A Qualitative Study of Internal Medicine Subspecialty Fellowship Program Directors’ Perspectives on Short-Term Hospitalist Employment Prior to Fellowship Open Access

Two-thirds of internal medicine (IM) residents pursue Accreditation Council for Graduate Medical Education (ACGME)-accredited subspecialty fellowship training,¹  but not all proceed directly to fellowship. In IM and other fields such as family medicine and pediatrics, residents may elect to defer fellowship application instead of going “straight through” from residency to fellowship. In IM, traditional graduate medical education (GME) fellowship timelines require career decisions early in residency training.^2,3  Some residents pursue one or more years of short-term employment as a hospitalist between residency and fellowship, or a “pre-fellowship hospitalist year.”^4-6  Residency program directors (PDs), fellowship PDs, and mentors regularly advise residents on whether pre-fellowship hospitalist years are right for them but have a dearth of evidence to guide them.

The literature describing pre-fellowship hospitalist years is sparse and limited to IM.^4-6  Other specialties such as pediatrics or family medicine lack any literature describing this decision. Reasons for pursuing pre-fellowship hospitalist years vary, and may include accommodating personal or financial circumstances, desiring additional time for career consideration, or crafting a more competitive application.^4,6,7  The benefits and drawbacks of pursuing pre-fellowship hospitalist years are likely viewed differently depending on the stakeholder. A perspective authored by cardiology fellows who had been employed as hospitalists prior to fellowship outlined practical advantages, such as flexibility in scheduling fellowship interviews and strengthening clinical and academic skills.⁴  Hospitalist leaders may view hiring short-term hospitalists as less desirable or risky for their groups,⁸  though a differing perspective authored by an academic hospital medicine group leader highlighted the benefit of experience in hospital medicine to foster advanced communication skills and professional identity formation for future subspecialists.⁵  Residents perceive fellowship career planning as stressful⁹  and desire to know what fellowship PDs think—residents often doubt they prepare applications correctly and believe fellowship PDs can most reliably provide fellowship application–related information.¹⁰ 

No published studies report on IM subspecialty fellowship PDs’ experience with or perspectives on residents who pursue pre-fellowship hospitalist years. The purpose of our study was to explore the perceptions of fellowship PDs regarding potential benefits and drawbacks of pursuing short-term hospitalist employment prior to fellowship, including experience with fellows pursuing pre-fellowship hospitalist years and perceived effects on how that decision affects fellowship application candidacy.

We used rapid qualitative analysis to analyze interview transcripts.^11,12  This approach is best aligned with the tradition of phenomenology,¹¹  seeking to understand the common experience of a group of individuals from a pragmatic interpretive framework, intending to describe an approach to a real-world challenge. Rapid qualitative analysis utilizes a structured analysis in rapidly changing health care learning environments and is appropriate when a project’s scope is narrow.^11,12  Qualitative researchers have concluded, based on studies comparing rapid and traditional qualitative methods, that rapid methods are equally effective and rigorous.^13,14  Study team members represented leaders in GME (E.G., S.K.M., who are associate program directors in IM residency programs) and hospital medicine (T.C., A.S.L., B.K.), and researchers with specific experience and expertise in rapid qualitative methods (A.S.L., E.G., A.K., L.M.).

Between September and October 2021, we conducted semistructured interviews of IM subspecialty fellowship PDs in 4 subspecialties: cardiology, pulmonology/critical care medicine, hematology/oncology, and gastroenterology. These were selected because they are both the most competitive (ranging from 1.3 to 1.5 applicants per fellowship position) and the most commonly chosen subspecialty training pathways for IM residents.^15-17  In 2023, applicants for these 4 subspecialties represented 4848 (61%) of the 8013 applicants for all 18 National Resident Matching Program IM subspecialty fellowship positions.¹⁶ 

Participants were recruited from the 4 subspecialty fellowship programs in the 5 home institutions of the authors: Icahn School of Medicine at Mount Sinai, Indiana University School of Medicine, University of California San Diego School of Medicine, University of Chicago Pritzker School of Medicine, and University of Colorado Anschutz Medical Campus. We used a convenience sample of eligible PDs at the authors’ institutions as they represented geographically diverse academic programs with all target subspecialty fellowship programs. Twenty eligible PDs were identified from fellowship websites, and invitations were sent via email in September 2021. PDs were invited to participate voluntarily without compensation.

