Results
We invited program leaders from all 74 PHO fellowship programs, and at least one representative from 49 programs (66%) responded. A total of 162 completed surveys (79 fellows and 83 faculty) were submitted. Table 1 illustrates the distribution of respondents regarding the U.S. region of the program, size of the fellowship program, and the respondent’s role.
The overall perception of fellow stress was endorsed by the vast majority of respondents, both by faculty and fellows. When asked to rate fellow stress level, faculty were more likely than fellows to perceive that fellows are either “extremely stressed” or “stressed” due to the job search (95% of faculty versus 75% of fellows,P= 0.0003). The struggle to find post-fellowship jobs was perceived more by fellows than by faculty (72% of faculty versus 87% of fellows, P= 0.0198). The majority of fellows (89%) reported feeling anxious thinking about the job search on “several days”, “more than half the days”, or “nearly everyday”.
Overall, the distribution of desired career types by fellows was similar at all time points during their training with ‘academic clinician-educator’ and ‘academic clinician with focus on clinical, outcomes, or population sciences research’ being the most common. Expectedly, the number of ‘unsure’ fellows was higher at the beginning of fellowship compared to later timepoints. When asked about the ideal position for immediately after fellowship, the number who responded as planning to pursue further ‘sub-specialty fellowship’ declined from the beginning of fellowship (21.5%) to the time of survey completion (12.6%). In contrast, the number of fellows who responded as planning to pursue a ‘faculty position’ increased from the beginning of fellowship (58%) to at the time of survey completion (72%).
Fig. 1 illustrates the various reported barriers to the job search, as recognized by both faculty (n=83) and fellows who had initiated the job search (n=44). About half of faculty responded that fewer jobs were available (63%), and fewer positions were being posted (49%). Other commonly noted barriers to the search included geographic constraints, clinical focus constraints, partner employment opportunities, practice format constraints, visa limitations, and family situations. Notably, income constraint was only noted as a barrier in 6% in faculty, and in 5% of fellows.
By June 2021, 30 out of 44 (68%) graduating fellows who had participated in the job search had been offered a position. Of those thirty, 24 (80%) had accepted a position. Most fellows (75%) had started the job search process during late second year or early in the third year of fellowship. In the setting of the COVID-19 pandemic, the majority of fellows (82%) thought that the multitude of consequences of the pandemic impacted the job search. Fellows noted that COVID-19 had affected the search in that fewer positions were posted (73%), fewer jobs were available (71%), they were unable to interview in person (55%), and and job offers had been changed or rescinded (7%). Among the 30 who had been offered a position, about half (47%) of fellows felt that the position was “extremely close” or “very close” to their ideal job goals, and 44 of 83 (53%) faculty believed that fellows were having difficulty finding jobs that aligned with their career goals. Fig, 2 demonstrates that regardless of whether a job had been offered, stress levels were still quite high among fellow respondents. There was no significant relationship between stress level and whether a job had been offered (P= 0.345), the degree to which the job offer aligned with ideal career goals (P= 1.00), nor whether or not fellows had a change in career goals (P= 0.112).
Fellows reported online job centers/mailing lists (82%), fellowship program leadership (80%), word of mouth (75%), and prior connections to other institutions (48%) as resources used to identify available positions. However, when asked which resource was most helpful, the majority responded online job centers/mailing lists (20 of 44, 45%). Of the 10 respondents who had not utilized ‘word of mouth’, 50% of them were from smaller fellowship programs with 0 – 6 fellows. Only 6 of the 44 (14%) fellows who had been offered a job felt that their program leadership was the most helpful resource. Fellows noted that their clinical mentor (61%), program director (55%), research mentor (52%), near peers (30%), and division chief (25%) were helpful in their job pursuits. These mentors were marked as helpful in a variety of ways, including sharing information about potential jobs (61%), writing letters of recommendation for a job at another institution (50%), sharing information about past fellows’ employment and contact (41%), advocating for a position at the home institution (41%), and advocating for a position at another institution (39%). In contrast, twelve of the 44 fellows (27%) also reported that they did not receive any assistance from their home institution.
Several fellowship programs offer educational resources for fellows in various aspects of career development including CV preparation (40%), lessons on negotiation (23%), giving job talks (20%), and practice interviews (17%). Fellows identified CV preparation (22%) and giving job talks (12%) as the two most helpful resources. Other available resources included panel discussions with program graduates and individualized job application advising through program leadership. Notably, however, almost half of the fellows (48%) reported that there is no current formal education available at their institution.
All respondents identified a need for more readily available resources for fellows to help alleviate some of this stress and anxiety. Sample responses to an open-ended question regarding tools that might be helpful are shown in Table 2 and 3, by faculty and fellow, respectively. The distribution of perceived needs, however, differed slightly for faculty and fellows. The top three responses for both respondent types were formalized training on career development tools (33% of faculty, 59% of fellows), a centralized, up-to-date job listing (36% of faculty, 20% of fellows), and an overview of all career types within PHO (23% of faculty, 18% of fellows). Comments from both respondent types regarding open positions not being listed online and having to rely on ‘word of mouth’ were categorized as part of the ‘centralized, up-to-date job listing’ theme. Specifically, 15 of 79 (19%) of fellows mentioned the need for guidance on negotiation. Networking needs were mentioned by 8% of faculty and 11% of fellows. Emphasis on early mentorship was suggested by 12% of faculty and 11% of fellows. About 7% of faculty also noted ‘increased flexibility and managing expectations of a first job’, while 14% of fellows commented that ‘increased transparency on the job search process’ would have been helpful.
Despite the high degree of stress, fellows who had undergone the job search experienced benefits like networking (32%), learning how to market oneself (16%), learning about available positions (14%), clarifying one’s career interests (7%), and mentorship (2%). When asked about what aspects of the process were most challenging in an open-ended context, fellows most commonly reported the lack of job opportunities (57%) and lack of transparency (34%).