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.