This article is more than 5 years old. Information may no longer be current.
The case for fellowship: Why I came back
Click Here to Manage Email Alerts
Physicians are accustomed to making major care decisions every day. A notoriously self-abusive group, doctors frequently overlook their own personal needs to attend to the well-being of their patients. But as I neared the end of my 9-year tenure as an Army otolaryngologist, I was faced with perhaps one of the most important decisions for my own well-being, and one that could not be ignored: What do I do next? As this crossroad in my career approached, I was faced with three distinct options: Join a private group, become employed by a health care system or pursue a fellowship to further refine my skills and define my practice.
Although the first branch in the algorithm, return to training or continue a general practice, seems the easier of the two choices, it is actually a complex, multifaceted decision, one that is influenced by financial liability, geographic constraints, family considerations and questions of long-term professional satisfaction.
For some, fellowship is a way to expand their professional scope by offering expert level care in certain aspects of a general practice. Others seek to focus their practice to one specific area of interest. Having a general practice for several years after residency gave me the opportunity to independently explore all the diverse facets of otolaryngology and discover the areas that I most enjoyed. The most important factor in my decision to return to training was a desire to dedicate my professional efforts to my area of greatest interest.
The decision to focus my practice to one specific area was bittersweet. It was difficult to accept that I may no longer, with any regularity, care for patients with many of the pathologies I trained so long and hard to treat. However, I prefer to think that rather than giving up anything, I now have the tools to provide an entire group of patients a level of service I would otherwise not have been able to offer, and my plan to stay in academic medicine will hopefully allow me to remain abreast with continued advances in other fields of otolaryngology.
Money, family concerns play role
Financial considerations are also likely to weigh heavily in the fellowship algorithm. Presumably, most practicing physicians have established a lifestyle based on their post-residency salary, and some may have obligations that necessitate a specific minimum income level. Returning to training will entail a salary reduction in most cases. While this reduction may be manageable for a year, those with longer fellowships may need to consider alternate sources of supplemental income, such as a working partner or loan assistance if budget restrictions are not feasible or adequate.
There is no guarantee that successful completion of a fellowship will translate into increased earning potential, especially if one chooses to pursue an academic career. Physicians contemplating fellowship should be willing to accept this possibility, and it is important to consider the financial needs and potential contributions of partners and dependents in this decision.
William Duke
Family and social factors contribute to the fellowship decision in more than just financial terms. Fellowship programs are usually concentrated in academic centers that may be located far from one’s current residence. Relationship or family considerations may make it difficult to pursue a distant fellowship opportunity. A partner may be unable or unwilling to move, particularly if employed in the local community, and children may be established in school and social activities. Some families may be willing to live apart temporarily if a permanent relocation for the fellowship duration is not reasonable, but this situation may be unpalatable for those with long training obligations. Even if moving for a fellowship is theoretically feasible and agreeable, one’s local real estate market may make it financially impossible to consider at the present time.
Advantages to delaying fellowship
Despite these potential obstacles, returning to fellowship after being in practice has many distinct advantages. First, although the possibility of limiting one’s scope of practice may mean giving up some other very enjoyable aspects of a specialty, some people find themselves drawn toward a specific area of interest. Practicing general otolaryngology for several years afforded me the opportunity to fully explore the discipline and really identify the patients, pathologies and treatments that excited me the most. Every residency program has strengths and limitations, and a resident may not receive meaningful exposure to every aspect of a specialty during their initial training. Application deadlines frequently mandate a commitment early in residency, so those who enter fellowship immediately after training may not have been able to completely experience the breadth of their specialty or develop alternate areas of interest prior to making their fellowship decision. Conversely, those years in practice also allowed me to identify the aspects of the specialty I was less enthusiastic about, strengthening confidence in my fellowship decision.
The additional time in general practice not only allowed me to clarify the direction I wanted to steer my career, but it gave me time to search for the perfect fellowship opportunity. I was not pressured to commit to advanced training by my second or third year of residency, so I had time to seek a fellowship, mentor and institution that fit my professional, personal and family needs.
An unintended benefit of delaying fellowship is that it allows a young physician to complete board examinations before starting training. This may seem trivial and, certainly, should not be the only reason to delay starting a fellowship, but I have seen many fellows either take time away from their training to prepare for board examinations, or worse — take time away from adequate board preparation to continue to meet the rigorous demands of fellowship. Prior board certification and real world experience as an independently practicing physician may be desirable to some fellowship directors, particularly if the fellows are expected to take call and oversee residents and medical students.
The decision to return to fellowship is complex and influenced by many factors. Most physicians entertaining the move have identified areas of particular interest in their given field that they would like to either explore more fully or practice exclusively. Some may be driven by a desire to pursue research or participate in academic medicine. Ultimately, though, the decision to return to fellowship training should be about happiness. Thirty years is a long time to practice, with a lot of patients who need their doctor performing at his or her best every hour of every day. It is easy to come to work when you love what you do.
William Duke, MD, is a board-certified otolaryngologist and a clinical fellow in head and neck endocrine surgery at Georgia Health Sciences University in Augusta. He can be reached at 1120 15th Street, Augusta, GA 309112; email: wduke@georgiahealth.edu. He reports no relevant financial disclosures.