I would like to quit fellowship

[enjoy living]

I would like to quit fellowship but don't know what to do next. I know it's stupid but I feel overwhelmed. I'm doing endocrine at university hospital. And feeling like I'm drowning everyday. With 30+ patients on the list and new consult 7 to 10+. I don't expect anything like this. Feeling like I should stop torturing myself but don't know what to do. Sometimes, I think I would rather die than doing this.
Any advice ?

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[enjoy living]

Feeling like I'm a target that anyone can shoot. APRN can put consult by writing that dm management, insulin management. I feel like this is too much for me. And we don't have NP for inpatient dm management. Feeling I'm stupid machine. I believe that this is the most malignant endocrine program. I'm sorry to conplaint but don't know where I can get more options about this issues.

 

[Crayola227]

Feeling like I'm a target that anyone can shoot. APRN can put consult by writing that dm management, insulin management. I feel like this is too much for me. And we don't have NP for inpatient dm management. Feeling I'm stupid machine. I believe that this is the most malignant endocrine program. I'm sorry to conplaint but don't know where I can get more options about this issues.

Please be careful about mentions of self harm on SDN, it is taken very seriously and can get the thread taken down, not to be mean, but for obvious liability reasons.

If you are in any danger of harming yourself, please seek help immediately.

 

[Crayola227]

SDN is a great place for those interested or in the healthcare fields to vent their frustrations and talk about their feelings, and to get support, so I don't mean to discourage your posting at all.

 

[Successor12]

Two questions for you
1) Do you like endo?
2)what was your expectation?
3)You realize as a hospitalist/primary care you are still expected to see 20 plus patients ?
4)How many consult months you have? How many fellows are at your program?

 

[deleted480308]

Two questions for you
1) Do you like endo?
2)what was your expectation?
3)You realize as a hospitalist/primary care you are still expected to see 20 plus patients ?
4)How many consult months you have? How many fellows are at your program?

My home hospitalists run <=17

 

[Endocrine123]

Two questions for you
1) Do you like endo?
2)what was your expectation?
3)You realize as a hospitalist/primary care you are still expected to see 20 plus patients ?
4)How many consult months you have? How many fellows are at your program?

1) yes
2) 10 patients with 3-4 consults a day
3) 5 months a year x 2 years

 

[Chalo1986]

First year will always be difficult, however I still remember enjoying the mental thought process behind even some of the "run of the mill" diabetes cases. As a second year things get better with more electives and you get more of a taste of thyroid, adrenal, pituitary and bone pathology. Things are a lot better as an attending, I'm very happy with my patient load, the variety of cases and even the salary (which is typically considered low) surprised me in a very competitive first tier city. At the end of the day what really matters is if you still enjoy the specialty, and if you're willing to put up with the workload and the crap you'll experience in fellowship. Going by the grammar you probably are an IMG (like me), the job market, to my appreciation, was thriving when I was looking and you should have no issues finding work, if you're willing to be flexible.

 

[Successor12]

I am curious to learn more about endo job market if you don't mind?

 

[Successor12]

As for the answers to my questions I think the key is: whether you like what you do or not!
I just started fellowship myself and consults have been rough especially juggling the load with clinics and attending to clinic tasks which keep popping up!
Long lists and too many consults-not as many as what you talking about though but I will be looking at 8 months of consults total during my training

And I am doing rheum so you can assume my expectations were less than this However this is in no way comparable to residency working hours for example so I guess I was like eh it could have been worse

Also I like what I do ALOT so this makes it way easier honestly

That being said I get that you must have been overwhelmed/frustrated not sure though if quitting fellowship is the answer to your problem just looking at how it will adversely impact your future fellowship applications if you ever decided you want to go back to fellowship (esp given your issues with work load I don't think hospital medicine will make you happy)
If I were you I would have tried to find ways to make it easier and this is mostly achieved through a positive attitude /focus on learning/ reminding yourself it does get better after fellowship and if you still feel abused in terms of being overworked may be discuss it with your PD!? Time off?

 

[Chalo1986]

I am curious to learn more about endo job market if you don't mind?

