Fellowship Training Goes Down The Drain

[calvinhobbes]

Did you all see the new abysmal fellowship match rates? So many open spots, even PEM and GI didn’t fill. So many children’s hospitals are now hiring NP-only pediatric hospitalist teams, but if you’re a pediatrician who wants to work as a hospitalist, woops sorry you need to be hospitalist fellowship trained! And there is recently an EM fellowship that accepted an NP and the NP completed it (ultrasound). Peds may be next …

Peds training has become a joke. So sad and if you think I’m being hyperbolic here, then look at this years NRMP data and speak to pediatrics who are looking for jobs after they complete a fellowship and ask them what their salary offers are.

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[GoSpursGo]

Peds heme/onc, we felt very fortunate to fill.

The biggest problem is that most pediatric subspecialties other than NICU are more or less tied to academic medicine, where you are inherently going to be undercompensated and also expected to have some sort of academic output. Not everything has to be incentivized by money... but losing 3 (or 4 or 5...) years of attending salary, then being paid less because you chose an academic setting, and then having to deal with academic requirements (which, I'm a physician scientist, so it's my jam but I know it's not for everyone) is a recipe for burnout. And residency graduates are seeing the burnout in subspecialties and many are making the choice that it isn't worth it. In contrast to adult subspecialties where people stay in academia because they LIKE academia and are willing to be paid less, many peds specialists feel forced or trapped into academics, and also undercompensated.

I don't know what the solution is. Maybe eventually we will get to a place where subspecialists are in such short supply that compensation comes up. But that seems like such a long term outlook that I struggle to imagine that being useful for just about anyone reading this.

 

[calvinhobbes]

Peds heme/onc, we felt very fortunate to fill.

The biggest problem is that most pediatric subspecialties other than NICU are more or less tied to academic medicine, where you are inherently going to be undercompensated and also expected to have some sort of academic output. Not everything has to be incentivized by money... but losing 3 (or 4 or 5...) years of attending salary, then being paid less because you chose an academic setting, and then having to deal with academic requirements (which, I'm a physician scientist, so it's my jam but I know it's not for everyone) is a recipe for burnout. And residency graduates are seeing the burnout in subspecialties and many are making the choice that it isn't worth it. In contrast to adult subspecialties where people stay in academia because they LIKE academia and are willing to be paid less, many peds specialists feel forced or trapped into academics, and also undercompensated.

I don't know what the solution is. Maybe eventually we will get to a place where subspecialists are in such short supply that compensation comes up. But that seems like such a long term outlook that I struggle to imagine that being useful for just about anyone reading this.

I’m definitely an optimist but I agree with you, the facts are the facts 🙁 and it’s so disappointing reading about the state of current pediatric medicine in the US. Why go through medical school, residency, and fellowship, only then to get a job that pays less or about the same as an NP who became a ”provider” with a ridiculous online degree?

😔

 

[HemeOncHopeful19]

Peds heme/onc, we felt very fortunate to fill.

The biggest problem is that most pediatric subspecialties other than NICU are more or less tied to academic medicine, where you are inherently going to be undercompensated and also expected to have some sort of academic output. Not everything has to be incentivized by money... but losing 3 (or 4 or 5...) years of attending salary, then being paid less because you chose an academic setting, and then having to deal with academic requirements (which, I'm a physician scientist, so it's my jam but I know it's not for everyone) is a recipe for burnout. And residency graduates are seeing the burnout in subspecialties and many are making the choice that it isn't worth it. In contrast to adult subspecialties where people stay in academia because they LIKE academia and are willing to be paid less, many peds specialists feel forced or trapped into academics, and also undercompensated.

I don't know what the solution is. Maybe eventually we will get to a place where subspecialists are in such short supply that compensation comes up. But that seems like such a long term outlook that I struggle to imagine that being useful for just about anyone reading this.

The problem is 99% money, although I will say that for some of the adult subspecialties the allure is that you’re no longer the PCP handling 6-8+ issues every visit, but can focus on your 1 issue. I imagine in Peds there isn’t that big of a gap and patients that see a subspecialist may even be more complex on average.

NICU won’t be any better off in 10 years IMO since your options will be Academics or MEDNAX

 

[SurfingDoctor]

It’s probably a good thing. There’s too many fellowship spots anyway for not enough jobs when they graduate.

 

[DO2015CA]

Is the data out there yet about this match? I’m curious, do you all think the PEM drop is perceived impending doom that happened to EM residency? So people don’t want to risk it?

 

[Angler]

Is the data out there yet about this match?

https://www.nrmp.org/wp-content/uploads/2023/11/2023-MPSM-Match-Results-Statistics-Report.pdf

 

[Putkernerinthehall]

Peds heme/onc, we felt very fortunate to fill.

