I don't want to grow up...

[masterofmonkeys]

So I know lots of people post questions about fellowships, but I figured i'd ask for input about my specific situation. I've posted on here for years and had great conversations with many other posters here for years, so I figured some of yall might have some specific insight for me.

When I started residency I was in an integrated child track, and would've graduated from fellowship this July. Instead, I had to take a couple of years off and am now looking at graduating from general residency in 2015. That doesn't mean I can't still do a fellowship, but it does mean that I'll be several years older than I'd originally planned on being. The money doesn't mean much, but my physical health remains somewhat--challenging. While I'm doing tons better, it's still a constant time- and energy-intensive battle to stay ahead of my spine and nerve damage, and I really can't say for sure I'll stay out of a wheelchair or be able to function as well as I do now for how much longer.

I also really chafe at institutional control and the inherent limitations in freedom of being a trainee.

And my SO does not live in a city with any fellowships offered at all, which is another headache.

So that's three, mostly pragmatic, strikes against doing fellowship.

As far as what I want for my future, that's where everything gets confusing:

I'm really academically-oriented, and can't imagine not teaching residents and/or med students. That's a rewarding experience for me and I don't think I'd feel complete without that. I don't think I'd want to be a PI in clinical research, but I certainly enjoy being a PART of that process. I also just plain enjoy being in academic environments.

On the other hand, I'm pretty weird and like doing things my own darn way, and really want to practice in a holistic/alternative/complentary/integrative model that is heavy on psychotherapy and the kinds of assessments and interventions that insurance doesn't like, which screams private practice cash-only to me.

I can't really say for certain which way I'd go in the future or if I could somehow find a way to combine the two.

So now that I've written a Russian novel, we can get to the meat of the post lol: Fellowships.

Child/Adolescent - I love the population, have already had lots of experience (for a resident) with 4 months of inpt/consult and 1 day/week of outpt as a third year, and know it's a good fit for me. But it's two years, and I can probably do the part that I really like (adolescent) without the fellowship.

Consult/Liaison - I haven't seen Doc Samson post in a while, but I still love this. It was my favorite rotation in my first program, in part because of the varied nature of the practice. I also really had fun getting to use my stethoscope, follow complex medical issues, and pretending to be a 'real doctor'. The fellowhip's great for academics but largely worthless for private practice.

Sleep - Found this surprisingly interesting (one of my adult attendings is also boarded in sleep and does sleep work half of his time). It involves a lot of medical, and apparently many opportunities to do it part-time and do regular psych part time. Downside, I've heard it can be saturated in a lot of markets and arguably difficult for a psych doc to get a position.

Overall, as far as I can make out, doing a fellowship would be of strong benefit if I decide to go academic, but of minimal benefit if I decide to go private. I'm trying to decide whether it's worth the gamble to go for a fellowship and if so, which one would still have relevance if I did decide to go private. Currently, I think I'm going to apply for child and C/L and probably interview at a few of each and then make a decision by the seat of my pants the day that rank lists are due, but I'd also appreciate any feedback.

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[MacDonaldTriad]

You are right, a psychosomatic fellowship is completely unnecessary except for academics. You can do plenty of C&L work without it, that is of course if you don’t mind not being truly excellent at what you do. To answer your question, you have to know if you are truly satisfied with your level of training for what you like to do. There are a lot of loose non-APBN certified PGY-V things that are flexible and look the other way while you moonlight to make up the difference in pay. They can cover your benefits, and it sounds like you need that.

Teaching is fun, but if you are looking for a lack of rules and regulation, you couldn’t get much further from this by being an investigator for a PI on a research project. Becoming junior faculty or taking a PGY-V position are not as different as you might think. The former pays a little better, but not that much better. If you are surrounded by mentors who are invested in your development, they look a lot like each other.

 

[Mad Jack]

I know just the place for you:

 

[F0nzie]

You already know the pros and cons of fellowship.

Private: Do a fellowship because you're ok with losing time and money and because you want to learn more.

