Let’s talk about fellowship. According to the American Medical Association, it’s never too early to start to think about fellowship.
Medicine is a field where you are continually learning, and fellowship is a way to learn and subspecialize. As you subspecialize, you will likely give up some of the field’s broader aspects. An internal medicine physician who subspecializes in gastroenterology (GI), after 5-10 years of working as a GI specialist, may not be as comfortable with managing ICU patients or in stroke units the way they used to during their early training years as an internist. The further away you get from the general practice, it’s natural that some of the skill sets will erode.
Fellowship is all about specializing in an area. There are many factors to consider.
For example:
You are an internal medicine resident physician completing post-graduate training (i.e., residency), making $50-70K for 3 years.
You have $300K in student loan debt.
Option 1: Leave residency in 8 months (graduation 6/30/2021) and go on to make $220K.
Option 2: Complete a fellowship (i.e., stay for an additional 3 years of training), become a gastroenterologist (GI), and go on to making $400K+ a year.
Option 3: Take the $220K job, work for 4-5 years, pay off debt, then go back and complete the GI fellowship at a base salary of $60-70K and make $400K+ once the fellowship is complete.
You can argue a GI physician will have a better or similar lifestyle than an internist.
In the meantime, you may have a family, wife, and kids who are missing you (working a lot 80+ hours a week during training). Student loans are incurring interest. Lastly, you’ve been in school/training for a long time with significant delay gratification.
These are some of the many factors you may face when deciding the route to take.
Some fellowships may only take one extra year. For example, as a family medicine physician, I can choose to subspecialize in sports medicine, addiction medicine, geriatrics, hospice/palliative care, obstetrics, women’s health, dermatology, or emergency medicine. These only take one year; therefore, the time factor is significantly less than the 3 year GI fellowship.
After training, I can choose to work strictly in these subspecialties. Also, I can do a hybrid where I work as a general family physician while also incorporating the subspecialty into my practice. There are a plethora of possibilities. However, some subspecialties do not have that option.
There are many aspects to consider when looking into a subspecialty. If you are looking at the math, it says go for the highest paying job.
Looking at the GI example above, let’s keep it simple, not worrying about interest or inflation.
If you were to start simultaneously, obviously, $400K would lead to a higher total salary, the first four rows show.
Comparing directly if you were to take the GI fellowship, which takes three years, that would mean you would have been making money for only 2 years out of the 5years compared to the internist. Year 10 for the internist would be your year 7 as a GI specialist. As can be seen, by year 7, you would have caught up and passed the internist in total compensation.
If you extrapolate it by 20 and 30 years, the fellowship wins out when it comes to salary.
However, during that time, you worked 80-100 weeks, while the internist was living a “normal” working life, hopefully, a 40-50 work week, enjoying vacations, time with family, and so on. These are some of the hidden costs of fellowship.
Another one is that you may complete a subspecialty that does not necessarily equate to a higher income. If you will be spending an extra 2-3 years of training to make the same salary, is that worth it?
If you are genuinely in love with the specialty and can’t imagine yourself doing anything else, then it may be worth it to you. Do what you value.
Lastly, let’s talk about option 3 above.
It is a realistic option. However, how many of you making 200K+ are willing to go back and work as a resident and undergo scrutinized training. That can be a hard pill to swallow.
Getting into a fellowship is a competitive process like anything else in medicine.
Going back to try and get into a GI fellowship after working for many years will be difficult. You may be seen as less competitive as you are a bit older, and the attendings may see it as more challenging to train you, as it may be difficult for you to submit to their training as you have been working as an attending yourself.
I posted this on a Facebook group, and someone replied, “Option 3 is not an option as it’s already difficult to get into a GI fellowship, and I doubt people want fellows who have already been practicing (and used to not slaving away 100 hours a week like a medicine resident). Your attendings will need you eager to please to do all their work, and it’s difficult to give orders to an older physician”.
In medicine, specifically in internal medicine, there’s a push to subspecialize. If you enjoy the subspecialty and if the job affords you a better salary instead of practicing as an internist, why not?
I kept it simple. However, there are more complex subspecialties. For example, radiology is a 4-year residency, they have the option of doing one-year fellowships. Surgery is a 4- 5-year residency, with fellowship options for up to 3 years. These extra years of training are needed in the field, and we need experts to do them as we rely on their skills; however, that is a long path.
It’s up to you to do the research, talk to mentors, family, loved ones, and weigh the pros and cons to make sure you are making the right decision that fits your needs.
