CL Fellowship...or not?

[Daedra22]

---

Members don't see this ad.

I’ve read every thread I could find about the fellowship vs job issue. I’m still struggling with it, so here I am looking for input.

I was sure I'd do a fellowship up until the end of PGY2. PGY3 was the worst year in my medical education experience. I seriously considered leaving medicine entirely; glad I didn’t, in retrospect. PGY4 is better, in part because my class has worked hard to right the systemic issues (happy to say our current 3’s are much better off than we were). Nevertheless, the sting of burnout lingers. I always wanted to be able to balance medicine with my non-medical pursuits, but feel more urgency about it now. I want to be able to travel and use my creativity. And yet...

I still love CL. I applied to fellowships despite my mixed feelings because I was so sure of it before, and interviewed at some great places. The idea of being able to flesh out my passion for CL is exciting. When I’m on the CL service, which never feels often enough, the work is meaningful and intellectually stimulating. That said, I know I don't *need* a fellowship. I don’t know if I want to be in academia – I have flirted with the idea over time. It saddens me to think of delaying the rest of my life for another year. More than that, I fear submitting to training where the hierarchy lends to abuses of power (possible in a job, but moreso in training). I worry about feeling trapped, dehumanized, and powerless again. I have no reason to believe that the places where I interviewed are like that.

TLDR: Love learning about CL a whole lot, may or may not go into academia. Want to get on with living the rest of life, worried about potentially being abused by the medical education system again. Any perspectives on the matter are appreciated…particularly from those recently/currently in fellowship.

 

[splik]

I did not do a C/L Fellowship but my day job is running a busy C/L service at a major academic medical center and I interview applicants for our C/L fellowship. I usually quite frankly tell them they do not need a C/L Fellowship to work on a consult service or to do outpatient consults/integrated care etc. You only need to do a C/L Fellowship if you want to be a C/L fellowship director. That is literally the only thing it specifically qualifies you to do.

If you are going to make it worth your while you need to figure out what you want to get out of doing the fellowship and make it worth your while. imho there is no point in doing the fellowship unless you do it a major academic medical center where you will see all the weird zebras and get exposure to the specialist areas of C/L psychiatry including neuropsychiatry, HIV psychiatry, psycho-oncology, transplantation psychiatry (for example doing evaluations for transplant candidates and living donors), evaluation of management of somatization and functional neurological disorder, get skilled in managing alcohol withdrawal in the medical setting, learn basic psychotherapeutics in the medical setting (including things like hypnosis), get exposure to outpatient consultation including innovative models like collaborative care or telepsychiatry consults, have the opportunity to get trained in ethics consultation, and for the more academically inclined get opportunities to be involved in education and research. A good C/L fellowship should also train you in the business aspects of C/L and how to effectively develop, lead, and manage a financially solvent C/L service.

The utility of a C/L fellowship will also depend on where you did your residency training. If your training was at an academic medical center and you have plenty of months of consults and spent a lot of your time on call doing consults then the value of a C/L fellowship is probably diminshing returns. If on the other hand you didn't spend that much time doing consults and/or it was at a smaller hospital where you didn't get to see all the esoterica and get exposure to the sub-subspecialties of C/L psychiatry then it might not be an unreasonable thing to do, especially if you would not be able to get a job on a C/L service at a major academic medical center otherwise.

I think your concerns about it being an extension of residency are unfounded. You'll have residents and med students to scut out unless you end up in a fellowship without said residents. You will be spending a year being able to study in depth a field that you love. You won't have to take call. You will basically be charged with leading the team, under supervision. I think it's common for people to burn out in fellowships/get senioritis during the final phase of any fellowship however but by that point you should have a job set up. The other thing is unlike residency, you know you can quit at any time (if you really wanted to) and they can't hurt you. Sure it burns some bridges, but you can easily get a real job if you so wished. Makes a world of difference.

 

[TexasPhysician]

CL is about as lucrative as academics in Texas. In other words, you will have little competition for these jobs. My recent offer was 85% of billed Medicare rate.

 

[chajjohnson]

What was so bad about your PGY-3 year?

 

[Daedra22]

What was so bad about your PGY-3 year?

Complicated. Some of it personal, some of it structural, all of which has been addressed to the extent it can be. Not really worth going into detail for this purpose, except to say that I'm still recovering from the experience and that makes this decision more difficult than it would have been otherwise.

