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To Fellowship or not to fellowship, from a financial perspective

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  • #16




    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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    I had to look up the Pediatric Hospital Medicine subspecialty.  I find it interesting that IM/FP docs have been doing hospitalist medicine for a couple decades and don't seem to need a subspecialty, but I digress.  From what you say above, it would seem that you want to find a permanent place and settle down.  Do that.  It's gonna take a decade or more to spin off enough boarded pediatric hospitalists to saturate the market (MAYBE 3-5 years at the top tier academic places--and isn't that what residents are for?!).  If she has been working in the field for all those years, she will either implicitly or explicitly grandfather in.  And if you're in your permanent place, I have a hard time believing that she would be asked to leave her job to do a fellowship to come back to do the exact same job.  If you're looking to move at some point, it would be important to do the formal grandfather pathway and be boarded (for sake of the most competitive hospitals)...or worse case scenario do a fellowship at that time for the entire range of job options (if that even matters).

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    • #17
      Another vote for no to the chief year and the hospitalist fellowship. Unless she does not care about money and wants to be academic no matter what, it will not make an ounce of difference, and, in fact, it might turn some private practice people off if she wants to go the private practice route afterward.

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      • #18
        The only reasons to do an extra chief resident year are as a resume builder to apply to competitive specialties, as a gap year to keep dual-physician couples "on track" together, or if you see yourself going into academic administration eventually. It is definately not a wise financial decision unless it gets you into a high paying specialty you might not have gotten otherwise.

        A two year pediatric hospitalist fellowship sounds like a terrific waste of time unless your wife is going to use the time to springboard into academics, getting funding, etc. 0 usefulness in private practice IMO.

        One piece of information that is critical for med students, residents, and fellows to remember is that academic advisors don't necessarily have your best interests in mind, and even if they are trying to help their experience is limited to what they know, which is usually academics only. Keep in mind what YOU want to do, then seek out people who know how to guide you where you want to go.

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        • #19




          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.

           
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          No, thats just super unlikely to happen. Unless you know of a very specific hospital, in a very exclusive neighborhood in an exclusive state, city, etc...that may operate this way at some long drawn out time into the future. Everyone, everyone over estimates how long it takes for real change to occur, and for this there is zero impetus aside from prestige of the institution to make "fellowship" etc...a big point. Theyre more concerned with money and filling positions, and the prestige group will be a small % of overall hospitals and doubt even then its a real issue.

          We're mostly discussing fear of shutting doors and finally being finished. Theres no reason to fear, just do it (obviously doesnt seem like she has a burning desire for it, which is a good reason for it).

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          • #20




            We’re mostly discussing fear of shutting doors and finally being finished. Theres no reason to fear, just do it (obviously doesnt seem like she has a burning desire for it, which is a good reason for it).
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            She does not. But being in an academic environment, the guidance she has received is to pursue more training. She likes hospital medicine, and she chose pediatrics because its what her passion is.

            Did many of you feel the pressure to "keep going" and continue to delay other life goals while in residency? How did you approach it, and what ultimately helped shape your decision?

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            • #21







              We’re mostly discussing fear of shutting doors and finally being finished. Theres no reason to fear, just do it (obviously doesnt seem like she has a burning desire for it, which is a good reason for it).
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              She does not. But being in an academic environment, the guidance she has received is to pursue more training. She likes hospital medicine, and she chose pediatrics because its what her passion is.

              Did many of you feel the pressure to “keep going” and continue to delay other life goals while in residency? How did you approach it, and what ultimately helped shape your decision?
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              Yes, thats what they do in academic centers, they push push push from their narrow world view and they assume that what they experience is how it is all over. It most certainly isnt. There isnt necessarily anything sinister about it, its just human behavioral folly to assume your situation is the standard.

              Take plastic surgery for instance. The overwhelming majority of residency is complex recon work, flaps, micro, trauma, crazy stuff. Some places get near zero cosmetic experience. However in the real world its flipped, most procedures by far volume wise are cosmetic, recon is exceedingly tiny, yet they poo poo cosmetics as the wicked step child when really it deserves a lot more attention if we are talking about reality. Its a sample bias problem, and selection as well obviously.

