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Keywords:

  • ultrasound;
  • fellowship;
  • emergency

Abstract

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Limitations
  7. Conclusions
  8. Acknowledgments
  9. References

Objectives:  Over the past decade, emergency medicine ultrasound (US) fellowships have proliferated, yet there are no published data describing employment trends among fellowship graduates. This study sought to assess factors motivating emergency physicians to pursue an US fellowship and to characterize their employment and job satisfaction after graduation.

Methods:  An electronic survey was conducted of US fellows and graduates representing all 35 known fellowship programs. Non-responders were contacted at 2 weeks to encourage participation. Primary outcome measurements were the importance of factors motivating individuals to pursue an US fellowship (as rated on a numeric scale), job satisfaction among US fellowship graduates, the proportion of respondents practicing in academic versus community hospitals, clinical hours per week, and the rate of procurement of one’s top choice of job after graduation. The chi-square test or Fisher’s exact test was used for categorical variables, and the Mann-Whitney U-test was used to compare continuous variables between two groups.

Results:  Of 170 invitations sent, 10 were undeliverable. The response rate was 61%; 74 graduates and 23 fellows completed the survey. Enhancing job opportunities, enjoyment of US, long-term job satisfaction and gaining skills not learned in residency rated highest as reasons for pursuing an US fellowship. Among graduates, 20% are satisfied with their current job, while 78% are very satisfied or extremely satisfied. Nearly one-third of graduates (31%) work primarily in non-academic hospitals, while only 9% of current fellows aspire to work in non-academic settings in the future. There was no difference in job satisfaction between academic- and community-based graduates. In comparison to those graduating in previous years, fellows graduating in 2008 were less likely to get their top job (97% vs. 75.0%, p = 0.018).

Conclusions:  Job satisfaction is high among US fellowship graduates and is unrelated to academic versus community affiliation. Three-fourths of recent graduates obtain their top choice of job upon completion of fellowship.

ACADEMIC EMERGENCY MEDICINE 2010; 17:644–648 © 2010 by the Society for Academic Emergency Medicine

Following publication of the first model curriculum for emergency ultrasound (US) in 1994,1 emergency physician (EP)-performed ultrasonography evolved in a few short years into a core component of residency training in emergency medicine (EM).2–4 Early on, those tasked with training residents5,6 and providing quality assurance5,7 were EPs who had completed residency before the advent of US fellowships. Since the late 1990s, however, US fellowships have proliferated.8,9 Over 170 EPs are known to have pursued fellowship training at 35 different institutions. Numerous graduates of these programs have pursued careers as academic EPs, many as US fellowship directors. Others have applied their skills in the community setting. In view of the increasing interest in specialized training in ultrasonography, academic mentors must be prepared to offer sound career advice to residents considering postgraduate training in this fast-growing subspecialty of EM. Additionally, departmental leaders seeking to hire specialists in emergency US will be well served by having an appreciation of the job characteristics of individuals who have completed US fellowship training. To our knowledge, no published studies have examined the factors motivating EPs to pursue further training in US or have sought to determine whether these individuals are satisfied in their postfellowship employment. The purpose of this study was to describe motivating factors for pursuing fellowship, job satisfaction after completion of training, the rate of obtaining one’s top choice of job upon graduation, and the career track taken by graduates.

Methods

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Limitations
  7. Conclusions
  8. Acknowledgments
  9. References

Study Design and Population

This institutional review board–approved study was conducted electronically using questionnaires drafted by the investigators. Current and former US fellows were identified by contacting US fellowship directors. Any current or former US fellow for whom an e-mail address could be obtained was eligible for inclusion in the study.

Survey Content and Administration

Two questionnaires were developed, one for current and one for former fellows. The questionnaires were piloted once for readability and clarity among five local EM fellows pursuing further training in areas other than US. The functionality of the Web-based surveys was tested by the investigators prior to distribution. No questions were mandatory for survey completion, and respondents were able to review and change answers to preceding questions before submission.

Three of the investigators, who are active in the Society for Academic Emergency Medicine (SAEM) Ultrasound Interest Group, contacted group members and residency programs to identify additional individuals not identified through the query of fellowship directors. The project was advertised, and participation was encouraged at an interest group meeting held 1 month prior to distribution of the survey.

The survey was distributed by e-mail with an electronic link in November 2008. A follow-up e-mail was sent to non-responders 2 weeks later. The e-mail informed potential participants that the survey was entirely voluntary and that identifying data would be kept confidential. No incentives were offered for participation. Duplication of surveys was prevented by review of linked e-mail addresses.

Primary outcome measurements were the importance of factors motivating individuals to pursue an US fellowship (as rated on a numeric scale), job satisfaction among US fellowship graduates, the proportion of respondents practicing in academic versus community hospitals, clinical hours per week, and the rate of procurement of one’s top choice of job upon graduation.

