Is there really a need for so many subspecialty fellowships?

[medicine2006]

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I know that it takes a lot of learning to become a fully competent practicing physician but sometimes I feel that the medical education system in the USA is exploitive of students. They make us jump thru so many hoops before we actually can become "fully trained". I believe this more of an economic issue than a training issue. For example they are having a trauma surgery fellowship now. I think this is just another way to get cheap labor. Most truma surgeons in the ER now never did a fellowship specifically for this and they are doing fine. What about pain management fellowship for anesthiology? Couldn't they just squeeze in what you need to know for that in the time already alotted? What about CT surgery why do you have to do 5 years gen surge then 3 years of CT fellowship? I think doing only the first 3 years of gen surgery and 3 years of fellowship would suffice. In other countries the philosophy of training physicians is more efficient.

Graduate medical education in this country is somewhat of a scam. Trust me you'll see more and more subspecialties poping up with more training involved. It's all about the cheap labor in this country! Please let the exploitation stop!

 

[Berns]

I see your point but I also think that there's another perspective. First of all, you, the student/physician-in-training, can decide when enough is enough. There's nothing that says that you must jump through the hoops (and I agree, our profession has more hoops than most, though not THE most). Different people have different goals and not all doctors want to be that sub-specialized anyways. I, for one, want to be a doctor with a broad base of practical/clinical knowledge and not be confined to one specific area of practice. Hence, I'm interested in internal medicine/primary care.

Also, another point is that although it may be true that the teaching hospitals benefit by getting "cheap labor" out of the residents/fellows, I don't believe that is the motive behind the recent proliferation of subspecialty training programs. I don't profess to know much about what it takes to start up and maintain a program but I would speculate that it's not just about getting cheap labor. I think that the departments are responding to increased interest (by the residents themselves) in subspecializing. In other words, there's a demand and ppl want to go on and get more training. Furthermore, as the body of knowledge continues to grow, there's an increased need for subspecialists. True, the old-school learned as they went b/c they were they ones who developed these fields. But it took them many many years to gain that sort of experience/expertise.....and the learning curve was steep for them. The subspecialty training programs gives these well-experienced docs an opportunity to pass on what they have learned/developed to the new doctors.

THe fact that other countries don't have such extensive training may just be because they simply don't have those sorts of services.

Finally, one last point, in many cases it probably is about the money. People who subspecialize make lots more money than generalists. Yes, they have to provide cheap labor while in training, but after they get out of their fellowships their earning power is increased substantially and they make that up and then some!

My humble thoughts...

 

[BellKicker]

In other countries the philosophy of training physicians is more efficient.

I can't claim to know every country's system but in Scandinavia (sub)specialty training is considerably longer than in the US. By the time we enter residency, we've been out of school 3-5 years!

Now, we're paid more and work less as residents, so the situation isn't really comparable. Residency isn't the same white-knuckle rite of passage here as it is in America. Another difference is that we have far more specialists here, so practically everyone spends more than 10 years after med school specializing. For real 😱

America is often looked upon as a fast way to specialize. I've seen threads here in SDN where students weigh the pros and cons of US vs GB residencies; they all talk about the shorter time spent in American residencies (I don't know too much about UK residencies, though).

 

[Retinamark]

Similar in Australia. If you want to do a competitive subspecialty like Ophthal, Radiology or Derm, it can take 3 or 4 years after graduating from Med school to get into a subspecialty training program. This can be a frustrating & stressful few years!

 

[ALTorGT]

true it takes longer to get into a program in UK or Aus, but the upshot is that after 4 years of college and 4 years of med school in US, you still haven't set foot in the workforce, whereas in Aus you are at least making a salary from your 7th year onwards (after coming out of high school).

 

[edfig99]

I know that it takes a lot of learning to become a fully competent practicing physician but sometimes I feel that the medical education system in the USA is exploitive of students. They make us jump thru so many hoops before we actually can become "fully trained". I believe this more of an economic issue than a training issue. For example they are having a trauma surgery fellowship now. I think this is just another way to get cheap labor. Most truma surgeons in the ER now never did a fellowship specifically for this and they are doing fine. What about pain management fellowship for anesthiology? Couldn't they just squeeze in what you need to know for that in the time already alotted? What about CT surgery why do you have to do 5 years gen surge then 3 years of CT fellowship? I think doing only the first 3 years of gen surgery and 3 years of fellowship would suffice. In other countries the philosophy of training physicians is more efficient.

Graduate medical education in this country is somewhat of a scam. Trust me you'll see more and more subspecialties poping up with more training involved. It's all about the cheap labor in this country! Please let the exploitation stop!

There really isn't time to squeeze in anything into current residency programs without adding time to them, or taking away certain experiences which the powers-that-be have determined are crucial to training. The ACGME and the RRC set forth specific guidelines for each residency and accredited fellowship program, in some cases up to the exact number of cases of disease X that must be taken care of before someone can be considered "ready to go". you can check out those requirements (and in some cases the rationale) at www.acgme.org. While, yes, some people have been "grandfathered" through, for matters of reimbursement in the long term, you need standards.

Though there is to some extent some exploitation, and delayed gratification, the whole point of (at least accredited) fellowships is to have a minimum set of standards and competencies before someone is deemed ready to "crack a chest" for example. if the powers-that-be have determined that it takes a minimum of 5 years of training to be deemed a competent surgeon, why would I want someone who only did it in three just to subspecialize?