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              • #22
                Many, many fellowships are not a value-ad, and more a prolonging of one's residency, or perhaps a prolonging of one's adolescence whereby the fellow can avoid the job search and delay moving onto the real world as a big boy attending.  A lot of these fellowships are pretty cushy for the fellow too, so they are very appealing when an ideal job hasn't yet popped up.

                Outside of the value-ad fellowships (which are competitive), it seems like the only real argument for the other fellowships is somehow improving your marketability or giving you some sort of edge over those without.  Of course if X subspecialty is your personal calling, then of course you have to go for it.  But for many it's more a case of falling into an easy extra year since the right job didn't land in the resident's lap.

                And yeah, almost all of these fellowships are another source of cheap/free labor to the hospitals that have them.  Why pay someone an attending salary when you can just pay them as a PGY4, 5, 6, and call it training?  Bleh.

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                • #23
                  We chose to pursue a fellowship because it:

                  1. allowed us to have a great 1 year adventure.

                  2. Allowed my spouse to have the job/life balance/career she wanted. She couldn't have done so w/o the year of training.

                  3. It better allowed us to life where we wanted to, post fellowship. (but this wouldn't be the case w/ everyone).

                   

                  Like you, I see the business side of it, and saw a huge loss in the potential year of attending salary disappear. When we look at 1,2,3 and the cost - the cost was a pittance. Is the future salary better, not appreciably, but we have the life we wanted. At some point, the business decision is less about an extra dollar or measuring risk and more about open doors (gaining entree) to new opportunities.

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                  • #24
                    Zaphod's points are spot on.  Don't let her get snared by people who are clearly biased.  It may be the best thing for her (I doubt this on many levels), but as others have noted I don't see the marginal benefit of delaying the attending experience for 3 years if she wants to work in hospital pediatrics.  Her general training should be enough for that.  She should ask her program director why he/she thinks their program doesn't prepare them well enough to take care of inpatient pediatric patients.  I'd love to hear the answer.

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                    • #25
                      KUDOS for being net zero coming out of residency!  Sounds like non-academic track.  With that remains completely true, then get into the work force in your desired location and start her career.  The other potential large factor (or monkey wrench!) not mentioned -- kids.

                      A fellowship in peds hospitalist certainly will give one exposure to that peds residency didn't compared to internal med.  My wife's children's hosp peds still was 50% outpatient compared to my 10% outpatient.  But, the fact is that she would get hands on experience year-for-year compared to fellowship and grandfathered into the position.  Would I take a person with 3 years of hands on floor experience over a freshly minted fellow?  All things equal, i'd take the experienced one with real data, real feedback from colleagues, and real experience.

                      From the financial point, it's three years of real income, compounded.  Think of it as extending your savings cycle, like NOT starting saving for retirement for three years later.

                       

                       

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                      • #26
                        In internal medicine a cheif year is total waste of time unless you need to do it to get a certain fellowship... you a do year of chief residency in exchange for a Cards or GI fellowship spot....TWO?! years of peds hospitalist fellowship sounds like overkill...maybe ONE year max...probably just rotate on the floor an and through the ICU plus a lot of research time....typical Academia milking the residents/fellows for all they are worth.  Very cheap MD labor for them.

                        My chair wanted me to stay at the U (I'm not anything special) and get paid a pittance instead of go out into practice....within 2 years I had more time off and 3x the salary of those who stayed in academics.

                        Buyer beware.

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                        • #27
                          In my view, chief years are for two groups of people: 1. those who want a competitive fellowship but aren't competitive applicants.  2. those who can't say "no" to their program directors.

                          I did a one year fellowship.  Financially, it will take 5-7 years to get back to neutral impact financially (impossible to say, since apart from my pay specific to the subspecialty training, I think it also allowed me to negotiate for more compensation for my "regular" specialist pay).  It also allowed a year with minimal responsibility, paid paternity leave, fun times in a city we enjoyed, etc.  We were paying for all that in lost income, but it was enjoyable.

