November 28th, 2012
The End of Fellowship: What Happens Next?
John Ryan, MD
Our training programs have a uniform deficiency — they do not prepare fellows on how to leave. I know this well, as I am currently transitioning from cardiology fellow to faculty member.
Fellows typically enter medical school in their twenties and over the next ten years become institutionalized into full-time understudies. Part of this is nice, because it helps fellows concentrate on developing the craft of medicine rather than being distracted by the perils of adult life (e.g., funding, RVUs). But perhaps a larger part makes them ill-prepared and naïve when it comes to the end of fellowship.
Increasingly, fellows are entering into 2+ years of subspecialty fellowships and advanced training. People argue that this is necessary because the individual fields within cardiology have become so complex that more time is needed to create better doctors. However, using expert consensus to justify this extension of training is contradictory to our field, where we rely so heavily on data and shun anecdotal medicine. Most leaders and master clinicians within cardiology did not do subspecialty fellowships but rather developed their skills as faculty members.
In addition, this situation involves a clear conflict of interest that would be unacceptable in any RCT: Faculty who want fellows to stay on benefit from having trainees under their purview. The counterargument of course is that the trainees also benefit from this apprenticeship — but how long can we justify that reasoning, while deferring major (both personal and professional) life decisions?
The phrase “boomerang generation” is applied to today’s young adults in U.S. and European society, because so many have chosen to cohabitate with their parents after a brief period of living on their own. I fear that we are creating our own boomerang generation of medical graduates who are underprepared for entering the workforce and who thereby extend the time they spend under the supervision of their mentors.
Like any species, we survive by sending our young into the world to make their own way. But, almost universally, formal training in how to search for a job is absent. Looking for a job itself is like the Wild West, with very few positions actually being advertised and no uniform time line for interviews and recruitment.
I know — this is real life. During my own job search, I did enjoy the anarchy, somewhat. But graduates are entering into a job market in complete disarray, having lived for the past decade in a protective bubble of matching systems and stability within training programs.
We need to train fellows how to graduate. We need to teach practical lessons — what is needed to get a job and how to enter into a job market. Fellows need some preparation, with objective guidance and mentorship. And I feel we currently are not doing that.
What changes would you make to help fellows make the jump into the job market? Or do you think that the system works well as is?
10 Responses to “The End of Fellowship: What Happens Next?”
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John, Thank you for this interesting post. As a individual currently searching for a job with multiple practice options to choose from I would have appreciated some education in this. Even an introduction into the differences between multi-speciality groups, solo practice, hospital employment, etc is important. Instead I have been learning about these models as I encounter them. I have heard of various fellowships that have sessions, typically led by physicians previously in private practice, about starting as a physician. These courses not only include information about practice groups but also practical things such as financial and retirement planning.
I agree that it would be useful to incorporate more specific advice and support for transition from fellowship to the “real world” because as you stated the duties and responsibilities are different from fellowship and we’re no longer protected. There is a whole degree of complexity out there that we just often are not exposed to.
I also agree with your comments about the length of training. Although I am all for people following their passion in life, the realities of the cost – financial and personal – of extended training are becoming very apparent to me. I’m now in my 8th year of post-graduate training and have 6-figure debt looming over me.
There is a little help transitioning from fellow to a career from the ACC Fellows-In-Training, but more opportunities would be great.
Great post John. Our fellows have had the same feelings about lack of preparation for the job search. In fact,this has been the area that they have considered the biggest deficiency in our program. One of the main problems is that few of us in leadership positions knows much about how to get a job outside of traditional academics either!
We added a couple of programs to enhance this area over the past few years. We now have dinners with second and third year fellows and a few faculty members who have been in practice previously, and can provide both the academic and practice perspective. We also now have a dinner where we “come clean” with senior fellows about how cardiologists make a living in academics and in practice, what general salary expectations might be, and how some academics supplement their income, and the plusses and minuses of the various income supplementation strategies. There are a series of negotiating seminars for those interested in academics to talk about “what to ask for and how to get it.”
Finally, this is now a major focus of our semi-annual review meetings with the fellows. We begin job discussions and guidance in this area much earlier than we did in the past.
In my opinion, the second part of the transition is also a problem–we don’t do well enough with “on boarding” for new faculty members when they start. This contributes to loss of some very talented individuals early on because we did not do a good enough job of helping them get started. Finding the job is one problem…knowing what to do and how to succeed once they start is another one.
Good piece. If you would to post this on http://currentmedicine.tv/ please contact us
Steven E. Greer, MD
Great post John – and an honest perspective from the Fellowship. And I love James’ thoughtful response – we owe it to our trainees to help them in this often challenging transition – and the efforts that James describes should be part of every Program.
The 800-pound gorilla in the room, of course, is that too few jobs exist in prime urban areas once fellows leave their sheltered workshops. The real world is seeing pay cuts. The real world is concerned about the expense of recruiting, training, and hiring new fellows-turned-attendings. It’s tough to put all the responsibility for job transition on training programs when the market is affecting chances of being hired, too.
Welcome to the reality of health care “reform.”
This is a great post, John. And good discussion that has followed.
The end of training a unique time in the lives of our fellows. It represents for many of them the first time they are looking for a “real” job – one that they can chose that does not involve a match day, one that is not measured in finite terms of a few years, and one that may involve contract negotiations. In addition, this is also the first time that many fellows will be actively recruited and have someone pay there way as the seek opportunites – these types of compliments can be overwhelming for many. Moreover, this is the first time for many that decisions are made that involve a spouse or significant other and possibly children.
All these factors make it even more important that we try to individualize our advice to fellows. As with James, we begin discussions for long term goals early in their training and then counsel as their training progresses. This has helped. I would think that discussions on nuances of academics vs. private practice and expectations for quality of life, salary, job satisfaction, etc from former fellows would be helpful as well.
Folks might find this post from earlier this year somewhat helpful.
John-excellent points again!
I have to say very curious to hear more from Dr. de Lemos about the “coming clean dinner”. Here is my list of issues:
1.Really hard to get into a back-and-forth negotiation with folks who may have trained you from a scratch.
2. Impossible to come across as an academic with a reasonable expectation as regards income and not sound greedy.
3. “supplemental” income tends to be variable and inconsistent.
4. Folks try to tell me to the contrary but I am still not convinced that the difference in income isn’t sizeable between private versus academic and non-invasive versus invasive cardiologist in the current time.
5. Do I need a lawyer to look over my academic contract as well just as my colleagues going into pvt practice do?
I could go on…
Excellent post and discussion. I work in Buenos Aires, Argentina, but have the same problem here! I think it is a universal concern related to the way we learn Medicine and the way we do our training as physicians. I especially agree with Dr de Lemos comments when he says that “knowing what to do and how to succeed once they start” is another problem. I am experiencing that problem right now and it is not easy to bear with….Kind regards.