#449 - What Do Division Heads Think About the Shortened Fellowship Proposal?

Hello friends 👋

What would it really mean to shorten neonatology fellowship training to two years? In this episode, Ben and co-host Dr. Shetal Shah sit down with three division heads, Dr. Jill Maron (Brown), Dr. Patrick McNamara (University of Iowa), and Dr. Sarah Taylor (Yale), to examine the ABP's proposed changes from the perspective of those who run major academic NICUs. From the operational and financial strain of losing an entire class of third-year fellows, to the erosion of scholarly development, dwell time, and faculty wellbeing, the conversation makes clear that the costs of this proposal go far deeper than the curriculum. How do you staff an 80-bed NICU without junior fellows? Who funds the gap? And what happens to the next generation of academic neonatologists if we train them in isolation from the very experiences that shape their identity as clinicians and scholars?

Link to episode on youtube: https://youtu.be/jcGJHwdCZvw

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The transcript of today's episode can be found below 👇

Ben Courchia (00:00) Hello, everybody. Welcome back to the Incubator Podcast. We are back today for a special episode. I am in the studio with my co-host for the day, Dr. Shah. Thank you for helping me co-host this important episode.

Shetal Shah (00:15) Thank you so much for having me. I'm happy to ride shotgun to you, Ben, as always.

Ben Courchia (00:19) We are joined in the studio by three impressive guests today, who are all respective division heads at their institution, to discuss some of the proposed changes to fellowship training. We have the pleasure of having with us Dr. Maron from Brown. Jill, welcome to the podcast.

Jill Maron (00:43) Thanks for having me, Ben. I'm happy to be here.

Ben Courchia (00:45) We have Dr. Patrick McNamara, who is division head at the University of Iowa and co-chair of the Association of Academic Division Directors of Neonatology — the AANDD — which he co-chairs with our good friend Dr. Misty Good, who for scheduling reasons is not here with us today. Patrick, thank you for coming back to the podcast.

Patrick McNamara (01:13) Thanks, Ben, for the introduction and for hosting this initiative.

Ben Courchia (01:16) And last but not least, we have Dr. Sarah Taylor, division head of the Neonatal Division at Yale. Sarah, thank you so much for joining us as well. I would love to get this conversation started. We had the pleasure of hosting another group of physicians earlier on — fellowship directors — to discuss the implications of these changes. And when we talk to fellowship program directors, the focus is usually on curriculum, on whether we can really train a fellow in 24 months. But as division heads, you manage entire clinical service lines. If we lose an entire class of third-year fellows who very often function as junior attendings, what does that do to the operational stability of major NICUs? Jill, I'll let you take this one first.

Jill Maron (02:14) Sure, thanks Ben. I mean, logistically, it's been really hard to even begin to wrap our heads around what this would mean mathematically — what it would mean for coverage, what it would mean for training. I'm a little unique in the world of division heads because I sit at a Women and Infants Hospital, entirely separate from the Department of Pediatrics from both a financial and regulatory standpoint. So I think about two options: do I actually reduce the class, or do I try to keep five in one year? We are hoping to have ten and hold five in a year. And can I train them, or am I really going to dilute their training? Because to get them their hours, I'd need two fellows on every night. And from my standpoint, when you're staffing an 80-bed high-level NICU, two fellows a night are cheaper than two advanced care practitioners. There's a lot that goes into this, and I think you'll hear from all of us — we're all coming from different perspectives about what this looks like mathematically. I haven't committed one way or the other.

Patrick McNamara (03:46) I think everywhere has its own unique situation. But the starting point for us is that we do align in thinking that our trainees are graduating with perhaps less expertise than before, and there are a lot of reasons for that. Most programs have more fellows, so people do less call. In our program alone, over the last eight to ten years, the number of hours per year of night call per individual has dropped by about 300 hours — so it's not a big surprise that trainees are missing roughly a thousand hours of work over three years compared to the past. And then we've gone in-house, which has benefits but also ramifications. The challenge is putting a square peg into a round hole — concentrating high-acuity, high-intensity learning into a shorter period of time. The big question for me is: is it sustainable from a wellness perspective? Who will actually do that job? It's more hours of work in a shorter period of time. That's my biggest immediate concern.

Ben Courchia (05:13) And those time periods between clinical duties are very healthy — they're a resourceful time for people to reset, because it's emotionally taxing to be in the NICU. Sarah, I'm wondering if you have any thoughts on the clinical and operational impact this might have on your unit.

