How is a swap during fellowship perceived during job search?

[Stone Cold]

Hi,

I'm currently a US IMG pursuing PICU fellowship at my top choice which is also the top children's hospital in my state and among one of the best in the country. Due to a variety of reasons, I'm considering the possibility of swapping to a program to be closer with family and friends

I'd highly appreciate if anyone could answer the following

• I've seen swaps in residency but is it even possible in fellowship
• If yes, what is the process or are there any set guidelines provided I'm able to find a vacant spot (highly unlikely) or find someone in an appropriate program who is willing to swap
• I heard some positions went unfilled during 2022's match. Can I approach them provided they aren't already filled in SOAP
• How do I approach my program with such a request and how do they perceive it
• How do potential employers/recruiters perceive this during job hunt and will it have any repercussions or negatively impact my profile

Best

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[SurfingDoctor]

Gotta be honest, why even go through with this? I mean, the process is gonna be opaque and fraught with hurdles. Most programs don't lose current fellowships so active vacancies are rare. In the 10 years I've been at my program, 1 fellow quit. It wasn't re-filled so I don't know if someone could have transferred into. In addition, 50% of PICU fellowship is measured by scholarly activity. I mean, sure its generally a joke for most (which is a whole different topic), but at the end of fellowship you do need a faculty (beyond your PD) to sign off on the completion of the project and this gets directly submitted to the ABP and is required for board-eligibility. Has this person already been identified at a different institution? Actually and realistically, that is the only way I could see this working out is that the institution of interest 1) has a spot open (or someone willing to trade I guess) and 2) has an academic mentor who you know and begging for you to come and can put pressure on the PD to make it happen. I have honestly never seen that happen ever. I can't imagine a swap ever actually happening and I've never personally seen it in the PICU. If you are having issues with your program specifically, I would find the PD and talk to them. I guarantee, they don't want to lose a current fellow for any reason and I would bet they would be willing to hear your specific concerns about the program within reason.

All that being said, and if I'm being honest, I sense a different issue. PICU fellowship is 3 years. In the grand scheme of things, that's a pretty short time. Despite that, you are entertaining the idea that throwing training into a tizzy for family/friends. I obviously can't speak about priorities, but to me, this suggests that priorities are family/friends >>>>>>> being a doctor. I do want to stress that there's absolutely nothing wrong with that. Priorities are very individual and its your happiness, no one elses so you gotta make the choices that are right for you. But if that's the case, changing fellowship location is not going to fix that. Because frankly, jobs in the PICU are geographically limited. Pretty much every fellow I've known (except for maybe a handful for specific reasons) ended up in a location that did not expect or maybe even want, they just took the job that seems the best and rolled with it. For the ones I've seen prioritize friends/family/location, actually, most just left the PICU and became hospitalists or GP (or occasionally applied for another, different fellowship) because those were the jobs available in the location they wanted. Because this is all to say, just because you go to a fellowship in one spot, does not mean they will have a spot to hire into after graduation. In fact, its more likely that they will not and you will just have to go where the jobs are, not where friends/family are.

 

[DO2015CA]

Gotta be honest, why even go through with this? I mean, the process is gonna be opaque and fraught with hurdles. Most programs don't lose current fellowships so active vacancies are rare. In the 10 years I've been at my program, 1 fellow quit. It wasn't re-filled so I don't know if someone could have transferred into. In addition, 50% of PICU fellowship is measured by scholarly activity. I mean, sure its generally a joke for most (which is a whole different topic), but at the end of fellowship you do need a faculty (beyond your PD) to sign off on the completion of the project and this gets directly submitted to the ABP and is required for board-eligibility. Has this person already been identified at a different institution? Actually and realistically, that is the only way I could see this working out is that the institution of interest 1) has a spot open (or someone willing to trade I guess) and 2) has an academic mentor who you know and begging for you to come and can put pressure on the PD to make it happen. I have honestly never seen that happen ever. I can't imagine a swap ever actually happening and I've never personally seen it in the PICU. If you are having issues with your program specifically, I would find the PD and talk to them. I guarantee, they don't want to lose a current fellow for any reason and I would bet they would be willing to hear your specific concerns about the program within reason.

