By James Foran, MD

2008-12-06

Fellowship has come a long way since I trained in the early 1990s when the curriculum consisted of “Just read Williams’ textbook!” Back then, the 80-hour work week was still a distant concept, and changing “on call” to every third night was considered a new humane innovation. That seems like a long time ago now, and any hematologist involved in residency or fellowship training will agree that there has been a quiet revolution in hematology training programs in the past five years. The Accreditation Council for Graduate Medical Education (ACGME) has dramatically changed the landscape for fellowship programs as it has pursued its mission of improving the quality of health care through advancing the quality of residency and fellowship training. In just a short time, these changes are now firmly entrenched, and indeed a new vocabulary has emerged — the world of core competencies and competency-based curricula. There is no doubt that there is a new training culture.

Don’t get me wrong; I am not nostalgic for old-fashioned fellowship — to quote Shakespeare, “I come to bury Caesar, not to praise him.” Still, the advances in fellowship training have brought with them new problems and the need for new solutions. The Training Program Directors Workshop held on Thursday, December 4, was developed to help program directors face the new challenges of training fellows.

What does it take to run a fellowship program? Being the program director (PD) has become a profession in itself — part educator, part administrator, part cheerleader, part innovator — and requires achieving a careful balance for the fellows in the battles of education versus service, research versus clinical care, and supervision versus autonomy. Sometimes the fellows are the easy part; it is training your colleagues in the core competencies that can be even more difficult!

Well, the future has arrived, and the transition to a competency-based curriculum is at an advanced stage. I can tell you firsthand the work that comes in preparing for a site visit by the Residency Review Committee (RRC), and this remains a concern for all PDs in the new fellowship era. According to Joe Basso, ASH Training Manager, it is important for ASH to be aware of “what is going on in the mind of the RRC.” To help with this, the Workshop included a presentation by Dr. Jeanette Mladenovic, RRC representative, with an update on new hematology/oncology program requirements and on common citations and survival skills for an RRC site visit.

Still, the emphasis is now on innovation in training and the development of improved PD skills, and the Workshop was an opportunity for PDs to learn about “alternative training pathways” and to discuss new models of competency assessment and outcomes. The Workshop was chaired by Dr. Scott Gitlin, program director at the University of Michigan and chair of the ASH Committee on Training Programs. According to Dr. Gitlin, there is also a growing perception among PDs that teaching professionalism and supporting fellows’ personal needs can be challenging. The formal introduction of the core competencies into the curriculum has highlighted awareness of professionalism, something we had not previously tried to teach or measure. There is a new recognition of the importance of both recognizing and supporting fellows who struggle with this competency, and the workshop, therefore, included a breakout session on “Remediation of the Disruptive or Struggling Fellow” to help PDs address this issue.

ASH continues to take an active role in supporting fellowship training programs on other fronts, including the popular and competitive Clinical Research Training Institute and the development of a new Hematology In-Service Exam in April 2009 to help evaluate fellows. Mr. Basso deserves special recognition for his hands-on relationship with individual fellows and training programs. After Hurricane Katrina, he personally helped displaced fellows find new programs to continue their training. In addition to the Program Directors Workshop, ASH developed a dedicated fellows program at this meeting, which included Trainee Day and a reception for fellows on Friday, December 5. Welcome to Fellowship training in the 21st century!

Dr. Foran indicated no relevant conflicts of interest.

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