Sarah Taylor (05:39) Yeah, I think there are really two areas we've already touched on. The financial impact is huge. We're doing a lot of math right now trying to figure out how this could work while prioritizing fellows' exposure within 18 months or two years and balancing their wellbeing. I honestly don't see how the wellbeing math works. About 40% of fellows report feeling emotionally drained and worn out at the end of shifts. To me, that math doesn't work to protect people's wellbeing. And then there's the workforce question — if we have fewer fellows, or they're doubling up and covering fewer positions, do we fill those gaps with attendings? With advanced practice providers? Some fellows are already doing a year as a pediatric hospitalist before fellowship and getting fantastic training. There's a cost to that compared to a fellow, of course. And if we're bringing in more APPs who are also learners, you've got multiple people competing for procedures on a given night. There's so much math here around dividing up clinical time, skills-building, and cost.

Shetal Shah (07:44) I just want to add one thing. Everyone has talked about integrating wellness into a potential shortened timeline. But there's more and more discussion online about the concept of what they call "dwell time" — the time you need not just to rejuvenate, but to become more reflective. When we're in the unit, a lot of us are reading and reacting constantly. It's really in those non-service periods — doing research, stepping back — that you figure out what kind of neonatologist you want to be. When we talk about the end of training, we also need to ask: what are the skills of the people we're graduating? Are we going to graduate people who are superb at reading and reacting, or people who can also think about why protocols exist, whether they should be reevaluated, and how data should be integrated? That's a really important point for the long-term future of the specialty. Can I ask a question to all three of you? When you first read the ABP's statement, what was the first thing that came to mind from your perspective of overseeing an entire division?

Ben Courchia (09:26) Sarah, do you want to take this first?

Sarah Taylor (09:28) Sure. I think the first thing that came to me was that it was a call to change the approach to optimize confidence — recognizing some weakness there, and trying to correct it. And to me, the approach is going to do the opposite. I really don't see how this works. We all share the goal of confidence — the board, us, the fellows themselves. We want everyone to feel confident that they can handle what comes into the NICU, assess the situation, know the literature. And Shetal makes a really important point — preparing to present in an academic setting is a huge part of the learning, as is really understanding quality and safety. If they don't have time for those things, they're going to miss a significant part of their education. We can do better in neonatal fellowship, but I don't see how this current approach achieves that.

Patrick McNamara (10:50) Yeah, apart from the immediate shock — and we had a similar shock two years ago with the reduction in resident training time — I think the second big thing for me was: what is actually broken? If we look at neonatology as a field, outcomes have gotten better, clinical care has progressed, we've evolved as a specialty. So what is the problem that needs to be solved? Yes, new faculty are less experienced, and if you train fewer hours as a trainee, you will be less experienced as faculty. But why did nobody reach out to the people who are the experts — the training program directors — to get their guidance on what's wrong and how to fix it together? That was my concern. You want the most expert people to come up with the solution.

Jill Maron (12:26) I agree with everything that's already been said. When I first saw that statement, my gut instinct was: they don't understand what we're doing. They don't understand how this works. And it's also very clear to me that the ACGME and the ABP are not talking to each other. The right hand doesn't know what the left hand is doing, because now they've set us up for failure. They've reduced training during critical time in residency, handed us near-complete novices, and said: train them in 18 months. And by the way, we're doing this because what you're training now isn't coming out confident. To me, this is 23 years in the making. It was 23 years ago that hours were reduced — for all the right reasons — but nobody ever made up for the loss in training. And now the fruits of that are coming to the forefront. The root of it, in my mind, is money. Individuals have too much debt and are making too little for too long. And in addressing that problem, we've created trainees that aren't ready and aren't passing boards. Of course they're not ready. We took away hours and hours of training and said: go do it. But training is essential. There was a reason we all did it. And the solution was never going to be: you can become the same neonatologist with far fewer hours. It doesn't work, and now we're seeing it.

Ben Courchia (14:34) Very interesting. I want to give the mic to Shetal, because one of the components of the ABP's proposal is to completely remove the mandatory scholarly work product. Shetal, do you want to share your thoughts on that, and what our panelists think?

Shetal Shah (15:01) Sure. Obviously all three of you come from academic medicine, as do I, and we have a deep attachment to our scholarly work. I found my groove in academic medicine during my fellowship, and I worry significantly about two things. One is the potential loss of scholarship — understanding the biologic basis of disease, clinical trials, how we care for babies at the bedside. But I also worry about all the other things that now qualify as scholarship: QI, neonatal hemodynamics, bench research, clinical research, education scholarship. If we remove those requirements, what does that mean when you're interviewing new faculty who've come out of a two-year program without a developed focus — or without the opportunity to develop one?

