To the Editor:
The most challenging period of my medical training was the last week of pediatric residency, when I was simultaneously working a grueling overnight call schedule as the senior resident in the neonatal intensive care unit, attending fellowship orientation events post call, and preparing for a housing move. The July 1 fellowship start date created significant conflicts in terms of professionalism for me and for many of my co-residents, who were forced to choose between professionally completing our residency programs and professionally starting fellowship on time; in many instances it was impossible to accomplish both. These professional obligations were also weighed against the stress of moving, family obligations, graduations, and orientations.
Given significant advocacy for resident and fellow well-being in recent years and a realization that physician fatigue impacts patient safety,1 fellowship programs should voluntarily delay the start of fellowships to July 7 or later. The Association of Pediatric Program Directors (APPD)2 and the Association of Medical School Pediatric Department Chairs (AMSPDC)3 have both endorsed a delay in the pediatric fellowship start date to July 7 or later. A survey of 439 graduating pediatric residents entering fellowship in 2014 demonstrated that a vast majority (93.7%) expressed a preference for a delayed fellowship start date.3 Although half of 495 pediatric fellowship directors surveyed did not initially believe there was an issue with the current fellowship start date, after hearing about incoming fellows’ preferences, 81.8% expressed a preference for a delayed fellowship start date.3
While changes in the fellowship start date may lead to some logistical challenges, particularly in the transition year, these issues can be addressed. For instance, although there may be a lapse of health benefits between June 30 and the start of a delayed fellowship, COBRA may be purchased up to 30 days retroactively, and the vast majority of trainees will not require these benefits. Similarly, trainees with educational visas are allowed 30 days between positions. Current fellows and faculty may be recruited to provide clinical coverage for the first week of the transition to the delayed fellowship start date.
For trainee wellness, for patient safety, to avoid professionalism conflicts, and in line with the preferences of current fellows and fellowship directors, the fellowship start date should be delayed to July 7 or later. Although the APPD and AMSPDC have endorsed this position, the fellowship start date is ultimately determined by individual fellowship programs, whom I urge to implement this important change on behalf of their trainees.
Jason M. Nagata, MD, MSc
First-year fellow, Division of Adolescent and Young Adult Medicine, University of California, San Francisco, San Francisco, California; [email protected]; ORCID: http://orcid.org/0000-0002-6541-0604.
1. Wallace JE, Lemaire JB, Ghali WA. Physician wellness: A missing quality indicator. Lancet. 2009;374:17141721.
2. Hofkosh D; Association of Pediatric Program Directors letter to the Council of Pediatric Subspecialties regarding the fellowship start date. April 18, 2014. https://www.appd.org/home/PDF/LtrCoPS_StartDate_4_18_2014.pdf
. Accessed March 21, 2017.
3. Mink R, Caputo G, Fried E, et al. Delaying the pediatric fellowship start date to improve trainee well-being. J Pediatr. 2015;167:222223.