All that being said, and if I'm being honest, I sense a different issue. PICU fellowship is 3 years. In the grand scheme of things, that's a pretty short time. Despite that, you are entertaining the idea that throwing training into a tizzy for family/friends. I obviously can't speak about priorities, but to me, this suggests that priorities are family/friends >>>>>>> being a doctor. I do want to stress that there's absolutely nothing wrong with that. Priorities are very individual and its your happiness, no one elses so you gotta make the choices that are right for you. But if that's the case, changing fellowship location is not going to fix that. Because frankly, jobs in the PICU are geographically limited. Pretty much every fellow I've known (except for maybe a handful for specific reasons) ended up in a location that did not expect or maybe even want, they just took the job that seems the best and rolled with it. For the ones I've seen prioritize friends/family/location, actually, most just left the PICU and became hospitalists or GP (or occasionally applied for another, different fellowship) because those were the jobs available in the location they wanted. Because this is all to say, just because you go to a fellowship in one spot, does not mean they will have a spot to hire into after graduation. In fact, its more likely that they will not and you will just have to go where the jobs are, not where friends/family are.

Do you think PICUs job market will improve in the future?

 

[SurfingDoctor]

Do you think PICUs job market will improve in the future?

I hate to be a pessimist but I think a fundamental problem with a several subspeciality fields (especially ones that are niche or procedural) is that they train way more individuals that the field has future openings for. Specific to PICU, someone did a little study on this a couple of years ago.

Employment Opportunities for Pediatric Critical Care Fellowship Trained Physicians in the United States

Pediatric Critical Care Medicine (PCCM) training programs and trained fellows in the United State increased steadily without a corresponding increase in population growth. PCCM trainees worry about limited employment prospects. This study aimed to quantify ...

www.ncbi.nlm.nih.gov

I’m sure this is true for other fields though I don’t know the data nor have the personal experience.

My best advice (though no one typical asks for it ) is to network like hell and make your scholarly project a true niche that makes to marketable and can truly differentiate you from the rest of the line inserting, drip titrating herd. Alternatively, I have seen an increasing number of fellows do dual fellowships (anesthesia-PICU, cardiology-PICU, palliative-PICU) to provide a clinical niche as opposed to an academic/research niche. Even then, jobs opportunities aren’t what they used to be. Some of our more recent fellows who ended up doing extra training didn’t necessarily have a hard time finding a job, but didn’t necessarily end up somewhere desirable either (though that’s relative).

 

[DO2015CA]

I hate to be a pessimist but I think a fundamental problem with a several subspeciality fields (especially ones that are niche or procedural) is that they train way more individuals that the field has future openings for. Specific to PICU, someone did a little study on this a couple of years ago.

Employment Opportunities for Pediatric Critical Care Fellowship Trained Physicians in the United States

Pediatric Critical Care Medicine (PCCM) training programs and trained fellows in the United State increased steadily without a corresponding increase in population growth. PCCM trainees worry about limited employment prospects. This study aimed to quantify ...

www.ncbi.nlm.nih.gov

I’m sure this is true for other fields though I don’t know the data nor have the personal experience.

My best advice (though no one typical asks for it ) is to network like hell and make your scholarly project a true niche that makes to marketable and can truly differentiate you from the rest of the line inserting, drip titrating herd. Alternatively, I have seen an increasing number of fellows do dual fellowships (anesthesia-PICU, cardiology-PICU, palliative-PICU) to provide a clinical niche as opposed to an academic/research niche. Even then, jobs opportunities aren’t what they used to be. Some of our more recent fellows who ended up doing extra training didn’t necessarily have a hard time finding a job, but didn’t necessarily end up somewhere desirable either (though that’s relative).

That’s kinda what I heard/saw which pushed me ultimately away from PICU even though it was maybe the most interesting to me

 

[SurfingDoctor]

That’s kinda what I heard/saw which pushed me ultimately away from PICU even though it was maybe the most interesting to me

I mean, it’s the same reason things like Pediatric Surgery, Pediatric Interventional, Pediatric EP are really tough market. They are dependent on big cities with big infrastructures. Neither of those are growing at the same pace as the number of training spots.

It’s all a misguided understanding of market forces and data. Regionally, there are shortages of physicians including PICU physicians. But just because there isn’t a pediatric intensivst to manage ECMO in Fargo ND doesn’t mean that CHOP needs to train more trainees who can manage ECMO.