The biggest problem is that most pediatric subspecialties other than NICU are more or less tied to academic medicine, where you are inherently going to be undercompensated and also expected to have some sort of academic output. Not everything has to be incentivized by money... but losing 3 (or 4 or 5...) years of attending salary, then being paid less because you chose an academic setting, and then having to deal with academic requirements (which, I'm a physician scientist, so it's my jam but I know it's not for everyone) is a recipe for burnout. And residency graduates are seeing the burnout in subspecialties and many are making the choice that it isn't worth it. In contrast to adult subspecialties where people stay in academia because they LIKE academia and are willing to be paid less, many peds specialists feel forced or trapped into academics, and also undercompensated.

I don't know what the solution is. Maybe eventually we will get to a place where subspecialists are in such short supply that compensation comes up. But that seems like such a long term outlook that I struggle to imagine that being useful for just about anyone reading this.

I'm locked in on pediatrics, specifically interested in both pediatric hospitalist and pediatric critical care. Not sure which as I'm still an M4. What is your sense of these two paths in terms of job satisfaction, job security, and compensation?

 

[GoSpursGo]

I'm locked in on pediatrics, specifically interested in both pediatric hospitalist and pediatric critical care. Not sure which as I'm still an M4. What is your sense of these two paths in terms of job satisfaction, job security, and compensation?

Hard to say since I don’t do either. I also remain offended that PHM even is a thing. But the decision probably comes down to whether you like procedures or not. You’ll have plenty of time to figure it out during residency

 

[DO2015CA]

Hard to say since I don’t do either. I also remain offended that PHM even is a thing. But the decision probably comes down to whether you like procedures or not. You’ll have plenty of time to figure it out during residency

PHM as it stands is ridiculous but with all the ridiculous acgme changes they’re forcing its legitimacy by quitting the preparation residents for hospital work while in residency. Which is absolutely disgusting. I really enjoy what I do and would likely make the same decision going back (I loathe adult medicine). But peds leadership decision making in suspect. I’m starting to lean towards “students shouldn’t apply peds unless they couldn’t see themselves doing anything else”.

 

[GoSpursGo]

PHM as it stands is ridiculous but with all the ridiculous acgme changes they’re forcing its legitimacy by quitting the preparation residents for hospital work while in residency. Which is absolutely disgusting. I really enjoy what I do and would likely make the same decision going back (I loathe adult medicine). But peds leadership decision making in suspect. I’m starting to lean towards “students shouldn’t apply peds unless they couldn’t see themselves doing anything else”.

That honestly probably is most peoples’ default 🙂

 

[DO2015CA]

That honestly probably is most peoples’ default 🙂

Fair enough lol. I get plenty of med students saying “I’m deciding between peds and X”. The answer moving forward is X lol.

 

[HemeOncHopeful19]

Do a different specialty such as Anesthesia and subspecialize in “Pediatric ________” if you wish to work with children IMO

 

[SurfingDoctor]

I also remain offended that PHM even is a thing.

Every pediatrician should be offended.

 

[SurfingDoctor]

I'm locked in on pediatrics, specifically interested in both pediatric hospitalist and pediatric critical care. Not sure which as I'm still an M4. What is your sense of these two paths in terms of job satisfaction, job security, and compensation?

No one can predict that.

When I started critical care medicine over a decade ago, the most important job qualification was having a pulse. Nowadays there are 30 applicants for 1 position. Granted, this is like a top 10 NIH funded research institute… but still.

If anything, a reduction in fellows is a blessing and a version of the system correcting itself until hospitals (including children’s hospitals) realize that not every hospital needs some dogsh-t post-graduate training program to train mediocre applicants just to supplement a cheap labor pool.

As an MS4, you can reassess in a couple of years and actually pick a career path where you actually contribute to medicine, instead of being a overpaid, glorified APP.

 

[Rumalum]

I think people sleep on the financial potential in academic research - work on intellectual property, not basic science (leave that to the PhD's). Frankly I find there is nothing better for work/life balance than buying down clinical time with grant income

 

[DO2015CA]

I think people sleep on the financial potential in academic research - work on intellectual property, not basic science (leave that to the PhD's). Frankly I find there is nothing better for work/life balance than buying down clinical time with grant income

How does someone get involved in intellectual property work?

 

[mvenus929]

It’s probably a good thing. There’s too many fellowship spots anyway for not enough jobs when they graduate.

We have at least 4 open positions in my division and until very recently, no applicants for those jobs. There are also multiple jobs in my specialty that have been open for a couple years. I graduated in 2021 and job prospects that year sucked, but since then, there have been a lot of openings are good institutions. Not in places that would induce me to leave my current job. Yet. But they are there.

