The Fellowship Experience: Starting and Leading a Program

Dr. Jennifer Spector:

Welcome to Podiatry Today podcast, where we bring you the latest in foot and ankle medicine and surgery from leaders in the field. I'm Dr. Jennifer Spector, the assistant editorial director for Podiatry Today. This episode marks the second of a two-part series on the fellowship experience. The first episode looked mostly at the perspective of a participant or potential participant in fellowship and now this installment focuses on starting and leading a fellowship program.

Jeffrey McAlister, DPM's a fellow of the American College of Foot and Ankle Surgeons and practices at the Phoenix Foot and Ankle Institute. Jacob Wynes, DPM, our other guest today, is also a fellow of the American College of Foot and Ankle Surgeons and is an assistant professor in the Department of Orthopedic Surgery at the University of Maryland Medical Center. We'll turn it over to Dr. McAlister and Dr. Wynes now as they continue their discussion.

Dr. Jeffrey McAlister:

So we both started and are starting and part of fellowship programs. Because one of the big questions obviously is let's go to one side of it away from the applicant part, more so the practitioner that is actually thinking about starting a fellowship. Let's get into that a little bit because I think that is a common question I get and you probably got as well. So one, how did you get to thinking about Fellowship? When do you think the right time is, if a person like myself in private practice or maybe a multi-specialty group wants to start a fellowship program, what would you say is your top three recommendations and maybe what not to do?

Dr. Jacob Wynes:

Yeah, I actually appreciate that. I think, first and foremost, as a rule of what not to do is it should not be for free labor. I think there has to be a motivation on your part, first and foremost, to want to educate and to allow this person that you educate to be more badass than you are. And I think that motivation, if that is real and that's something that is there, then I think that's the first step.

Number two, I think what is very important is to find your rhythm in your practice. And the way I think about it in retrospect, this is honestly the first time I've actually thought about this, and what prompted the timing was sometimes you have to understand that it's going to take some time to get it started especially if you're dealing with an academic center or putting together your manual and minimal competencies for the American College of Foot and Ankle Surgeons, CPME, or whatever entity is going to recognize, not accredit, but recognize your fellowship.

But I think that it's very important to be able to know when you've hit your stride and when you know that you have the consistency to provide a suitable resource in training for that fellow. Meaning that you have the case volume to support it. Not that it's about surgery because there's different fellowships for different reasons, but I would say that you have to have enough of a portfolio of experience for this trainee. So you can honestly say that, heaven forbid, something like COVID happens, and I pray that it never does again, that you're going to be okay for the sake of the trainee.

Now I know that's a very isolated circumstance, but it is important to know that the opportunities will be there for the fellow. And lastly, I think that it's important to have an environment that's going to be sustainable for a fellow, meaning that it's not going to be too much call. I think a fellow is there to be there for training and not be there for indentured servitude to some degree. So I think that it's very important while experiences and opportunities equate to training, I think it's very important to have an environment that's going to be sustainable for the fellow.

Dr. Jeffrey McAlister:

Yes, all of the above. Great points, Jake. A little different situation. I helped start a program when I was at the core institute that's still running with Dr. Scott. Great program, top three in the country probably besides Jake's.

Dr. Jacob Wynes:

Thank you.

Dr. Jeffrey McAlister:

You're welcome. I've been in a situation where it was group funded, group supported, ACFAS accepted and then my round two fellowship program, now getting acceptance and going through the process again on my own is a learning experience for sure. My high recommendation would be number one, I would be out for at least, I want to say five years is my gut minimum to learn your rhythm, learn your practice, learn your style, be able to cut yourself and know complications that you can teach someone else on how to improve. And you don't need to be handing over the knife a year out from residency.

My focus is really on the total ankle side of thing and the complex side of things. And then also the simpletons, I mean the simple MTP fusions and the post-op protocols and having my fellow in clinic to learn how to start a private practice, to be honest. And be able to join either private practice, go into an ortho group, go into a multi-specialty group, go into a pod group. Definitely the in indentured servitude servant thing is definitely not high on the list of recommendations and that's just to be for the applicants and things be very, we leery and weary of, hey, all of a sudden you're on call every week and you are running three days of clinic and the fellow director is in Miami or down the shore, if you will, hanging out. I don't think that's appropriate.

