Background/Purpose:

Subspecialty fellows may play an important role in Internal Medicine (IM) residents’ education and career specialty choice (Horn 2008). This may be particularly important in rheumatology where a projected workforce shortage may require the expansion of the current training capacity (Deal 2007), and over 75% of fellows decide to pursue a career in rheumatology during residency (Kolasinski 2007). In this context, fellows may be underutilized as clinical teachers and role models, possibly due to the existence of barriers to an effective resident-fellow interaction (Miloslavsky 2010).

To our knowledge, the working relationship between IM subspecialty fellows and IM residents has not been examined. We conducted a study to determine the barriers and facilitating factors to the IM resident-fellow interaction on the wards.

Methods:

We conducted 4 focus groups: IM residents at the Massachusetts General Hospital (MGH) and the Brigham and Women’s Hospital (BWH), IM fellows at BWH/MGH, and IM fellows at MGH who received teaching awards. There were 32 participants from all residency classes and 7 IM subspecialties including rheumatology. Four investigators analyzed focus group transcripts via a theory driven immersion-crystallization process using activity theory (Engestrom 2011).

Results:

Five themes of barriers were identified:

– Intrinsic: residents’ and fellows’ expectations of each other; absence of familiarity/personal relationship between residents and fellows; interest and availability (fellows – willingness to see the consult, residents – being available/interested in discussing the consult); knowledge (residents – patient history, fellows – subject matter).

– Logistical: resident work hours (e.g. frequent patient handoffs); primary team structure (e.g. team-based care model, de-regionalized teams).

– Attending-related: primary team attending (role in formulating the consult question, communication); consult attending (role modeling).

– Workload: resident and fellow patient census and the duration/complexity of the consult.

– Teaching: time available to teach and fellows’ teaching skills.

Focus group participants cited increasing familiarity/personal relationships between residents and fellows as a critical variable in improving the interaction. Other means of overcoming barriers included limiting fellow pushback on residents’ consult requests, standardizing fellows’ and residents’ expectations about the consult interaction, and improving fellows’ teaching skills.

Positive and negative feedback loops appear to be important in the resident-fellow interaction, with positive interactions strengthening future ones and negative interactions creating additional barriers. 

There was broad agreement between fellows from different subspecialties and residents with respect to both barrier and facilitating factors.

Conclusion:

The resident-fellow interaction faces multiple barriers from both systems and personal domains, however many of these barriers may be modifiable. Future efforts should focus on implementing strategies to overcome these barriers.  Such efforts may enhance IM residents’ rheumatologic clinical skills and potentially influence their career choice.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/the-resident-fellow-interaction-limiting-barriers-and-maximizing-learning/