My experience looking for work was limited, I did not use a recruiter and I finished fellowship 2 months ago. I got a call before the end of my first year to interview at a big tertiary hospital in a nice area of the city I live in. That was in 6/2016, they expressed interest in recruiting me and let me know I'd be receiving a contract in 12/2016. Money, vacation, CME and academic appointment were discussed up front. The only two other offers came without me looking or asking for them; they were from my own fellowship program at a university-affiliated hospital, and from the main university hospital that issued my diploma. They offered significantly less pay that was at the mean annual salary that is offered in the first tier city I live in. I went with the first offer I got as the money was better (75th percentile for a new graduate's mean salary) and they offered to pay for all visa/greencard expenses. The 2 other places tried to match the salary from the initial offer but I had already committed to a verbal agreement with the place I'm now working at. All in all I know I was lucky, on hindsight maybe I should've placed some phone calls and visited other places for comparison, but everything turned out well. I'm working at an academic center in a university affiliated hospital with private practice money, incentives and perks.

PS: My fellowship experience was different then what has been described here. I was in a program with 4 fellows and did 12 straight months of consults on my first year (average 2-5 consults per day with a census of around 5-12 patients + weekend call every other week). However, 2nd year I only covered one weekend every 6 weeks with the rest of the time purely focused on research and elective rotations.

 

[rokshana]

1) yes
2) 10 patients with 3-4 consults a day
3) 5 months a year x 2 years

the beginning of fellowship can be difficult in that you may feel that you already have an idea of what the work will be like, since you have been working as a resident. Realize you are again an intern of sorts...and those 1st few months will be, again, a period of adjustment.

I do feel that your #2 - expectations are inaccurately low...especially if glucose management for other services is part of the consult service (though 30 + pts is a bit high...are they mostly sugar control or are they more complicated then that?).
Eventually you will be able to handle (and will need to learn to handle) the 16-20 clinic pts that tends to be the norm as an attending (depends on where you are and how you are paid). You easily saw 10 pts as an intern and resident...and frankly the IM notes had to be detailed about many things...endo notes are usually about one thing and the f/u notes for glucose management are short (level 2 at best).

Talk to your seniors about how to prioritize your work. What is exactly overwhelming about your fellowship? the volume? the hours? the notes? the knowledge needed? if you can pinpoint the things that are making you feel overwhelmed, then you can start to take steps to fix it. Do you have a mentor that you can speak with? If not, maybe finding someone that you feel would be helpful in givning you advice.

 

[Endocrine123]

the beginning of fellowship can be difficult in that you may feel that you already have an idea of what the work will be like, since you have been working as a resident. Realize you are again an intern of sorts...and those 1st few months will be, again, a period of adjustment.

I do feel that your #2 - expectations are inaccurately low...especially if glucose management for other services is part of the consult service (though 30 + pts is a bit high...are they mostly sugar control or are they more complicated then that?).
Eventually you will be able to handle (and will need to learn to handle) the 16-20 clinic pts that tends to be the norm as an attending (depends on where you are and how you are paid). You easily saw 10 pts as an intern and resident...and frankly the IM notes had to be detailed about many things...endo notes are usually about one thing and the f/u notes for glucose management are short (level 2 at best).

Talk to your seniors about how to prioritize your work. What is exactly overwhelming about your fellowship? the volume? the hours? the notes? the knowledge needed? if you can pinpoint the things that are making you feel overwhelmed, then you can start to take steps to fix it. Do you have a mentor that you can speak with? If not, maybe finding someone that you feel would be helpful in givning you advice.

Thank you very much.

 

[IM2GI]

I would like to quit fellowship but don't know what to do next. I know it's stupid but I feel overwhelmed. I'm doing endocrine at university hospital. And feeling like I'm drowning everyday. With 30+ patients on the list and new consult 7 to 10+. I don't expect anything like this. Feeling like I should stop torturing myself but don't know what to do. Sometimes, I think I would rather die than doing this.
Any advice ?

Thats a ton of volume for endo. Can you more aggressively sign off on people so your list is more managable?

Are you by yourself? Residents?

You really need to be provided a midlevel or add another fellow to that rotation, it is just not a manageble number of patients if that is the regular volume. Your attendings also could step up and agree to see some of the follow ups. Lazy entitled academics.

