Fellowship Summary 3.3

St. Joseph's Hospital

Department of Academic Affairs

January 2006

Fellowship training is generally considered to be in additional basic science or clinical medicine organized experience after completing one of the 24 basic postgraduate residency training programs recognized by the ACGME.

The ACGME does not formally recognize the term "fellowship", but prefers that these post-residency training programs also be termed "residencies", and the fellows called "residents". Nevertheless, like the term "intern" the terminology has not died.

Official "recognition" of new fellowship programs in the U.S. comes about after a period of "unapproved fellowship status". For example, critical care medicine fellowships started 12 years before formal recognition by the ACGME. Therefore, non-accredited fellowships exist in many areas that are not yet recognized by the American Boards of Medical Specialties or the Accreditation Council for Graduate medical Education. Some Fellowships begin the accreditation trail by first winning recognition from their respective specialty society.

Accredited fellowships are generally tethered to the base residency required for entry into the fellowship. For example, an internal medicine residency may sponsor fellowship programs in cardiovascular disease (adult cardiology), hematology, rheumatology, and 13 other specialty areas, sometimes called subspecialties. Fellowships may not exist without a base residency.

Fellowship training Programs have several general characteristics:

  • They permit graduating residents the ability to develop further skills and more specialized expertise in a focused clinical specialty area
  • They permit residents an entry track to the academic world, with most fellowships requiring substantial basic science or clinical research, in addition to the further specialized clinical training
  • They allow clinical departments to develop a breadth of junior faculty, assisting in research projects and clinical service
  • They permit a decreased clinical workload for faculty
  • Subspecialty fellowships usually come under the sponsorship of a primary residency program
  • They have funding opportunities from extramural sources, from endowments, or private medical groups

ST. JOSEPH'S FELLOWSHIPS

St. Joseph's Hospital's Department of Academic Affairs currently sponsors 4 ACGME accredited fellowship programs:

Geriatric Medicine sponsored by the Family Practice residency

Neurodadiology sponsored by the Diagnostic Radiology Program

Clinical Neurophysiology (epilepsy) sponsored by the Neurology Residency

Sports Medicine sponsored by the Internal Medicine residency Program

Neurovascular Medicine (stroke) <accreditation pending June RRC Meeting>

In addition, Saint Joseph's currently sponsors other non-ACGME Fellowships which are currently "unfilled", including:

Movement Disorders (Parkinson's)

Neuro-Otology (Balance)

Neuro-Oncology

Behavioral and Developmental Pediatrics

Child Abuse Assessment

Academic General Pediatrics

Medical Ethics

Several other fellowships are currently being proposed for 2005-2006 or 2006-2007 within the neurology division:

Cognitive and Behavioral Disorders

Neuro-Immunology

Neuro-Ophthalmology

Five fellowships come under the direction and purview of the Barrow Neurosurgical Associates group through funding by the Barrow Neurological Foundation:

Robert H. Chamberlain Biomechanics Fellowship

Robert F. Spetzler Neurosurgical Research Fellowship

Spine Neurological Surgery Fellowship

Cerebrovascular/Skullbase Surgery Fellowship

Endovascular Surgical Neuroradiology Fellowship

In the past, St. Joseph's medical groups, the hospital, the St. Joseph's / Barrow Foundation and the Flinn Foundation have sponsored other fellowship programs for short periods of time, including

Radiation Oncology

Neuropathology

Neonatal Medicine

The Flinn Fellowship in General Internal Medicine

Pediatric Critical Care

FELLOWSHIP FUNDING

Many fellowships in the United States come under specific research grants or sponsored agencies. Some institutions offer initial findings for two years as "startup" capital so that research can begin and further funding can be sought. For example, NIH grants may cover all or part of the salary of an individual fellow. The American Heart Association sponsors some fellowships in cardiovascular medicine.