Splik, I sincerely appreciate your thoughts. A lot of that is very relevant to me, and it's nice to have reinforcement around the idea that the fellowship role is different than the role I've been in.

 

[tyrionlannister00]

If you are worried about job opportunities with or without the fellowship... I say no to fellowship. But then again I'm a jaded 4th year and looking forward to my 300k salary with no call 9-5 outpatient only... Without a fellowship of course.

 

[boogaaloo]

It's absolutely unnecessary. Unless you want to be a fellowship director someday and want to inculcate more residents into this scam, you do not need it!

 

[SeniorWrangler]

I would never encourage people to do a fellowship that doesn't let you do anything that you couldn't do without the fellowship, but it's only a year and if you love the subject, why not go for it?
Unless you already have a ton of student loans or a baby on the way, in which case you should probably get a real job already.

 

[Merely]

PGY3 is supposed to be the easiest part of your medical education...how the hell was it the worst?

 

[st2205]

PGY3 is supposed to be the easiest part of your medical education...how the hell was it the worst?

Ours was pretty terrible. The call significantly tapered off but we were holding that clinic together. There were twice as many people (between residents, staff and outgoing NPs) who had left as there were our class coming in. There was a waitlist of about 9 months for established patients. There were two nurse practitioners who had virtually no supervision and we got the joy of inheriting all those patients. They’d pack your schedule pretty tight and often schedule over supervision times. I’d still be picking up 2-3 new patients per day when my closest follow up was 3 months out. They’d have “stand-by” patients, too, so if you get a no-show (after 15 minutes), you get the joy of seeing someone who’s been sitting in the waiting area for four hours and now you’ve got 15 minutes left and no chart review. Then imagine the selection bias for population of who thinks they need an appointment so bad they’d sit around all day. Then you get to wait in line to checkout — not because it will help you learn or help the patient, but so you can bill for that baby. Then you get to do all the prior authorizations yourself, which was nice when the insurance companies kick back on BuSpar or hydroxyzine, and ask if they’d first tried and failed a benzo. Then there was the one day per week at the VA that was a pure **** fest. Absolutely awful (the VA, that is — despite the above dramatics our clinic was far away better than the experience at the VA — I will never work a VA job so long as I live because of that experience).

 

[Daedra22]

Ours was pretty terrible. The call significantly tapered off but we were holding that clinic together. There were twice as many people (between residents, staff and outgoing NPs) who had left as there were our class coming in. There was a waitlist of about 9 months for established patients. There were two nurse practitioners who had virtually no supervision and we got the joy of inheriting all those patients. They’d pack your schedule pretty tight and often schedule over supervision times. I’d still be picking up 2-3 new patients per day when my closest follow up was 3 months out. They’d have “stand-by” patients, too, so if you get a no-show (after 15 minutes), you get the joy of seeing someone who’s been sitting in the waiting area for four hours and now you’ve got 15 minutes left and no chart review. Then imagine the selection bias for population of who thinks they need an appointment so bad they’d sit around all day. Then you get to wait in line to checkout — not because it will help you learn or help the patient, but so you can bill for that baby. Then you get to do all the prior authorizations yourself, which was nice when the insurance companies kick back on BuSpar or hydroxyzine, and ask if they’d first tried and failed a benzo. Then there was the one day per week at the VA that was a pure **** fest. Absolutely awful (the VA, that is — despite the above dramatics our clinic was far away better than the experience at the VA — I will never work a VA job so long as I live because of that

So you know my pain. Not all the details are the same, but very, very similar (down to the excessive transfers part). Also, I now weep with joy when someone comes to me on 4 psych meds or less. I don't even care what they are.

 

[Mass Effect]

PGY3 is supposed to be the easiest part of your medical education...how the hell was it the worst?

I suppose if you enjoy outpatient and psychotherapy, maybe. For me, it was the worst year of my medical education. I hated it and it's the reason I will never do outpatient outside of a one-time consultation for PCPs. I'd rather take 2nd-year call than do a single day of PGY 3 year over. Patients who call you multiple times a day, family members who call you repeatedly, tons of disability forms, patients pissed at you, prior auths for everything, patients who show up to the clinic and demand to be seen and the front desk, not knowing what to do, page you to actually see them. Borderlines wanting to be seen every other week and no matter how many times you try to set boundaries, they call the clinic anyway and worm their way into your schedule. And residents have almost no say in their schedule. And all of this isn't even considering the sometimes dangerous conditions in the clinic with offices upstairs, away from everyone, psychotic patients and no panic buttons. It was a terrible experience and the reason I will never take a full-time outpatient job.

