The phases of hematology-oncology fellowship: A single site qualitative Study

Abstract Background: Medical training consists of stepwise transitions to new and progressively specialized roles (e.g., medical student to intern or fellow to faculty). Each new role requires new clinical knowledge and comes with increasing responsibilities. There are a growing number of studies and interventions created to ease the transition from medical student to residency. However, similar exploration of the transition to subspecialty fellowship is lacking despite this being a challenging period in training. We sought to better understand this crucial inflection phase of training to inform future interventions to support this transition. Methods: Fifteen hematology-oncology fellows at the University of Colorado were recruited to participate via email. To explore fellows' experiences, semi-structured interviews were conducted via Zoom. All fellows were interviewed in September/October 2024. First-year fellows participated in a second interview in March/April 2025 to capture their longitudinal experience. All interviews were audio-recorded, transcribed, de-identified, and then coded in ATLAS.ti (Atlas.ti v.25, Berlin, Germany). The codebook was created using both deductive and induction approaches through iterative review of three transcripts and was reconciled by three team members. The coded data were queried and summarized. Then themes were developed through iterative discussions during team meetings. Results Thirteen fellows were interviewed (5 first-year fellows and 8 upper-year fellows), comprising of 6 men and 7 women. Three distinct transitional phases emerged from the data: 1) pre-fellowship, 2) initial active transition, and 3) plateau/stabilization period. The pre-fellowship phase involves the period before fellowship officially begins and includes preparation for fellowship both professionally (e.g., hematology-oncology specific residency experiences or rotations) and personally (e.g., moving, relationship or family milestones with a new partner or children). During this period, fellows felt an “anxiety of the unknown” and “a fear of failure of not knowing things” (participant #5, first-year). The second phase or active initial transition consists of the first 4 months of fellowship. First-year fellows are taking on the expert consultant role and despite orientation didactics, fellows describe feeling unprepared and overwhelmed. In this initial transition, fellows describe a steep learning curve because “when you start off, everything takes more effort than it does later on. You hafta look everything up” (participant #7, second-year). Work takes longer early on in fellowship because the work is new and unfamiliar, and fellows are having to learn on the job. After 4-6 months, fellows progress into the stabilization/plateau phase. As fellows experienced more repetitions, they gained confidence (e.g. “when you’re asked to solve the same problem over and over again, you become better at doing it” participant #13, second-year and “I've been through all the rotations now, so I kind of-it's more familiar” participant #6, first-year). They also became more comfortable in the hematology-oncology specialist role and excited for their future career. However, the plateau phase was also characterized by cumulative exhaustion from the constant workload and lack of work life balance (e.g. “I still have to finish notes when I get home” participant #4, third-year and “I feel when I leave the hospital I’m still not done most days” participant #11, first-year). Conclusions We identified three distinct phases of the transition to hematology-oncology fellowship: pre-fellowship, active initial transition, and stabilization/plateau. The identification of these phases is crucial as fellowship training programs design interventions to ease the transition, as these interventions should be tailored to the needs and characteristics of each period to be most impactful. Limitations of this study include this being a single center study as program specific structures and culture may have influenced timing of phases. Through qualitative semi-structured interviews, we were able to better understand the transition process from a fellow perspective illustrating the value of qualitative approaches in medical education evaluation and research.