Abstract
Introduction
Wilderness medicine (WM) graduate medical education (GME) fellowships were established in 2003. Outcomes and satisfaction of US WM GME fellowship alumni can inform prospective applicants and program directors of the strengths of fellowships and professional gaps in them.
Methods
A 34-question Qualtrics survey was emailed to 111 alumni from 17 institutions listed in the Wilderness Medical Society’s GME database in May 2019. Professional service, scholarship, and satisfaction were queried. Results are represented as percent response (n=answered affirmative) based on the number of respondents per question.
Results
The survey response rate was 41% (n=46); 67% reported (n=31) Fellowship of the Academy of Wilderness Medicine recognition. Within the last 5 y, 71% (n=32) reported publications in WM. Free text entry questions had 78% (n=28) describe improved clinical skills, and 68% (n=26) were exposed to new career choices in fellowship. Those who rated exposure to a variety of WM knowledge and skills highly rated the overall fellowship experience higher (P<0.001), as did those reporting a higher number of WM publications (P=0.023). Nearly half, 48% (n=21), felt they could hold their current position without fellowship training. In hindsight, 76% (n=34) would follow the same professional path.
Conclusions
WM GME fellowship alumni reported high rates of professional engagement and scholarly productivity in the subspecialty. Responding alumni overwhelmingly rated the fellowship experience positively. Fellowships that ensure a wide exposure to experiences and foster scholarly productivity are more likely to yield professionally satisfied graduates.
Keywords
Introduction
University-based graduate medical education (GME) programs offer physicians and other healthcare providers an opportunity to train within a subspecialty and obtain a unique body of knowledge. There is a paucity of studies on wilderness medicine (WM) GME fellowships, and completion of these programs does not generally earn graduates higher pay but instead offers unique knowledge and skills, academic leadership, and scholarship within a subspecialty field. WM GME fellowships are often emergency medicine based, accepting emergency medicine trained physicians and in some cases family medicine trained physicians; few programs accept self-supported physicians from other training backgrounds, nurse practitioners, and physician assistants. Currently all WM GME fellowships, as described above, are US-based programs. The first WM GME fellowship program was established in 2003, and at the time of the survey, there were 15 active WM GME fellowship programs (Table 1). Between the time the study was performed (2019) and time of manuscript publication, the number of active programs has increased 25%, with 5 institutions adding new WM GME fellowships (Table 1 footnote). To date, the accreditation council for GME does not accredit WM fellowship programs since WM is not one of the specialties represented by the American Board of Medical Specialties member boards.
Wilderness medicine fellowship programs and alumni in the United States in 2019
Note: Between the time the survey was sent out and publication, the number of active programs had increased to 20, with the State University of New York Upstate Medical University reinstating its program and Madigan Army Medical Center not currently recruiting. The 5 new institutions include The University of California Irvine School of Medicine; The Geisel School of Medicine at Dartmouth; The University of Nevada, Reno School of Medicine; The Oregon Health and Science University School of Medicine; and The Joe R. and Teresa Lozano Long School of Medicine at The University of Texas Health Science Center at San Antonio.
Retired program as of 2019.
The WM fellowship curriculum is designed to shape fellows into academic leaders, educators, and researchers within the field of WM.1,2 An evaluation of professional outcomes and satisfaction of WM GME fellowship alumni in the United States may guide current and future programs. The objective of this research was to understand how fellows apply their training to advance the WM subspecialty and their careers and to learn about the perceived value of and program satisfaction with a WM fellowship from the perspective of fellowship graduates.
Methods
An online Qualtrics survey was emailed to 111 GME WM fellowship graduates from 17 different institutions in May through June 2019 (Table 2). Emails were obtained through the Wilderness Medical Society (WMS) GME fellowship alumni database. This database is updated annually to include contact information for graduates of GME WM fellowship training programs and is maintained by WM fellowship program directors.
Study survey and response rate
CME, continuing medical education; DiMM, Diploma in Mountain Medicine; FAWM, Fellow of the Academy of Wilderness Medicine; WEMT, wilderness emergency medical technician; WM, wilderness medicine; WMS, Wilderness Medical Society.