 

[SurfingDoctor]

We have at least 4 open positions in my division and until very recently, no applicants for those jobs. There are also multiple jobs in my specialty that have been open for a couple years. I graduated in 2021 and job prospects that year sucked, but since then, there have been a lot of openings are good institutions. Not in places that would induce me to leave my current job. Yet. But they are there.

Depends on specialty of course. Currently we are hiring. 30+ applicants for 1 spot.

 

[Oso]

Depends on specialty of course. Currently we are hiring. 30+ applicants for 1 spot.

Wow, that’s crazy. Are most picu fellows even finding jobs?

 

[SurfingDoctor]

Wow, that’s crazy. Are most picu fellows even finding jobs?

There are jobs. It’s just probably not where people would perceive as “desirable”.

For instance, I just got a notification from a Shiners hospital looking for intensivists to take care of pediatric burn patients. It’s a 12 bed unit. It’s in a major city or at least in proximity. Most trainees would scoff at that job.

 

[Putkernerinthehall]

There are jobs. It’s just probably not where people would perceive as “desirable”.

For instance, I just got a notification from a Shiners hospital looking for intensivists to take care of pediatric burn patients. It’s a 12 bed unit. It’s in a major city or at least in proximity. Most trainees would scoff at that job.

Why, specifically, would trainees "scoff at that job"? Sole focus on burn patients ?

 

[SurfingDoctor]

Why, specifically, would trainees "scoff at that job"? Sole focus on burn patients ?

Most trainees graduate from programs where they get to be involved with ECMO, and weird neurological and immunological zebras as well as cardiac disease. This is generally buried with the bread and butter of ICU (ie it’s a 1:20 pathology), but most “feel” if they aren’t doing the most obscure pathology… somehow, they aren’t living up to their potential.

The reality is far different from that, but still, that is the “feeling”… It also happens to be the one number reason they choose a fellowship… which is again, displaced from reality.

Any monkey can say someone needs or can manage ECMO… it’s when the ECMO causes a catastrophic brain bleed of that family’s only child that no one wants to deal with…

On the contrary, most pediatric burn patients do well and don’t need ECMO, but that’s not cool enough…

 

[dozitgetchahi]

I think people sleep on the financial potential in academic research - work on intellectual property, not basic science (leave that to the PhD's). Frankly I find there is nothing better for work/life balance than buying down clinical time with grant income

Huh? My experience in “high academia”/clinical research was exactly the opposite. Research is extremely labor intensive and time consuming, getting grants is also time consuming and exhausting, and the pay at the end of the day for the vast majority in academia is trash. And only a few people at the top of academia are going to get access to the ability to get significant intellectual property etc. IMHO this is akin to saying “go to Hollywood and become an actor, it worked out great for Johnny Depp and Brad Pitt!”

 

[thetubes]

Huh? My experience in “high academia”/clinical research was exactly the opposite. Research is extremely labor intensive and time consuming, getting grants is also time consuming and exhausting, and the pay at the end of the day for the vast majority in academia is trash. And only a few people at the top of academia are going to get access to the ability to get significant intellectual property etc. IMHO this is akin to saying “go to Hollywood and become an actor, it worked out great for Johnny Depp and Brad Pitt!”

I think there is some sarcasm in there. When anyone says leave basic science to the PhD's, you pretty much lose credibility. Regardless, this sentiment is entirely why fellowship is becoming less popular, let alone trying to build a research program as a physician scientist.

 

[SurfingDoctor]

Two things SHOULD happen:

1) Fellowship should have a shorten clinical track or a longer research track

2) They should reduce the number of spots in fellowship based on expected number of jobs, like how Pediatric Surgery does it.

Neither of those thing will happen because fellows are cheap and most program leaders are old and stupid, but it is what should happen.

 

[Oso]

Two things SHOULD happen:

1) Fellowship should have a shorten clinical track or a longer research track

2) They should reduce the number of spots in fellowship based on expected number of jobs, like how Pediatric Surgery does it.

Neither of those thing will happen because fellows are cheap and most program leaders are old and stupid, but it is what should happen.

I feel like #1 HAS to happen otherwise we’re going to run out of peds nephro, ID, rheum, etc. it probably won’t though.

Doubt a shorter training path would ever even be considered for the more competitive specialties

 

[SurfingDoctor]

I feel like #1 HAS to happen otherwise we’re going to run out of peds nephro, ID, rheum, etc. it probably won’t though.

Doubt a shorter training path would ever even be considered for the more competitive specialties

I dont know, but I will say, having done academic critical care for over a decade, for a vast majority of trainees, I see no benefit to a longer path. For the ones that want to career build outside patient care, there is absolutely a benefit and frankly, the scholarly times isn’t sufficient enough to build that skill set. I did 4 years of fellowship and it was just sufficient in that regard, but still not robust enough.