 

[rokshana]

Thats a ton of volume for endo. Can you more aggressively sign off on people so your list is more managable?

Are you by yourself? Residents?

You really need to be provided a midlevel or add another fellow to that rotation, it is just not a manageble number of patients if that is the regular volume. Your attendings also could step up and agree to see some of the follow ups. Lazy entitled academics.

I suspect if he is having 30+ pt on his list, the majority of them are glucose management.

generally if the consult is for glucose management, then no you can't really sign off...those services are looking for someone to manage the sugars and either tell them what changes to make or make the changes for them, but they are simple enough in that you are really looking at the sugars and directing the change (and once you get the pt on a schedule insulin regimen instead of the reflex sliding scale that the service has put them on, the sugars tend to be better controlled to the point you may not even make any changes) rather than seeing the pt...the attending know that this generates, at best, a level 2 billing.

Dude's a fellow....not exactly easy for him to demand a midlevel and endocrine fellowships are not like GI fellowships and have 4-5 fellows a year...2 is the average and there are plenty of places where there is only 1 a year.

If not calling for glucose management, then many time they are calling an Endo consult just to get the pt connected with Endocrine...for example, pt breaks a hip and Ortho calls for a consult...well not much for Endo to do INpatient...you see the pt, make recs for outpt referral and get them scheduled for an OV (which, of course, Ortho could just make the referral for OUTpatient Endocrinology , but...).

 

[IM2GI]

I suspect if he is having 30+ pt on his list, the majority of them are glucose management.

generally if the consult is for glucose management, then no you can't really sign off...those services are looking for someone to manage the sugars and either tell them what changes to make or make the changes for them, but they are simple enough in that you are really looking at the sugars and directing the change (and once you get the pt on a schedule insulin regimen instead of the reflex sliding scale that the service has put them on, the sugars tend to be better controlled to the point you may not even make any changes) rather than seeing the pt...the attending know that this generates, at best, a level 2 billing.

Dude's a fellow....not exactly easy for him to demand a midlevel and endocrine fellowships are not like GI fellowships and have 4-5 fellows a year...2 is the average and there are plenty of places where there is only 1 a year.

If not calling for glucose management, then many time they are calling an Endo consult just to get the pt connected with Endocrine...for example, pt breaks a hip and Ortho calls for a consult...well not much for Endo to do INpatient...you see the pt, make recs for outpt referral and get them scheduled for an OV (which, of course, Ortho could just make the referral for OUTpatient Endocrinology , but...).

sliding scale with meals, will sign off, see us in clinic, call if questions. Who cares if someone runs a little high while in the hospital?

Do you really need to hold someones hand their entire admission? sure follow a DKA for a few days, but inpatient glucose management is not rocket science. Endo would not even be consulted for most DKA where I trained.

Sure he a fellow, but anyone would tell you that it is impossible to provide high quality care for a list 30 deep, dont care how easy the consult is.

OP what is the breakdown of reason for consult for your 30 patient deep list?

 

[rokshana]

sliding scale with meals, will sign off, see us in clinic, call if questions. Who cares if someone runs a little high while in the hospital?

Do you really need to hold someones hand their entire admission? sure follow a DKA for a few days, but inpatient glucose management is not rocket science. Endo would not even be consulted for most DKA where I trained.

if you are joking, then haha...same as who really needs to do a complete bowel prep for colon...if not, then you just prove the point of why medical (yes, Hospitalists and IM seem to consult Endo for DM management now a days) services seem to consult for glucose management.

And yes, apparently they do...BTW, its not the DKA that one needs to follow, ICUs have protocols for that...its the transition to sq insulin that seems to be troubling...impressive how many people i have seen that go back into DKA because they didn't get their sq insulin before the gatt was turned off...

as a fellow, the simple glucose consults annoyed the crap out of me...but as an attending, they take 5 minutes at best for f/u so not a big deal.

 

[PlutoBoy]

sliding scale with meals, will sign off, see us in clinic, call if questions. Who cares if someone runs a little high while in the hospital?