Academic: Get as many certificates as you can to work your way up to big cheese.

 

[vistaril]

You are right, a psychosomatic fellowship is completely unnecessary except for academics. You can do plenty of C&L work without it, that is of course if you don’t mind not being truly excellent at what you do.

so most of the 'top' people and 'thought leaders'(for whatever those things are worth) are not excellent? After all, the vast majority of them didn't do a fellowship. At least not a psychosomatic fellowship. And unlike in other areas(for example surgical subspecialties)where new technology/robotics are introduced), you can't say the same for consult-liason psychiatry.

I'm not going into academia so it's not a relevant to me either way, but I'm completely unconvinced that one should do a C-L fellowship even if they wanted an academic C-L career.

 

[notdeadyet]

I'm not going into academia so it's not a relevant to me either way, but I'm completely unconvinced that one should do a C-L fellowship even if they wanted an academic C-L career.

You can't look at people at the top now and use this as a guide for what will be required for professional success now. 20 years ago, when many of these people established themselves, fellowship was not the norm (or even available in many fields). You look at trending, and there are many more people entering C/L with the fellowship than there used to be.

You still don't need a C/L fellowship to get an academic job in psychiatry right now at most places, but if you're looking to advance in the academic field, you would be foolish to not anticipate a potential glass ceiling without one down the road. Especially because many academic departments run C/L fellowships themselves.

 

[vistaril]

You can't look at people at the top now and use this as a guide for what will be required for professional success now. 20 years ago, when many of these people established themselves, fellowship was not the norm (or even available in many fields). You look at trending, and there are many more people entering C/L with the fellowship than there used to be.

You still don't need a C/L fellowship to get an academic job in psychiatry right now at most places, but if you're looking to advance in the academic field, you would be foolish to not anticipate a potential glass ceiling without one down the road. Especially because many academic departments run C/L fellowships themselves.

for your first point I explained much of this difference already......many subspecialties now have fellowships because new technologies and procedures evolved to make it into something more. That's *not* the case with C-L, and even if some strange argument popped up to suggest it was, certainly not to anywhere near the same extent. Of course an ent who wants to work in cochlear implants at a big academic center is going to do an ent fellowship related to that....and one that probably wasn't around 30 years ago. That same example does not translate to psychiatry/C-L in any way.

I don't think it would be foolish at all to not anticipate the need for a fellowship in C-L to move up in academia. People are likely going to move up in academia over the next few decades the same way they have over the previous few decades- publications(and the right ones), connections, grants, etc...the usual stuff. Now if you're fellowship gets you in a position to do those things much better than taking a junior faculty position, well so be it. But in many cases it isn't going to. That said, I think if one wants to pursue a fellowship for academic advancement I'd much rather look into a research track fellowship than C-L fellowship....perhaps even if one wanted to do C-L eventually. Yeah there are C-L fellowships where you are going to have an opportunity to do research, but it's going to be very clinically oriented and more importantly there isn't going to be a lot of growth expected with it. When people talk about all this research that could easily be published in C-L related to medical illness and psychiatric morbidities, there *is* a reason for that void- what's the end game?

As an aside having nothing to do with fellowship utility, my prediction for the next few decades is that depts within large academic medical centers will become even more bottom line oriented. Rainmaker researchers and on the clinical end of things volume volume volume.....I don't know that the future is as bright for people who want the academic environment, but don't/can't be bigtime grant attainers and don't have the stomach for clinical work that actual brings in decent revenue for the dept's bottom line through volume.

 

[MacDonaldTriad]

A couple of decades from now you will be very happy that you minimized concern over debt and maximized concern over life. Geeez everyone money isn't why we do what we do. It isn't near enough if that is why you are here.

 

[michaelrack]

so most of the 'top' people and 'thought leaders'(for whatever those things are worth) are not excellent? After all, the vast majority of them didn't do a fellowship. At least not a psychosomatic fellowship. And unlike in other areas(for example surgical subspecialties)where new technology/robotics are introduced), you can't say the same for consult-liason psychiatry.