Semi-structured interview questions (provided as online supplementary data) addressed 3 domains: (1) PD experience with fellows who had pursued pre-fellowship hospitalist years (denoted in the interview guide as “hospitalist gap years”), including frequency of these fellows in their programs, common reasons for choosing pre-fellowship hospitalist years, and observations related to their fellowship performance; (2) PD perceptions in evaluating fellowship candidates who completed pre-fellowship hospitalist years; and (3) how PDs advise residents applying in their subspecialty considering pre-fellowship hospitalist years. Participants were given an opportunity to discuss additional observations. The interview guide was developed following literature review^4,5,8  and based on the expertise and experience of authors within GME and hospital medicine. We elected for 5 study authors (T.C., A.S.L., E.G., B.K., S.K.M.) to conduct interviews due to ease of scheduling and coordination. Authors underwent interview training in 2 one-hour Zoom sessions led by team members (E.G., A.S.L.) with experience in rapid qualitative methods.

Participants were invited and interviewed by an author from their own institution. Participants consented to participate and gave permission to record. Interviews lasted approximately 30 minutes and were conducted via Zoom. Recordings were de-identified and transcribed via the Zoom transcription function or traditional transcription, including both manual and transcription company services.

Using the rapid qualitative analysis method, we used a structured template to create summaries of each interview transcript.^11,12  Summaries were bullet points of information included in each interview organized based on the 3 interview guide domains. For consistency, one transcript was selected for all authors to summarize, and summaries were compared between authors to standardize the approach. Following this process, 3 authors (T.C., A.S.L., E.G.) completed summaries for each interview, and 1 author reviewed all summaries against the transcripts (T.C.).

An analysis matrix was then created from the summaries of each interview. In this method, a matrix is an analytic tool used to organize summarized data to understand themes occurring within the data.^11,12  We constructed the matrix by transferring the content of the interview summaries for each domain into a Microsoft Excel file, where each row was an interview, and each column was a domain from the summaries. After information was transferred, authors individually reviewed the data using a standard approach—looking across rows, down columns, and then in a zig-zag pattern to identify recurring themes and subthemes. An inductive approach was taken as we identified concepts, themes, and subthemes organically from the data. The group met to iteratively discuss themes and subthemes and reach consensus. Throughout the process, authors reviewed transcripts to determine that data saturation had occurred.

We recognized that our analysis could be influenced by potential working relationships within the same institutions by authors and participants. All authors are hospitalists or employed by hospitalist groups, involved in training programs, and have worked with individuals pursuing short-term hospitalist employment. In acknowledgement of potential existing relationships as well as beliefs or thoughts about the study question held by each author informed by their unique perspective, during the initial development of the research question and during analysis, reflexivity was fostered via regular group discussions to examine how individual circumstances or relationships may have influenced data interpretation. Each participant was interviewed by an author from their own institution; however, the summaries were created by authors outside the participants’ institution, and all authors participated in analysis. Investigator triangulation was used to ensure multiple observations and perspectives.¹⁸  Lastly, member checking was employed via discussion of results with several interviewed fellowship PDs to enhance trustworthiness and ensure credibility of results, and minor revisions to the order of the themes were made based on feedback on their relative importance.¹⁹ 

This project was deemed exempt by the University of Colorado Institutional Review Board (#21-3531).

Sixteen (80%) of 20 fellowship PDs participated (Table 1). Four major themes were identified: (1) Explain the “Why”—residents should have a reason for choosing a pre-fellowship hospitalist year which should be well-described in their applications; (2) Characteristics of the Hospitalist Position—considerations regarding the type of hospitalist employment; (3) The Challenges—acknowledging potential perceived downsides for residents selecting pre-fellowship hospitalist years; and (4) Describe the “What”—the importance of describing how the year contributes to the resident’s career development. Table 2 presents additional subthemes and representative quotes.