Do you really need to hold someones hand their entire admission? sure follow a DKA for a few days, but inpatient glucose management is not rocket science. Endo would not even be consulted for most DKA where I trained.

Sure he a fellow, but anyone would tell you that it is impossible to provide high quality care for a list 30 deep, dont care how easy the consult is.

OP what is the breakdown of reason for consult for your 30 patient deep list?

I don't see why I would consult Endocrinology for DKA, much less for diabetes.

If I can't manage that on my own then I can't manage anything in endocrinology.

 

[PlutoBoy]

Also, did OP use two different accounts in the same thread?

 

[Raryn]

I don't see why I would consult Endocrinology for DKA, much less for diabetes.

If I can't manage that on my own then I can't manage anything in endocrinology.

Many community hospitals have Endocrine consulted on almost everyone who isn't controlled on sliding scale alone. Whether the hospitalists just have a high census or are really, really, truly lazy, the community Endos put up with it because it's easy money. A reasonably competent IM intern should be able to handle the majority of the consults we get at those hospitals, but they're still put in by the presumably fully trained hospitalists.

As a fellow, I rotate at a hospital like that, where the consult list is regularly 40+ patients. Thankfully I personally only see a dozen or so, with the attending/NP/residents seeing the remainder. If I had to cover the full service myself, I could do it... but it would be a true PITA. I can see why the OP hates it. If you made me do that for 10 months of my fellowship? I'd be tempted to quit too.

OTOH, at our academic hospital, the consult list is regularly <10 patients total, and at most 2-3 diabetics that are either truly complicated (transplant patients, on insulin u500, whatever) or just on the neurosurgical service or something. Of course, we also have almost daily clinics when we cover that service, so it isn't "easy" by any means.

 

[Scope guy]

Many community hospitals have Endocrine consulted on almost everyone who isn't controlled on sliding scale alone. Whether the hospitalists just have a high census or are really, really, truly lazy, the community Endos put up with it because it's easy money. A reasonably competent IM intern should be able to handle the majority of the consults we get at those hospitals, but they're still put in by the presumably fully trained hospitalists.

As a fellow, I rotate at a hospital like that, where the consult list is regularly 40+ patients. Thankfully I personally only see a dozen or so, with the attending/NP/residents seeing the remainder. If I had to cover the full service myself, I could do it... but it would be a true PITA. I can see why the OP hates it. If you made me do that for 10 months of my fellowship? I'd be tempted to quit too.

OTOH, at our academic hospital, the consult list is regularly <10 patients total, and at most 2-3 diabetics that are either truly complicated (transplant patients, on insulin u500, whatever) or just on the neurosurgical service or something. Of course, we also have almost daily clinics when we cover that service, so it isn't "easy" by any means.

I have had exact opposite experience with residency and fellowship. In residency in a univ affiliated comm hospital, I dont remember consulting endocrine in 3 years other than for a bad thyroid storm and DM with insulin pump which was hard to control. But in fellowship at a true university program, consults are placed for trivial reasons, which I was told was to give fellows enough educational experience, at the expense of resident education and experience. I hate to say but comm programs are far better in IM training than university training that I see. have done away elective in a top IM program in southwest and they do the same as my fellowship program too.

 

[rokshana]

I have had exact opposite experience with residency and fellowship. In residency in a univ affiliated comm hospital, I dont remember consulting endocrine in 3 years other than for a bad thyroid storm and DM with insulin pump which was hard to control. But in fellowship at a true university program, consults are placed for trivial reasons, which I was told was to give fellows enough educational experience, at the expense of resident education and experience. I hate to say but comm programs are far better in IM training than university training that I see. have done away elective in a top IM program in southwest and they do the same as my fellowship program too.

eh, my fellowship experience was all academic (true university program) so generally it was the non medical services that consulted Endo for sugar and there was an understanding with CT surg that anyone with uncontrolled DM (A1c>7.5) Endo was an automatic consult. Liver transplant pt were an automatic consult as well, otherwise the IM services consulted for pumps and U500 use in-house (this was required since Endo approval was need for U 500). My second year, we did have an NP on the service and the glucose follow ups went to her. My attending experiences have been both academic and community and generally Endo was consulted for sugar on practical everyone in the community hospitals...not sure if it was to help generate revenue since many places had community consultants or if it was due to the high census the hospitalists carried (maybe a little bit of both).

maybe the difference between SW and NE?

