To Fellowship or not to fellowship, from a financial perspective

[lilsnappa]

My wife is a 2nd year pediatric resident, and we're beginning discussions about what's next for her career. Being in an academic setting, she's being pushed to pursue more training either by doing an additional chief year or a 2-year pediatric hospitalist fellowship (very new subspecialty) .

I'm trying to better understand, from a financial perspective, if there is a ROI for extra training in peds. I am a business management consultant, so I spend most of my time proving out business cases and understanding capital investments. The subspecialty is so new that there isn't any evidence to show whether foregoing 2 years of physician level income will produce additional income in the future. Also, because the subspecialty is so new, she can begin working as a hospitalist immediately after residency and will essentially be grandfathered in an be able to sit for the boards. I see it as a sort-of short cut to a subspecialty without the Fellowship, but I am not in Medicine so I may be misinterpreting this approach.

I come seeking advice from the many physicians on this board. How would you approach this?

[Zaphod]

Sounds like for sure, and history also bears this out in new subs, that fellowship will make no financial sense. There will be no extra boards for being a hospitalist, just the regular ones so dont even worry about that. If there is some clinical reason she feels will really help her out in her career then thats a different scenario, its not usually a wise money choice though, and probably triply so in peds.

If she doesnt want to do a fellowship and feels prepared to do do the work now, then dont do it. I have a motto/test I live by when others are pushing their opinions strongly to me, it is...unless you're paying my bills, you have no say, I dont care about your opinion. The moment someone offers to subsidize my lifestyle so they can be vicariously fulfilled by my choices I'll reconsider. Until then, I'll continue to make choices that make sense for me and they can shove off. I'll in fact do 100% pro bono work to whatever charity niche/group floats your boat so long as you agree to above said rule/expenses we can agree on. No one has taken me up yet.

Medicine is really crazy about that kind of thing, and sometimes it seems academic and those in large generational gaps that dont appreciate the newer paradigm in medicine can really be oblivious.

[CM]

Agree with Zaphod. From financial perspective, it is nuts to do this fellowship or chief year. From just about every other perspective, also nuts. Only exception might be if she intends career in academics, but doubt she'd want to pursue hospitalist fellowship in that case (versus cardiology or other).

[G]

As far as I know, none of our adult or pediatric hospitalists have done a fellowship (at a busy referral center).  So I guess if it ever becomes a thing, yes, they could grandfather.

If finances don't matter, where would she be happiest?  This would be my approach and if it happens to fit into finances, well, that's the answer.

[ENT Doc]

I don't know about the ROI for Peds sub specialties, but there have been analyses for some of the surgical specialties that show that doing a fellowship doesn't make economic sense.  Of course this may be different in peds, which if it's anything like internal medicine may have a good ROI.  GI and Cards get a big pay bump compared to a hospitalist.  Doing a Chief year and a two year hospitalist fellowship strikes me as terribly wasteful from an economic perspective.  Doesn't seem that this would add much value to warrant additional income compared to a general peds trained doctor (or NP, which are being used in increasing frequency).  However, I would say it depends on her goals.  Does she want to be in academics?  Publish?  Or go into private practice in a rural community?  While it may be a negative NPV decision from a strict financial perspective if doing that fellowship or chief year will provide her with enough utility to overcome that deficit then of course do it.  Not easy to answer definitively in my position.  She/you are in the best position to make this determination.

[RadDoc6876]

Please keep in mind that the institution where she is has a very strong financial incentive to create more Residency and especially Fellowship positions.  These positions are free to the hospital--they are paid for by the government.  (Ever notice how people post questions here asking about how to handle their stipend "letter" reporting their fellowship income--notice that's it's not reported by the hospital on a 1099 or W-2?  That's because it is not being treated as earned income and payroll taxes were not deducted during the year.)  In the case of a Fellow, the hospital gets a free, often Board-certified, legally fully functional clinician who is cranking out work and generating revenue, at almost no cost to the hospital.  The government pays the meager salary and the hospital barely has to pay any overhead if they're not AGME accredited.  (I would ask that question btw - if the Fellowship is not accredited, they can do whatever they want with your wife since the position is not regulated.)

When I did Radiology Fellowship after 4 years of general practice (the Fellowship was not ACGME accredited), the program said after the first month I was there that I could practice independently and they promptly sent me to cover a community hospital with a Resident helping me.  ("You're doing awesome--feel free to go read 50 CTs for us!")  We cranked out work all day, for zero labor costs to the "affiliated" community hospital.  Great deal for the hospital, not sure about a great deal for me.  So keep in mind that the people who are encouraging her to do this have an inherent conflict of interest--they would love nothing more then a free, energetic clinician to bring in 2 years' worth of revenue for them.

Having said all that, if your wife has specific training goals for *herself* (in my case I did have specific goals to increase my skill set and improve my marketability), really wants to go into academics, needs to do this to line up a specific job after, or has other specific goals for herself, then by all means go for it.  But just be aware the hospital will push very hard to bring her on as a Fellow because it is in their financial interest to do so.

[DMFA]

Afaik peds sub-specialties aren't really worth it for the money (kind of like peds overall), at least not nearly enough as internal medicine ones. Most of that is lack of reimbursement from patient volume and insurance; how many kids need an endocrinologist or cardiologist? An exception *might* be academics, since in many geographic areas, that's the only place to find a pediatric sub-specialist. You have to pick something you really want to do and stick with it, not because it pays.

If you wanted higher pay, probably should've done something other than the lowest-paying specialty or at least kept the option, like med-peds.

[Miss Bonnie MD]

Wouldn't say all fellowships are not worth it - peds, I don't think it helps at all.

But derm - if you do mohs/procedural, you can almost DOUBLE your salary. That is one year well spent. Wish I liked it more.