 

[Oso]

I have to agree with @SurfingDoctor here and wanted to reiterate a few things. Disclaimer: I'm in the NICU not PICU

1. I doubt any unfilled match spots are still open, but you'd have to double check
2. I have never heard of 'swapping' for fellowship positions
3. Without an exceptionally compelling reason, I don't think 'swapping' would look good. At best it would look neutral, but I feel it would look unfavorable and that's not something you want when the job market is already so competitive
4. Assuming you're going to finish this academic year (which you should), there's just 2 years left. Why not just finish? In the grand scheme of things, it's just not that much time and doesn't seem worth the trouble to try to switch. Also, at this point you've probably done ~50% of the clinical time and have learned the ins/outs of your unit.
5. I don't know how far away geographically you are from home, but I feel like the chances of finding any currently open spot is low, but especially low for somewhere closer to your friends/family
6. Even if you did find a spot, there's a strong chance that you'd have to move in 2 years for an attending job (ie. there's no guarantee you'd be able to stay there as an attending)

If you got your top choice at a top place as a US IMG, that's quite an accomplishment and I would think long and hard before potentially throwing this all into disarray

 

[SurfingDoctor]

How did the graduating fellows fare in their recent job search? M program's grads and those who will be graduating this year were all able to find pretty decent gigs although some received offers almost 2x the others which is kinda puzzling as I've not seen such a varying range in other peds specialities

I suppose the answer to that question is pretty relative. They all found spots. The variety in salaries is due to a number of factors including sedation billing, number of providers, call amount, bonus structure. There can also hidden payments and incentives. Stock options for private companies comes to mind.

That being said, salaries as raw dollar values are almost never comparable across hospital systems in a 1:1 manner.

 

[HemeOncHopeful19]

It’s all a misguided understanding of market forces and data. Regionally, there are shortages of physicians including PICU physicians. But just because there isn’t a pediatric intensivst to manage ECMO in Fargo ND doesn’t mean that CHOP needs to train more trainees who can manage ECMO.

It’s not misguided… a new fellow slot is cheaper for CHOP than a new midlevel AND the fellow will work more hours/nights/weekends… so it really becomes a new fellow is cheaper than 1.5 midlevels.

 

[SurfingDoctor]

It’s not misguided… a new fellow slot is cheaper for CHOP than a new midlevel AND the fellow will work more hours/nights/weekends… so it really becomes a new fellow is cheaper than 1.5 midlevels.

Misguided in the bigger picture. But yes, I know for a fact that fellowship spots remain in greater supply than demand for the exact reason you mention, the short-term bottom line.

 

[oldbearprofessor]

Hi,

I'm currently a US IMG pursuing PICU fellowship at my top choice which is also the top children's hospital in my state and among one of the best in the country. Due to a variety of reasons, I'm considering the possibility of swapping to a program to be closer with family and friends

I'd highly appreciate if anyone could answer the following

• I've seen swaps in residency but is it even possible in fellowship
• If yes, what is the process or are there any set guidelines provided I'm able to find a vacant spot (highly unlikely) or find someone in an appropriate program who is willing to swap
• I heard some positions went unfilled during 2022's match. Can I approach them provided they aren't already filled in SOAP
• How do I approach my program with such a request and how do they perceive it
• How do potential employers/recruiters perceive this during job hunt and will it have any repercussions or negatively impact my profile

Best

Surfing doc covered a lot and I agree with all of that, a few more general comments. First, "swaps" are virtually impossible at the fellowship level. Any fellowship move is incredibly difficult and a "swap" would be pretty nearly impossible. Moving into an open spot (I don't think that PICU or NICU have many of these right now, being unfilled in the match doesn't mean it wasn't ultimately filled) is theoretically possible but extremely hard to arrange. I've seen it done once ever in NICU, can't speak for PICU. Much of the problem is that even if a spot exists, programs organize their time very differently leading to mismatches in meeting clinical time needed for a fellowship. A one-way move would also leave your current fellows in the lurch, at the very least for night call. No one will appreciate it unless there is a truly compelling reason and even then they will be upset. A better option is to finish your primary in-patient clinical time as much as possible and try to find a fellowship research project that you can do which is based on dataset evaluation and can be done remotely in large part allowing you more time between calls to travel to where you want to be.

 

[SurfingDoctor]

Surfing doc covered a lot and I agree with all of that, a few more general comments. First, "swaps" are virtually impossible at the fellowship level. Any fellowship move is incredibly difficult and a "swap" would be pretty nearly impossible. Moving into an open spot (I don't think that PICU or NICU have many of these right now, being unfilled in the match doesn't mean it wasn't ultimately filled) is theoretically possible but extremely hard to arrange. I've seen it done once ever in NICU, can't speak for PICU. Much of the problem is that even if a spot exists, programs organize their time very differently leading to mismatches in meeting clinical time needed for a fellowship. A one-way move would also leave your current fellows in the lurch, at the very least for night call. No one will appreciate it unless there is a truly compelling reason and even then they will be upset. A better option is to finish your primary in-patient clinical time as much as possible and try to find a fellowship research project that you can do which is based on dataset evaluation and can be done remotely in large part allowing you more time between calls to travel to where you want to be.

