Pursuing a second fellowship a few years after being an attending

[Anon0008]

Hi everyone-will try to keep this brief as possible but was looking for some advice/perhaps experiences of those who have been in similar situations.

Since I was a medical student, I was torn between 2 fellowships- ID and pulm/crit. I did electives in both as a medical student AND as a resident. I participated in research projects in both fields. I tried very hard to talk with fellows/attendings in both specialties over the years- in short, I tried my absolute very best to make the best-researched, best-informed decision that I could. I considered doing a fellowship in ID/critical care, but I was deterred for several reasons- firstly, there are not a lot of these programs around, and I was (and will forever be, for family reasons) geographically restricted. I was also advised by people in both specialties (including an ID/CC attending who only practiced ID) that the job market doesn't really support that combination- most people end up having to work in one or other of the specialties, and although I do enjoy critical care, I didn't want to risk picking something that would relegate me to solely be an intensivist, and I didn't want to pick ID and never work again in the ICU. In the end I settled on pulm/crit because it seemed like the best way to have flexibility- I'd still get the ICU and a healthy dose of ID overlap in both the ICU and pulm.

However, having completed pulm/crit fellowship, I really am having regrets that I didn't pursue ID fellowship. I absolutely still enjoy the ICU but I really just don't find pulmonary to be fulfilling and I just genuinely find ID so much more interesting and fulfilling. (I could expound on this much more in a constructive way if I were writing a personal statement but I'll spare everyone the unnecessary details). I'm a non-traditional (took some time off after undergrad before med school to save up money to apply to med school) and come from very modest means, so if I were a few years younger and if I could keep going on a fellows' salary a little longer, I would have just pursued ID fellowship immediately after PCCM and called it a day. However, that's just not realistic.

My partner has been extremely supportive (he's known me the entire time I've been having this debate with myself so he, too, can attest that I've been debating this for close to a decade now...) and we decided that I will work as an attending for a few years and then, if I still really haven't found the professional and personal satisfaction I desire in my current specialty, we will see where we are financially and perhaps I will go back and complete an ID fellowship. It goes without saying that I would never put my sense of 'personal fulfillment' in front of my family's well-being so if there is not a realistic way I can do this, I will deal with it and move on.

But that being said- wondering if anyone here pursued a second fellowship a few years after a first. Besides the considerable financial considerations (decrease in salary for 2 years + opportunity cost of that lost salary), I'm wondering if it's feasible because I'm not sure how one crafts a reasonable application. I don't know how I would get LORs for a new application after being an attending for a few years in a different specialty. My research (mostly QI, and not a lot at that) is all related to the overlap between PCCM and ID so I have that going for me (I guess). I can't really do "rotations" in another specialty as an attending. I would still be geographically limited so if I didn't get into a fellowship in my current city (I do have several options although most are competitive institutions), again, I would just have to move on from this since an ability to move anywhere in the country for the sake of fellowship isn't an option. I was always a fairly strong applicant throughout this whole process (honored every single one of my clinical rotations in med school, strong step scores on all three steps, chief resident, good evaluations/good professional and clinical reputation throughout medical school, residency, and fellowship) but I imagine a lot of this kind of stuff is less important the further you go along and so I'm not sure how to be a 'strong applicant' when I've been an attending for a few years trying to pursue a different specialty.

I truly appreciate anyone taking the time to read this and perhaps offer some thoughts. Please don't quote- I tried to keep the details as scarce as possible but still needed to give enough so my post isn't so vague as to be useless for someone to give advice.

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[DrMetal]

However, having completed pulm/crit fellowship, I really am having regrets that I didn't pursue ID fellowship. I absolutely still enjoy the ICU

So be an intensivist! Don't do outpatient Pulm. There's plenty of critical care work. You'll see plenty of ID in the ICU. Be more interested in it, don't be the typical intensivist who only knows 3 antibiotics.

I say no second fellowship. Please, go practice. Let's get ourselves out of the GME rut. While you're busy becoming a PGY11+ , some NP will gladly take your job in the ICU.

 

[Señor S]

Didn't do it personally but here's an ID/PCCM person (albeit in reverse order from what you're aiming for):

Christian Woods, MD, FCCP, FACP, FIDSA - Program Director

www.medstarhealth.org

My take as an outsider:

ID is not competitive. The letters thing I wouldn't worry about; get one from your PCCM PD, your IM PD and your department chair at your current job and you should be good. Write to the ID PDs at the programs you're interested and tell them your story. I'm guessing they'll find it sympathetic. Your med school CV will still carry weight. I think you'll be fine.

Are you working at an academic institution that has an ID fellowship currently? If not, I'd recommend switching over to one if you can. If yes, work hard to ingratiate yourself to the ID faculty at your institution.

 

[dozitgetchahi]

So be an intensivist! Don't do outpatient Pulm. There's plenty of critical care work. You'll see plenty of ID in the ICU. Be more interested in it, don't be the typical intensivist who only knows 3 antibiotics.

