How many years can you practice before entering fellowship?

[GettinAfterIt]

I would like to get a little more insight, as I am in a bit of a unique situation. I have been offered a scholarship from a school that will pay for all of my tuition + living expenses, if I agree to practice primary care for four years following residency. I'd love to take the scholarship, but I do have a decent level of interest in some of the subspecialties of internal med.

If I take this scholarship, and go into internal medicine, how accessible will fellowships be after being in practice for 4 years post-residency? If it helps, I'm specifically interested in Nephrology, Pulm, and GI.

Also, I am a 29-year-old non-trad who could use the help. This program is offering an accelerated 3-year degree as well.

All feedback is appreciated!

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[voxveritatisetlucis]

Depends on the fellowship

Pulm, heme onc, cards, and GI? Probably not.

The others are much less competitive and probably more likely to take a less traditional fellowship applicant.

Also are you bound to doing residency at a certain place? Residency strength is an important factor in fellowship match for the competitive subspecialties

 

[RangerBob]

Honestly I think the bigger issue at play is whether you'd actually want to go into fellowship after being an attending for four years.

Four years is a long time. Once you're used to attending independence/autonomy for that long, it's hard to give it all up and go back to being a resident/fellow. It's also hard to give up that income as well.

Perhaps even more important, if you have a spouse/family it's even harder because you may be uprooting your spouse from their job, their social supports, your kids from their schools. Not only might you be doing all that, but it would also be in concert with them actually seeing less of you since you'd be back to resident/fellow hours.

Just being honest here. There's no way I'd go back to residency or fellowship right now. It was fun then. But now our lives are established, my son is in school, my wife has built up her support network/community, etc.

It's worth considering the scholarship if you'd be happy in primary care. But if your plan to pursue a sub-specialty anyway, it's much easier to do that straight out of fellowship. And probably cheaper too, as there's a lost-opportunity cost by delaying sub-specialty income for four years, and while I don't know the averages of IM subspecialty compensation vs primary care, or the cost of your school, it's very possible that all evens out or comes close.

 

[GoSpursGo]

Agree with everything above.

This is a tough call without a good answer. It is hard to know when entering med school exactly what specialty you want to go into. At the same time, chopping a year off your training (gaining a year of attending salary) and saving a boatload of cash would be a huge windfall. My advice is that you should only take this scholarship if you really and truly could be happy in primary care, as that is the most likely outcome if you go down this path. Less competitive fellowships like nephro could be in play, but probably not pulm/CC and almost certainly not GI. If you would regret not having a shot at choosing your fate later on, then I would likely decline.

 

[Shunsui]

I would like to get a little more insight, as I am in a bit of a unique situation. I have been offered a scholarship from a school that will pay for all tuition + living expenses, if I agree to practice primary care for four years, in the state, following residency. I'd love to take the scholarship, but I do have a decent level of interest in some subspecialties of internal med.

If I take this scholarship, and go into internal medicine, how accessible will fellowships be after being in practice for 4 years post-residency? If it helps, I'm specifically interested in Nephrology, Pulm, and GI.

Also, I am a 29-year-old non-trad who could use the help. This program is offering an accelerated 3-year degree as well.

All feedback is appreciated!

Was offered the same and debated this quite intensively.

if you have any curiosity to pursue a fellowship at this stage in the game, you are considering the scholarship for the wrong reasons. Also, the short-term relief provided by this scholarship can be vastly outweighed by the potential earnings that come with specializing. You are not the first 29 y/o non-trad to go to med school without support and still come out on top.

If you would pursue primary care regardless of the scholarship, then take it

 

[smq123]

I would like to get a little more insight, as I am in a bit of a unique situation. I have been offered a scholarship from a school that will pay for all tuition + living expenses, if I agree to practice primary care for four years, in the state, following residency. I'd love to take the scholarship, but I do have a decent level of interest in some subspecialties of internal med.

If I take this scholarship, and go into internal medicine, how accessible will fellowships be after being in practice for 4 years post-residency? If it helps, I'm specifically interested in Nephrology, Pulm, and GI.

Also, I am a 29-year-old non-trad who could use the help. This program is offering an accelerated 3-year degree as well.