I'm not going into academia so it's not a relevant to me either way, but I'm completely unconvinced that one should do a C-L fellowship even if they wanted an academic C-L career.

A lot of the top people did grandfather into psychosomatic certification without doing a fellowship

 

[vistaril]

A lot of the top people did grandfather into psychosomatic certification without doing a fellowship

well yeah so did a lot of the mediocre and below average people as well.....

I'm not sure what the value of having psychosomatic cert even is. If someone tried to give it to me for 20 bucks, I literally wouldn't give up the 20. You're not going to be able to bill any more for your consult. Insurance companies arent going to reimburse you more. Consulting physicians aren't going to be like "hmmm, I was thinking about consulting to see whether this suicidal guy needs psych transfer but now that I see the consult person isn't even C-L certified I better just handle it myself"......and if what notdeadyet is saying is right and academic actually will require C-L fellowship for promotion within these circles, then people will still know you didn't do the fellowship if you were grandfathered in.

The whole thing imo, from the existence of the C-L fellowship to certification in psychosomatics, is fishy imo.

 

[michaelrack]

....and if what notdeadyet is saying is right and academic actually will require C-L fellowship for promotion within these circles, then people will still know you didn't do the fellowship if you were grandfathered in.

The whole thing imo, from the existence of the C-L fellowship to certification in psychosomatics, is fishy imo.

In academics what matters are 1) your abilities/skills and 2) your certification. No one cares if you actually did a fellowship or not.

The grandfathering process for psychosomatics was typical for new ABMS subspecialties

 

[Chimed]

You already know the pros and cons of fellowship.

Private: Do a fellowship because you're ok with losing time and money and because you want to learn more.

Academic: Get as many certificates as you can to work your way up to big cheese.

I'm assuming you're talking about being board certified in things like Child, etc? How does having more certificates matter? My understanding is that what they really care more about are papers and grants. If certificates matter then I should be golden with 2 fellowships under my belt? But I wonder about that as my research background is pretty limited.

 

[vistaril]

I'm assuming you're talking about being board certified in things like Child, etc? How does having more certificates matter? My understanding is that what they really care more about are papers and grants.

agreed.....as an outsider that's what I see and hear as well. What value can you bring to an institution is what matters. Having done a fellowship or two doesn't neccessarily create more value.

 

[F0nzie]

I'm assuming you're talking about being board certified in things like Child, etc? How does having more certificates matter? My understanding is that what they really care more about are papers and grants. If certificates matter then I should be golden with 2 fellowships under my belt? But I wonder about that as my research background is pretty limited.

Your contributions to the institution and the field matter. But having 3 certificates puts you in a much better position than the other guy that only has 2. Getting as many fellowships and certificates is a good starting point IMO. Granted I am not an academician but I have seen the politics. When you are fighting for that chair position for an extra 100k bump in salary-- that competitive edge will help.

 

[Doctor Bagel]

A couple of decades from now you will be very happy that you minimized concern over debt and maximized concern over life. Geeez everyone money isn't why we do what we do. It isn't near enough if that is why you are here.

Overall I agree with this sentiment, but it's sometimes hard to keep when you're facing huge student debt burdens, which is something physicians who graduated 10 or more years ago don't get. On top of that, you've delayed all the other financial moving ahead steps due to being in training for so long. So money is still pretty important.

 

[SteinUmStein]

Agreed Dr. Bagel. I think it's tough for physicians who graduated 10+ years ago to understand today's debt situation. It's easy to forget how quickly med school tuition has risen even in the last 5 years.

 

[TexasPhysician]

I think you need to focus on practical matters first. Do you have good disability insurance already or could you get it outside academics? If your medical problems are a big concern, your long-term earnings may be limited no matter what you decide. If you can't get good disability insurance outside a large group practice/academics, I'd highly consider making darn sure you can stay in such a system. If this means doing 1-2 years of fellowship to help guarantee an academic gig with good benefits, it may be well worth your time.