PDs emphasized that residents should have a clear reason to pursue a pre-fellowship hospitalist year. In the fellowship application, residents should be able to explain that reason well, ideally in the personal statement, even if the reason is that they were previously unsuccessful in matching. One PD commented, “Being explicit of what those years are consisting of and why is really, really important” (PD10). PDs described more and less permissible reasons for pursuing pre-fellowship hospitalist years (Table 2). Personal reasons, such as aligning timelines with a partner, were mentioned frequently and described as “understandable and reasonable” (PD5, PD8) or even “benign, acceptable…legitimate” (PD10).

Many PDs felt pre-fellowship hospitalist years have become more common and acceptable. The majority of PDs characterized deferring fellowship after many years of “straight-through” training as “understandable and reasonable” (PD5, PD8) in many circumstances. Some attributed this change to the profession’s increased emphasis on well-being: “In my generation it was really frowned upon…I have to admit I started off kind of biased against people who were doing a hospitalist year…I came to realize that there’s a lot of valid reasons why people would take a gap year” (PD15).

PDs had mixed views on using pre-fellowship hospitalist years to strengthen fellowship applications or extend time available for career decisions. Some viewed this as acceptable whereas others indicated a degree of risk associated with this decision (“When someone does a hospitalist year because they just aren’t sure what they want to do… there’s not the level of commitment that we like to see” [PD7]). PDs tended to view some reasons for pursuing short-term hospitalist employment more negatively, such as not matching or pursuing financial gain or leisure activities (Table 2).

PDs described characteristics of types of short-term hospitalist employment that influence their assessment of applications. A single year of employment was perceived as more acceptable than multiple years. Longer periods were perceived as a break in training and viewed more negatively, as PDs described concern for lack of commitment to the subspecialty field and historical experience with subsequent fellowship performance (Table 2).

Several participants discussed subspecialty-specific hospitalist positions, such as employment focused on subspecialty-defined patient populations (eg, oncology hospitalist positions) or non-ACGME-accredited fellowships (eg, nutrition fellowships within gastroenterology). PDs perceived clinical benefits of these positions inconsistently—some felt they contributed to developing subspecialty expertise, while others viewed them as unnecessary because “it’s more important to us that someone arrives in our program as a really good internist than that they’re already beginning to specialize” (PD9). PDs did point out some potential academic benefits of subspecialty-focused positions (Table 2). Some highlighted that applicants can pursue these positions to demonstrate continued commitment to the subspecialty or attain mentorship that may be needed to strengthen applications: “It may be a little bit easier for them to make those connections than a general medicine hospitalist” (PD11).

PDs generally encouraged hospitalist employment in academic institutions for residents pursuing academic fellowships (Table 2). Many recommended residents stay in the same institution or city as residency for continued access to mentorship and to complete scholarship, as well as to demonstrate commitment to academic subspecialty clinical practice. Staying near residency training could facilitate “keep[ing] your foot in the door in terms of keeping research projects ongoing” (PD4).

Most PDs made a clear distinction between a pre-fellowship hospitalist year and a chief resident year, which were viewed as more selective and prestigious: “The [chief resident] is the mark of approval by the program director. The gap year is something to be explained” (PD7). They also described the chief resident year as more standardized in terms of professional development and skills obtained (Table 2).

PDs highlighted substantial challenges when advising residents whether to pursue a pre-fellowship hospitalist year. While PDs emphasized that pre-fellowship hospitalist years are becoming more acceptable and residents should “do what is best for your life” (PD9), they also acknowledged that historically PDs have been anxious that this decision is associated with hidden red flags in applications, and this fear may still persist (Table 2). Several PDs discussed this concern in the context of application inflation and administrative burden of application review. With high application volumes, PDs were less willing to search for reasons why an applicant pursued a pre-fellowship hospitalist year if not immediately apparent (Table 2).