@Daedra22 I'm sending you a PM because I have some thoughts on your predicament.

 

[NickNaylor]

I’m in a somewhat similar position as you, OP, just a year behind: much prefer inpatient work, love C/L but ambivalent about a fellowship because of wanting to get started with my career, etc..

I’ve spoken with a number of faculty about this, and all echo everything splik said. Fellowship training is not a requirement outside of the academic setting, though some have said that many hospitals prefer fellowship-trained docs for clinical leadership positions (though will happily take all-comers if they can’t find a fellowship-trained candidate) and it is a requirement for academic leadership as mentioned above. I’m very interested in academia and clinical/administrative leadership so these are draws for me, but if you’re not completely sold on academia then I’m not sure what you would actually get out of the experience beyond being able to sell yourself as fellowship-trained - which in and of itself is not all that valuable as far as I can tell. I’m at a big academic institution/county hospital, and most of the C/L faculty aren’t fellowship-trained - in fact I think the only person that is is the fellowship director and a couple of the faculty at the VA. Take that for what you will.

At the end of the day, it’s only a year and likely to be a fairly relaxed year (at least compared to residency), so I’m not sure that your worries of reliving a residency experience are realistic. The downside is continuing in the role of trainee and a deferred year of attending salary.

The one piece of advice that I’ve consistently heard, however, is to make the decision now, because there is likely zero chance that you will ever return to training should you change your mind once you’re in practice.

 

[aim-agm]

If C/L fellowship is valuable only for academic leadership and psych residency is adequate training for C/L, what of the other psych fellowships? Are some of them also covered by residency training with the fellowship not really necessary for practice?

 

[OldPsychDoc]

If C/L fellowship is valuable only for academic leadership and psych residency is adequate training for C/L, what of the other psych fellowships? Are some of them also covered by residency training with the fellowship not really necessary for practice?

Essentially, yes--though most general programs' training in geropsych and addictions is far too superficial for someone who was either deeply interested in those realms or wanted to practice as a true sub-specialist. (And certainly not adequate for someone seeking academic leadership in those areas, as stated.) Nevertheless, you should graduate competent to care for those issues in general psychiatric practice.

 

[splik]

If C/L fellowship is valuable only for academic leadership and psych residency is adequate training for C/L, what of the other psych fellowships? Are some of them also covered by residency training with the fellowship not really necessary for practice?

I didn't say a C/L fellowship was not valuable, simply that it is not necessary. Value is in the eye of the beholder. If you see my generic fellowships threads you will see there are a plethora of reasons why people choose to do fellowships. It could be valuable for someone to get training in things they didn't get during their residency training depending on where they do the fellowship and what they want to get out of it. It might be a way of going to a more "prestigious" place. If your dream job is to work on the c/l service at MGH, doing your fellowship there might be the only way to make that happen etc. For a lot of people (?most) their residency training wasnt very good so a fellowship may be a way of actually gaining the skills for independent practice. For certain jobs a c/l fellowship may make you a more desirable candidate.

My point is people should do a fellowship because they want to, not because they fell they have to. You should have very clear goals for what you want to get out of that and how it might fit into my career trajectory, which might be as basic as "I want to move to a new area and another year of training will let me chill and get the skinny on jobs in the area for signing up to the real deal." For some jobs, additional board certification may mean an additional 5% compensation.

 

[SeniorWrangler]

Somatic fellowship could open doors but only if you're looking for jobs doing a lot of somatic interventions.
Geropsychiatry... it seems to me that you could bone up on Geropsych on your own and do some rotations and be a pretty good geropsychiatrist, but you should ask somebody who's done the fellowship. I know one guy who said that doing the geropsych fellowship has made his practice a little busier and more lucrative because the demand is great.
Pain fellowship opens a whole new realm of possibilities but also takes you away from psychiatry to a large extent.

 

[Daedra22]

An update for anyone who later finds this thread and wonders how the decision went...

