As I wrapped up my first year of fellowship this summer, I have spent a lot of time reflecting on the challenges, successes, and failures that I have encountered thus far as an inaugural fellow. After a year of clinical training, I remain zealous for both my training and program, but I have been humbled at several junctures along the way.

No one discusses it, but most of medical training is modeling. Trainees gain an understanding of their role and function through learned observation. In my own experience preceding fellowship, there was always a blueprint to success at every phase, whether it be generations of passed-on study guides, tips on how to succeed on clinical rotations or senior trainees you can model yourself after. It was not until this year that I realized how heavily I relied on these preestablished foundations for my own guidance and learning. Specifically, clinical training without a senior fellow can be disorienting and discouraging as there’s an absence of both a standard and litmus to gauge growth.

Given these factors, the first few months of training in a new program felt clumsy. I was uncertain of the boundaries and expectations for myself. Likewise, many of the attendings within my division, although having gone through fellowship training themselves, had not experienced training a fellow before. As a result, early exchanges felt like a dance without a lead, which led to awkward shuffling of expectations and, in some instances, toes being stepped on. 

Not only was I uncertain of how to be a fellow but also my team, including doctors, physician assistants, residents, and clinical staff, had to work on creating a space for a fellow to learn and function. Throughout this process, I have learned that there is a great and unique opportunity in pioneering and molding a program. It’s been quite an honor to work so closely with the division. There have been many lessons learned and below are some of the strategies that worked for us.

Identify and Address What’s Not Working

It sounds simple, but identifying a problem is a crucial first step that can take time and thoughtfulness. More importantly, it has helped me delineate between addressable factors and factors that are outside my control or can be resolved only with time. Identifying challenges also requires engagement of all team members, as it’s easy to have tunnel vision and helpful to have others identify blind spots.

A prime example from my experience in my first year of fellowship was workflow development. In the early trials of fellow rounding, I sporadically conducted fellow rounds throughout the day with the objective of accommodating operating times and maintaining care updates on patients on the floor. However, I was unaware of the workflow disruptions it could cause, which was a challenge noted by the inpatient care team. As a solution, there is now a system of standardized rounding in the afternoon to minimize workflow disruption while creating an intentional block of time for communication.

Keep an Open Forum and Request Constant Feedback

This is a standard that my program director and division strongly spearheaded. A few months into the program, I realized how much feedback was being requested and was circulating from various team members, ranging from attendings to residents. There is skill involved in requesting feedback.

It is well known that broad, generalized feedback is unhelpful. In the same light, requests for feedback should be specific and intentional in order to gather useful and manageable information. This approach was applied
by my program director in the multiple check-ins we had throughout the year as she inquired about various aspects of the program.

Whether it be my surgical, inpatient, or outpatient clinic experience, all questions were very directed. How are my relationships with the inpatient team? What surgical procedures are going well? What outpatient clinical experiences do I feel are lacking? How do I feel about patient counseling and goals of care conversations?

This approach allowed me to provide my program director with specific feedback and prompted me to pay attention to areas I wouldn’t have noticed otherwise. This is a strategy that I have applied to my own role as a fellow and educator by asking for targeted feedback from all team members, including during rounding, surgical teaching, and patient care discussions. Encouraging
an open forum and promoting effective feedback has worked for us to think critically about the program and its growth.

It is easy to fall into a trap of operating in a silo, and it is important to remember to not reinvent the wheel. I found myself reaching out to several colleagues who are fellows at other institutions or departments to seek advice on operations, education, clinical care, and even personal wellness. What I found in my slew of mini surveys was that there are many ways to get a job done and not all solutions are universally feasible or practical. It’s about finding the best fit for you and your program but with the understanding and acceptance of the dynamic nature given its nascency.

Our program is nowhere near perfect, and I do not claim that we have everything figured out. In fact, there continues to be change and development as we work out the nuances of having multiple fellows. I look forward to applying these lessons and gaining many more as we grow our program, and I feel fortunate to have a supportive division that is passionate about fellowship training, education, and oncology.

Articles

Reflecting on the first year of fellowship, the author highlights the challenges and learning experiences encountered as an inaugural fellow in a new program. The absence of senior fellows led to initial uncertainty and awkwardness, but also presented opportunities to shape the program. Key strategies for success included identifying and addressing workflow issues, maintaining open communication for feedback, and seeking advice from peers. The author emphasizes the importance of collaboration and adaptability in developing a successful fellowship program, acknowledging ongoing growth and the support of a dedicated division.

Nujsaubnusi C. Vue, MD

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