In considering experience with fellows following pre-fellowship hospitalist years, some PDs discerned no differences in performance, whereas others observed enhanced clinical skills like efficiency, communication, more independent clinical decision-making, and maturity (Table 2). Others related challenges with these fellows’ ability to re-enter a learning environment as a trainee, particularly for those with multiyear employment. Most PDs framed any differences as largely incidental and emphasized that fellowship training itself corrects any variability: “The incremental knowledge that you get from being on a hospitalist team, you make that up in the first week or 2 of fellowship” (PD6).

PDs uniformly emphasized it was essential that residents describe not only why they chose a pre-fellowship hospitalist year, but also what was gained or produced during the year. PDs expect residents to clearly detail what was accomplished and how the experience fits with their overarching career trajectories, ideally with deliverables: “It’s not whether they do a hospitalist year or not, it’s what they did with that hospitalist year” (PD12). The personal statement was frequently suggested as an ideal space to summarize both the “why” and the “what” behind a pre-fellowship hospitalist year.

Nearly all PDs explicitly stated that residents should participate in scholarship and academic pursuits during the pre-fellowship hospitalist year to maintain connection to the subspecialty. One PD summarized: “Contribute academically, whether that’s in education, quality improvement, implementation research, clinical science, translational science, foundational science—any of those we identify as academic leadership and scholarship” (PD2). Some PDs felt a higher burden is placed on applicants deferring fellowship to clearly describe how activities pursued during their pre-fellowship hospitalist year contributed to their overarching career development than those who go straight through training: “There’s a little bit of risk there, where someone does a hospitalist year but then can’t quite explain why they did it. Whereas someone who does residency—well, everyone does a residency, you don’t have to explain that” (PD11).

The longer an applicant was out of training, the more PDs expected in terms of academic productivity. PDs acknowledged residents choosing a one-year position may have difficulty producing meaningful products by the early months of their employment when they submit their applications: “We’re interviewing them in typically September/October, so there’s a whole rest of that gap year to happen. So when we meet them a lot of times there is a big plan to do research…but probably a minority had a real significant research experience” (PD9). When short-term hospitalist employment extends beyond one year, PDs expected to see even more tangible results of projects.

This qualitative study of fellowship PDs in 4 competitive IM subspecialties at 5 academic centers describes how pre-fellowship hospitalist years are perceived in assessing residents’ candidacy for and performance during fellowship. Pre-fellowship hospitalist years may be increasingly recognized as an acceptable path to fellowship, but PDs describe a high burden of proof for residents to explain the reasoning for, the products of, and the professional benefits attained from this decision. The insights gleaned from this study are important for both prospective fellowship applicants and their advisors who assist applicants in making career planning decisions that must balance personal needs, well-being, time available in training, and ultimate success of matching into their desired field.

PDs in our study recognized pre-fellowship hospitalist years as relatively common, and many indicated they are becoming more widespread. Nearly all PDs described what they deemed as “understandable” reasons for pre-fellowship hospitalist years—most often to better sync with personal or family needs. Social support in residency is protective against burnout,²⁰  but also potentially vulnerable to the stressors of training.²¹  Potential negative effects of “straight-through” training may include deferring family or life decisions, particularly for female physicians.²²  Shifting generational expectations, particularly regarding well-being, may also be contributing to PDs’ perceptions that trainees are seeking more flexibility in training timelines.^23,24  This aligns with trends in undergraduate medical education: over 70% of entering medical students in 2022 reported a gap year between college and medical school, an increase over the preceding 3 years.²⁵  Taking a gap year is associated with decreased risk of burnout in medical students.²⁶  With more recognition of trainees’ holistic needs, PDs in our study indicated a sense of acceptance (or at least permissiveness) for alternative timelines in medical education.^27-29  PDs and advisors should recognize the weight of these personal timeline decisions for trainees when advising them during application periods.

