Step 5: Implementation � � � � � � � � � � � � � � � � � � � �

During this step, the necessary actions are taken to make the fellowship a reality� This includes obtaining support, trialing the curriculum, initiating the program, and the dynamic process of constantly evaluating and refining the program�

Obtaining Support

Obtaining institutional and departmental support for the fellowship program is a crucial step during implementation� The initial step includes acquiring support and buy-in from additional faculty members in the subspecialty and the administrative team in the department� Once support has been established within the department, the fellowship program can be presented to the graduate medical education (GME) office and hospital leadership� A new program may be required to seek approval from additional departments if the training program impacts multiple departments�

Identifying and Procuring Resources

One potential barrier to long-term success of a fellowship is sustainable funding� Local, institutional practices generally determine funding sources and mechanisms� Funding for ACGME-accredited fellowship programs typically falls to the sponsoring institution, whereas non-ACGME fellowship program funding is complex, derived from departments or divisions, grants, or even partnership with public entities or private industry� This presents both additional opportunities and challenges� Strategies for funding of non-ACGME accredited EM fellowships appear to be highly variable across institutions� No single, definitive best practice was identified, however some common themes did emerge in our exploration� In general, to support long-term viability, fellowship programs should at least be budget neutral� Expenses to be considered include: fellow(s) salary and benefits, fellowship director(s) stipend and/or reduction in clinical commitment, fellow malpractice coverage if practicing clinically as part of the program, institutional overhead expenses calculated and allocated per local practice, fellow CME/travel expenses, fellow membership in relevant national/regional organizations and other resources to support fellow education and scholarly activity such as online access to journals, statistical analysis tools, etc�

In the majority of EM fellowship programs interviewed, funding to support the fellowship primarily derived from revenue generated by fellows’ practice in clinical settings affiliated with the sponsoring institution� In a common model, fellows are paid a trainee salary based on local post-graduate year norms for a predetermined clinical commitment� The difference between a faculty salary and a post-graduate trainee salary for that clinical commitment served to support the cost incurred for the fellows’ training� In many programs, fellows are given the opportunity to practice clinically beyond the base commitment in order to increase their overall salary� The additional clinical time appeared most often to be compensated at rates similar to junior faculty, although some models compensated fellows at a lower rate than faculty� Alternative sources of funding were uncovered in our exploration, but they were rare� In a few cases, programs and/or fellows were able to secure scholarships to partially support salary or other fellowship related expenses� In general, these appeared to be one-time opportunities or of limited duration� Philanthropy represents another potential alternative source of revenue� One EM fellowship program reported securing an endowment sufficient enough to support a portion of fellowship-related expenses in perpetuity� If the fellowship can provide a paid service or partner with a business or non-governmental organization, it may be possible to generate funds to offset costs associated with the fellowship� This method is rare and can be complicated� It may require additional oversight, institutional buyin, and approval�

Pursuit of additional degrees (e�g� Master’s, PhD) as part of a fellowship program adds further complexity to the funding modeling for fellowship programs� Funding for this portion of training appears to vary to an even greater degree among programs� Several EM fellowships report partnering with local institutional programs to arrange for a reduced tuition� Fellows may be required to work additional clinical shifts to offset the cost of an advanced degree� During investigation, rare cases of waived tuition were found due to established institutional policies or as a result of collaboration between the department and the program supporting the degree program�

Identifying and Addressing Barriers to Implementation

What are the barriers to implementing the fellowship? Potential barriers to consider are buyin from leadership, personnel including administrative, buy-down for faculty time spent on education, space for fellowship activities including both clinical and educational, equipment, potential impact on other training programs, and funding�

Piloting the Curriculum

One step in the implementation phase that may identify additional barriers is trialing the curriculum via a pilot program� For example: for a medical education fellowship, the curriculum may be trialed via a medical education elective for residents� This provides an opportunity to elicit feedback� Once the curriculum and infrastructure for the fellowship is in place, the program is ready for the first fellow