Learning the ins and outs of not just OR experiences, but office experiences. And then also I think an important part of fellowship is being able to see one, do one, teach one. So being involved in a residency program as well, like you are Jake. Having the ability for fellow to teach not only him or herself, but another resident I think is a huge thing. Because like you said, you want that person to be more "badass" than you.

And so teaching that person how to teach is important and allowing that person to garner the skills to be able to educate and carry on the "name" ... a lot of air quotes going on here ... name of the program and teach, and even start a residency, or fellowship, or whatever it is themselves, is the mission and the growth factor involved in starting a fellowship. So it takes a lot and a lot of oomph. And the credentialing and not just the money part of it, just all the little logistical things that go into starting this is, not as much as a residency, obviously, but definitely getting that way. It is a mountain to move and it definitely shouldn't be done by someone that just started private practice.

Dr. Jacob Wynes:

I think that raises an interesting point, Dr. McAlister. While you said that may not be important, but you can't necessarily have a fellowship if there's no funding. What have you heard as far as different funding streams for fellows? I'll tell you mine. Mine was through the University of Maryland Wound Care Center. While I didn't anticipate my fellowship to be having a chronic wound component ... although thankfully, well not thankfully, I think there's definitely value in having a chronic wound experience that is only one day a week.

Now that provides the substantive funding as they were able to allow the program to be a program through the hospital due to having a program around it and the volume to support it. So I think it was a little bit of proof of concept, but also being creative in finding a funding stream through the actual hospital that made sense. That was my particular situation. And I know that some people get industry funding. What other methods of funding are there out there if you did want to start a fellowship?

Dr. Jeffrey McAlister:

Yeah, I went up and down the charts a little bit and when it came down to it, if I wanted to get funding from industry, it doesn't easily flow from their pocket to my office to my fellow's bank. And so generally speaking, I think that I was misguided a little bit thinking that I could just simply get a large sum of money from a industry partner and all of a sudden I have a fellow. Maybe in my wildest dreams, but that is not reality.

So in my mind and from my experiences and my fellow mentors and Dr. Cotum and Decarbo and other people, honestly, in my mind, it makes it more meaningful for me and allow ,y fellow to be a part of my practice a little bit more. He/She is on the door. You are signage on the door, if you will, and you're running your own clinic. And you are able to make decisions on your own and take people to the OR. And you are a self-funded fellow. I would put it like that, you are a self-funded fellow and that's been the easiest way for me.

Dr. Jacob Wynes:

I like it.

Dr. Jeffrey McAlister:

It's pure. That's a good way to put it. It's pure and it's not misguided, if you will. What has been the hardest part of ... kind of rounding this out a little bit, Jake, what if you had to give any final advice to anyone starting a program, is there any mot to do's? What are you on your fifth year now?

Dr. Jacob Wynes:

Yeah, I'm graduating the fourth toe this year. I'm getting the fifth toe next year.

Dr. Jeffrey McAlister:

Okay. So for the people just starting now, you have some holes in your belt, is there any fat to trim? Have you streamlined it enough? Is there anything from a rotation standpoint have you fine tuned it to where they're rotating with ... I know you have a couple, or at least you did, have a private practice partner, how have you really fine tuned it into what maybe the current fellow applicants want and maybe how you've changed your fellowship over the past couple years?

Dr. Jacob Wynes:

Yeah, I think that's a great question. As far as any modifications that we've made and yeah.

Dr. Jeffrey McAlister:

Yes, yes.

Dr. Jacob Wynes:

I think that's definitely been trimmed. And I will definitely have to thank one of my former fellows, Dr. Corey Dubois, for helping me streamline my OR schedule such that we're not split amongst clinic or on the same day. That makes it incredibly challenging when you have a fellow, because sometimes a fellow works autonomously and independently, but they still require your educational input. And it's very hard to do if let's say you need to be somewhere else physically at the same time that the fellow is busy doing their autonomous stuff like surgery.

