and training
• Medical training

  Abstract

Background: The transition from medical resident to subspecialty fellow is a critical time period in fellowship training that has not been well described. The current practices of fellow orientation in pulmonary and critical care training programs are not known. Objectives: The aim of this study was to describe orientation practices for training programs in the United States. Methods: A 10-question survey was sent via e-mail to program directors of pulmonary/critical care fellowship programs identified on the American Thoracic Society (ATS) webpage of current programs. Results: Eighty-seven programs responded (61.7%), of which 86% had a formal orientation program. The mean time spent in fellow orientation was 5-10 h in didactic sessions and 0-5 h in wet labs. The most frequent didactic sessions were bronchoscopy in 69 programs (80.2%), pulmonary function testing in 63 programs (73.3%) and orientation to hospital services in 63 programs (73.3%). The most frequent use of wet labs was in bronchoscopy training in 60 programs (81.1%) and ventilators in 45 programs (60.8%). Simulators were used in 37 programs (43%). The majority reported that these areas were covered with on the job training, without a formal designated orientation. Conclusion: This survey demonstrated that early fellow training differs across programs in both time spent and clinical and procedural topics covered. An early, standardized approach to clinical and procedural training can assure appropriate exposure that cannot be guaranteed by on the job training. To provide justification for such an approach, clinical outcomes need to be correlated with training methods.

Copyright © 2006 S. Karger AG, Basel

 Introduction

The subspecialty program directors face substantial challenges as they help medical residents with the transition into their new roles as fellows. They must prepare their new fellows to accept new responsibilities, learn new skills and prepare to master a detailed body of subspecialty information. The variable levels of procedural competency and knowledge exhibited by new fellows from different residency programs coupled with the need to continue to provide clinical service set the stage for the classic service versus education conflict. Attention to patient safety means that entry level fellows should meet a certain threshold of competency before they are allowed to perform clinical functions in their new fellowship. While this is true in all fellowships, it may be particularly important in those fellowships that routinely deal with the care of critically ill patients. Logically, the time to assess basic skill competency and to provide structured subspecialty relevant education is at the start of the fellowship program. Unfortunately, this critical time period in fellowship training has not been well described and the mechanisms to best assist with this transition period are not known.

The ideal components of orientation programs in fellowship training or the impact of such programs on trainees are not known. Previous studies have looked at factors associated with fellow satisfaction in procedure training [1;] however, the optimal timing of this training has not been explored. The purpose of this study is to describe the current practices of fellow orientation in pulmonary and critical care training programs in the United States.

 Methods

This project was approved by the Institutional Review Board of The Ohio State University.

 National Survey of Pulmonary/Critical Care Fellowship Training Programs

A descriptive survey was sent via e-mail to Pulmonary/Critical Care Fellowship Directors identified in the American Thoracic Society (ATS) webpage of current pulmonary and critical care programs. One hundred and forty-one program directors had deliverable e-mail addresses. An initial e-mail was sent with a follow-up e-mail sent 2 weeks later to nonrespondents of the first.

The survey consisted of 10 questions focusing on the duration, process and content of the fellow orientation program. Directors were asked to select topic areas and wet labs (opportunities for hands on practice) from a list constructed from The Ohio State University (OSU) pulmonary/critical care orientation curriculum (table 1). An option to write in additional topics was also provided. Questions regarding the availability of simulators and their use in fellow orientation were presented in the same fashion. The questions were reviewed for clarity by three faculty members of The Ohio State University before the survey was sent to the program directors.

Table 1. Response of program directors for topic areas covered during fellow orientation

 Data Analysis

Simple descriptive statistics were calculated for each survey question. Multivariant analysis of variance was used to explore relationships between time spent in orientation procedures and content areas addressed. Data was analyzed using STATA Statistical Software (Stata Corp.; College Station, Tex., USA).

 Results

Of the 141 deliverable e-mail addresses, 87 responded (61.7%). Five programs listed had undeliverable e-mail addresses. One program listed had recently closed and was excluded from data analysis.

 Formal Orientation Programs

Of the programs who responded the mean number of fellows per year per program was 3.3 (range 1-9). Eighty-six percent of the programs (74 respondents) had some form of fellow orientation. The mean time spent in fellow orientation was 5-10 h in didactic sessions and 0-5 h in wet labs. Only twenty-four programs (28%) spent more than 15 h in didactic sessions. No program spent >15 h in wet labs (tables 1, 2).

