Fellowship at a later date?

[ScoutQ4]

Anyone here graduate residency, practice in the community and later return to academics for a fellowship? I’m contemplating pursuing a CCM fellowship but weighing if going straight from residency would be a better option than taking a few years to pay off student loan debt and developing my own independent practice style post-residency.

I’ve discussed this with a few of my attendings who are not fellowship trained and they unanimously say one is unlikely to return (pay decrease, work hour increase, family obligations etc). Curious to hear if any counter arguments exist.


Sent from my iPhone using SDN

---

Members don't see this ad.

 

[gamerEMdoc]

Anyone here graduate residency, practice in the community and later return to academics for a fellowship? I’m contemplating pursuing a CCM fellowship but weighing if going straight from residency would be a better option than taking a few years to pay off student loan debt and developing my own independent practice style post-residency.

I’ve discussed this with a few of my attendings who are not fellowship trained and they unanimously say one is unlikely to return (pay decrease, work hour increase, family obligations etc). Curious to hear if any counter arguments exist.


Sent from my iPhone using SDN

I'm sure its happened, but I doubt its common to go into a fellowship several years out of residency for the reasons you mentioned. Once you start making a decent salary its a tough pill to swallow to all of a sudden go back to a fellow salary. Same with getting used to being independent and having a better schedule. To all of a sudden give that up would be jarring to most people I think.

I'm sure people have done it, but personally I doubt its very common unless someone is just burnt out and trying to do something completely different like pain or palliative medicine.

 

[deuist]

Don't wait. Go through the fellowship now. Your attendings are correct. Once you get a stable job, get married, and have kids, taking a substantial pay for 2 years and moving to a different city is going to be a no-go for most families.

 

[GatorCHOMPions]

Anyone here graduate residency, practice in the community and later return to academics for a fellowship? I’m contemplating pursuing a CCM fellowship but weighing if going straight from residency would be a better option than taking a few years to pay off student loan debt and developing my own independent practice style post-residency.

I’ve discussed this with a few of my attendings who are not fellowship trained and they unanimously say one is unlikely to return (pay decrease, work hour increase, family obligations etc). Curious to hear if any counter arguments exist.

I'm in this boat, a few years out and attempting to go back for a fellowship. For me, I always toyed with the idea of specializing but could never settle on exactly what so I decided to be an attending for a little while to see if I could do general EM for 30 years. I don't regret this decision, as doing a fellowship is usually a money-loser and I wanted to be sure this was right for me in the long term. I was also fixated on my debt and wanted to be very aggressive at paying this down which I've done by now.

I would recommend you do some self-reflection before going this route, however. First and foremost, if you have a family they must be on board. This will essentially be uprooting for your loved ones for two years (deciding to do a two year fellowship will be doubly as hard as a one year fellowship especially after graduation - have you considered US, EMS, sports med, palliative or pain?) and will be very difficult for them. Second, you need to make a commitment to live like a resident while you are an attending so you don't get used to the lifestyle and thus make it even harder to go back into training (no fancy car, house, big vacations, etc.). Third and finally, I would recommend staying in academics instead of going into the community. A fellowship in CCM is not an automatic "in" for EM applicants and you will need updated, recent LOR's and a network of contacts to give yourself the best chance. You will also need to apply broadly and not be restricted to one area of the country (see point #1).

Best of luck. I think the way health care is going these days, the best thing one can do is diversify their skills and money streams whether that's inside or outside of medicine. Fellowship is an easy way to accomplish this for the former.

 

[WilcoWorld]

Anyone here graduate residency, practice in the community and later return to academics for a fellowship? I’m contemplating pursuing a CCM fellowship but weighing if going straight from residency would be a better option than taking a few years to pay off student loan debt and developing my own independent practice style post-residency.

I’ve discussed this with a few of my attendings who are not fellowship trained and they unanimously say one is unlikely to return (pay decrease, work hour increase, family obligations etc). Curious to hear if any counter arguments exist.


Sent from my iPhone using SDN

I went back to fellowship after several years as an attending. It's not easy, but then neither is doing fellowship right after residency. I think there's a lot to be said for it. One is that I think my experience helped me to pick a subspecialty that was much better suited to me than those I was considering when I was finishing residency.

So I think it's a great idea...for me. YMMV. The facts that I spent my time as an attending living below my means and that my spouse is very supportive were extremely important in making this a viable path.

