Perspectives on fellowship from a new faculty member
Arun S. Rao, M.D.
Assistant Professor of Medicine
Weill Medical College of Cornell University
New York, NY
Joe Agostini recently asked me to consider writing something for the Fellows-In-Training Newsletter. Having recently graduated from a fellowship, and started an academic job, I was initially reluctant. I haven't built up a niche of findings to report on, and so, what could I offer? However, after a little thought, I felt that offering some of my perspectives on the fellowship experience might be helpful.
Quite often, the transition from residency to geriatrics fellowship is unnerving. Fellowships in geriatrics have many structured clinical experiences, but there may be times when you find yourself "free" of a clinical obligation or if on a rotation. This "down time" can be very unsettling, especially early in a fellowship when clinic schedules may be light and other projects haven't yet developed. You may also notice that your role on clinical care teams has changed from one of a primary caregiver to more of a supervisor or teacher. Many geriatrics fellows feel lost trying to find their way in these new experiences during those first few months.
For those of you who have also experienced this, I offer the following suggestions to help you structure your days as a new fellow or for that matter, at any point in your fellowship:
EXPLORE: Meet as many members of your division/department as you can. Find out what they are doing, and see if their projects/focus match well with your interests. Could some of this work lead to an educational or research project? Ask about other faculty projects occurring outside your division, and see if there are opportunities for collaborative projects relating to geriatrics. Interdisciplinary work is a critical process in disseminating geriatrics information to other fields.
I would also encourage you to use this time to explore clinical experiences with other members of your division. Spend some time with gerontologic social workers in counseling sessions or home visits. Shadow some of the nurse practitioners who may be experienced in diabetes management, older patient education, incontinence treatment, wound care, or some other area. Meet with physical, occupational, or speech therapists and see what they have to offer for your patients. Perhaps, even meet with administrators and practice managers to learn about the business aspects of geriatric care (as we all know how little we get trained in this during medical school or residency.
Finally, many fellowships allow for you to attend a conference during the course of your training. AGS is definitely an important one as this is where many of the developments in our field are presented, and also, it is an excellent opportunity to meet and network with other fellows, practitioners, faculty, and administrators. But there are other groups that may be interesting too. AMDA (The American Medical Directors Association) offers a program through their Futures Foundation that is specifically geared for geriatrics fellows interested in learning more about careers in long-term care and medical directorship. GSA (The Gerontologic Society of America) also has annual meetings that present developments in geriatrics, but with more of an inter-disciplinary focus.
READ: There are few times in your career that you will actually have the time to sit down and have dedicated time to read. Remember, you are training as a geriatrician, and whether you go into an academic career or clinical one, you will be expected to be "the expert" on your subject. Use this time to familiarize yourself with the basics of geriatrics from a textbook as well as some of the "sentinel" literature pieces on different areas. Use this time to read up more on possible areas of interest for research ideas. Remember if you decide to do some research, there will always be much to read and fill your time. Not only will you familiarize yourself with your specific topic, but you will learn its broad category as well.
ORGANIZE & PRIORITIZE: Lists are good and calendars are even better! Make 2 lists during your fellowship: one for your "broad goals" (i.e. what you want to learn, career goals, research & publication aims) and one for your day to day or weekly goals which will help you manage the details and minutia that are part of the broader goals. Keep a calendar so you can track your appointments, clinical times, research/administrative times, and deadlines (VERY IMPORTANT!!!). Remember to always prioritize your lists so you always know what really needs attention.
LIVE LIFE: Again, as long as your clinical obligations are being met and you are keeping up to date on your reading, allow yourself some time to enjoy life without guilt. Geriatrics fellowships can be time intensive, but for the most part, they are not as demanding as cardiology or critical care. The early days of fellowship are especially good time to explore the area where you are living, get involved in some extra-curricular activities, work-out, develop new friendships with colleagues and co-fellows, and most importantly, re-connect with family, friends and loved ones. They may not recognize you at first, having come out of the isolation and hibernation of residency, but they will grow on you once again, and you will find yourself laughing again!
MENTOR(S): For guidance with any of the things mentioned previously, it is critical to find a mentor who will help you mould your fellowship time into a productive and meaningful experience. This person is often the guide who is able to provide concrete structure to your clinical and academic experiences, and hopefully become someone you can turn to with questions and for advice. I think an important point to remember is that you don't have to have only ONE mentor. Quite often you will have a few; one may be a research mentor with whom you are working on a project. Another could be your clinic attending who can teach you the important parts of clinical care of the older patien . One of the most important aspects of the mentorship experience is career guidance. Mentors are the people who can give you insights on the various career opportunities for geriatricians (e.g. private practice, clinician-scientist, clinician-educator, administration, long-term care, etc) and help you with the strategies needed to fulfill your career goals.
FOCUS: With so many opportunities to fill your time, you can sometimes find yourself overwhelmed or spread too thinly. The best way to handle this is KEEP YOUR FOCUS. Remember, choose wisely and avoid spreading yourself too thinly. Keep your career goals in mind whenever you undertake new projects.
Part of keeping your focus also entails reminding yourself periodically why you chose this field. Quite often, especially early on in geriatrics fellowships, questions as to what makes us a "legitimate" specialty arise. I felt this most strongly in my continuity clinic sessions. As a trained internist, I wanted to diagnose and treat everything to the fullest extent. I would ask myself, how am I doing anything now that is different than a general internist aside from seeing older patients? Slowly, I began to see that a geriatrician's clinical strength comes from the fact that we are the most adept physicians at taking care of the most complex medical, psychological, and social issues. Geriatricians know how to sort through the issues, and keep the "big picture" (functional status, quality of life, etc.) in mind; becoming proficient at this daunting task is one of the great challenges of fellowship training.
INNOVATE: Academically, we are in a field that has many questions to answer and is poised to make breakthroughs in research that can really have a great impact on our aging population. This creates many opportunities for research and funding. I found that many of the "research" questions I asked had very little background work done, and thus, A LOT of room for investigation! If you do embark on a research project, use your mentors to find out about sources of funding available to you as a fellow or down the line as junior faculty
FALLS: Remember you can have a fall at any stage of your life or career. There will be many times during your fellowship when you question your value as a geriatrician, experience the stresses of taking care of very complex patients and families, have pitfalls in your research, and always have someone ask you that one question to which you don't know the answer. Try not to be discouraged by these stumbles, but use them to strengthen yourself. We all go through a period during fellowship when we question what is it that makes us "special" as geriatricians. As you do research, you learn that things do not always go as planned, and pitfalls always come up. Use these to create innovative solutions and learn the basics of academic work. This is real life; no better place to learn about it than in the protected world of fellowship.
I know much of what I said is rather "philosophical", but the process of finding ways to apply them to your fellowship experience can only be empowered by you. I know that not all fellowships are structured the same way, but hope that there is something here that many of you can use as you train to become geriatricians! Maybe as I get more experience as a junior faculty member, I can divulge my thoughts on the transition from fellow to faculty….stay tuned!
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