Data Analysis

Data were down-loaded into Microsoft Excel (Microsoft Corp., Redmond, WA) and imported into SPSS 17.0 for Windows (SPSS Inc, Chicago, IL) for analyses. The survey results were de-identified by support staff so that responses remained anonymous to the investigators. The scale ran from 0 to 10, and missing values for scaled variables were automatically coded by the survey instrument at midrange (5). The chi-square test or Fisher’s exact test was used for categorical variables, and the Mann-Whitney U-test was used to compare continuous variables between two groups. Statistical significance was assumed when p < 0.05; Bonferroni’s correction was performed for multiple comparisons.

Results

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Limitations
  7. Conclusions
  8. Acknowledgments
  9. References

We identified 172 EPs who had graduated from or were currently enrolled in an US fellowship as of November 2008 (130 graduates, 42 current fellows). No e-mail address could be ascertained for two individuals; 10 others had a nonworking e-mail address. Among the remaining 160 potential respondents, 97 fellows (74 graduates, 23 current) completed the survey for a response rate of 61%. There was no difference in response rate between graduates and current fellows.

Survey results for primary outcome measures are listed in Table 1. Fellows rated enhancing job prospects highest among factors influencing their decision to pursue fellowship, followed closely by enhancing job satisfaction, gaining new skills not acquired in residency, and enjoyment of US. More than three-fourths of those surveyed reported being very satisfied or extremely satisfied with their current employment; only one respondent was unsatisfied. Approximately two-thirds of fellowship graduates work primarily in an academic setting. There was no difference in job satisfaction between academic- and community-based practitioners. Graduates employed in academic settings work fewer clinical hours and devote more time to education, research, and administrative duties than their peers in community practice. While the large majority of fellows got their top choice of job upon completion of their training, significantly fewer did in 2008 than in previous years.

Table 1.    Survey Data From 74 US Fellowship Graduates (Questions 1–5) and 23 Current (2008–09) Fellows (Question 1)
1) Please rate the importance of each of the following in your decision to pursue an ultrasound fellowship, median (range)
 Enhance job prospects9 (2–10)
 Enhance job satisfaction8 (1–10)
 Gain new skills 8 (1–10)
 Enjoy ultrasound8 (0–10)
 Augment salary5 (0–10)
 Decide on career5 (0–10)
 Fits with spouse/partner/family’s plans3 (0–10)
2) Please rate your overall job satisfaction, n (%)
 Extremely satisfied23 (31)
 Very satisfied35 (47)
 Satisfied15 (20)
 Unsatisfied1 (1)
 Very unsatisfied0 (0)
Extremely unsatisfied0 (0)
3) Which of the following best describes the hospital where you spend most of your clinical time? n (%)
 Academic47 (64)
 Community23 (31)
 Nearly equal at each4 (5)
  1. Importance scale: 0 = not at all important; 10 = very important

  2. US = ultrasound.

  3. *Bonferroni correction required a p-value less than 0.0125 for statistical significance.

4) Please indicate the approximate number of hours per week that you spend on each of the following, median (range)
 AcademicCommunityp-value*
Clinical shifts24 (8–80)32 (21–100)<0.001
Education8 (2–40)2 (0–10)<0.001
Research4 (0–24)0 (0–1)<0.001
Administrative duties6 (0–20)1 (0–15)<0.001
5) After fellowship did you get your top choice of jobs? n/N (%)
 Graduates, 1997–2007Graduates, 2008p
Yes56/58 (97)12/16 (75)0.018

Secondary results are listed in Table 2. In addition to the job titles listed, 12 graduates (16%) also reported serving as fellowship directors. All respondents describing themselves as assistant or associate US directors graduated within the past 5 years. Fewer than 10% of current fellows planned to work primarily in a community-based practice after graduating. Among both academic- and community-based graduates, 36% reported that an US fellowship had increased their earnings.

Table 2.    Survey Data From 74 US Fellowship Graduates (Questions 1–3) and 23 Current Fellows (Question 4)
1) Which of the following accurately describes your current position? n (%)
Ultrasound director50 (68)
Assistant/associate ultrasound director12 (16)
Other12 (16)
2) Do you currently have American Registry of Diagnostic Medical Sonographers (RDMS) certification? n/N (%)
 Graduates, 1997–2007Graduates, 2008p-value
Yes41/58 (71)7/16 (44)0.074
3) Compared to colleagues in your practice who completed residency around the time you did, how has graduating from a fellowship affected your clinical hours?*n (%)
 AcademicCommunityp-value
Decreased33 (70)9 (39)0.013
Not decreased14 (30)14 (61) 
  1. US = ultrasound.

  2. *Data excludes four graduates who spend equal time in academic and community settings.