But most fellows just want to take care of patients and get their hands dirty, so to speak. Of course, when you are approaching your 2nd decade of doing this, that luster has long wore off and you look for things that are more rewarding from a career standpoint. The clinical pathway doesn’t really afford that opportunity, but again, most trainees don’t have any interests or passions outside patient care anyway (or if they do, they don’t have enough foresight on how to build it into a successful career) so why waste everyone’s time? Having trainees “dedicate” 18 months of their lives to useless projects that they hate and come out embarrassingly terrible seems pointless to me. I don’t know if critical care is considered “competitive” but historically pediatric emergency medicine was the most competitive fellowship prior to hospital medicine and next to pediatric critical care, is probably the least academic of all subspecialties.

 

[DO2015CA]

I dont know, but I will say, having done academic critical care for over a decade, for a vast majority of trainees, I see no benefit to a longer path. For the ones that want to career build outside patient care, there is absolutely a benefit and frankly, the scholarly times isn’t sufficient enough to build that skill set. I did 4 years of fellowship and it was just sufficient in that regard, but still not robust enough.

But most fellows just want to take care of patients and get their hands dirty, so to speak. Of course, when you are approaching your 2nd decade of doing this, that luster has long wore off and you look for things that are more rewarding from a career standpoint. The clinical pathway doesn’t really afford that opportunity, but again, most trainees don’t have any interests or passions outside patient care anyway (or if they do, they don’t have enough foresight on how to build it into a successful career) so why waste everyone’s time? Having trainees “dedicate” 18 months of their lives to useless projects that they hate and come out embarrassingly terrible seems pointless to me. I don’t know if critical care is considered “competitive” but historically pediatric emergency medicine was the most competitive fellowship prior to hospital medicine and next to pediatric critical care, is probably the least academic of all subspecialties.

Still wild hospital medicine is the most competitive lol

 

[pedsIDguy]

I’m a second year peds ID fellow and we haven’t matched the last two years. Non-procedural fellowships are in serious trouble- and based on this thread, that possibly applies to procedural fellowships as well.

I think the major issue is that non-procedural fellowships represent a definite loss in earnings potential during and post-fellowship. Compensation structure needs to change so that we make at least as much money as hospitalists. Secondly, there aren’t enough community based positions for these specialties, so doing a fellowship makes it likely that you’re going to have to stay in academics. So it doesn’t make sense for someone who has little appetite for research to do a three year fellowship in ID. There are some propositions of shortening to two years, but this doesn’t really make sense for peds ID, since you need that time to actually establish yourself as a credible investigator who can self start and find funding after graduating fellowship (which is what most institutions kind of expect), whereas adult ID folks can easily find community jobs after graduation. I’m only speaking for ID, but I suspect the same issues apply to other fields as well. We’re heading for massive shortages- but I don’t really know what the solutions are, because the problems are really systemic. I completely understand why someone who loves ID would have misgivings about doing a peds ID fellowship.

 

[DO2015CA]

I’m a second year peds ID fellow and we haven’t matched the last two years. Non-procedural fellowships are in serious trouble- and based on this thread, that possibly applies to procedural fellowships as well.

I think the major issue is that non-procedural fellowships represent a definite loss in earnings potential during and post-fellowship. Compensation structure needs to change so that we make at least as much money as hospitalists. Secondly, there aren’t enough community based positions for these specialties, so doing a fellowship makes it likely that you’re going to have to stay in academics. So it doesn’t make sense for someone who has little appetite for research to do a three year fellowship in ID. There are some propositions of shortening to two years, but this doesn’t really make sense for peds ID, since you need that time to actually establish yourself as a credible investigator who can self start and find funding after graduating fellowship (which is what most institutions kind of expect), whereas adult ID folks can easily find community jobs after graduation. I’m only speaking for ID, but I suspect the same issues apply to other fields as well. We’re heading for massive shortages- but I don’t really know what the solutions are, because the problems are really systemic. I completely understand why someone who loves ID would have misgivings about doing a peds ID fellowship.

All peds fellowships should have a clinical track and research track. Clinical should be 18-24 months. Research should stay 3 years but 18-24 should be dedicated research.

As a current fellow, I have also been fed the bull**** about having to stay in academics so research is a must. While simultaneously everyone is saying we are headed to a massive shortage. There still needs to be docs to see the patients. The productive research docs buy out their clinical time anyway. This means we need more clinical docs so those that do the clinical track should not have to do any research to stay in academics if they don’t want to. Even if they are put on productivity incentive tracks like pp. They would work harder than the research heads but would also be compensated better. This will drive more people to do fellowship clinical tracks.