Table 2. Response of program directors for wet labs offered during fellow orientation

 Didactic Sessions

The topics covered are listed in table 1 with the number of programs addressing these topics indicated. The most frequent topics for didactic sessions were bronchoscopy in 69 programs (80.2%), pulmonary function testing in 63 programs (73.3%) and orientation to hospital services in 63 programs (73.3%). The least commonly covered topics were moderate/deep sedation in 38 programs (44.2%) and intubation in 39 programs (45.3%). Additional topics that were provided by program directors in 31 programs included: preoperative assessment, acid-base disorders, pulmonary physiology, coding and documentation, and ethics. A common response was that the topics listed in the survey were covered throughout the first year but not in designated fellow orientation.

 Wet Labs

The wet-lab topics are listed in table 2. The most frequent use of wet labs was in bronchoscopy training in 60 programs (81.1%) and ventilators in 45 programs (60.8%). The least common topics included exercise testing in 17 programs (23%) and central venous catheter/Swan-Ganz catheter placement in 19 programs (25.7%). The majority of program directors reported that these areas were covered during the year with on the job training, without a formal designated orientation and with no formal measure of competency. Wet labs were also used to teach chest tube placement, advanced airway management, closed pleural biopsy, transbronchial needle aspiration, noninvasive ventilation, pericardial drainage procedures and Blakemore tube placement.

 Simulators

Simulators are listed in table 3. Of the respondents, 37 programs (43%) used simulators in fellow orientation. The most frequently used simulator was a bronchoscopy simulator, used in 31 programs (36%). The least commonly used simulator was a central line simulator in only 17 programs (19.8%). Simulators were also used for chest tube placement and lumbar puncture.

Table 3. Simulators in fellow orientation

 Discussion

Transitions happen frequently in medical education and each transition is met with unique learner needs and challenges for educators. Previous studies have examined some of these transitions: medical student to resident [2,3,4,5] and intern to second year resident [6]. The jump from resident to subspecialty fellow has been less well explored. As was seen with many of our survey respondents, traditional orientation programs often focus exclusively on an introduction to the institution and faculty, although some programs have begun to use this transition period to train and assess procedural competency [3, 5].

Our study demonstrates that orientation programs are common but that the content of these programs is highly variable. The duration of the programs is short: 44% of programs devote less than 2 days to orientation. More than half of the surveyed programs have no didactic instruction on line placement and one third had no formal instruction on intubation or airway management. Surprisingly, one fifth of programs have no formal training sessions on bronchoscopy. Even fewer focus on basic ICU-oriented procedures. This is compatible with the data published by Haponik et al. [1]. In that survey of fellows attending the American College of Chest Physicians Fellows' Course, 25% of fellows had no formal didactic component to bronchoscopy training. More recently, surveys of program directors and fellows have suggested that current approaches in training interventional bronchoscopy techniques may not meet the needs of trainings to establish operator competency [7, 8]. Though trainees continue to be mentored and receive procedural training throughout the course of a training program, basic cognitive disciplines and procedural skills are required for patient interactions.

Educational approaches for trainees may have particular importance given the increasing interest in medical error prevention and patient safety. Prior studies have demonstrated that procedures performed in an academic setting by trainees are safe only if the trainee has received appropriate training and is supervised accordingly [9]. Since procedural competency is a component of the American Board of Internal Medicine certification for core internal medicine residents, fellowship program directors may feel that instruction on technique and competency assessment is unnecessary. However, recent studies have suggested that many internal medicine residents may be inadequately trained in common medical procedures [10,11,12]. As such, all first year fellows may not be proficient in essential ICU procedures such as central lines and intubations. Therefore ensuring adequate training and establishing competency before patient encounters in fellowship is prudent.

Several educational approaches certainly exist, however the initial orientation period would seem to be an ideal time frame for addressing the cognitive domains of procedure training, establishing good technique among trainees, and for some procedures, documenting procedural competency. In addition, some of the core competencies to assess educational outcomes now emphasized by the Accreditation Council for Graduate Medical Education (ACGME) could be addressed with a structured educational approach in the transition period. Whether an early, intensive training approach has any benefit over more traditional approaches such as rigorous faculty mentoring is unknown.

One additional benefit to a more intensive orientation program is the potential to alleviate anxiety and encourage feelings of preparedness for trainees in their new roles. Feelings of anxiety about a trainee's new role in graduate medical education have been documented in specialty training programs [3], however whether these attitudes are persistent at a subspecialty trainee level remains unknown. Our institution has implemented a more intensive orientation curriculum which includes didactic lectures and procedural skill training. Though this curriculum has not been validated for effectiveness, fellow self-assessed readiness for procedures and clinical requirements was improved by the intensive curriculum (data not shown).