The survey consisted of 34 multiple choice, fill in the blank, and preference rank questions written by the researchers (Table 2). Commonly used terms, such as “publication,” “leadership,” and “professor” were not strictly defined in the survey, and respondents independently interpreted each question.
All participants were initially contacted via email and invited to participate in an anonymous and voluntary survey. The survey was active for 8 wk after the first email. An email reminder was sent out to all contacts 1 wk after the initial survey was sent, and a second reminder after 3 wk. Each email contained the same link to the confidential survey. To control for duplicate submissions, only 1 survey response per email address was accepted. Respondents were not offered monetary compensation for their participation.
Inclusion criteria from the database included alumni of any US GME WM fellowship program, with documentation that they graduated on or before June 2019. Alumni of WM fellowship programs from Eastern Virginia Medical School and The State University of New York Upstate Medical University were included as they are part of the alumni database, even though at the time both programs were inactive. For each question on the survey, individuals who provided an answer were included in the data analysis, and not answering a question was permitted.
Exclusion criteria included individuals who hold a Fellow of the Academy of Wilderness Medicine (FAWM) distinction from the WMS but did not complete a GME fellowship. Respondents who did not enter a fellowship institution or graduation year were excluded, and any individual entry with all questions left blank except fellowship institution and/or graduation year was excluded. Any individual who did not answer a question (ie, left blank) but completed the survey was excluded only from the data analysis of the single question.
Data were exported from Qualtrics survey software into an Excel spreadsheet. Descriptive statistics are represented as percent response (n=answered affirmative). Respondents were asked to rate their level of satisfaction across 6 areas of the fellowship program as well as the program overall (Table 3). To determine if satisfaction were equal across satisfaction domains, we conducted a 1-way within-subjects analysis of variance. To determine the factors that impacted the overall satisfaction rating (satisfied overall), we conducted a multiple regression. Analyses were conducted using the R statistical program; missing data were treated using listwise deletion. Regression analysis is presented as (R2 value, P-value) and (β coefficient value, P-value). A P-value of <0.05 was considered statistically significant. Institutional review board approval was obtained through the University of California San Francisco Fresno medical education program.
Satisfaction-related questions
Note: Numeric coding: extremely dissatisfied=1, very dissatisfied=2, slightly dissatisfied=3, neutral=4, slightly satisfied=5, very satisfied=6, extremely satisfied=7. A 1-way within-subjects analysis of variance was conducted to compare differences in satisfaction between questions. The results were not statistically significant (P=0.34).
Results
The survey response rate was 41% (n=46/111). Each survey question and its response rate are outlined in Table 2. In total, respondents collectively reported publication of 190 articles, 114 of these articles within WM and 76 within another field. Satisfaction with different aspects of a structured fellowship training program were all rated highly (Table 3). The survey responses relating to satisfaction were not statistically significantly different depending upon section (P=0.34).
In terms of the overall experience (satisfied overall) we analyzed various covariates to determine which factors of the experience related to overall higher satisfaction ratings. A multiple regression that included satisfaction ratings (Table 3), number of publications, and participation as a mentor in WM was statistically significant (R2=0.80, P<0.001). The results (Table 4) showed that participants who rated exposure to a variety of wilderness medicine knowledge and skills tended to rate the overall experience higher (β=0.79, P<0.001). Additionally, those who had a higher number of publications in wilderness medicine also rated the overall experience higher (β=0.10, P=0.023).
Factors impacting overall WM fellowship program satisfaction
Note. N=43, r2=0.80, P<0.001. Missing data were treated using listwise deletion.
WM, wilderness medicine.
P<0.001.
P<0.05.
Overall, 48% (n=21) of respondents felt they would be able to hold their current occupation and/or job title without the WM fellowship training, with 39% (n=17) feeling it would not be likely and 14% (n=6) unsure or unclear. Professional titles endorsed by respondents in free text responses included emergency medicine physicians, medical directors, assistant professors, clinical instructors, WM fellowship directors, and nurse practitioner. Medical directors reported overseeing emergency medical services, search and rescue, and endurance racing events. Sixty-eight percent (n=26) of respondents felt their WM fellowship exposed them to career choices previously unknown, and named an introduction to academics, fellowship direction, race medicine, and expedition medicine as specific examples. Fifty-six percent (n=14) of respondents stated the WM fellowship influenced their choice in professional position(s), 36% (n=9) of respondents did not think it was influential, and 8% (n=2) were unsure. In hindsight, 76% (n=34) of respondents confirmed they would follow the same professional path, and 7% (n=3) asserted they would have chosen a different institution for their fellowship or criticized their own institution.