                          Two extra years for peds hospitalist training?  What on earth did they manage to not teach her in 3 years of (probably at least half inpatient) peds residency?  That is absurd.  There's a reason they let residents moonlight as hospitalists after a 12-month internship.  It ain't neurosurgery.

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                          • #28
                            Agree with most of above. My co-residents in IM who went straight into hospitalist positions tell me it's like an extension of residency (especially with how much inpatient we had). I'm sure peds is the same. There is a similar fellowship in IM and none of them did it. Some went into community positions, others stayed at fairly prestigious academic centers. The only reason I can think of doing it in her case is if she's dead-set on an academic position and thinks it will help her climb the ranks as an academic hospitalist. However, given that peds is overall less competitive and hospitalists are ubiquitous, I doubt it will significantly help her career. I would pass and start working.

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                            • #29
                              Relatively new pediatrician here.  I think the only specialties that might come out ahead financially (when considering income lost during fellowship) are neonatology, cardiology, pediatric critical care, and pediatric EM.

                               

                              The pediatric fellowship system is broken in my opinion (3 year fellowships that for the equivalent adult fellowship would require only 2 years of additional training, too research-heavy).  Hospital medicine might be the most outrageous example...few of her cohort will have done the fellowship.   She'll be eligible to grandfather if she wishes.  I don't think she'll have a problem getting a hospitalist job without it.

                               

                              I have some subspecialty interest but refuse to participate in a system that I'm increasingly convinced is focused on cheap labor, not provided the needed training in the most efficient way.

                               

                              If you want an academic career, you may need something to distinguish yourself (research, specialty expertise, admin experience) which are often gotten through a chief year or fellowship.  But there are other ways.

                               

                              Consider also, for peds, if you are a subspecialist there may only be one "game in town".  You may be tied to working in big cities with pediatric hospitals.  And in some cities, if you are the peds GI doc, there's only one system to work for...which can make it difficult if the work environment changes for the worse and you want to change jobs.  Peds hospital medicine and neo won't have these issues as much as they are often practiced in general hospitals as well as full-service children's hospitals.

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                              • #30




                                Relatively new pediatrician here.  I think the only specialties that might come out ahead financially (when considering income lost during fellowship) are neonatology, cardiology, pediatric critical care, and pediatric EM.

                                 

                                The pediatric fellowship system is broken in my opinion (3 year fellowships that for the equivalent adult fellowship would require only 2 years of additional training, too research-heavy).  Hospital medicine might be the most outrageous example…few of her cohort will have done the fellowship.   She’ll be eligible to grandfather if she wishes.  I don’t think she’ll have a problem getting a hospitalist job without it.

                                 

                                I have some subspecialty interest but refuse to participate in a system that I’m increasingly convinced is focused on cheap labor, not provided the needed training in the most efficient way.

                                 

                                If you want an academic career, you may need something to distinguish yourself (research, specialty expertise, admin experience) which are often gotten through a chief year or fellowship.  But there are other ways.

                                 

                                Consider also, for peds, if you are a subspecialist there may only be one “game in town”.  You may be tied to working in big cities with pediatric hospitals.  And in some cities, if you are the peds GI doc, there’s only one system to work for…which can make it difficult if the work environment changes for the worse and you want to change jobs.  Peds hospital medicine and neo won’t have these issues as much as they are often practiced in general hospitals as well as full-service children’s hospitals.
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                                Its crazy these are 3 years. Whats really crazy are the research requirements that really do a large benefit for the institution and only sometimes for the fellow/resident (if theyre planning on academics). Worse are residencies with mandatory research years, and there were and probably still are those around. Michigan was 7 years long due to a mandatory research year, I nearly left that interview right then. That is nuts and totally just cheap labor institution prestige building. Its impossible for the majority of residents to be very research heavy, and its a huge disservice to them clinically and financially for many institutions to be moving in that direction. It is however what the incentives would predict. What a weird world.

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