Patrick McNamara (16:29) It's a big issue and one of my biggest concerns. In training, you need time to think, reflect, and build yourself. I tell our trainees: when you're going to faculty interviews, you need to be able to shine, to stand out. The most uninspiring letters say something like "I like taking care of sick babies and I like to teach." That's nothing — that's what everybody should be able to do. Who are you as a person? What's your area of academic focus? Whether it's research, a subspecialty niche like hemodynamics or neurocritical care, QI, or education — you can't develop that without time. The future of our field depends on people who can look at a case, reflect on it, review the literature, engage with colleagues. I think there's been a misinterpretation that the purpose of the third year is to train physician scientists. Yes, we need them — but we also need people with diverse expertise. Like in football: you can't have 11 forwards. You need a goalkeeper, midfielders, wingers. Developing those unique skills and bringing them together under a philosophy of care — that's all going to be lost. What we're talking about is training people who can only do X, Y, and Z and cannot think beyond that. That's terrifying.

Ben Courchia (18:40) Eighteen minutes in and we finally got the football reference from Patrick.

Patrick McNamara (18:44) Hey, it took me 18 minutes. Okay.

Ben Courchia (18:49) Sarah, any thoughts on what we're compromising from an educational standpoint?

Sarah Taylor (18:52) Absolutely. Your ability to review and analyze the literature improves through all of it — QI work, research, all of that academic activity. What I worry about personally is that I hire people on an academic track here at Yale. We have a clinical academic track where you can be promoted for programmatic development — leading QI, leading education. There are wonderful pathways. But you need that foundation from fellowship to understand what a scholarly product is and how to be promoted. So I've been thinking not only about the math of how we would do this, but about the fact that I'm going to need to spend the first six months with new faculty doing a bootcamp: this is how you are an academician in neonatology, let's find your niche, let's find where you're going to make a difference. Because if they're not getting that during fellowship, the academic confidence is going to be lost — not only from removing the scholarly product requirement, but from the inability to have that reflection time to dig deeper.

Jill Maron (20:42) Just like Sarah, at Brown you cannot maintain your academic appointment without publishing. They look at it in three-to-five-year blocks. That's a requirement. I want to hone in on what Shetal said about "dwell time," because I didn't know that concept but it's so true. I'm proud of the diversity of skill sets my faculty bring. I have people who fell in love with clinical informatics during their training — I'm now supporting them in getting a master's. I have faculty who fell in love with QI and I've supported one in finishing a QI master's at Penn. And every single one of my faculty — whether it's med-ed, POCUS, informatics, palliative care, qualitative science — brings those skills to the patient at the bedside every single day. If that's lost, the impact isn't abstract. It's tangible. And the idea that most fellows won't have academic careers? That's just not where we want this field to go.

Ben Courchia (22:39) One of the advantages of having such a strong panel today is that when fellows enter fellowship, they meet program directors — our guests from the previous episode. But when they're looking for a job, they'll be in front of you. How will you evaluate someone who graduated from a two-year fellowship versus someone who did the optional third year? I think your answers will matter tremendously for people making decisions about their training. Patrick, maybe you can take this one first.

Patrick McNamara (23:36) That's probably the most important question, and I think you'd see a lot of consistency across our answers. To be in an academic center, you have to be trained as an academic person. My own pyramid of recruitment starts with: are you a good person, do you care about patients — and then: do you have a unique area of academic focus, and does it align with our subprograms in hemodynamics, neurocritical care, and extreme prematurity? I don't know how anyone coming out of a two-year program differentiates themselves enough to be on a division director's radar. And I'd go even further: I think of our hemodynamics program, which is a post-subspecialty fellowship. I don't know how fellows from a two-year track would be attractive candidates for that — and that's not even a faculty position. The ramifications for academic medicine are major.

Sarah Taylor (24:55) I agree with everything Patrick said, and I'd add: sometimes fellowship gives you the opportunity to figure out what you don't want to do. I love that about fellowship. Go to the lab and find out if you love it or you don't. Lead a QI project and do the same. What makes me most nervous is that people are losing that opportunity — to either fall in love with something new, or to realize it's actually not the right fit.

Jill Maron (25:47) Confronted with that question, it's just not appealing to me at all to hire someone who only had two years. I love building complementary teams. How do you fit here? I deliberately keep clinical hours for all my faculty lower than recommended because I expect substantial contribution to the academic mission — QI, whatever their passion is. I have K awardees. That is the expectation at Brown. And that is how I want to build and sustain a division. There are private practice NICUs. I'm not that. And it would make me very sad if that's what we became, because it is a detriment to the care we provide.

Ben Courchia (26:53) Time is flying, so I want to make sure Shetal gets to ask a few more questions.

Shetal Shah (27:01) One of the unique things you do as division heads — something most of us are somewhat blind to — is managing budgets and income. So my question is: how are you looking at financing for someone who either finishes two years and hasn't yet met all the competency-based milestones and needs more time, or who has completed two years and wants a third year to pursue scholarly work? Where is the money going to come from?