One limitation to our findings is the number of nonrespondents to the survey. Almost 30% of programs are not represented in these results. Though nonrespondents were not examined, we believe this descriptive study shows the lack of consensus among training programs in the goals and curriculum of early fellow training. Whether an early intensive orientation program helps train fellows to be more effective in their new roles or if this type of curriculum interferes with the goal of training and delays the process of learner development of independence needs further investigation.

The development of such orientation programs is accompanied with the need for increased resources. Curriculum development can be time consuming and requires additional faculty time both for didactic development as well as presentation. Additionally, service responsibilities traditionally assumed by new trainees need to be shifted or shared during training sessions. Also, ideally the curriculum would include simulation-based training for procedure skills, which may not be available at all institutions.

This data demonstrates that many programs approach early fellow education with a traditional type of knowledge gained through patient interactions, faculty mentorship and lectures over the course of the training program. Few currently use orientation to hypereducate trainees prior to patient care responsibilities. Though we believe an intense educational program in this transition period can be beneficial, further studies are needed to validate this approach. Ideally, such an educational intervention would result not only in knowledge gain and improved procedural skills, but would also result in improved patient outcomes and decreased procedure-related complications.

 Conclusion

This survey demonstrated that early fellow training differs across programs in both time spent and clinical and procedural topics covered in fellow orientation. An early structured approach to clinical and procedural training has the potential to insure that new fellows receive standardized instruction on and can demonstrate basic competency in specific clinical and procedural skill areas. Formal instruction can also help early fellows to master the concepts of pathophysiology that are essential to success in this career. Simulators can allow learning to occur without risk to patients and can provide trainees with the opportunity to practice until they have adequate familiarity with a given skill. Establishing competency in these areas earlier in the fellowship training program has the potential to decrease medical errors and procedure-related complications and to increase the effectiveness of the early fellows in their consulting role. We hope these data provide useful information for individual programs to use as a basis for review of their current orientation processes.

  References

1.

Haponik EF, Russell GB, Beamis JF Jr, et al: Bronchoscopy training: current fellows' experiences and some concerns for the future. Chest 2000;118:625-630. 

2.

Duff P: An orientation program for new residents in obstetrics and gynecology. Obstet Gynecol 1994;83:473-475. 

3.

Grover M, Puczynski S: Residency orientation: what we present and its effect on our residents. Fam Med 1999;31:697-702. 

4.

Grover M, Puczynski S: Right from the start: the family practice orientation study. Fam Med 1999;31:177-181. 

5.

Nielsen PE, Holland RH, Foglia LM: Evaluation of a clinical skills orientation program for residents. Am J Obstet Gynecol 2003;189:858-860. 

6.

Merenstein JH, Preisach P: Orienting interns to being second-year residents. Fam Med 2002;34:101-103. 

7.

Pastis NJ, Nietert PJ, Silvestri GA: Variation in training for interventional pulmonary procedures among US pulmonary/critical care fellowships: a survey of fellowship directors. Chest 2005;127:1614-1621. 

8.

Pastis NJMN, Paul J, Silvestri GA: Fellows' perspective of their training in interventional pulmonary procedures. J Bronchol 2005;12:88-95. 

9.

Pue CA, Pacht ER: Complications of fiberoptic bronchoscopy at a university hospital. Chest 1995;107:430-432. 

10.

Hicks CM, Gonzalez R, Morton MT, et al: Procedural experience and comfort level in internal medicine trainees. J Gen Intern Med 2000;15:716-722. 

11.

Wickstrom GC, Kolar MM, Keyserling TC, et al: Confidence of graduating internal medicine residents to perform ambulatory procedures. J Gen Intern Med 2000;15:361-365. 

12.

Wigton RS, Blank LL, Nicolas JA, et al: Procedural skills training in internal medicine residencies. A survey of program directors. Ann Intern Med 1989;111:932-938. 

  Author Contacts

Maria R. Lucarelli, MD, Division of Pulmonary and Critical Care Medicine
The Ohio State University Medical Center
201 Dorothy M. Davis Heart & Lung Research Institute, 473 West Twelfth Avenue
Columbus, OH 43210-1252 (USA)
Tel. +1 614 293 4925, Fax +1 614 293 4799, E-Mail Maria.Lucarelli@osumc.edu

  Article Information

Received: September 19, 2005
Accepted after revision: December 20, 2005
Published online: March 31, 2006
Number of Print Pages : 5
Number of Figures : 0, Number of Tables : 3, Number of References : 12

  Publication Details

Respiration (International Journal of Thoracic Medicine)

Vol. 74, No. 4, Year 2007 (Cover Date: July 2007)

Journal Editor: Bolliger, C.T. (Cape Town)
ISSN: 0025-7931 (print), 1423-0356 (Online)

For additional information: http://www.karger.com/RES

  Drug Dosage / Copyright

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