All feedback is appreciated!

I was an NHSC scholar. If you're not familiar with the scholarship, it is similar to what you described - you promise to practice primary care in an underserved location for as many years as you got the scholarship (at least 2).

I tell med students who are considering the NHSC scholarship to assume that they will not go back into fellowship. Certainly, some people do - there is no magical reason why you can't. But it's hard to go back into training once you've been out. It's not just the money - the job flexibility, the ability to go part time after a few years, the weekends and holidays off, etc.

You may also find that the bread-and-butter stuff that you see as the average specialist in the community isn't all that more exciting than plain primary care. The average community GI is not seeing a ton of autoimmune cholangitis or pancreatic cancer or anything exotic. After rotating through our community GI office as a resident, they were seeing the same stuff that we, the family med residents, were referring to them - gastritis, GERD, diarrhea, IBS, and colon cancer screening. So I would really think about why you're interested in specializing, for sure.

 

[GettinAfterIt]

Depends on the fellowship

Pulm, heme onc, cards, and GI? Probably not.

The others are much less competitive and probably more likely to take a less traditional fellowship applicant.

Also are you bound to doing residency at a certain place? Residency strength is an important factor in fellowship match for the competitive subspecialties

Thanks for the info!

If I choose the 3-year accelerated option, I am bound to a certain residency, yes.

 

[GettinAfterIt]

Honestly I think the bigger issue at play is whether you'd actually want to go into fellowship after being an attending for four years.

Four years is a long time. Once you're used to attending independence/autonomy for that long, it's hard to give it all up and go back to being a resident/fellow. It's also hard to give up that income as well.

Perhaps even more important, if you have a spouse/family it's even harder because you may be uprooting your spouse from their job, their social supports, your kids from their schools. Not only might you be doing all that, but it would also be in concert with them actually seeing less of you since you'd be back to resident/fellow hours.

Just being honest here. There's no way I'd go back to residency or fellowship right now. It was fun then. But now our lives are established, my son is in school, my wife has built up her support network/community, etc.

It's worth considering the scholarship if you'd be happy in primary care. But if your plan to pursue a sub-specialty anyway, it's much easier to do that straight out of fellowship. And probably cheaper too, as there's a lost-opportunity cost by delaying sub-specialty income for four years, and while I don't know the averages of IM subspecialty compensation vs primary care, or the cost of your school, it's very possible that all evens out or comes close.

Agree with everything above.

This is a tough call without a good answer. It is hard to know when entering med school exactly what specialty you want to go into. At the same time, chopping a year off your training (gaining a year of attending salary) and saving a boatload of cash would be a huge windfall. My advice is that you should only take this scholarship if you really and truly could be happy in primary care, as that is the most likely outcome if you go down this path. Less competitive fellowships like nephro could be in play, but probably not pulm/CC and almost certainly not GI. If you would regret not having a shot at choosing your fate later on, then I would likely decline.

Was offered the same and debated this quite intensively.

if you have any curiosity to pursue a fellowship at this stage in the game, you are considering the scholarship for the wrong reasons. Also, the short-term relief provided by this scholarship can be vastly outweighed by the potential earnings that come with specializing. You are not the first 29 y/o non-trad to go to med school without support and still come out on top.

If you would pursue primary care regardless of the scholarship, then take it

I was an NHSC scholar. If you're not familiar with the scholarship, it is similar to what you described - you promise to practice primary care in an underserved location for as many years as you got the scholarship (at least 2).

I tell med students who are considering the NHSC scholarship to assume that they will not go back into fellowship. Certainly, some people do - there is no magical reason why you can't. But it's hard to go back into training once you've been out. It's not just the money - the job flexibility, the ability to go part time after a few years, the weekends and holidays off, etc.

You may also find that the bread-and-butter stuff that you see as the average specialist in the community isn't all that more exciting than plain primary care. The average community GI is not seeing a ton of autoimmune cholangitis or pancreatic cancer or anything exotic. After rotating through our community GI office as a resident, they were seeing the same stuff that we, the family med residents, were referring to them - gastritis, GERD, diarrhea, IBS, and colon cancer screening. So I would really think about why you're interested in specializing, for sure.