PDs wanted residents to describe outcomes of their pre-fellowship hospitalist year. While PDs were interested in scholarly products, they also desired something slightly less tangible: a thoughtful explanation of the experience’s contribution to the resident’s overall career trajectory, such as skills gained or other contributions to professional development. They sought this explanation specifically in personal statements, consistent with prior literature evaluating what PDs value in personal statements.^30,31  PDs acknowledged that timing of the application cycle can pose a challenge to residents hoping to improve the competitiveness of their application with scholarship. The demand for scholarly products in competitive IM fellowships is high and potentially rising.^3,32  Following the COVID-19 pandemic, competition may be even further heightened due to the virtual interview format and lower barrier to application.³³  For residents choosing to pursue a pre-fellowship hospitalist year, the fact that most of the year occurs after the fellowship application cycle intensified the importance placed on scholarship and career decision-making during residency proper for PDs in our study.

Career choice in residency is stressful,⁹  and may change throughout training.^1,34  Our study underscores the importance of clear guidance from PDs and advisors for all residents in how to craft a competitive application in a timely fashion. One of the primary purposes of moving the IM fellowship application timeline later in residency in 2012 was to allow more time for career decisions.³⁵  Nevertheless, time in GME training is scarce, and residents face many competing demands related to career decision-making, including finding mentorship and producing scholarship. Even subspecialty clinical experiences may represent a challenge as traditional GME rotations often prioritize service needs and may not be optimally designed for career consideration.^36-38  Particularly for residents choosing to pursue a pre-fellowship hospitalist year, the final year of IM residency must be designed such that these residents possess a well-developed academic portfolio by the time applications are submitted (ie, at the start of the pre-fellowship hospitalist year).

Our study has limitations, including the small number of subspecialties and institutions included. We lack representation from community-focused fellowship programs that may assess applicants differently. We did not obtain participant racial/ethnic identity information, and our participants were predominantly male; the representation of these identities may have influenced perspectives provided and our results. Participants were interviewed by authors from their home institutions with whom they may have had working relationships, representing a potential threat to trustworthiness of data. However, measures were taken to ensure credibility by having multiple study authors perform analysis, as well as member checking. Finally, in studying only competitive IM subspecialties, our conclusions may not transfer to less competitive fields or non-IM fields.

Our study provides important guidance to residents navigating career decisions, and to residency PDs, fellowship PDs, mentors, and hospitalist leaders invested in advising, recruiting, and mentoring these individuals. Advisors should coach residents on the importance of stating a clear and concise reason for choosing a pre-fellowship hospitalist year in personal statements, engage them in thoughtful discussions of how the year will fit within their overall career trajectory (including skills or products attained), and help residents brainstorm how to demonstrate continued commitment to the subspecialty via the activities and outcomes of the pre-fellowship hospitalist year. Future work should examine perspectives of residency PDs and hospitalist leaders, as well as fellows who have completed and are currently undergoing pre-fellowship hospitalist years.

Fellowship PDs in 4 competitive IM subspecialties described pre-fellowship hospitalist years as providing a flexible training timeline but highlighted important considerations for individuals considering this option. PDs offered mixed opinions regarding benefits and drawbacks of hospitalist years prior to fellowship but acknowledged that the decision to pursue short-term hospitalist employment may receive closer scrutiny due to deviation from standard training pathways, particularly for multiyear gaps. While many perceived pre-fellowship hospitalist years as becoming more common and acceptable, PDs emphasized the importance of careful fellowship application preparation and thoughtful advising regarding activities and products of the pre-fellowship hospitalist year to guide residents toward a successful Match.

The authors wish to acknowledge the Society of Hospital Medicine Physicians in Training Committee for their support and assistance with this work.

The online supplementary data includes the semi-structured interview guide used in the study.

Funding: The authors report no external funding source for this study.

Conflict of interest: The authors declare they have no competing interests.

Preliminary results were presented as a poster presentation at the Society of Hospital Medicine Converge Annual Conference, March 27-29, 2023, Austin, Texas, USA, and at the Alliance for Academic Internal Medicine AAIM Week Conference, April 2-5, 2023, Austin, Texas, USA.

Disclaimer: Angela Keniston reports receiving funding from the Agency for Healthcare Research and Quality, which is not related to this work.