I ended up matching into CL. The argument that got me is that I know I want to do CL as a mainstay of my professional life, and I believe I would regret encountering some CL opportunity in the future where I wasn't qualified or felt I didn't have the skills to do it. While I realize fellowship is not a common requirement for most positions, I'm young yet and things could change in ways I don't expect - including me suddenly deciding I want to be involved in academia after all. Also, I ended up interviewing at a place which offered rotations in specific areas I want to learn more about, and would have a hard time learning outside of an academic center. If not for that particular opportunity the outcome may have been different. I'm happy with the decision - hopefully will still be happy with it in 6 months!

Thanks to everyone who responded. 🙂

 

[boogaaloo]

An update for anyone who later finds this thread and wonders how the decision went...

I ended up matching into CL. The argument that got me is that I know I want to do CL as a mainstay of my professional life, and I believe I would regret encountering some CL opportunity in the future where I wasn't qualified or felt I didn't have the skills to do it. While I realize fellowship is not a common requirement for most positions, I'm young yet and things could change in ways I don't expect - including me suddenly deciding I want to be involved in academia after all. Also, I ended up interviewing at a place which offered rotations in specific areas I want to learn more about, and would have a hard time learning outside of an academic center. If not for that particular opportunity the outcome may have been different. I'm happy with the decision - hopefully will still be happy with it in 6 months!

Thanks to everyone who responded. 🙂

Come back and report in six months, or better still, a year. I doubt you will be.

 

[Dharma]

An update for anyone who later finds this thread and wonders how the decision went...

I ended up matching into CL. The argument that got me is that I know I want to do CL as a mainstay of my professional life, and I believe I would regret encountering some CL opportunity in the future where I wasn't qualified or felt I didn't have the skills to do it. While I realize fellowship is not a common requirement for most positions, I'm young yet and things could change in ways I don't expect - including me suddenly deciding I want to be involved in academia after all. Also, I ended up interviewing at a place which offered rotations in specific areas I want to learn more about, and would have a hard time learning outside of an academic center. If not for that particular opportunity the outcome may have been different. I'm happy with the decision - hopefully will still be happy with it in 6 months!

Thanks to everyone who responded. 🙂

I'd like to hear about your experience so far. PGY3 sitting on the CL fellowship fence.

 

[deleted736562]

Ours was pretty terrible. The call significantly tapered off but we were holding that clinic together. There were twice as many people (between residents, staff and outgoing NPs) who had left as there were our class coming in. There was a waitlist of about 9 months for established patients. There were two nurse practitioners who had virtually no supervision and we got the joy of inheriting all those patients. They’d pack your schedule pretty tight and often schedule over supervision times. I’d still be picking up 2-3 new patients per day when my closest follow up was 3 months out. They’d have “stand-by” patients, too, so if you get a no-show (after 15 minutes), you get the joy of seeing someone who’s been sitting in the waiting area for four hours and now you’ve got 15 minutes left and no chart review. Then imagine the selection bias for population of who thinks they need an appointment so bad they’d sit around all day. Then you get to wait in line to checkout — not because it will help you learn or help the patient, but so you can bill for that baby. Then you get to do all the prior authorizations yourself, which was nice when the insurance companies kick back on BuSpar or hydroxyzine, and ask if they’d first tried and failed a benzo. Then there was the one day per week at the VA that was a pure **** fest. Absolutely awful (the VA, that is — despite the above dramatics our clinic was far away better than the experience at the VA — I will never work a VA job so long as I live because of that experience).

Makes me feel very thankful (thanksgiving time) about our PGY-3.

 

[Mass Effect]

I'd like to hear about your experience so far. PGY3 sitting on the CL fellowship fence.

Not that poster, but may I offer the same advice given above -- do it, but only at a major academic center.

 

[Dharma]

Not that poster, but may I offer the same advice given above -- do it, but only at a major academic center.

Agreed. I'm at one already (1500+ beds) and one with a great consult service. We have ~6 months total. But the time on service flies by given how busy it is. Most of the month is spent keeping one's head above the water considering the volume. Don't get me wrong, it makes for great learning but I can see how the fellowship could provide the opportunity to really dig into the intricacies of each case. The fellows have the chance to work on the more complicated cases or those zebras that come through. There is also a great opportunity to work with the PCP's in the collaborative/integrative care setting which IMO will play a huge role in coming decades.

I see that our CL service only hires board certified CL docs. As the field produces more CL BC docs, I would imagine more places preferring this training (many already ask however beggars can't be choosers?). For somebody who wants to ensure being in CL, the fellowship will likely give them the one-up. With more one-ups being produced each year, competition may eventually get tight.