 

[Raryn]

I have had exact opposite experience with residency and fellowship. In residency in a univ affiliated comm hospital, I dont remember consulting endocrine in 3 years other than for a bad thyroid storm and DM with insulin pump which was hard to control. But in fellowship at a true university program, consults are placed for trivial reasons, which I was told was to give fellows enough educational experience, at the expense of resident education and experience. I hate to say but comm programs are far better in IM training than university training that I see. have done away elective in a top IM program in southwest and they do the same as my fellowship program too.

I've rotated at a number of community hospitals, including working at some as a (moonlighting) hospitalist.

At every single community hospital I've been, they were extremely blase about consults. Everything got a consult. Patient coughs once? Pulmonary consult. Elevated LFTs? They don't even order a single hepatitis lab, they just order a GI consult. Sugar of 201 once? Endocrine consult.

OTOH, the academic services where I've trained, people were always very hesitant to put in any consults. The teaching attendings took pride in doing as much of the workup as possible before calling anyone. We'd only call pulmonary at the point we needed a bronch. Or GI at the point we needed a scope. Endocrine was basically never called outside of circumstances like what you described. At least not as an inpatient. This was true for teaching services both in a community and a primary university hospital (and in the community hospital was extremely different compared to the consult pattern of the private guys who were taking care of the same patient population).

There do exist academic hospitals that are much more "fellow run". There's a few like cleveland clinic that are absolutley notorious for it, having a weak IM program because everything is run by the subspecialists. But I like to think that's unusual.

Edit: typo

 

[EasyRider]

This is TRAINING. It is not suppose to be easy.

When you are done you will be better prepared than a Cush fellowship program.

Also in private practice you will be paid for these consults by NPs. It is purely eat what you can kill.

NPs have increased private practice endocrinologists salary for these easy consults.

 

[enjoy living]

I suspect if he is having 30+ pt on his list, the majority of them are glucose management.

generally if the consult is for glucose management, then no you can't really sign off...those services are looking for someone to manage the sugars and either tell them what changes to make or make the changes for them, but they are simple enough in that you are really looking at the sugars and directing the change (and once you get the pt on a schedule insulin regimen instead of the reflex sliding scale that the service has put them on, the sugars tend to be better controlled to the point you may not even make any changes) rather than seeing the pt...the attending know that this generates, at best, a level 2 billing.

Dude's a fellow....not exactly easy for him to demand a midlevel and endocrine fellowships are not like GI fellowships and have 4-5 fellows a year...2 is the average and there are plenty of places where there is only 1 a year.

If not calling for glucose management, then many time they are calling an Endo consult just to get the pt connected with Endocrine...for example, pt breaks a hip and Ortho calls for a consult...well not much for Endo to do INpatient...you see the pt, make recs for outpt referral and get them scheduled for an OV (which, of course, Ortho could just make the referral for OUTpatient Endocrinology , but...).

You are right. no Midlevel for simple glucose management. Just only 1 fellow.

 

[enjoy living]

This is TRAINING. It is not suppose to be easy.

When you are done you will be better prepared than a Cush fellowship program.

Also in private practice you will be paid for these consults by NPs. It is purely eat what you can kill.

NPs have increased private practice endocrinologists salary for these easy consults.

I understand that. But don't get it. They don't know much and do thins routinely. Like consult cases for dm management

 

[enjoy living]

I've rotated at a number of community hospitals, including working at some as a (moonlighting) hospitalist.

At every single community hospital I've been, they were extremely blase about consults. Everything got a consult. Patient coughs once? Pulmonary consult. Elevated LFTs? They don't even order a single hepatitis lab, they just order a GI consult. Sugar of 201 once? Endocrine consult.

OTOH, the academic services where I've trained, people were always very hesitant to put in any consults. The teaching attendings took pride in doing as much of the workup as possible before calling anyone. We'd only call pulmonary at the point we needed a bronch. Or GI at the point we needed a scope. Endocrine was basically never called outside of circumstances like what you described. At least not as an inpatient. This was true for teaching services both in a community and a primary university hospital (and in the community hospital was extremely different compared to the consult pattern of the private guys who were taking care of the same patient population).

