Transition to fellowship: A qualitative exploration of the experience of hematology-oncology fellowship at the university of Colorado

Abstract Background: The transition from internal medicine residency to fellowship is a crucial phase as physicians terminally differentiate into hematology and oncology specialists. This transition can be daunting as first-year fellows are required to rapidly learn and synthesize knowledge while providing specialized expertise in a new field. Although this period is recognized as a challenging stage in training, there are limited studies describing this transformative period and identifying barriers and challenges to smooth transitions and positive experiences. This project aims to understand the concerns, challenges, and perspectives of fellows as they take on their new role to inform the development of future interventions to improve the fellowship transition and experience. Methods: Hematology-oncology fellows at the University of Colorado (n=15) were recruited to participate via email. Semi-structured interviews were conducted via Zoom to explore fellows' experiences, with a focus on the immediate transition period. All interviews were audio-recorded, transcribed, and de-identified. The codebook was created using both deductive and induction approaches through iterative review of transcripts and was reconciled by three team members. All interviews were then coded in ATLAS.ti (Atlas.ti v.25, Berlin, Germany). Coded data were queried and summarized. Subsequently, through iterative discussions during team meetings, themes were developed. Results: Thirteen fellows were interviewed (5 first-year fellows and 8 upper-year fellows), comprising of 6 men and 7 women. Three themes emerged from the data: 1) limited preparedness creates a steep learning curve in fellowship, 2) imbalance between responsibility and knowledge, and 3) fellows feel a sense of isolation and lack of community. First, fellows describe limited exposure to hematology and oncology during residency where “you don't really learn a lot about cancer” (#7, second-year), creating a steep learning curve in fellowship. Fellows must balance learning with their oftentimes heavy workload which can be time-intensive, especially when “everything that you're seeing in your clinical duties is a new problem” (#13, second-year). While this transition can be challenging, fellows appreciate expectations management by attendings and leadership where early on during the first-year of fellowship “attendings don't expect you to know a lot” (#6, first-year). Second, fellows describe the challenge of navigating the imbalance between responsibility and knowledge. Early in first-year fellowship they describe, “I'm supposed to be the expert” (#8, third-year) despite having recently completed internal medicine residency. In adapting to a new “expert” role with increasing autonomy, they still need attending support because “I wanna make sure I'm doing the right things” (#6, first-year). Further contributing, fellows have high self-imposed expectations (“I was under the impressions that I should have all the answers” [#12, first-year]). Finally, fellows feel a sense of isolation and lack of community with other fellows, because “fellowship could be lonely at times” (#4, third-year). There was variable collegiality amongst co-fellows particularly within the different cohorts and a desire for more intentional community building. Conclusions: The transition to fellowship is a complex and lengthy process shaped by limited preparedness leading to a steep learning curve, an imbalance between responsibility and knowledge, and feelings of isolation and lack of community. These themes highlight multiple opportunities for intervention to ease the transition period, leading to better learning, growth, and connection.