And therefore, I think it's best, in my opinion, one thing that I have learned is to streamline the process such that it's all office on one day, all OR on another. Sometimes I'll cover and I'll allow the fellow to go do an add-on case or something to that effect, but it's always their choice. I also have felt that having partners in private practice that are credentialed the same hospital was the easiest transition to get multiple faculty members on board. And my program is a little unique in that it's cp-sponsored by the orthopedic department as well as the graduate medical education committee, so that everything is almost as stringent as applying for anything through ACGME.

So that if I wanted to add another site, I'd have to go do a whole shark tank type of presentation to the GME committee. But all in all, it's been met quite favorably. And what we've done is we've been able to add other providers. We have lost one provider that was the yin to my yang, provided TAR, trauma, sports, whereas my focus is primarily reconstruction, ex fix, Charcot. Not to say I don't get the other stuff, but it was nice to have that other aspect of it, to create a well-rounded experience such that the fellow, even if they wanted to, could pick.

And I never felt strange in any way if the fellow wanted to go a different direction and wanted to pick a more interesting, not a more interesting case, but you know what I mean, something that interests them more. At least because it's their experience and it's them taking the time to do an extra year of training. So for whatever that's worth, I think that was important to me. And added value is something I'm always looking for. And to say something that's a constantly evolving process that is trying to find other aspects and resources to help make the program that much stronger, whether it be from a more well-rounded perspective or a more efficient standpoint. And I'm still learning.

Dr. Jeffrey McAlister:

Agreed. I think a big part of that is making sure that if you're going to involve faculty, which I would highly recommend, other faculty, make sure that they are credentialed in your neck of the woods, if you will, because it is highly complicated. And make sure you're starting the credentialing process for said fellow six months in advance. Make sure you are utilizing your staff appropriately. And I have a credentialing staff and everything that from a private practice standpoint and delegating those duties, but we have adjunct faculty that do the same sports stuff and it is cumbersome to have too many chiefs in the tent, and too many hospitals, and 10 hospitals to get credentialed data. It's like residency all over again.

So make sure your processes are streamlined and you are able to keep the faculty high quality, low volume, and low numbers, but high quality cases. Because that's what a fellow wants in my mind is not to do 10,000 cases and be dead at Friday at 8:00 PM. It's to do very high quality, high thought out, high perioperative, conclusions drawn and how am I going to conquer this case, and how am I going to see this patient post-op.

Dr. Jacob Wynes:

Absolutely.

Dr. Jeffrey McAlister:

And all of that kind of stuff. Because you can't do that with 20 attendings. So we could probably have a volume too with a couple other people across the country with different types of fellowships. But I hope that the listeners were able to at least take a nibble of information from this because it is complicated.

And for the applicants coming through, sometimes you probably have second thoughts about doing it and that's okay. You are not going to be a bad surgeon or a bad doctor if you don't do a fellowship. It's okay. Don't think that you have to do one. It is highly sought after and allows you to peak your performance a little bit, but always be learning. And I think Jake would agree, attend courses, always be on the hunt for higher education. And even in terms of just going to courses and industry sponsored stuff, there's always room to grow and it doesn't have to be necessarily during a fellowship. But Jake, any last thoughts?

Dr. Jacob Wynes:

No, I appreciate the opportunity. I echo all your comments. I really love the fact that you are more of a quality over quantity person. That was really reassuring and validating for me to hear as I subscribe to it too. Believe me, I meet my numbers. ACFS makes it such that you have to, but aside from that, I am all about chasing those quality opportunities. So I think fellow applicants, in general, should chase quality. I think that program directors should strive for quality. And yeah, I just wanted to thank you for the opportunity. So I thought that was great.

Dr. Jeffrey McAlister:

Well thanks Dr. Wynes. Thank you to the listeners. Enjoy all these podcasts. I think Podiatry Today does a great job and I want to thank you, Jennifer.

Dr. Jennifer Spector:

Well thank you as well, Dr. McAlister and to you also Dr. Wynes for sharing all of your insights with us today. And thank you to the listeners for tuning in as always. You can see this and other episodes of Podiatry Today Podcasts by going to podiatrytoday.com. Spotify, Apple Podcasts or your favorite podcast platforms.