One quick comment on this specific point. It may or may not be relevant to the OP but it will be relevant at some juncture (and probably relevant to finding a job but maybe not the most desirable job). A fellow approached me about a scholarly project. Mind you I don’t do clinical research because that’s not my forte and I’m not sure it is of many academic people. But I studied their topic of interest so there I was. But I stressed to them that if they were to pursue academics and do clinical research, database mining was not that avenue. Database mining is literally the task of people with no skill set. I know this because I’ve had undergrads do it. With more sophisticated tools, you can have a “filter” do it. If you are a physician doing the tasks of what is achievable by a person who has at most a high school diploma, you are not marketable. This isn’t so much a reflection of high school students so much as an academic physician not achieving anything of significance.

Maybe the NICU and PICU are different (from a current market force, I bet they are), but if I was hiring a physician and the best skill set they could put forward that differentiates them is that they can mine data like a high school student… that doesn’t jump to the top of the “offer a job” pile. Again, there’s probably enough jobs in PICU where this advice doesn’t matter right this moment, but someday….

Just general food for thought.

 

[Oso]

One quick comment on this specific point. It may or may not be relevant to the OP but it will be relevant at some juncture (and probably relevant to finding a job but maybe not the most desirable job). A fellow approached me about a scholarly project. Mind you I don’t do clinical research because that’s not my forte and I’m not sure it is of many academic people. But I studied their topic of interest so there I was. But I stressed to them that if they were to pursue academics and do clinical research, database mining was not that avenue. Database mining is literally the task of people with no skill set. I know this because I’ve had undergrads do it. With more sophisticated tools, you can have a “filter” do it. If you are a physician doing the tasks of what is achievable by a person who has at most a high school diploma, you are not marketable. This isn’t so much a reflection of high school students so much as an academic physician not achieving anything of significance.

Maybe the NICU and PICU are different (from a current market force, I bet they are), but if I was hiring a physician and the best skill set they could put forward that differentiates them is that they can mine data like a high school student… that doesn’t jump to the top of the “offer a job” pile. Again, there’s probably enough jobs in PICU where this advice doesn’t matter right this moment, but someday….

Just general food for thought.

I don’t necessarily disagree, but I feel like this is often what many fellows do because of the time crunch, easy accessibility, and ability to come up with a question themselves and then go try to answer it.

I feel like researchers often start with a data set or do a secondary analysis of data prospectively collected for another study, and then eventually use the momentum from these projects to obtain funding to design and conduct their own studies. Otherwise how is a fellow supposed to come up with an idea for a robust (ie. good quality, large enough sample size) study that can be done in roughly 3 years?

The last thing I’ll say is in neonatology lots of people do epidemiological research which is done mostly with data sets.

Of course the RCT is the gold standard, but people need to start somewhere.

Now I’m not saying all these projects from data sets are good studies or even interesting questions - that’s another discussion…

 

[SurfingDoctor]

I don’t necessarily disagree, but I feel like this is often what many fellows do because of the time crunch, easy accessibility, and ability to come up with a question themselves and then go try to answer it.

I feel like researchers often start with a data set or do a secondary analysis of data prospectively collected for another study, and then eventually use the momentum from these projects to obtain funding to design and conduct their own studies. Otherwise how is a fellow supposed to come up with an idea for a robust (ie. good quality, large enough sample size) study that can be done in roughly 3 years?

The last thing I’ll say is in neonatology lots of people do epidemiological research which is done mostly with data sets.

Of course the RCT is the gold standard, but people need to start somewhere.

Now I’m not saying all these projects from data sets are good studies or even interesting questions - that’s another discussion…

That was kinda my point though. If everyone is doing it, it’s not a unique skill set when it comes to looking for jobs and standing out from the pack. Not at the most basic level.

Now, if you analyze datasets and databases AND in the process, to start to learn (not expert but understanding and beginner abilities) of statistics and R or Python, then we are talking about a whole different ballgame. The number of fellows I’ve seen do that is zero in pediatric critical care, but that training does exist for those who seek it and it is doable during fellowship because I’ve seen both a neonatology fellow and hospitalist fellow do those very things.