Navigating the Transition from Residency to Fellowship

By Brienne Ryan

You think one would be used to this by now. As medical professionals, we transition frequently into new environments, new roles with new responsibilities. It is the dogma of medical training that we gain graduated autonomy with each step we advance and the closer to attendingship we become. So, what makes fellowship different and why do some struggle?

If you are one of the hundreds of fellows in the early months of fellowship who find yourself uneasy about your performance, uncertain about your decision, or just plain overwhelmed with your new position, please know that you are not alone. Struggling during fellowship is commonplace and these might be a few reasons why.

Fellowship is an entirely different beast from residency. First and foremost, it is a much smaller cohort of peers. When I graduated from surgical residency, a friend and prior senior co-resident said something that I, initially, found strange. He said “Let me know if you need anything, fellowship can be really lonely”. That statement did not resonate with me at the time, and I did not quite understand what he meant. I had come from a surgical residency that was small by residency standards, but still had a group of 15-17 co-residents. This group became a family with whom you could commiserate about the annoying consults, grab a quick bite to eat between cases, and hang out with on off hours. A special bond is formed during those grueling and tiresome years of residency, where sleep is elusive and burnout is common. And then fellowship comes along and you may become a cohort of two, or quite possibly, only one. Residency afforded a built-in support system of like-minded individuals who were going through the same daily trials and tribulations, who could truly understand the experience, and help navigate the difficulties of residency life. For most fellows, this daily support system suddenly vanishes, and you might find yourself struggling to acclimate to this new reality.

One of the second biggest changes may be the method of education. As a resident, faculty and administration recognize that most medical students graduate with limited knowledge and practical experience in their specialty of choice and thus, there is usually a plethora of structured academic time. Maybe you had a group conference, or dedicated lectures to assist with the fountain of knowledge that was expected to be learned. Furthermore, especially with a surgical specialty, residency allots five to seven years to absorb and truly learn the knowledge that is required for board certification. Fellowships, especially those without a co-integrated residency, may lack that level of structure for education and the expectation for learning key material may be more independent or clinically focused. For some, this may be a relief. Not having to sit  through another lecture made by a resident who was likely tired and delirious while making it – sounds great! Others may miss that component of their education where there was dedicated time to ask questions, learn about a specific topic, or generally learn the fundamentals. The expertise (or lack thereof) with which a resident enters their respective fellowship differs significantly. For some, there may be a steep learning curve as you enter your specialty of choice. Maybe you spent only one or two months of your residency in that specific specialty. No matter what, it can feel overwhelming, as you once again start at a new hospital, in a new role with a new curriculum to learn. Furthermore, the timeline is significantly condensed, usually with fellowship lasting between one and three years.

Lastly, the light at the end of the tunnel is there, but just out of reach. For any medical trainee, the process is arduous. For surgeons, fellowship represents the 8^th or 9^th year of training. It can feel frustrating to start at square one at a new institution, where attendings may be attempting to fine-tune your skills when you simultaneously feel like you are ready to spring the proverbial training coup.

There is a long list of what can make fellowship particularly hard – maybe you didn’t match at your number one program, maybe you are in a new part of the country, or maybe you are struggling to acclimate to a new learning style or attending preferences. Whatever is making this transition difficult, here are some tips to help:

First and foremost, speak up for yourself. If you are struggling or having issues, express them to your program director or chair. Most of the time, these are things that they may have dealt with before and can help you overcome the obstacles. Give yourself grace, even if you feel like no one else will. As mentioned, we all enter fellowship with a different degree of specialty knowledge and experience. If you are putting in the effort in cases, reading, and attempting to establish a strong knowledge base, no one can fault you. The key thing to remember is that your fellowship wants you to succeed. It is in their and their hospital’s best interest to produce the best fellow they possibly can – for patient care, for reputation, for all the reasons that are both selfish and altruistic. Therefore, it is in their best interest to help you with the problems that arise. Secondly, use your support system. You may have left residency but remember that your prior co-residents are likely also experiencing these ebbs and flows. Lastly, keep the end goal in mind. Within a few months (maybe more), you will be entering the world as a full-fledged attending. The next few months to years represent the last chances to hone your skills under the guidance of someone else. It can be easy to let the negatives overwhelm the positives and focus on what you feel is going wrong rather than right. But what truly matters is the type of surgeon you want to be when you leave fellowship – that is the only prize you should be working towards. Everything else is noise.

If you take anything from this article, please remember that no one is alone in this process. There are hundred of physicians who die by suicide every year – an epidemic that is being addressed by changes to surgical training and the healthcare system overall, albeit slowly and with great turbulence. Be your own advocate. Do not struggle alone, because you are not alone in this. A cursory google search of “struggling in fellowship” will show you innumerable examples of people who are in your boat. Wherever you are, whatever specialty, and with whatever time you have left – remember that the timeline is finite. Just as you have done with each step prior (and we all know there have been many), you will overcome this hurdle – and for the majority, this will be the final summit! Attendingship is waiting on the other side.

Brienne Ryan is a current vascular surgery fellow at the University of Missouri. She has been a member of the Association of Women Surgeons since 2015, and has a strong interest in residency education and wellness initiatives. Her professional interests include limb salvage and endovascular treatment of peripheral arterial disease. In her spare time, she enjoys spending time with her husband and two dogs.