 

[ShockIndex]

I graduated EM residency back in 2006, and spent about 15 years practicing in a variety of settings (mil, cmg, edu, gov) before going back and starting a CCM fellowship this year. Like most people my age, I’ve got kids, pets, and other first world problems. However, I’m glad that I took some time to use my EM training to do fun stuff when young. My wife was a little apprehensive at first, but we spent a couple years saving and created a nice financial cushion so that our standard of living would not take a big hit.

 

[Birdstrike]

Anyone here graduate residency, practice in the community and later return to academics for a fellowship? I’m contemplating pursuing a CCM fellowship but weighing if going straight from residency would be a better option than taking a few years to pay off student loan debt and developing my own independent practice style post-residency.

I’ve discussed this with a few of my attendings who are not fellowship trained and they unanimously say one is unlikely to return (pay decrease, work hour increase, family obligations etc). Curious to hear if any counter arguments exist.


Sent from my iPhone using SDN

I went to my Interventional pain fellowship 8 years after residency. It was a tough time to do it. It was hard because unlike my earliest EM day, I Noe had a wife, two kids 5 and under, and had to move to a new a new city for one year, with the whole family (plus a cat and 50 lb dog) and financially maintain two homes on a house staff salary. That was hard.

Still, I’m glad I did it and I would’t change my EM tour of duty for the world, not doing the fellowship, but doing it earlier would’ve been easier from the above standpoint.

On the other hand, being in the ED for a few years made me appreciate the change so much more and likely helped me get accepted to my fellowship. The admission committee told me it was my “maturity”was what set me apart from other candidates who they turned down.

From my wife’s perspective, being married to someone in EM for a few years, also made her greater appreciate the need to get out of the rotating shift work, which was harmful not only to my peace of minds, but to the whole family.

Also, when I started as an EM attending at age 29, I still believed the lies I was told, such as EM being a “lifestyle specialty,” burnout being a “myth” that only affects defective people, and could “easily be avoided.” Personally, I needed a few circadian-murdering years of randomly rotating dysphoria shift work in the pit to learn none of that was true. But most other tangible ways, going to fellowship right after residency would have required much less heavy lifting.

Do what’s best for you, depending on your current situation and mindset.

 

[Dr.CCM]

Anyone here graduate residency, practice in the community and later return to academics for a fellowship? I’m contemplating pursuing a CCM fellowship but weighing if going straight from residency would be a better option than taking a few years to pay off student loan debt and developing my own independent practice style post-residency.

I’ve discussed this with a few of my attendings who are not fellowship trained and they unanimously say one is unlikely to return (pay decrease, work hour increase, family obligations etc). Curious to hear if any counter arguments exist.


Sent from my iPhone using SDN

I did CCM. Go straight through. You need the connections, research, yours scores are more applicable all now. It’s only going to get more competitive especially if this new ER surprise billing goes through.

If you are thinking about doing community EM, you won’t get much actual CC but maybe some /a lot of resus experience at high acuity places but your job in the community is to triage, stabilize enough and dispo. You won’t get the icu boarders in a functioning Hospital. You won’t keep down your CC patients for 8 hrs waiting for all the ancillary services to debate bs about where that patient goes. Not a lot of CC doing that. Go to a program you can moonlight.

If you need to take a break for a year before diving back in that’s probably fine too but stay connected in academics somehow and get all your letters for fellowship done before you leave. Don’t wait too long.

 

[Frazier]

Do the fellowship stat.

Historically, very few go back to CCM once attending status. It is one of the more grueling schedules/difficult to moonlight options. Few go back. Much easier going straight in.

That was a good point above, I bet CCM, sports, pain, and palliative will all be getting a significant increase in EM attending applications if/when the surprise billing movement happens. A lot of the docs won't want -- or be able to leave medicine -- but they wont want to do traditional EM for 40% less either.

Enter the world of fellowships. They might make less, but at least they will enjoy whatever they pick (theoretically).

Nearly every one of my palliative med interview days had at least 1 EM attending present. The trend thickens.

If you wait then you will be another face in the tsunami.

Do it and never look back.
Congrats on making the right decision!

 

[ShockIndex]

Do the fellowship stat.

Historically, very few go back to CCM once attending status. It is one of the more grueling schedules/difficult to moonlight options. Few go back. Much easier going straight in...If you wait then you will be another face in the tsunami.

Do it and never look back.
Congrats on making the right decision!

While I’m glad that I took some time to sow my career’s wild oats, going straight through is probably pretty smart for today’s applicants. Remember, there was no pathway to US board certification for EPs back when I graduated and the job market was far less certain. Times have changed.

