On the fellowship directors’ list serve of the Academy of Psychosomatic Medicine, a psychosomatic medicine program director expressed dismay on discovering that another program director had signed up an applicant, knowing that the applicant had already signed a contract at the first program. An extensive interchange followed.
In a different program, the day before a psychosomatic medicine fellow was to start, he called to say that he had also signed a contract with another program in a city where his mother-in-law lived, and his wife wished him to go there instead.
Although psychiatric residencies and child psychiatry fellowships use the National Residency Matching Program, other psychiatric fellowships (e.g., geriatric, forensic, addictions, psychosomatic medicine, administrative) do not. Therefore, applicants may accept positions at more than one program and programs might offer positions to applicants who have already signed contracts with other programs. How often such problems occur is unknown; we could find no relevant literature. Consequently, one of us (JLL) anonymously surveyed the directors of all 35 psychosomatic medicine fellowship programs registered on the web site of the Academy of Psychosomatic Medicine (1). The response rate was 100%.
The survey asked four questions:
1. Have you ever had a fellowship applicant accept a position in your program and sign a contract and then back out of the contract?
Nine programs answered yes. Reasons for backing out included accepting a position at another psychosomatic medicine fellowship (n=4), a fellowship in a different specialty (n=2), or another job (n=10), especially a J-1 waiver job; personal or family illness (n=5); and other (e.g., the physician’s partner took a job in a different city, the physician’s license had been suspended, the physician’s family had a crisis, the physician decided to do nothing). These results are qualitative and should not be taken as representing specific frequencies, because the programs vary in how many fellows they have trained and these were retrospective reports by fellowship directors of varying lengths of time in that role.
2. Have you knowingly offered a contract to an applicant who had accepted a position elsewhere?
Only one program director answered yes (see also question 4).
3. Have you unknowingly offered a contract to an applicant who had accepted a position elsewhere and then discovered he or she had made a prior commitment?
Two programs answered yes. In one, program director B called program director A, who released the applicant to attend program B. A few weeks later, despite having signed a contract, the applicant withdrew from program B. In the other, program directors C and D were notified the day before the fellow was to start that he had signed contracts with both because he and his wife could not agree on where they wished to move. He attended D and performed poorly.
4. Under what (if any) circumstances would it be acceptable to offer a position to an applicant who has already committed to another program?
Fourteen respondents indicated that they could not conceive of any conditions under which it would be acceptable to offer a position to an applicant who has already signed a contract with another program. Twenty-one respondents described possible acceptable scenarios (e.g., an applicant who must live in a different city because of family illness or a partner’s job transfer) but only if the first program released the applicant. Rare possibilities included loss of accreditation and death or incapacitation of a program director without adequate replacement. One program director (who also answered yes to question 2) took a “free market” approach: “As long as there are no rules or regulations, and no match, it is fair to offer any applicant any spot anytime.”
The results of this survey were presented at the Fellowship Directors’ Forum at the 2007 annual meeting of the Academy of Psychosomatic Medicine. Limitations were noted, including that only program directors, not applicants, had been surveyed; the survey was retrospective and not quantitative; and it drew responses from programs of varying size and age. Although the survey was anonymous, some respondents might have been hesitant to answer yes to the second question.
At the same meeting, a member of the Subcommittee on Fellowship Training (PB) proposed improving the fellowship application and selection process, specifically to make it orderly, transparent, and fair. This proposal is currently under review by all psychosomatic medicine fellowship directors and the Academy of Psychosomatic Medicine. Elements include the following:
1. While recruitment for psychosomatic medicine fellows will generally open after July 1 for positions that will start the following July 1, there should be no restrictions on when recruitment may begin.
2. An agreed-upon date for offering positions would be designated (e.g., December 1). All programs would agree not to make any offers before this date.
3. After applicants have verbally accepted offers of positions, programs would send letters of agreement for their signatures, formally attesting to acceptance, as well as a statement indicating that the applicant has not accepted a position in any other psychosomatic medicine program. By signing this letter of agreement, both parties (the program director and applicant) would agree to all terms of the letter.
4. Programs will be asked to submit the names of all candidates who have formally accepted positions to the Academy of Psychosomatic Medicine by January 15. This list will be circulated to all program directors using the Academy’s list serve. Programs that fill positions after this date will inform the Academy, and the list of filled and unfilled positions will be updated monthly.
5. Program directors would agree not to recruit applicants who have accepted positions elsewhere unless the directors of the other programs have agreed to release the candidates.
6. The subcommittee on fellowship training would review compliance and administration of the application process.
7. All program directors would agree in principle to follow these guidelines.
To our knowledge, forensic psychiatry is the only other psychiatric subspecialty that has guidelines for recruitment (2). These were approved in May 2005, and they allow offers to be made to applicants anytime during the recruitment process, but responses to offers cannot be demanded prior to October 31. Thus, if applicants receive early offers, they may continue looking at other programs before making final decisions.
The proposed guidelines have advantages beyond preventing an applicant from accepting more than one position or a program from offering a position to an applicant who has already accepted another offer. For applicants, the current process is anxiety-provoking and confusing. Applicants may receive an offer from one program with pressure to accept before they have opportunities to interview at other programs. A regularly updated online list of programs that have openings after the initial round of acceptances will be very useful for applicants still seeking positions and also helpful to residency directors who are advising fourth-year residents on options for further training.
For subspecialties with more available positions than applicants, competition between programs can be intense, and there are anecdotal reports of applicants feeling unduly pressured and other questionable practices. As noted earlier, one respondent indicated that as long as there are no official rules, it is acceptable to offer a position even to an applicant who has committed to going elsewhere. Although no other program director took a similar position on our survey, without a universal consensus on recruitment, we cannot rule out the possibility that other programs share that position in practice.
The guidelines are intended to promote professionalism, a core competency, for all involved in recruitment. We believe that the adoption and dissemination of fellowship recruiting guidelines will clarify what constitutes ethical recruiting. If the rules for programs are clear, a program director who offers a position to an applicant who has already signed a contract with another program is behaving unprofessionally, and consideration should be given to informing the department chair and/or the Academy. Similarly, applicants who accept positions at more than one program are behaving unprofessionally, and consideration should be given to informing their residency directors.
Some fellowship directors have expressed concern that the guidelines would become a mechanism for policing recruitment methods and would be unenforceable. In fact, the guidelines are not strict rules, nor are they intended to be legally binding. We are unaware of any published reports regarding attempted legal enforcement of a residency or fellowship contract when an applicant refused to honor it, but legal recourse seems counterproductive and unlikely to produce a sufficiently timely resolution. Proper functioning of the guidelines would depend on an honor system among programs and applicants, and this may be one of the proposal’s limitations. Even under the National Resident Match Program, violations by both applicants (3) and programs (4, 5) have been common.
Our hope is that the proposal will strengthen the recruitment process and serve as an example for other subspecialties. If the proposal is adopted by the Academy of Psychosomatic Medicine, we recommend that participating programs and applicants be surveyed after the subsequent recruiting cycle to evaluate the guidelines.