Pearls of Fellowship Orientation: A Perspective From Two Programs

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July…the start of a new cycle.

Thinking about it can bring up feelings of angst and trepidation for both PDs and incoming fellows, especially this year with fellows whose only experience with the program may have been on their virtual interview day. How can we best orient this new group of fellows?  There are many aspects to consider – hospital orientation, core educational topics, clinical rotations and role as a fellow, and community introduction to both the program and the city.  The standard hospital orientation and EMR training requirements can’t be changed. But what can be? How can we best alleviate the anxiety of incoming fellows, increase their preparedness, and acclimate them to their new environment?  Herein, we present some pearls of fellowship orientation from our own programs.

 

Education: “What do I need to study?”

Incoming fellows have varied clinical and procedural experiences. Thus, having a set of core topics and procedural training in the beginning can help to level the playing field. This can be done via an immersive dedicated “boot camp” period or longitudinally over the first few months to overlap with clinical rotations. Education delivery can also take many forms – independent, asynchronous, or simulation (low- and high-fidelity). Asynchronous learning facilitates education that is not restricted to a particular time or place.  For example, fellows could be assigned online modules to complete at their own pace.

Establish core topics: Many of these topics will be covered during the fellows’ first year but would be advantageous to have earlier on. Having core topics sets the foundation for progressive learning over the years and helps fellows feel more prepared for clinical rotations.  Core topics can include:

  • PFT interpretation
  • Ventilator management
  • Introduction to thoracic radiology
  • Common pulmonary/critical care diseases

Establish procedural training: In-person hands-on training, if able to be accommodated, is also an opportunity for fellows to get to know each other outside of a virtual meeting.

  • Bronchoscopy
  • Central lines and arterial lines
  • Intubation and advanced airway management
  • Ultrasound training
  • Thoracentesis and chest tube placement

Leverage technology: With the ubiquitous use of virtual platforms, didactics on the core topics could be recorded and made available for future fellows. Thus, faculty don’t have to repeat the same lecture and education time could be more focused on application to patient cases. A multitude of online resources are available and collating a brief list can help direct fellows where to look for independent learning. Examples include:

  • ATS Reading List
  • Best of ATS Video Lecture Series.
  • Bronchoscopy.org
  • Ohio State University Pulmonary School
  • Chest Trainee Hub Fellows-in-Training Medical Knowledge Resources
  • maryland.ccproject.com

Collaborate with local or regional programs to maximize resources: Many programs will similarly be orientating their trainees to the core topics. Collaborating with local or regional programs can decrease the burden on each individual program while promoting a sense of community. The ATS Resident Boot Camp is also an invaluable resource for residents who have matched into PCCM fellowship and, with some advanced planning, could be a way for incoming fellows to get an “early start” to orientation alongside rising fellows from other programs.

 

Clinical Orientation: “What do I do on this service?” and “Where do I find the bathroom?”

A critical piece of fellowship orientation is introducing new fellows to the patient care settings (wards, ICUs, clinics), clinical service logistics, and the roles/responsibilities of fellows. With increased complexity to services across multiple sites, it can oftentimes be more important to orient fellows early about where they can find information and who to ask for help rather than service specifics.

Fellow expectations and clinical responsibilities: We used to spend significant time during orientation reviewing all of our different clinical rotations and expectations. Over time, this became time-intensive, less helpful, and more overwhelming to new fellows. However, clear communication of key expectations and fellow roles is important to setting the stage for success in fellowship (often part of the “norming” aspect of team development). In our orientation, PD/APDs spend only 1-2 hours reviewing critical fellow expectations (guidance for procedural supervision, logs for duty hours, etc), and then we focus on introducing fellows to key leaders and clinical faculty for core clinical rotations who will work alongside them to help longitudinally.

Easily accessible and searchable service guides: We have a searchable fellow handbook housed on a secure cloud platform available to fellows on their phones or any home/medical center computer. This resource is available for in-the-moment questions and is where we include FAQs like “Where do I take pleural fluid specimens for processing?”, “How do I schedule a bronchoscopy?”, “Where do I find the ultrasound?”. This handbook is updated annually by program leadership and current fellows. Key to the success of this strategy is having this be searchable and easily accessible – resources that require multiple log-ins, a VPN, or other barriers may make it less useful in real-time.