I also agree with everyone who thinks that CCM is going to get a lot more competitive over the next 5 years as EM residents wise-up to what awaits them in community EM. To be honest, I bet it’s already happening. When I interviewed for anesthesia CCM spots last year, at least 1/3 of the interviewees were EM applicants. Keep in mind that most of the programs had only 1 or 2 spots funded for an EM applicant; I’m one of 6 CCM fellows in my class - the other 5 are anesthesiologists. While it’s true there are plenty of unfilled anesthesia-CCM spots each year, they are all 1-year funded spots for anesthesiologists. The EM spots are generally filled months before the SF Match date with match exceptions - it’s that competitive for EM candidates.

Reports from this year’s IM-CCM season sounds similarly competitive. There were more than 1.5 applicants per position making CCM among the most competitive fellowships for internists. Keep in mind that some of those spots were not open to EPs.

Finally, my last EM job was with a university that had a very well established residency. Two of the graduating seniors are doing CCM fellowships. 4 of the PGY2s are applying for 2021...

 

[TheSingularity]

EM is a scam that somehow hundreds of medical students got sheeped into during the last ten years.

If you can develop a niche, I'm sure academic practice can be very rewarding. The rest of us head out to the community ED slaughterhouse.

I'm transitioning into a new position (borderline unicorn...mildly less money but great leadership and environment) that I believe will be much better, however external factors such as balance billing legislation may break even this.

Fellowship may be on the horizon for me, we shall see.

Sent from my Pixel 3 using SDN mobile

 

[ScoutQ4]

Thanks for the helpful comments. My wife is a fellow resident and wants to do a fellowship. The idea of doing another couples match sounds miserable and the CCM program at my institution is in its early years of development. I feel like it would be in my careers best interest to go somewhere established rather than help pave the way so my inclination is to wait until she is finishing and apply around that time all the while staying connected with my home shop regarding research etc. I’ve only really considered CCM and US — is pain really that popular these days? I love everything about EM but after so many years of sacrifice I’m ready to make a living and start a family but these forums make the future sound so abysmal. Job security is the driving force for my fellowship inquiry.


Sent from my iPhone using SDN

 

[Tenk]

Thanks for the helpful comments. My wife is a fellow resident and wants to do a fellowship. The idea of doing another couples match sounds miserable and the CCM program at my institution is in its early years of development. I feel like it would be in my careers best interest to go somewhere established rather than help pave the way so my inclination is to wait until she is finishing and apply around that time all the while staying connected with my home shop regarding research etc. I’ve only really considered CCM and US — is pain really that popular these days? I love everything about EM but after so many years of sacrifice I’m ready to make a living and start a family but these forums make the future sound so abysmal. Job security is the driving force for my fellowship inquiry.


Sent from my iPhone using SDN

If you’re married just go start making money. US is a joke and adds nothing outside of academics. It’s like, do you want $300,000 or do you want a certificate saying you are really good at ultrasound? CCM just adds more hours to your work life for the exact same pay plus the minus around $600,000 you’ll take for the two years of fellowship. I’m sure someone on these forums will try to argue with me but I paid off all my debt in just a few years and now only work 12 days a month, make great pay, and really enjoy my life. F the haters! EM is great!

 

[emletters]

When it’s all said and done, combined my girlfriend and I will have close to 600k in debt. She’ll be starting residency right after I finish. All the news about balance billing, Medicare for all, midlevels makes me feel like I should go for a fellowship just for the job security. But the years of lost income and the EM fellowships that are really only useful to do academics makes me worried that I wouldn’t be able to pay off those loans in the first few years out of residency like I want to. But at the same time, if the current pay and future of EM is going to be eviscerated anyway... I dunno. Really confused.

 

[ShockIndex]

Thanks for the helpful comments. My wife is a fellow resident and wants to do a fellowship. The idea of doing another couples match sounds miserable and the CCM program at my institution is in its early years of development. I feel like it would be in my careers best interest to go somewhere established rather than help pave the way so my inclination is to wait until she is finishing and apply around that time all the while staying connected with my home shop regarding research etc. I’ve only really considered CCM and US — is pain really that popular these days? I love everything about EM but after so many years of sacrifice I’m ready to make a living and start a family but these forums make the future sound so abysmal. Job security is the driving force for my fellowship inquiry.


Sent from my iPhone using SDN

You will not have to couples match in CCM as all pathways use rolling applications rather than a match day. While IM programs accept applications through ERAS or use their own forms, offers are made in a rolling basis usually from September to November the year before you start.

