Concerns before entering fellowship, any help would be appreciated

[JerseyDoc]

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Hello all,

My current situation has left me in a real predicament and has been torturing me the past few months. I'm currently in my last year of Internal Medicine residency, and scheduled to start a Pulm/CC fellowship at my home institution this upcoming July. I enjoyed my CCM rotations 1st and 2nd year, and always thought about going into that field, but never applied for the fellowship...the plan was to be a medicine hospitalist or maybe go to the outpatient setting and do primary care.

After the match, the Pulm/CCM dept approached me about a fellowship spot to start as early as this July. I grappled over it for a few weeks to a month, and ultimately took the position. I figured CCM would allow me to practice Internal Medicine on steroids, without having to deal with all the social BS, less arguments with the ED regarding admissions etc, while Pulmonary would provide me an escape from the hospital and regular hours.

Since that time unfortunately all I have been doing is going back and forth regarding my decision to take the spot. Many have stated that there is not much demand for Pulmonary outpatient and my life will end up being primarily in the ICU, which sounds horrible. Too stressful, and I fear it will give me less time with my family. I'm not worried about the fellowship itself (actually a fairly relaxed fellowship since there are 9 fellows total), but more so about my schedule and lifestyle after fellowship. It has driven me crazy, I havent been able to focus at work, and also havent been able to fully enjoy my time off at home with my family. My poor wife has had to hear about my indecisions every day for the last 2+ months.

What are everyone's thoughts? Would it be possible to work primarily Pulmonary outpatient, or does that not even exist? I would be open to combining that with IM Primary Care if needed. If that's what I end up doing, I'm not sure a 3 year fellowship is worth it.

CONS for going through fellowship:

-Potential for having very limited outpatient work, forced to do much more inpatient than I expected

-Potentially worse lifestyle

-Higher stress job

-3 more years as a trainee when I could have been an attending


PROS for going through fellowship :

-Much more pure medicine, much less of the social issues/scut work of IM

-Higher income potential

-Not a horrible schedule during fellowship

-Even if I dont end up practicing Pulm/CCM, I will have additional certifications that I would think make me more competitive for IM hospitalist or even outpatient jobs. It also gives me flexibility later in life incase I'm not happy in Internal Medicine or things get worse for generalists.

My question to all of you, if I do ultimately decide to not go through with my plans for fellowship, what would be the best way to do it? It was a spot created for myself - they had funding for the spot, but for whatever reason, were prepared to let that spot go unfilled. In other words, its not like I stole that spot from someone through the match. I've been a strong resident, and well liked by everyone throughout the institution. It would kill me if my lasting impression before leaving residency is of someone so indecisive and screwing over a fellowship program.

Everyone's thoughts will be very much appreciated, thank you so much in advance.

 

[dennisscott]

I dont know much about this as i will be beginning my career in internal medicine soon. But your post really displays the pros and cons of pulm/ccm. Keep me posted on what you decide and what you are planning. I personally believe that the demand for pulmonary medicine will increase, with new interventional techniques and already intensivist have potential to earn good money, but i dont know how hard they have to work for this. the average pay for an intensivist in texas was 330k last year.
If its crazy work hours maybe general IM is better. let me know the updates.
cheers

 

[redy]

I will attempt to answer. ICU is definitely a more hours/more stress/ poorer lifestyle. Having said that I do feel you can look for a job with less ICU and maybe more pulmonary/medicine. Obviously the pay will be less when compared to other pulm/CC people.

Basically what I am saying is perhaps you can get a less demanding ICU job. However I am not sure of the chances of such a situation existing. I know of one fellow though who told me he was going to do only pulmonary and no ICU. Why then he did CC too I do not know.

 

[VentJockey]

I think there is plenty of demand for pulmonary medicine, and I see the trend in the direction of more demand, not less. My thoughts on this are for the following reasons:

1) We're getting better at keeping people alive longer. The COPD and Pulmonary HTN etc kind of cases--over the next decade, I forsee us keeping these people alive for longer periods of time, meaning more work for this specialty. That could be offset by lower smoking rates, but that can be offset by an aging populatis on. Basically, I think it nets out to an increase in the demand for outpatient pulmonology services. Remember, in medicine, the better we get, the more work we have to do, because it takes a lot of work to care for someone who would have been dead three years ago were it not for our care.

2) Increased demand for intensivist work: more and more ICUs going to closed ICUs means rising salaries that will be pulling some docs out of the clinic and putting them in the ICU. Those docs leaving creates an opening for someone who wants to do pulmonary outpatient.

In short, I don't think you'll have a problem having a robust practice of pulmonary outpatient if that's what you want. Going forward, we're going to see more work, and increased demands on professionals to shift to ICU, meaning for those guys who really like outpatient, they're going to also be in high demand.

But ultimately, imagine yourself in 10 years and ask what you would have wished you'd have done. That should give you the answer you're looking for.

 

[sluggs]

Kind of interesting that the OP asked for advice on how he could duck out on the fellowship and all posts deal with pros and cons of PCCM?

 

[take the shot]

I am about to start an IM residency and you have pretty much summed out my dilemma for the future. I love pulmonary critical care and being in the ICU, but my family is so important to me and I also love traveling and having a good time. Seems so hard to balance career and family goals. I keep remembering I have one life to live: how do I want to spend it? I just never want to have any regrets.

Although I think there are a lot of different pulmonary careers, most of the attendings I have seen (private practice and academic) appear to alternate inpatient and outpatient. Some are really into procedures, others are more strictly focused on medical management. But along with cardiology it seems to be the toughest fellowship and I don't know if I want to spend my life like that. I am going to try to figure this out during residency