As for peds hospitalist - I really cannot imagine why you would need "extra" training to do this - 3 yrs of peds should be more than adequate to be a  peds hospitalist. I surmise peds hospitalists, like for IM, affords more flexibility with time/shift work and hopefully higher pay then just outpatient peds.

There is no internal medicine hospitalist fellowship.... (well maybe but don't know anyone who does it).

[VagabondMD]

Sounds like a bad financial deal. Sometimes a great experience outweighs the financial considerations. I took two years off from medical school and did an HHMI research fellowship at the NIH. I had a great time and would not trade the two years for anything (except maybe four years). Physician friends of my family advised my parents that I was harming myself for not getting out onto the gravy train ASAP. They were dead wrong.

[DMFA]

Vagabond MD wrote:

Sounds like a bad financial deal. Sometimes a great experience outweighs the financial considerations. I took two years off from medical school and did an HHMI research fellowship at the NIH. I had a great time and would not trade the two years for anything (except maybe four years). Physician friends of my family advised my parents that I was harming myself for not getting out onto the gravy train ASAP. They were dead wrong.

Click to expand...

Great point.  Define "harm."  Sure, you paid a couple more years of interest on some student loans, but what did you get for that price?

Despite what we might imply from these boards, there *is* more to life than money...or so I'm told.

[VagabondMD]

DMFA wrote:

Vagabond MD wrote:

Sounds like a bad financial deal. Sometimes a great experience outweighs the financial considerations. I took two years off from medical school and did an HHMI research fellowship at the NIH. I had a great time and would not trade the two years for anything (except maybe four years). Physician friends of my family advised my parents that I was harming myself for not getting out onto the gravy train ASAP. They were dead wrong.

Click to expand…

Great point.  Define “harm.”  Sure, you paid a couple more years of interest on some student loans, but what did you get for that price?

Despite what we might imply from these boards, there *is* more to life than money…or so I’m told.

Click to expand...

Actually, I grew in the era where student loans were not as ubiquitous as they are today, and I was fortunate to not have any. It's hard to imagine such a world, isn't it? Yes, there is more to life than money, but it takes a while to learn that lesson.

[lilsnappa]

Thanks for all the different perspectives. It's helpful to hear from people who've gone through medical training and are 'on the other side'. This pediatric hospitalist subspecialty is so new that it's not required to find a job in that field yet (but probably will be in the next 3-5 years). My wife's concern is that if she foregoes the fellowship in exchange for starting her career, it will handcuff her career and she will eventually get passed up by the incoming hospitalists with fellowships. My belief is that may be the case in academic settings, but not in the rest of medical world.

Financially, we've been very proactive and it's put us in a good position to this point (we actually hit net worth $0 in January!). Her loans were refinanced to a 5yr @ 3.5%, and we're aggressively paying it off. To do so, we've sacrificed the last few years in our personal lives (her residency training & I travel for work 48 weeks/yr). A fellowship would mean another move and another couple of years in a different city than we want to eventually settle down in.

 

[babydoc]

First, there is absolutely no financial reason to do a chief year. It is all about prestige and improving ones CV. It actually has a negative impact by delaying the attending salary by one year.

http://pediatrics.aappublications.org/content/127/2/254

This study several years back showed that the only pediatric subspecialties that made any financial sense were Neonatology, cardiology, and intensive care. You actually lost money by subspecializing and delaying an attending salary by 2-3 years. Ironically, many pediatric sunspecialities are paid LESS than general pediatrics as attendings!!!!

The American board of pediatrics is focused on increasing pediatric research and mandate scholarly research during fellowship (every fellowship). Their push to create a pediatric hospital fellowship is based on this desire to increase the volume of published Peds hospital medicine research. Peds residents do not need further clinical training to be a qualified hospitalist/clinician. A Peds hospitalist fellowship program is aimed at teaching the process academic research during those two years with clinical practice on the side. Therefore, if you want to do research as a hospitalist during your career, by all means do a fellowship. That being said, financially, it is a negative decision and he/she would be better going into General pediatrics (salaries are equivalent or actually lower) If you want to be a Pediatric hospitalist though (straight clinical- no research), then get a hospitalist job (if you still can) prior to the ABP closing the door on non-fellowship trained individuals.

[DMFA]

lilsnappa wrote:

Thanks for all the different perspectives. It’s helpful to hear from people who’ve gone through medical training and are ‘on the other side’. This pediatric hospitalist subspecialty is so new that it’s not required to find a job in that field yet (but probably will be in the next 3-5 years). My wife’s concern is that if she foregoes the fellowship in exchange for starting her career, it will handcuff her career and she will eventually get passed up by the incoming hospitalists with fellowships. My belief is that may be the case in academic settings, but in the rest of medical world.

Financially, we’ve been very proactive and it’s put us in a good position to this point (we actually hit net worth $0 in January!). Her loans were refinanced to a 5yr @ 3.5%, and we’re aggressively paying it off. To do so, we’ve sacrificed the last few years in our personal lives (her residency training & I travel for work 48 weeks/yr). A fellowship would mean another move and another couple of years in a different city than we want to eventually settle down in.

 

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Isn't being "truly broke" a great feeling?  Lol...I literally had a party when we hit zero on the way up.

[babydoc]

I cannot think of a reason that not being fellowshipped trained would handcuff her career. What does she want to do? Private practice or academic with a focus on research, education, or clinical? I work with several neonatologists that are grandfathered but not seen as second class citizens. They have the same opportunities as I.

The only disadvantage of being non-fellowship trained may be a lower salary. I doubt that it would be dramatic though. Defering two-three years of attending salary I can imagine would be significantly worse financially in the long run.