I say no second fellowship. Please, go practice. Let's get ourselves out of the GME rut. While you're busy becoming a PGY11+ , some NP will gladly take your job in the ICU.

I agree with this.

If you really really want to do an ID fellowship, it’s probably not going to be hard to match. This is probably the second easiest IM fellowship to match at the moment, aside from renal.

 

[NewYorkDoctors]

as someone who has done two unrelated subspecialty fellowships (renal then PCCM), the primary question to ask is what do you plan to do with the two (or three in our case) subspecialties?

currently I do not use the renal degree at all except for a handful of "legacy" glomerulonephritis patients, being comfortable calling the shots on vasculitis cases and also managing pulmonary edema (yeah I get referred a fair bit of CHF for management...….. though i just actively manage the diuretics without fearing the creatinine and electrolytes and using remote vital monitoring, remote weight monitoring, lung sono , POCUS echo, and bioimpedance spectroscopy to guide my diuresis. the local gen cards appreciates my doing their job for them lol)

to pursue ID on top implies you would not want to be in the ICU full time? as you do plenty of ID cases in MICU already.

to do ID implies you would like to manage outpatient chronic infections and also far less common acute infectious diseases in the ambulatory or non-ICU setting? you could become an NTM guru. Though you would not need both ID and Pulmonary for that. At Denver's national jewish hospital (where they write the NTM guidelines essentially), Dr David Griffith and Dr Charles Daley are both PCCM board certified initially. But they made the shift over to NTM research full time. They do not have ID board certifications.

do you want to become a post lung transplant swiss army knife to manage pulmonary complications and systemic infections?

do you plan to open a private practice because you have money and funding to do so?

if so, I am not sure how ID contributes much to revenue generation. seeing outpatient pulmonary in your own private practice can make show much more money (see my other threads in is outpatient so bad and neph is dead thread) because running all of the various outpatient pulmonary procedures are relatively quick, can pay on par with cardiology procedures outpatient (minus their nuclear stress test money printing machine), and for the most part do not require any prior authorization (aka delays)


anyway getting into ID should not be hard at all unless it's a top ID program at a research heavy institution. but going to research heavy institution

good luck.

 

[MifflinDunder]

@NewYorkDoctors did you have any funding issues? Was that brought up by any programs

 

[NotAProgDirector]

There are no funding issues with a second fellowship. All fellowships are paid at 50% DME and 100% IME since everyone is out of their IRP.

 

[NewYorkDoctors]

@NewYorkDoctors did you have any funding issues? Was that brought up by any programs

as NotAPD mentions , it's not the biggest of issues

Though I have HEARD (take with a grain of salt) that smaller hospitals in NYC that are not large tertiary care centers want to "pocket more of that GME money" and cut corners and would NOT want to take a higher PGY # for that reason unless there is some great benefit to be brought to that program. Again this might be an individual program situation and not a generalization.

 

[gutonc]

as NotAPD mentions , it's not the biggest of issues

Though I have HEARD (take with a grain of salt) that smaller hospitals in NYC that are not large tertiary care centers want to "pocket more of that GME money" and cut corners and would NOT want to take a higher PGY # for that reason unless there is some great benefit to be brought to that program. Again this might be an individual program situation and not a generalization.

Again, every single fellowship position is funded exactly the same regardless of PGY#. CMS pays the same for the PGY4 Cards fellow as they do for the PGY15 pediatric neurocardiothoracichepatobiliary fellow. This is true regardless of if it's your first, 2nd or 5th fellowship.

Funding is NOT an issue in this scenario and anyone who says it is either doesn't understand the system (most people) or is flat out lying to make you go away (a small, but non-zero number).

 

[NotAProgDirector]

I think what @NewYorkDoctors is hinting at is that programs pay residents based on PGY level. Hence, if you take someone who completed 6 years of GME training already, you might pay them as a PGY7. Since the salary of a PGY-7 is higher than a PGY-4, it might be in a program's best financial interest to avoid the person with the second fellowship.

But not all programs will "do the math" that way. Our programs would pay the OP as a PGY-4 should they come to us for a second fellowship. The PGY classification is the minimum needed to start the training.

 

[gutonc]

I think what @NewYorkDoctors is hinting at is that programs pay residents based on PGY level. Hence, if you take someone who completed 6 years of GME training already, you might pay them as a PGY7. Since the salary of a PGY-7 is higher than a PGY-4, it might be in a program's best financial interest to avoid the person with the second fellowship.

But not all programs will "do the math" that way. Our programs would pay the OP as a PGY-4 should they come to us for a second fellowship. The PGY classification is the minimum needed to start the training.

Gotcha. Agree that a first year fellow in a standard fellowship (not a sub-sub specialty) is going to be paid as a PGY4 the vast majority of places. If it's continued training, without interruption, at the same institution, then it might get paid at the next PGY level.

But we are talking tiny amounts of money here, a few thousand dollars at the most. So I do stand by my statement.