Discussion
This study is the first to demonstrate the degree of stress and anxiety
experienced by PHO fellows in search of their post-fellowship position.
The overwhelming majority of the PHO program leadership and fellows
perceive the difficulty in this transition from fellowship and
accompanying this challenge are substantive mental health consequences.
While the proportion of stress levels were different in fellows compared
to faculty, it is clear that both groups recognize the difficulty of the
job search. This emphasizes the crucial need for change on all fronts;
if left unaddressed, we may face worse challenges in recruiting and
retaining early career physicians in our field. Fellows who had been
offered positions that were only “slightly” or “not close to the
ideal” career goal reported high levels of stress. The amount of
anxiety felt by fellows when thinking about the job search process is
undoubtedly concerning and speaks to how this stress about
post-fellowship job search permeates day-to-day trainee life. It is
imperative that we continue to develop ways to incorporate fellow
wellness and support mental wellbeing to prevent these stressors from
contributing to future provider burnout. Investing in such interventions
for fellows may benefit these physicians throughout their careers when
additional job searches ensue.
Despite the high degree of stress related to the job search, fellows did
not seem to change their desired career types throughout their training.
In contrast to what we had hypothesized, the number of fellows
interested in pursuing a subspecialty fellowship had decreased from the
beginning of fellowship to the time of survey completion. A closer look
into those interested in a subspecialty fellowship and the reasons for
or against applying for these programs is warranted.
Only about two-thirds of the fellows who had initiated the job search
process had been offered a position by June 2021. Prior to the COVID-19
pandemic, this percentage might have been higher at this timepoint in
the academic year, so close to graduation. Several trainees and medical
educators have commented on the specific difficulties of the job search
due to the pandemic similarly to our respondents, including the virtual
interview format and hiring freezes. Outside of the pandemic, both
fellows and faculty perceive a variety of barriers to the job search,
with many respondents listing multiple, if not all of the possible
response choices. Most strikingly, about half of the faculty themselves
reported that few positions were being posted; the same comment is noted
by medical oncologists Ghobrial et al., “one must remember that just
because a position is not advertised does not mean it does not exist”.
This speaks to the fellows’ comments about the lack of transparency from
institutional leadership and calls for more open communication between
applicant and potential employer. Other barriers such as geographic
constraints, partner employment opportunities, clinical focus
constraints, and visa limitations also address the limited number of PHO
positions available throughout the country.
Our data highlight opportunities to improve the resources made available
to fellows engaged in a job search. We call attention to leaders at both
the individual fellowship program and national organization levels
(i.e., ASPHO) to work towards these unmet needs. First, strong program
mentorship from the trainee’s institution is key, and establishing this
relationship early is crucial. Like in any other industry, support from
experienced leaders is often needed in taking the first steps.
Individualized attention to our trainees’ career development should
without a doubt take priority within all fellowship programs. If
appropriate mentorship cannot be found within the institution, program
leadership should take the initiative to help the trainee look for
mentors at other programs. Programs in the Northeast have collaborated
to form a multi-institutional regional network to promote “cross-talk”
among mentors and encourage collaborative efforts. Next, the need for
more formal education on the timeline and various steps of the job
process is clear – with half of respondents commenting that no current
curriculum existed at their institution. The responses for what content
would be useful were heterogeneous, suggesting that perhaps a workshop
focusing on a diverse skillset (i.e., CV building, sample letters of
interest, mock interviews, negotiation strategies) might be helpful.
Respondents also make it clear that an overview of all types of PHO
career opportunities including those outside of academic medicine is
needed. The ASPHO Training Committee and the regional v-SYMPHONY group
have started to take on these responsibilities by hosting a virtual
career development session in the 2021-2022 academic year. Lastly, a
more up-to-date, organized list of job postings was in clear demand by
both fellows and faculty. Although it is unclear whose responsibility it
might be to organize and maintain this type of database, it is
imaginable that pediatric subspecialties could collaborate in a joint
effort to benefit fellowship graduates. Many commented on the
frustrations of relying on word of mouth, perhaps giving those at
smaller institutions a disadvantage.
There were limitations to this study. The response rate overall was low,
however, we had about two thirds of all U.S. programs represented.
Because we asked program leadership to disseminate the survey link to
their own fellows, it is possible that our data is skewed by having
multiple respondents from some programs but none from others.
Regardless, Table 1 shows a diverse representation of programs and
institutions represented based on geography and size, thereby
emphasizing the generalizability of our results to all PHO fellowship
programs. Additionally, some fellows may have been reluctant to respond
honestly, if at all, to a survey coming from their leadership. The
timeframe of the survey also could have led to some biased responses,
with majority of third year fellows having already accepted positions
and may therefore have underestimated the stress and struggles during
this job search process and overestimated the stress or anxiety of
negotiation and starting a new job. However, surveying graduating
fellows earlier in the fall/winter may have led to differing responses
about stress levels, and perhaps less focus on topics such as
negotiation. Lastly, generalizability of the issues within the PHO job
search to other specialties may be limited. However, studies in other
fields have demonstrated similarly difficult transitions from training
to practice – including low availability of desirable positions, need
for contract negotiation skills, difficulty with visa needs, and need
for formal guidance from mentors.
The results from our study reveal a role for not only institution-level
changes that can be established locally, but also for larger specialty
societies such as the Children’s Oncology Group, American Society of
Hematology, American Society of Clinical Oncology, or The American
Society of Pediatric Hematology/Oncology to provide more standardized
resources and opportunities for more guidance and expertise on the job
search process for pediatric hematology/oncology trainees. Based on our
fellows’ responses, creating roadmaps and establishing a curricula for
all phases of career development (i.e., even beyond the job offer with
negotiation strategies) would prove extraordinarily beneficial. Our
study emphasizes how crucial it is to continue to strive towards
improving the experiences of the PHO workforce, particularly those at
the beginning of their careers as we help set the stone for their
professional development ahead.