July 1st, 2022

Fellowship Transition and Developing a Sense of Belonging

Always a good time for a cute puppy picture.

It’s July 1, which means that today, or sometime very soon, many internal medicine residents will transition to becoming subspecialty fellows.

There are many appropriate words to describe this change, including exciting, nerve-wracking, and challenging, but one that doesn’t get quite enough attention is how strangely lonely it feels. The reason this sensation occurs is because medical residencies — through their size, structure, and voluminous shared experiences — engender a powerful sense of belonging. The bonds between you and your co-residents are strong indeed, especially after three years together.

Fellowships can’t instantly create this comforting feeling. Your fellowship group is smaller. You typically work alone, with an attending, and not as part of a team. Plus, there’s the disquieting experience of having mastered something (the bread and butter of inpatient clinical medicine), only now to be plunged into the uncertainties of a specialty that you haven’t yet learned.

How many incoming ID fellows are more comfortable managing chest pain than postpartum fever? I’d estimate it’s 100%.

If one adds to these factors the geographic relocation that may occur, it’s not surprising that subspecialty fellows take some time to feel really part of their new tribe.

Proof that the bonding of medical residency takes time to wear off is that most fellows spend the first part of their fellowship using the word “we” to describe their residency group, not their fellowship.

Here’s a smattering of select phrases that might be heard during the first few months of ID fellowship:

We used ceftriaxone and doxycycline, not azithromycin.

We would do the thoracentesis ourselves.

We don’t use procalcitonin, it’s not reliable.

And of course, the classic (and inevitable):

We would never consult ID on a case like this.

I completely get it and went through the same thing as a first-year fellow. I distinctly remember telling an inpatient medical team that their choice of antibiotics for spontaneous bacterial peritonitis was wrong — because “we” did it differently during my residency. A residency done at a different hospital, of course.

(For the record, it wasn’t wrong. It was just different.)

So to those of you making this transition, we (meaning the ID community) totally understand how you’re feeling. We want you to feel welcome and part of our ID world. It might take a little time, but you’ll get there.

Pretty soon, you’ll start saying “we”, and when you do, you’ll mean you and other ID docs like you. I promise.

Welcome to the club.

One Response to “Fellowship Transition and Developing a Sense of Belonging”

  1. Randall Edson says:

    Hi Paul:

    Thanks for your vivid portrayal of one of the many major transitions in the life of a resident/fellow. The pandemic has certainly had a monumental effect on the sense of fellowship and social interactions that are so critically important to the training experience. Meeting one’s colleagues in masks, virtual conferences (without food) and distancing are certainly not conducive to relationship building. Although things are definitely improving, compared to 2020 and 2021, we still have a very long way to go.

    Warm regards,


HIV Information: Author Paul Sax, M.D.

Paul E. Sax, MD

Contributing Editor

NEJM Journal Watch
Infectious Diseases

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