4) What type of practice setting do you want to work in? n (%)
Academic11 (48)
Community2 (9)
Blend10 (43)

Among graduates, 15% were members of their program’s inaugural class; 46% had no classmates during fellowship, and 17% had more than one classmate. Eleven current fellows (48%) trained at residency programs offering an US fellowship; 9 of those 11 remained at their home institutions for fellowship training. When asked to rate the US training they received during residency, 26% of current fellows reported receiving outstanding training, 30% excellent, 17% good or acceptable, and 26% poor or very poor training. Among all fellows surveyed, 34% considered pursuing a different fellowship; toxicology was the most frequently cited alternative. Overall, 90% of graduates and 100% of current fellows would recommend US fellowship to others.

Among all scaled variables, 16% were coded at midrange (5 of 10). A noticeably higher percentage of variables were coded at midrange for a question about the importance of salary augmentation in one’s decision to pursue a US fellowship (34%) and for a question about moonlighting opportunities (30%). Otherwise, no appreciable pattern existed for data coded at midrange.

Discussion

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Limitations
  7. Conclusions
  8. Acknowledgments
  9. References

Since the introduction of bedside US into EM residency training in the mid-1990s, demand has emerged for specialists in emergency US capable of training others in the use of this modality. To meet this demand, dedicated US fellowship programs began to appear in the late 1990s and have since proliferated.8 This survey reveals high job satisfaction among US fellowship graduates irrespective of practice setting. Nearly two-thirds of graduates remain in academia, while approximately one-third practice community EM. The breadth of clinical practice undertaken by US fellowship graduates demonstrates the maturation of emergency US as a subspecialty of EM. Academic mentors must be cognizant of employment trends within this subspecialty to provide sound advice to residents with an interest in emergency US.

Enhancing job prospects is the leading factor motivating individuals to pursue an US fellowship. Although three-fourths of 2008 graduates obtained their top job upon graduation, this proportion was significantly lower than in previous years. This decrement could reflect a decreasing availability of US directorships at academic institutions. It is interesting to note that 16% of all graduates are currently employed as assistant US directors and that all of these individuals graduated from fellowship within the past 5 years. Whether academic departments in the future will have one, two, or several faculty physicians with US fellowship training remains to be seen. As the subspecialty of emergency US continues to mature, it is likely that future fellowship graduates aspiring to an academic career will find higher demand for their training at newer residency programs or in areas of the country geographically distant from an US fellowship.

In addition to enhancing job prospects, other important motivating factors were enjoyment of US, enhancing long-term job satisfaction, and gaining skills not acquired during residency. The presence of the latter as a significant motivator is likely explained by two contrasting experiences with US during residency. For some, residency provided average or above average training in basic sonography, yet US fellowships represented an opportunity to obtain more advanced skills. For others, residency provided below average training in sonography, and fellowships offered an opportunity to acquire both basic and advanced skills. The fact that more than a quarter of current fellows surveyed described their residency training in US as poor or very poor underscores the need for more progress in teaching bedside US during residency.

Limitations

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Limitations
  7. Conclusions
  8. Acknowledgments
  9. References

Our survey is limited by the relatively small number of individuals who have completed an US fellowship. Identifying all of the individuals who have completed an US fellowship is difficult, and while it is possible that some current or former fellows were not identified, we believe that our efforts were exhaustive. Second, although our response rate of 61% was good in comparison to other electronic surveys of physicians,10,11 our results may be subject to selection bias if those not motivated to complete the survey had different views and experiences (e.g., more likely to work in community hospitals or to have lower job satisfaction) than those who responded. Third, as with any survey, ours may have been subject to response bias, whereby the respondent answers based on what he or she believes the surveyor wants to hear (e.g., that the respondent would recommend an US fellowship to others) rather than what he or she actually believes. Finally, for scaled variables, our survey instrument automatically coded missing data at midrange. Based on the high percentage of midrange responses related to remuneration, it is possible that our findings underestimated the importance of salary augmentation as a motivator for pursuing an US fellowship. Although we found no other questions that followed a similar pattern, the potential effect of coding missing data at midrange would be to bias our results against responses at either extreme.

Conclusions

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Limitations
  7. Conclusions
  8. Acknowledgments
  9. References

This study suggests that job satisfaction is quite high among ultrasound fellowship graduates and is unrelated to whether one practices in a community hospital, as nearly one-third do, or in an academic setting. While the proportion of graduates hired into their top choice of job after fellowship appears to be decreasing in comparison to previous years, three out of four recent graduates still get their preferred job upon completion of training. Academic mentors should be knowledgeable of employment trends in emergency ultrasound to provide proper guidance to those considering a career in this rapidly changing subspecialty of emergency medicine.

Acknowledgments

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Limitations
  7. Conclusions
  8. Acknowledgments
  9. References

The authors wish to thank Todd Roat for his assistance designing the web-based survey and managing data collection.

References

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Limitations
  7. Conclusions
  8. Acknowledgments
  9. References