There do exist academic hospitals that are much more "fellow run". There's a few like cleveland clinic that are absolutley notorious for it, having a weak IM program because everything is run by the subspecialists. But I like to think that's unusual.

Edit: typo

It's university hospital. Acedemic. The first day I worked I realized that this was my wrong decision I've made. Never expected this at all. And all consults we have to document and it takes time.

 

[enjoy living]

I have had exact opposite experience with residency and fellowship. In residency in a univ affiliated comm hospital, I dont remember consulting endocrine in 3 years other than for a bad thyroid storm and DM with insulin pump which was hard to control. But in fellowship at a true university program, consults are placed for trivial reasons, which I was told was to give fellows enough educational experience, at the expense of resident education and experience. I hate to say but comm programs are far better in IM training than university training that I see. have done away elective in a top IM program in southwest and they do the same as my fellowship program too.

Exactly. I did consult endo only real endo issues during my residency training in community based hospital ( except for cases with not so smart attending to consult endo for newly dx dm) on the other hand, university hospital I'm working, even ED runs by NP or midlevel

 

[rokshana]

It's university hospital. Acedemic. The first day I worked I realized that this was my wrong decision I've made. Never expected this at all. And all consults we have to document and it takes time.

well, yes documentation takes time, but not THAT much time....if its taking you more than 10 mins, then you are documenting too much for what little you get for glucose management. If you are crazy busy (lots of new consults) bill a level1 for these glucose pts and move on...if you have more time, then you can do the extra for a level2,though once you are doing this for a bit the level 2 billing won't take you more that the level1 billing.

S: Pt seen at bedside. No acute events overnight. Or fasting/prandial sugar still elevated
O: Vitals:
PE: General A&O x3 NAD
Labs: BMP (if one is there)
Blood Sugars: B L D B
A/P: Pt with DM2, (not) under good control on basal/bolus insulin.
- continue current management OR
- Increase Lantus to xxx
- Increase NovoLog to xxx
Endocrinology Fellow, PGY-4

Other than the initial consult, there is little that you need to do in regards to education in the note. If there was an event, say hypOglycemia, then there may be more in documentation then it may take more time.

 

[rokshana]

Exactly. I did consult endo only real endo issues during my residency training in community based hospital ( except for cases with not so smart attending to consult endo for newly dx dm) on the other hand, university hospital I'm working, even ED runs by NP or midlevel

have news for you...DM IS a real endo issue...and during training you need to learn how to manage these pts...how are you suppose to supervise the NP or even the nurses that run a diabetes management team if you don't know how to do it yourself...just reading about it isn't what trains you...you have to learn the basics...and while you may think you learned the basics in residency, its different in fellowship.

Endo is not all about the weird, unusual cases...your clinic will not be full of Cushing's, pheos, and MENs....its thyroid nodules, poorly controlled DM, and middle aged women with fatigue that they think is related to their thyroid and middle aged men with fatigue that think its related to their low T...In the hospital, you will have the occasional hypercalcemia and myxedema, but the reality is more DM and osteoporosis after a hip fracture...and if this doesn't seem interesting to you then may be you are in the wrong field, otherwise, its 2 years, and as you gain experience, the DM pts become quick pts to see and care for...

 

[Attending_007]

I would like to quit fellowship but don't know what to do next. I know it's stupid but I feel overwhelmed. I'm doing endocrine at university hospital. And feeling like I'm drowning everyday. With 30+ patients on the list and new consult 7 to 10+. I don't expect anything like this. Feeling like I should stop torturing myself but don't know what to do. Sometimes, I think I would rather die than doing this.
Any advice ?

I felt exactly like that in my nephrology fellowship. It was very hard to hang in there, but I convinced myself that I owed it to myself to finish what I started. Now, in retrospect, I realize that I was very sleep deprived, and I often get depressed when I get too little sleep. Life after fellowship is much better. You could even choose to work part-time. Hang in there.