Introduction: Advanced training experiences are required in certain countries for subspecialization. In the United States, a decline in Milestones and in levels of supervision for Entrustable Professional Activities for incoming subspecialty fellows has been described and attributed to changes in context that fellows experience. We aimed to explore this transition to advanced training, and specifically to describe which contextual factors are salient to fellows at the residency to fellowship transition and the supports available for a smooth transition to fellowship.

Methods: Using contextual competence as a sensitizing concept, ten semi-structured interviews with first- and second-year pediatric subspecialty fellows from three subspecialties were performed at a large academic medical center in 2023, using thematic analysis informed by elements of constructivist grounded theory.

Results: Contextual factors that impacted the transition included changes in systems, necessary knowledge, and roles and responsibilities. At times, participants describe a tension between feeling like novices while simultaneously feeling like they should have more expertise than they had. Supports in navigating this tension, and in navigating the transition more generally, included formal orientations, fellow behaviors and perspective, and input from others.

Conclusions: The transition to advanced training is characterized, at times, by experiencing tension between feeling like a novice while feeling like one should have expertise, with fellows’ own behaviors and the support of those around them being essential to fellows’ smooth transition. While fellowship programs offer orientations, systems-level solutions for supporting fellows’ navigation of the transition are underexplored.