Seventy-eight percent (n=28) of respondents described improved clinical skills because of their WM fellowship training, and 22% (n=8) reported minimal/no significant impact on clinical skills. In free text comments, several themes emerged: developed and/or improved outside hospital clinical skills (17%, n=6), developed and/or improved improvisational thinking/leadership and resource management/decision-making skills (17%, n=6), and broadened and/or improved a unique body of WM knowledge and skills (17%, n=6). Ninety-four percent (n=32) felt their personal identity and/or world views were influenced by their fellowship experience.
Discussion
A consensus wilderness medicine curriculum document stated that WM fellowship alumni should be able to demonstrate an understanding of WM knowledge and skills in different environments, possess the skill set necessary for an academic career in WM, and contribute to WM literature.1,2 WM fellowship programs are graduating fellows who report feeling comfortable with the unique skills and knowledge taught during fellowship. High rates of reported publications in WM within the last 5 y suggest the cohort is advancing WM knowledge, regardless of whether these publications were done during or after a fellowship program.
It would have been ideal to compare results of alumni from other nonaccredited GME fellowship pathways predominately populated by the specialty of emergency medicine. A search for similar work was done using the Emergency Medicine Resident Association fellowship guide as reference. 3 A limited number of articles was available; peer-reviewed articles from non-EM specialties are included because they still serve as a point of comparison as the methodology is similar. Fellows illustrate a high degree of professional involvement in a WM professional society or focused group, compared to 78% (n=18/23) participation in informatics professional societies among pathology informatics fellowship alumni. 4 WM fellows are participating in and contributing to the development of WM professional groups. WM societies and focused groups include but are not limited to the WMS, the Undersea and Hyperbaric Medical Society, the Society for Academic Emergency Medicine wilderness medicine interest group, and the American College of Emergency Physicians wilderness medicine section.
A large proportion of WM fellows work in academic medicine, with rates similar to those who complete a medical education fellowship in emergency medicine. 5 Respondents are contributing to the WM profession through high levels of medical society participation, but compared with pediatric emergency medicine fellows, WM fellows hold fewer leadership roles. The number of leadership positions held in the broader scientific community was 10% lower than among graduates of pediatric emergency medicine fellowships. 6 Similarly, the number of minimally invasive surgery fellows who occupy hospital or community leadership roles was 40% higher than among WM fellows. 7 Further research is needed to understand why few fellows hold WM leadership roles within community and hospital settings.
Eighty-eight percent of geriatric emergency medicine fellows and 89% of emergency ultrasound fellows believe completion of their respective fellowships helped them obtain their current career positions, compared to 40% of WM fellowship graduates.8,9 This is significant as it raises questions about the benefits of pursuing a WM fellowship. However, fellowship satisfaction in WM is still high among respondents, and our research shows that fellows are benefiting from their experience not only professionally but also personally. Common themes from free text entries included influence on career choice, a broadened awareness of the global medical community, and confidence and personal identity within the subspecialty. These multidimensional influences are similar to influences among those who complete a fellowship in medical education, without a focus on emergency medicine. 10 Fellows from medical education and WM fellows expressed confidence as educators, a sense of self-reliance, enhanced professional credibility, and an identity within a subspecialty community. 10 Future data collections may attempt to understand the relationship between high fellowship satisfaction and changes in professional and personal outlooks.
This paper focused on US GME fellowships. International medical educational opportunities are not included. There are international certification programs that do not require medical residency training for completion. Examples include the University of Exeter in England, which offers a clinical fellowship in extreme medicine for medical students. The Royal College of Physicians and Surgeons of Glasgow offers a nonclinical, postgraduate international diploma in expedition and wilderness medicine. Many organizations offer a Diploma in Mountain Medicine (DiMM), which is an internationally recognized certification. Although providing a complementary pathway to enhancing personal and professional satisfaction with incorporation of wilderness medicine into a career, fee-based certification programs are not analogous to postgraduate university-based GME training opportunities; direct comparison is not appropriate within the scope of this paper.