Thank you all so much for your feedback! I'll add a bit more context.

When I first decided to pursue medical school, I was in the Army serving as a medic. I originally wanted to become a rural-ish primary care doc or EM physician. When I wasn't in the field with my platoon, I worked in a primary care clinic. We were trained to act as limited primary care providers while in the field, due to limited resources. I felt like this was similar to the role of a rural PCP. I really appreciated the diverse knowledge base required of PCPs and the long-term relationships formed with patients. I also enjoyed the "relaxing" environment of the clinic vs the high-strung feel of the hospital. I liked working in the ER as well, but figured I might burn out over time.

After looking at the $400k COA of medical school, and factoring in my age, I quickly began exploring other specialties . I rotated in ortho, and worked with anesthesiologists and CRNAs. I found myself being more drawn to these specialties for the money rather than the job itself. Also, the long residencies weren't very appealing. I enjoyed anesthesia, but it didn't feel like you were practicing "real medicine" for lack of a better term i.e. treating conditions etc. Many of the IM fellowships interest me as well.

I think I could be happy in primary care or working as a hospitalist, but I'm not 100%. I'm also afraid of capping my salary at $250k for my entire career while handing out NSAIDs and atorvastatin.

If I go straight IM, could I bounce back and forth between the hospital/icu and the clinic for some variety?

This is a huge decision. Thanks again for your advice!

 

[voxveritatisetlucis]

If it’s the NYU program, that might be a strong enough IM residency to make up for the time off but not completely sure.

 

[DOVinciRobot]

Thank you all so much for your feedback! I'll add a bit more context.

When I first decided to pursue medical school, I was in the Army serving as a medic. I originally wanted to become a rural-ish primary care doc or EM physician. When I wasn't in the field with my platoon, I worked in a primary care clinic. We were trained to act as limited primary care providers while in the field, due to limited resources. I felt like this was a similar role of a rural PCP. I really appreciated the diverse knowledge base required of PCPs and the long-term relationships formed with patients. I also enjoyed the "relaxing" environment of the clinic vs the high-strung feel of the hospital. I liked working in the ER as well, but figured I might burn out over time.

After looking at the $400k COA of medical school, and factoring in my age, I quickly began exploring other specialties . I rotated in ortho, and worked with anesthesiologists and CRNAs. I found myself being more drawn to these specialties for the money rather than the job itself. Also, the long residencies weren't very appealing. I enjoyed anesthesia, but it didn't feel like you were practicing "real medicine" so to speak i.e. treating conditions etc.

I think I could be happy in primary care or working as a hospitalist, but I'm not 100%. I'm also afraid of capping my salary at $250k for my entire career while handing out NSAIDs and atorvastatin.

If I go straight IM, could I bounce back and forth between the hospital/icu and the clinic for some variety?

This is a huge decision. Thanks again for your advice!

Why would your salary be capped at 250k

 

[GettinAfterIt]

Why would your salary be capped at 250k

True, but in order to make $300-$400K+ wouldn't I have to work a ton of hours, and see a bunch of patients? Or have a side hustle?

Most of the jobs I see for IM positions are around $240-$275k.

 

[Shunsui]

is the program binding? or can you opt-out without penalty while in med school? Another important thing to consider.

 

[GettinAfterIt]

is the program binding? or can you opt-out without penalty while in med school? Another important thing to consider.

It’s not binding thankfully! You can opt out but then the school issues loans to you.

 

[srirachamayonnaise]

It’s not binding thankfully! You can opt out but then the school issues loans to you.

It’s unlikely competitive fellowships would consider non traditional applicants. Nephrology and infectious disease might be a lot easier. But then you won’t get any bump by doing that.

 

[collegestud2013]

True, but in order to make $300-$400K+ wouldn't I have to work a ton of hours, and see a bunch of patients? Or have a side hustle?

Most of the jobs I see for IM positions are around $240-$275k.