Funding of fellowships, has philosophically been viewed as the something not under the direct responsibility of institutions. This has evolved historically for several reasons:

  • Medicare, which funds resident positions, will find fellowship positions at a 0.5 FTE level after initial residency training up to a total of five years of postgraduate training.
  • When the Balanced Budget Act of 1997 capped reimbursement for resident positions, many institutions were over their established CAP, and considered residency of funding a higher priority for the institution, recognizing that fellowship programs can more easily seek outside funding.
  • An argument is often made that the accrual of academic, career, and clinical service benefits to senior faculty or the medical group sponsoring the fellowship is much greater than the compensation of the fellows, thus "the group or clinical division needs to come up with the funding".

St. Joseph's Hospital Academic Affairs held a meeting of fellowship directors in 1993 and found agreement that within two years our fellowships would seek outside funding with the priority of Medicare reimbursement going to our sponsoring residency programs. Thus fellowships would be considered "over the cap" and not be counted towards Medicare reimbursement.

Some of our fellowships sought funding through the Barrow Foundation, under the philosophy that fellows substantially contribute to the research goals of disease-specific endowments. Others sought external funding through community disease foundations, while some medical groups, decided they would directly fund their fellowships from their broader clinical revenues.

St. Joseph's GME Committee has adopted the position that all fellowships, both ACGME and non-ACGME, would come under the jurisdiction of the Department of Academic Affairs for purposes of oversight, employment, contracts, and consistent application of policies and procedures, including the requirement that non-ACGME fellowships are responsible to follow the ACGME Institutional and Common Requirements for all programs.

We have also taken the position that we pay fellows for the level of training designed in the fellowship. For example, the narrower radiology fellowship is designed for a PGY six mpg why seven year period after completion alone one year of internal medicine and four years of diagnostic radiology. If a resident has prior training that exceeds these five years, we still pay out the PGY six level, because that is the level of expertise. The fellowship is designed for.

Our current salary structure for fellowships is:

2004 -- 2005

PGY 4$ 49, 296.00 + 20% benefits = $ 59, 155.20

PGY 5$ 51, 230.40 + 20% benefits = $ 61, 476.48

PGY 6$ 52, 644.80 + 20% benefits = $ 63, 173.76

PGY 7$ 54, 953.60 + 20% benefits = $ 65, 944.32

We require new proposed fellowships to fill out a formal application for review by the GME Committee.

FELLOWSHIP LICENSURE / SCOPE of PRACTICE

Fellows in ACGME fellowships may receive a Residency Permit under A.R.S. 32-3000 for the supervised practice of medicine. Fellows in ACGME programs come under the Duty Hours rules and all ACGME "Common Requirements. "Fellows in non-ACGME Programs may receive a residency permit through A.R.S. 32-3001. Some fellows will have an independent Arizona medical license. In all three situations Fellows are considered to be supervised at all times by a member of the medical staff who is a Licensed Independent Practitioner appointed by the fellowship Director to supervise the Fellow in Clinical Patient Care or Bench research.

The exception to this rule are the BNI Neurosurgical fellowships where the Fellows are actually Licensed Independent Practitioners and credentialed through the Medical Staff and serve as employees of Barrow Neurosurgical Associates.

Some U.S. surgical residency programs have specialized 'fellowships' or a focussed training curriculum during the formal residency program. While technically not fellowships they are often called fellowships or "embedded fellowships".

Notes on St. Joseph's Fellowships 2004-2005

  1. St. Joseph's ACGME ACCREDITED FELLOWSHIPS
  1. Geriatric Medicine sponsored by the Family Practice residency

Program Director: Walter Nieri M.D.

Number of fellows: four at the PGY-4 level

Salary Funding: Sun Health pays the salary and benefits all of all fellows and St. Joseph's is a partial stipend to the fellowship director and for a geriatric nurse practitioner…est $250-350K (Sun Health) $75K (St. Joseph's)

--- this fellowship's accreditation is cosponsored with Sun Health in Sun

City, with St. Joseph's as the institutional sponsor.

--- the fellowship has requested an increase in their cap under the

Medicare modernization act. (decision in June?)

--- residents in completing family practice or internal medicine are

eligible for this fellowship

2. Neuroradiology sponsored by the Diagnostic Radiology Program

Program Director: Roger Bird, M.D.