A minority of respondents expressed career-changing frustration with the culture of the academic environment. Some did not feel respected, others wished they had chosen different institutions for fellowship, and 2 individuals ultimately did not choose an academic career because of their fellowship experience. This noticeable dissatisfaction could be due to a mismatch in a fellow’s expectations and the reality of their fellowship. Another explanation could be that some programs are new and there is a natural flow of trial and error. There may be a role for a GME committee at professional societies to fill this identified gap both confidentially and systematically.
Further research could explore the program satisfaction and academic productivity of individuals who attain the distinction of being an FAWM through the WMS. A comparison between GME WM fellowships and an FAWM distinction could lead to greater insight into enhanced training and professional satisfaction among professionals who are looking to advance the subspecialty. Fellows who have completed an honorary fellowship in psychiatry, for example, feel the associated mentorship program within the professional society had the greatest potential for future development and was an area of high value to early professionals. 11 The personal satisfaction from mentorship relationships may increase long-term involvement in the subspecialty and should be examined in the context of the distinction of FAWM.
Limitations
The sample and sample size are significant limitations to our study. The WMS GME fellowship database used to collect alumni email addresses was likely not a comprehensive list. Some fellowship directors are not active in the WMS and may not regularly update the database with their graduates. Researchers did not validate email addresses, which may contribute to the small sample size. The population size of WM fellowship alumni, at 111 persons in the database (in 2019), requires a proportionally large ideal sample size of 87 responses to keep the margin of error at 5% if maintaining a confidence level of 95%. Our sample size was only 48 respondents.
In order to make the survey user friendly, and to maximize the number of responses available to interpret, completion of all questions on the survey was not required. The shifting denominator and various sample sizes, by survey question, weakens the generalizability of our conclusions. Future studies would benefit from requiring answers to all questions prior to survey submission.
The study was based on a voluntary response survey and relies on retrospective self-reports, which introduce issues of selection and reporting bias. Due to the anonymity of the survey and the lack of required documentation, overinflated self-reports of research and publication activity are possible. Respondents may have included non-peer-reviewed publications, and it is likely that a single peer-reviewed publication shares multiple co-authors who responded to the survey, inflating the estimation of the total number of publications produced by fellowship alumni. Research publications were not objectively measured by a survey query for personal citations or PubMed IDs due to the time-consuming nature of such an inquiry, and such documentation would eliminate any sort of respondent anonymity. While the majority of respondents are involved in one or more fields of academia, the survey did not query a specify skill set for an academic career, and further research is required to understand if WM fellowship alumni are meeting academic standards.1,2 Honorary titles without administrative responsibilities could have been reported as leadership roles. The lack of verifying self-reports must be considered when reviewing any conclusions from this data. The survey outcomes were limited to US-based publications and leadership opportunities and did not include international programs or degrees.
Conclusions
WM GME fellowship alumni report contributing to the subspecialty through high rates of professional engagement and scholarly productivity. Reported peer-reviewed publication rate was strongly associated with satisfaction responses. Despite overall high satisfaction with their postgraduate programs, many respondents still felt they would be able to hold their current professional position(s) without the training. WM GME fellowship programs providing a wide exposure to wilderness knowledge and skills are more likely to yield professionally satisfied graduates, thereby increasing the perceived value of the training beyond future job titles.
Footnotes
Acknowledgements
Acknowledgments: The authors acknowledge graduates of WM GME fellowships for contributing to advancing the subspecialty and participating in this study. The authors acknowledge Jannet Castaneda, whose assistance with this project was invaluable.
Author Contributions: Study concept and design (AD, SS); acquisition of the data (AD, SS); analysis of the data (RC, AD, SS); drafting of the manuscript (AD, SS, RC); critical revision of the manuscript (SS, AD, RC); approval of final manuscript (AD, SS, RC).
Financial/Material Support: None.
Disclosures: None.