On-the-Job training: In July, we have a period of overlap between our incoming fellows and the senior fellow on clinical rotations. This “buddy system” allows on-the-job peer training and is a great way to orient fellows to clinical logistics and provides an extended time for patient hand-offs. This buddy system is a way to build peer relationships and connections for new fellows entering the program – and often where the really important questions such as “Where do I find the bathroom?” get answered.

Timing of clinical orientation: Differences in the timing of clinical rotations can impact how a program completes clinical orientation. Clinical orientation encompasses logistical issues – learning how a service runs, fellow responsibilities – and learning foundational medical knowledge about disease processes commonly seen on that service. At one program (MP), our fellows start clinical rotations after a two-day GME and fellowship orientation. Thus, much of our logistical clinical orientation happens “on-the-job” using strategies above, with a longitudinal curriculum of didactic sessions and workshops spread out over the first six weeks of fellowship to fill-in the foundational knowledge piece. At another program (VH), new fellows have a delayed start to clinical rotations – spending the first few weeks of fellowship in bootcamp or orientation activities learning the foundational medical knowledge of procedures, institution-specific protocols, team building. Then, after completion of this bootcamp, our fellows enter into clinical rotations with “on-the-job” orientation focusing on specifics of patient-management and service obligations.

 

Community Building: Fostering Connections to Your Program

Orienting new fellows to the community and culture of your program may be the most fun aspect of orientation, and many of us have faced challenges to do this in the COVID-19 pandemic. Below we share some aspects to consider for community-building in your program:

Introducing New Fellows to Current Fellows and Faculty

  • Bios. Consider compiling brief bios for incoming and current fellows/faculty. Distribute a list of fun questions and ask fellows/faculty to write a bio with information that they want to share about themselves/their family (question prompts like “favorite new activity during the pandemic”). We distribute the bios to core program faculty, new, and current fellows as a way for them to connect and get to know each other.
  • Welcome events. We typically host an outdoor event – a welcome dinner or gathering at a park or brewery – for fellows the first week of orientation. This is often a way to help fellows’ partners and families begin to feel connected to the community. It remains important to ensure fellowship events and gatherings abide by the rules/restrictions of our GME and institutional policies.
  • Orientation events. Asking faculty to be involved in orientation events (bootcamp, lectures, workshops) is a good way to connect new fellows to faculty and other leaders in the program.
  • Virtual events. One positive aspect of the ubiquitous nature of Zoom is the ability to host remote welcome events. Consider hosting a remote happy hour for incoming fellows in advance of “official” orientation activities.
  • GME/Institutional events. Encourage fellows to participate in institutional and GME activities – at our program (VH), there is an event to welcome all the medical subspecialty fellows, providing an opportunity for fellows to meet other new trainees outside of their core fellowship.

Team building. Simulation training is beneficial for team building, but there may be other activities to foster team relationships and make connections. Going hiking, doing an “escape room,” taking a whitewater rafting trip, doing a city-wide photo scavenger hunt, trivia night, or fellow/faculty “jeopardy” can all be fun ways to get to know each other and build your team. These activities are often planned by our social or wellness fellow committee.

Introducing new fellows to your city/region: Think about activities that might highlight unique aspects of your medical center or city. Consider including regional cuisines or favorite local restaurants (for us in Nashville it’s hot chicken, for us in Baltimore it’s crab cakes). Host an event at a location of historical interest to your medical center or city. Some programs take advantage of local sports teams or recreation areas to introduce new fellows to city culture/activities.

Be creative! This is especially important in the COVID-19 era where there continue to be restrictions on gatherings/events even for vaccinated individuals. Each of our programs and cities are unique – find things that fit the culture of your faculty, program, and city. Importantly, plan different types of events to showcase diversity. And lastly, share your great ideas with the APCCMPD community!

 

Van K. Holden, MD is an Assistant Professor of Medicine at the University of Maryland School of Medicine. She is an interventional pulmonologist and the Program Director of the PCCM Fellowship program. Dr. Holden specializes in minimally invasive methods of diagnosing and staging lung cancer, central airway obstruction and pleural disease. She also has strong interests in medical education and teaching.

Meredith Pugh, MD, MSCI is an Associate Professor of Medicine at Vanderbilt University Medical Center and Program Director of the PCCM Fellowship. Dr. Pugh’s clinical interests are in critical care and pulmonary vascular disease, and she teaches several courses in the School of Medicine in addition to contributing to fellow and peer teaching.

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