Number of Fellows: eight total spread at the PGY-6 and Pgy-7 levels

Salary Funding: The Southwest Neuroimaging group reimburses St. Joseph's for the salaries of their fellows…est $512K (from SNI)

--- one of our most competitive fellowships with stellar applicants

annually from the U.S. and Canada

  1. Clinical Neurophysiology (epilepsy) sponsored by the Neurology Residency

Program Director : David Treiman, M.D.

Number of Fellows : 1-2 at the PGY 5 and PGY 6 levels

PGY 5 is the accredited year PGY -6 may be taken as a research year

Salary Funding : the Barrow Neurological Foundation reimburses the Hospital

for Salary and Benefits of the Fellows…est $ 62-120K annual (from BNF)

---Very Competitive nationally for candidates

---The Child Neurology and Adult Neurology Faculty are both very active

in the Program

  1. Sports Medicine sponsored by the Internal Medicine Residency Program

Program Director : Steven Erickson, M.D.

Number of Fellows: 1-2 at the PGY 4 level

Funding: Arizona State University pays for the Fellow and Program Director

Stipends and all other associated costs including malpractice coverage

…est $60-120K (from ASU)

---currently being considered for ACGME Accreditation (decision June 2005)

---most Sports Medicine Fellowships (63) are under Family Practice

…ours is one of 2 nationally under Internal Medicine

  1. Vascular Neurology (Stroke)sponsored by the Neurology Residency

Program Director: Marc Malkoff, MD

Number of fellows: 1-2 at the PGY-5 level

Funding: the Barrow Neurological Foundation reimburses the

Hospital for Fellow Compensation…est $62-120(from BNF)

--- this fellowship has recently been designated as an 'official'

ACGME Fellowship.

---St. Joseph's has applied for ACGME accreditation status

--- currently there are no fellows in then 2004-2005 program

B. Active St. Joseph's Non-ACGME Fellowships

6. Movement Disorders (Parkinson's)sponsored by the Neurology Residency

Program Director:

Number of Fellows: one at the PGY-5 level

Funding: the Barrow Neurological Foundation reimburses the

Hospital for Fellow Compensation…est $62K (from BNF)

--- currently there are no fellows in then 2004-2005 program

  1. Neuro-Oncologysponsored by the Neurology Residency Program

(CURRENTLY INACTIVE 2005)

Program Director : William Shapiro, M.D..

Number of Fellows : 1-2 at the PGY 5 and PGY 6 levels

Funding : the Barrow Neurological Foundation reimburses the Hospital

for Salary and Benefits of the Fellows..est $62K (from BNF).

--- currently there are no fellows in then 2004-2005 program

  1. Neuro-Otology (Balance)sponsored by the Neurology Residency Program

(CURRENTLY INACTIVE 2005)

Program Director: Terry Fife, M.D.

Number of Fellows: one at the PGY-5 level

Funding: Through the Barrow Neurological Foundation (Muhammad Ali)

…est $62K (from BNF)

--- currently there are no fellows in then 2004-2005 program

  1. Behavioral and Developmental Pediatrics

sponsored by the Pediatrics Residency / Children's Health Center

(CURRENTLY INACTIVE 2005)

Program Director: Daniel Kessler, M.D.

Number of Fellows: one at the PGY-4 level…

Funding: Through the St. Joseph's Foundation …est $62

--- currently there are no fellows in then 2004-2005 program

  1. Child Abuse Assessment

sponsored by the Pediatrics Residency / Children's Health Center

(CURRENTLY INACTIVE 2005)

Program Director: Kathyrn Coffman, M.D.

Number of Fellows: one at the PGY-4 level

Funding: Through the St. Joseph's Foundation…est $62K

--- currently there are no fellows in then 2004-2005 program

11. Academic General Pediatrics

sponsored by the Pediatrics Residency / Children's Health Center

(CURRENTLY INACTIVE 2005)

Program Director: Sara Emerick, M.D.

Number of Fellows: one at the PGY-4 level

Funding: Through the St. Joseph's Foundation est $62K

--- currently there are no fellows in then 2004-2005 program

--- there will be one fellow in 2005-2006

  1. Medical Ethics

Program Director: Bruce White, M.D., J.D.