Anesthesia programs accept applications through the SF Match, but many (most?) fill their EM slots through match exceptions well ahead of the SF match day. This whole business of match exceptions is a bit confusing, but basically anesthesia programs can offer spots outside of the SF match to internal candidates or applicants staying at the institution for more than a year. While this was designed for people staying for additional 1-year fellowships such as cardiac, it has become a loophole of sorts for EM candidates since we are all staying for 2 years. Anesthesia programs can and will call up competitive applicants and make offers soon after they interview.

 

[Dr.CCM]

Thanks for the helpful comments. My wife is a fellow resident and wants to do a fellowship. The idea of doing another couples match sounds miserable and the CCM program at my institution is in its early years of development. I feel like it would be in my careers best interest to go somewhere established rather than help pave the way so my inclination is to wait until she is finishing and apply around that time all the while staying connected with my home shop regarding research etc. I’ve only really considered CCM and US — is pain really that popular these days? I love everything about EM but after so many years of sacrifice I’m ready to make a living and start a family but these forums make the future sound so abysmal. Job security is the driving force for my fellowship inquiry.


Sent from my iPhone using SDN

If your main motivation for CCM fellowship is job security, don’t do it yet. Wait and see how this all plays out. While I think CCM pays a little bit more nationally, you work more days so it’s really wash (full time is typically 14-15 days/month in the community) but you can practice CCM much longer full time than EM especially if you get a job with no nights (which is almost impossible to do in EM) so your overall earnings will be more with more years worked even if you include that Two year fellowship period.

You should always have a job and be able to find one anywhere if you do the fellowship. But it’s hard, harder than residency and you lose a lot of money for those years. I’d only do it if you like the work first. If it’s job security while you’ll have it why not look into pain? Palliative Care? Etc. less time, less stress

 

[Birdstrike]

is pain really that popular these days?

Pain is not at all popular with EM residents, but it is very popular and highly competitive among Anesthesia and PM&R residents, because they understand what the specialty is, and they see the value in it. On the other hand, many EM residents and attendings can't see the value because they think, "Pain equals seeing EM drug seekers, 100% of the time." But that's not at all what the subspecialty is. It's about 40% doing nothing but procedures (2 days set aside for only spine/joint/nerve procedures) and 20% seeing referrals sent to you, screened by you, who are told they won't get a prescription on the first visit, no exceptions (EMTALA does not apply). The remaining 40% is seeing patients either in follow up after a procedure or clinic follow ups, but only from patients you've agreed to accept into your practice. I focus on doing procedures, and prescribe as few opiates as possible, just like when I was in EM.

Getting shelled all day an all night with EM drug-seeking grenades while searching for lives to same, is not what practicing Interventional Pain Medicine is, but is in fact, unique to Emergency Medicine, alone. The drastic improvement in control you have over your life, schedule, levels of stress and patient population makes such a big difference, it can't even do it justice with an explanation. It may not be for everyone, but it's worth shadowing someone, or doing an elective rotation during residency if you can arrange it.

 

[deleted547339]

Tenk - it’s not all about money. I did CCM and now do part time EM and part time ICU. I have the worlds coolest job. It turns out when you only work 5-8 shifts a month in the ER and average a week a month in the icu, both are really fun. I’m only 1.5 years in, but I LOVE my job. I do enough if both to feel competent, but not so much that either are a slog.

Yes, I’m writing this in the middle of the night because I’m working a night shift, but I only do a week of nights in the icu about 2-4 times a year and 0-2 nights a month in the ER.

 

[TheComebacKid]

Fellowship is one of the best ways you can protect your job. Midlevels have no interest in going through MORE training (1 year of online classes was enough) to be subspecialty trained.

While it's certainly on the horizon, I don't see midlevels staffing ICUs solo overnight, becoming EMS medical directors, head of a poison control center, or the head of an US QI program anytime soon.

The rise of midlevels will slowly eat away at the blue collar community EM warriors first before going for fellowship trained grads.

The cat is already out of the bag in EM, and while I don't think there is a bubble that is "bursting", I do think over the next 5-10 years the bubble will deflate and your bread and butter community ED doc will be more of a rarity.

Bread and butter community EM is amazing. Emergency medicine is amazing. We as EM physicians were too stupid to protect it for future generations and sold it out to CMG vultures. It's a sad state of affairs, but I think at this point it's too late to really do much. I think it makes sense to add a layer of protection and make yourself more valuable by doing a fellowship.

Wait til the NPs start doing spine injections...