 

[SteinUmStein]

Good disability insurance is not contingent on a specific job offer or benefits package. Many recommend physicians get their own independent disability coverage outside of their employer's offerings, since you can make sure you are happy with the terms and conditions and the payout and there's no possibility of your employer changing things on you.

 

[TexasPhysician]

Good disability insurance is not contingent on a specific job offer or benefits package. Many recommend physicians get their own independent disability coverage outside of their employer's offerings, since you can make sure you are happy with the terms and conditions and the payout and there's no possibility of your employer changing things on you.

The OP mentioned a significant pre-existing disability that may make private disability insurance not worthwhile as they would exclude all current conditions.

If true and he is relatively certain he will eventually become disabled based on this already present condition, a group policy may be a huge player in job decisions.

 

[nancysinatra]

A couple of decades from now you will be very happy that you minimized concern over debt and maximized concern over life. Geeez everyone money isn't why we do what we do. It isn't near enough if that is why you are here.

I don't feel this way at all, and it's almost a decade since I took out my first med school loan. Concern over debt and concern of life are inextricably intertwined in our economy. Personally I regret every penny of the 300K at 9% interest I owe, and I would never do it again if I could go back ten years. It's not because medicine (or specifically psychiatry) is horrible either. It's because nothing is worth that kind of debt. Medicine is becoming an increasingly irrelevant field with the rise of midlevels and the staggering levels of debt that are demanded of med students. At some point you just want to say, "no thanks."

 

[2tall]

On the other hand, I'm pretty weird and like doing things my own darn way, and really want to practice in a holistic/alternative/complentary/integrative model that is heavy on psychotherapy and the kinds of assessments and interventions that insurance doesn't like, which screams private practice cash-only to me.

Consult/Liaison - I haven't seen Doc Samson post in a while, but I still love this. It was my favorite rotation in my first program, in part because of the varied nature of the practice. I also really had fun getting to use my stethoscope, follow complex medical issues, and pretending to be a 'real doctor'. The fellowhip's great for academics but largely worthless for private practice.

Sleep - Found this surprisingly interesting (one of my adult attendings is also boarded in sleep and does sleep work half of his time). It involves a lot of medical, and apparently many opportunities to do it part-time and do regular psych part time. Downside, I've heard it can be saturated in a lot of markets and arguably difficult for a psych doc to get a position.

Overall, as far as I can make out, doing a fellowship would be of strong benefit if I decide to go academic, but of minimal benefit if I decide to go private. I'm trying to decide whether it's worth the gamble to go for a fellowship and if so, which one would still have relevance if I did decide to go private. Currently, I think I'm going to apply for child and C/L and probably interview at a few of each and then make a decision by the seat of my pants the day that rank lists are due, but I'd also appreciate any feedback.

If you're interested in C/L, I'd think about geropsych as well. There are integrative models of care in geriatrics. Obviously CMS dictates most aspects of payments, but there are niche markets. You'd follow complex medical issues and would be viable as a C/L attending. You'd have more employment opportunities. You'd have flexibility particularly if interested in long-term care consultation or home-base care models. Lastly, it's guaranteed you'd enjoy the work...

 

[vistaril]

I don't feel this way at all, and it's almost a decade since I took out my first med school loan. Concern over debt and concern of life are inextricably intertwined in our economy. Personally I regret every penny of the 300K at 9% interest I owe, and I would never do it again if I could go back ten years. It's not because medicine (or specifically psychiatry) is horrible either. It's because nothing is worth that kind of debt. Medicine is becoming an increasingly irrelevant field with the rise of midlevels and the staggering levels of debt that are demanded of med students. At some point you just want to say, "no thanks."

agreed, but only for *some* fields. Midlevels haven't changed the way MANY specialties and subspecialties operate at all in terms of physician and importance. If anything they have made them more efficient. Neurosurgeons(really most all surgeons), interventional cardiologists, etc are under no 'midlevel' pressure.....