Jill Maron (28:09) Shetal, this is what makes my head spin. I present that budget directly to the hospital — I sit outside of pediatrics. And in addition to the competency question, I'm thinking about this: one maternity leave sends me into year three. One. We always have maternity leaves — this is the age when people have children. There is no way the 18-month model has accounted for a single maternity leave. So I have to budget for that every year, and I genuinely don't know how.

Sarah Taylor (29:21) We have to start by communicating deeply with the GME office. We have a great one here at Yale — incredibly collaborative and open to looking at needs. I had a conversation with the vice chair of education just last night about getting in front of the ACGME to have the right conversations about funding. After that, we have to ask: where is it a worthy investment? Using funds on one thing means taking them away from somewhere else. And I'm nervous, because GME offices are in budget crisis along with hospitals and universities. When they have the option to pay less, they have to weigh that against other obligations. So I'm very nervous about where the funds are going to come from — but we have to start working on it and see what we can negotiate.

Patrick McNamara (31:10) The answer will vary across institutions because hospital finances are so variable. My biggest concern is that we'll enter an era of haves and have-nots. Well-funded institutions will easily support three years. Others will become two-year programs because the hospital simply says no. And a group in the middle will be desperately trying to sustain a three-year program while begging and borrowing to make it happen. And the long-term effect — which we haven't talked about enough — is that when we have fewer neonatologists and NICUs become non-physician-led enterprises, the revenue stops flowing to departments of pediatrics. Our program here drives 60% of the revenue for the department. If you limit the pipeline to neonatology, the sustainability of not just our field but of pediatrics and pediatric subspecialties is at risk. Just like what Jill mentioned about 23 years ago — you make a change, and a generation later you see the effect. There are going to be major repercussions down the road if we don't pay attention to this now.

Ben Courchia (33:08) This is coming at a watershed moment for our field, where the struggles with recruitment and staffing are not going to be helped by any of these proposed changes. Shetal, do you have any parting questions for the group?

Shetal Shah (36:01) Yes, and I'm a little scared to ask it because it's more than a parting question. Taking advantage of your unique spheres of influence — you're overseeing not just the fellows but the attendings, the clinical enterprise, regional networks, nursing staff, all of it. We've spent a lot of time talking about the implications for fellows. What do you foresee as the implications — in terms of workload or financing — on the rest of your faculty, both newer attendings and those who've been with you for ten, fifteen, twenty years? Is this extra work just going to be added onto them, or are you going to have to find novel ways to incentivize it? I ask because in competency-based medical education, increased assessment workload is well-documented — every procedure, every skill needs to be evaluated, which is a significant time burden and takes time away from other patients.

Sarah Taylor (37:40) This whole exercise has made us realize how much we appreciate our fellows and what an incredible service they provide. They're often the constant in the NICU — finger on the pulse of everything, attuned to what the nursing staff is feeling. They play an incredibly important role in that environment. So yes, if this changes, the ripple effect is going to be large. I can make some predictions — you're likely looking at increased attendings or APPs in the NICU — but I don't have a full answer yet. What I do know is that the burnout piece really scares me. If you come out of fellowship already burned out, it's going to be hard to get motivated for the excitement of being a new attending. That's one of my biggest fears.

Jill Maron (39:20) Shetal, I'm going to have to trust some creative thinking here, because we're going to have to get creative. What I'm noticing is that the buck keeps stopping with the attending. And over the years, attendings have just continued to absorb more and more — and they're not going to keep absorbing indefinitely. We're going to have to figure out creative solutions to what these changes will do to our staffing models and our level of expertise. It can't just be "let the attending cover it" — and I'm guilty of that too. That will break the entire system if we don't start thinking differently.

Patrick McNamara (40:09) It's not just the clinical oversight — it's also training new faculty in how to do QI, how to develop a research project. That takes time. And we're in an era where hours matter. Neonatology has agreed on a statement of 1,650 hours as a 0.8 clinical FTE. All these added hours have to be factored in, which basically means we need more faculty — and more faculty means more cost. There's no way around that. If people have needs, we need to meet them, because our primary goal is to make sure patients receive the best possible care. That may mean having a second faculty member overseeing junior faculty during clinical hours or overnight. There's no way around it, and that's scary.

Ben Courchia (41:13) Dr. Sarah Taylor, Dr. Patrick McNamara, Dr. Jill Maron — thank you so much for making the time today. Shetal, thank you for co-hosting. This is only the beginning of a very important conversation for our field. Please continue to engage with the ABP, the ACGME, the AANDD, and others to make your voices heard. Thank you all, and have a good rest of your day.

Jill Maron (41:53) Thanks, Ben.

Patrick McNamara (41:53) Thank you, Ben. Thank you, Shetal.

Shetal Shah (41:54) Thank you.