Number of Fellows: one at the PGY-4 level

Funding: Through the St. Joseph's …est $62K

--- currently there are no fellows in then 2004-2005 program

--- there will be one fellow in 2005-2006

  1. PROPOSED FELLOWSHIPS
  1. Neuroimmunology Fellowship

(CURRENTLY BEING PROPOSED)

Program Director: Timothy Vollmer, M.D.

Number of Fellows: one at the PGY-5 level

Funding: Through the Barrow Neurological Foundation …est $62K

--- currently there are no fellows in then 2004-2005 program

  1. Cognitive and Behavioral Disorders

(CURRENTLY BEING PROPOSED)

Program Director: Patricio Reyes, M.D.

Number of Fellows: one at the PGY-5 level

Funding: Through the Barrow Neurological Foundation…est $62K

--- currently there are no fellows in then 2004-2005 program

  1. Neuro-Ophthalmology

(CURRENTLY BEING PROPOSED)

Program Director: Thomas Wolf, M.D.

Number of Fellows: one at the PGY-5 level

Funding: Through the Barrow Neurological Foundation…est $62K

--- currently there are no fellows in then 2004-2005 program

  1. INACTIVE FELLOWSHIPS
  1. Radiation Oncology

(CURRENTLY INACTIVE)

Program Director: Burton Speiser, M.D.

Number of Fellows: one at the PGY-5 level

Funding: Through the Radiation Oncology Group reimbursing

St. Joseph's Hospital …est $62K

--- currently there are no fellows in then 2004-2005 program

  1. Neuropathology

(CURRENTLY INACTIVE)

Program Director: Steven Koons, M.D.

Number of Fellows: one at the PGY-5 level

Funding: Through the Barrow Neurological Foundation…est $62K

--- currently there are no fellows in then 2004-2005 program

--- this fellowship was ACGME accredited for 4 years in the early 90's

18. General Internal Medicine (the Flinn Fellowship)

(INACTIVE since 1990)

Program Director: Daniel Duick, M.D.

Number of Fellows: one at PGY-4 level and one at PGY-5

Funding: Through the Flinn Foundation 1983-1989

…est $700K total grant for these 6 years

--- currently this fellowship no longer exists

---it was modeled after the Robert Wood Johnson Clinical Scholars Program

  1. SPECIAL FELLOWSHIPS

N.B. These "fellowships" are sponsored educational training years under the auspices of the Barrow Neuorsurgical Associates group through the support of the Barrow Neurological Foundation. Graduates of Neurosurgery programs in the U.S. are accepted for a year of special training, obtain an Arizona unrestricted license to practice medicine, are credentialed as full members of the St. Joseph's Hospital Medical Staff, and are employed by BNA.

They function as Licensed Independent Practitioners and as such do not come under the Arizona Medical Board (BOMEX) regulations pertaining to physicians in training.

19. Cerbrovascular / Skullbase Fellowship

Program Director: Robert F. Spetzler, M.D.

Number of Fellows: two at the PGY-7 level

Funding: Through the Barrow Neurological Foundation

---accredited through the Society of Neurological Surgeons

20. Spine Neurological Surgery Fellowship

Program Director: Volker K.H. Sonntag, M.D.

Number of Fellows: one to two at the PGY-7 level

Funding: Through the Barrow Neurological Foundation

---accredited through the Society of Neurological Surgeons

21. Endovascular Surgical Neuroradiology Fellowship

Program Director: Cameron McDougal, M.D.

Number of Fellows: one at the PGY-7 level

Funding: Through the Barrow Neurosurgical Associates group

---recently recognized as an accredited subspecialty of

Neurosurgery and Diagnostic Radiology by the ACGME

22. Robert H. Chamberlain Biomechanics Fellowship

Program Director: Volker K.H. Sonntag, M.D.

Number of Fellows: one at the PGY-7 level

Funding: Through the Barrow Neurological Foundation

23. Robert F. Spetzler Neurosurgical Research Fellowship

Program Director: Robert F. Spetzler, M.D.

Number of Fellows: one at the PGY-7 level

Funding: Through the Barrow Neurological Foundation