Those numbers are probably base salaries (before including additional compensation like RVU bonuses). Any decent IM job nowadays (either outpatient or hospitalist) should get you at least in low $300ks without working significantly extra, and in high $300ks-400ks if you work a bit more. In the past few years hospitalist has, on average, paid a bit more per hour than primary care; however, the differences are minimal nowadays as CMS reimbursements for primary care have also gone up and the hospitalist job market is getting more saturated.

If you're concerned about the money, run the numbers yourself but your goal should be to get done with training as quick as possible (Even if it means taking a slightly lower salary after training), especially if you're already nontraditional. Keep in mind that general IM training is 2-3 shorter (3 years instead of 5-6 years if doing one of the IM specialties) so you'll be 2-3 years behind as a specialist. Also, the extra money you make as a specialist will be taxed at around 37-45% (depending on where you live, so even an extra $150k per year could could end being just extra $90k after taxes). Not to mention this program offers a 3 year accelerated option AND will pay for your tuition/fees, both of which will put your further ahead financially quite significantly On the other hand, doing the traditional 4 years of med school (with a med school COA of $400k, most of which would be loans if you don't get any scholarships) + 3 years of IM residency + 3 years of fellowship will put you much more behind financially in your early and mid career, even if you can make an extra $150-200k per year pre-tax as a specialist once out of training.

 

[Med Ed]

I would like to get a little more insight, as I am in a bit of a unique situation. I have been offered a scholarship from a school that will pay for all of my tuition + living expenses, if I agree to practice primary care for four years following residency. I'd love to take the scholarship, but I do have a decent level of interest in some of the subspecialties of internal med.

If I take this scholarship, and go into internal medicine, how accessible will fellowships be after being in practice for 4 years post-residency? If it helps, I'm specifically interested in Nephrology, Pulm, and GI.

Also, I am a 29-year-old non-trad who could use the help. This program is offering an accelerated 3-year degree as well.

All feedback is appreciated!

n=1, but I have a colleague who did general IM for almost 10 years before going back and doing a cardiology fellowship. Currently happy as a clam. Probably helped that his years of IM practice were in an academic setting.

Look at the fine print on the scholarship. It's possible that you could elect to take it now and then change your mind later without significant detriment.

 

[GettinAfterIt]

Those numbers are probably base salaries (before including additional compensation like RVU bonuses). Any decent IM job nowadays (either outpatient or hospitalist) should get you at least in low $300ks without working significantly extra, and in high $300ks-400ks if you work a bit more. In the past few years hospitalist has, on average, paid a bit more per hour than primary care; however, the differences are minimal nowadays as CMS reimbursements for primary care have also gone up and the hospitalist job market is getting more saturated.

If you're concerned about the money, run the numbers yourself but your goal should be to get done with training as quick as possible (Even if it means taking a slightly lower salary after training), especially if you're already nontraditional. Keep in mind that general IM training is 2-3 shorter (3 years instead of 5-6 years if doing one of the IM specialties) so you'll be 2-3 years behind as a specialist. Also, the extra money you make as a specialist will be taxed at around 37-45% (depending on where you live, so even an extra $150k per year could could end being just extra $90k after taxes). Not to mention this program offers a 3 year accelerated option AND will pay for your tuition/fees, both of which will put your further ahead financially quite significantly On the other hand, doing the traditional 4 years of med school (with a med school COA of $400k, most of which would be loans if you don't get any scholarships) + 3 years of IM residency + 3 years of fellowship will put you much more behind financially in your early and mid career, even if you can make an extra $150-200k per year pre-tax as a specialist once out of training.

This is exactly what I needed to hear! Thank you for this!

If I could clear $300k working in IM I'd be extremely happy. With the 3-year degree, I'd be an attending with zero debt at 35 y/o... not that far off from someone who went straight through! I think I will go for it. It's nice to know there is a slight chance of doing a fellowship down the road, if I really wanted to.

 

[GettinAfterIt]

n=1, but I have a colleague who did general IM for almost 10 years before going back and doing a cardiology fellowship. Currently happy as a clam. Probably helped that his years of IM practice were in an academic setting.

Look at the fine print on the scholarship. It's possible that you could elect to take it now and then change your mind later without significant detriment.

Love to hear it. If I change my mind later it turns into a loan from the school.