Residencies / Fellowships...?

[Chris Seattle]

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Forgive the new person question, but I am strongly considering Medical school but lack the udnerstanding of the overall time-line. After 4 years of med school a student may, providing sufficient performance, graduate with an M.D. degree and proceed to residency. This residency may be anywhere depending upon 'matching' up with your requested specialty and location, (I guess, although I know little about this process and it intrigues me since I have a family, and dropping everything and moving may not be the easiest thing). Then, after enduring the rigors of 4 years (the standard), from there things get a bit hazy. My questions are;
What is a fellowship and why would someone take another year of pitiful pay instead of practicing to start making good money?
A fellowship sounds much like an extended residency. Is there anyone who could contrast the 2?

My gratitude extends to any answers to my inquiries.

 

[turtleboard]

Fellowships come after residency training in a specific field for sub-specialization. For example an internist (someone who did an internal medicine residency program which is only three-years long) who wants to sub-specialize and be a cardiologist can take a cardiology fellowship for an additional three-years.

Why would someone want to take extra years of "pitiful pay?" Perhaps part of it has to do with interest in a particular field. The general practice of many things in medicine, such as a general practice in internal medicine, pediatrics, and maybe even surgery, is terribly boring for some. The other part of it is subspecialists make anywhere between two and four times more than a "generalist."

The average internist in the United States makes somewhere between $120,000-$150,000. A cardiologist, an internist who has completed a three-year cardiology fellowship following a three-year internal medicine residency, makes somewhere between $200,000-$300,000. An invasive/interventional cardiologist, a cardiologist who has completed a one-year invasive fellowship after having completed a three-year cardiology fellowship and a three-year internal medicine residnecy, makes somewhere between $300,000-$500,000.

There are more subtleties between residency and fellowship, but you should ask a more senior student for that information.


Tim W. of N.Y.C.

 

[Chris Seattle]

after 3 years of residency, this individual takes a 1 year fellowship and then a three year fellowship, totalling 7 years after 4 years of med school. 11 years. ack. I might be too old to practice by then...haha

what about orthopedic surgery? I researched one local residency program that you must do one year of gen. surgery and then 4 years of ortho surg residency in a specific subspecialty. At that point it seems, a total of 5 years, a resident could then practice specialised ortho surgery with a very sizable income. Or maybe there is some hidden fellowship requirement there that I missed.

It is going to be tough supporting my family through med school with the stipends that are in existence and although my core motivation is specialized medicine I don't want to prolong the lower income pain for too long. And I wonder; during residency the school loan repayment can be deferred, (on those salaries it must), but what about fellowships? If fellowships are the equivalent to 'and extended specialised training' residency which continues to pay $40k a year one would hardly have the means to payback huge school loans and support a family. That is somewhat discouraging. And I would wager that the fellowships positions are probably competitive also. Sometimes it seems that school will never end.

 

[turtleboard]

Training doesn't end for the MD.

According to my financial aid administrator, you begin repayment of your loans nine months after graduation from MEDICAL SCHOOL, which means that you'll be repaying those loans as a resident and, unfortunately, with a resident's pathetic salary.

Fellowships are an interesting beast, and I've heard varying opinions on how to snag one. The "method" which makes most sense to me is seek the fellowship before applying for the residency. In other words, a med student who wants to go into Rheumatology at Mayo should probably do his IM residency at Mayo as well. Why? Connections and the like. Many fellowship programs, apparently, lock their positions a year early and many times with their own residents.

Orthopedics is a five-year program at all hospitals. It consists of one year (PGY1 year) of general surgery and four years of orthopedics. Orthopedics can be considered a "surgical subspecialty," but there are orthopedic subspecialties the orthopod can explore such as pediatric ortho, hand surgery, spine surgery, sports medicine, trauma, etc. These fellowships are hard to come by and tack onto the five-year program.

If you want to be a generalist, then training is pretty minimal compared to the field's specialists.


Tim W. of N.Y.C.

 

[Chris Seattle]

First of all i want to thank you for your responses. Secondly, I am desiring to head (at this time) towards Ortho surgery, either shoulder/elbow (upper extremety) or spinal. I know that education never ends, it is just merely making sure I can make ends meet during...

 

[turtleboard]

Last summer I was with an orthopod in New York who specialized in shoulder surgery, specifically for Erb's Palsy patients (brachial plexus injury). Fascinating and complicated stuff! There was a plastics guy who worked with him on most of the cases, so maybe that's a backdoor.

You should know that there are currently two fellowships in Hand Surgery for general surgeons.

Ortho is one of those programs for which you really need to kick butt in med school right from the get-go. Be open to other areas, however, and don't have orthopedic tunnel vision.

Good luck.


Tim W. of N.Y.C.

 

[kimberlicox]

Just a short note...

You can (and many do) defer your loans during residency - either opting to defer all or to pay the interest. Many residents find this necessary to do when their gross salary is < 35,000 and their loan payments are >2,000/month.

In regards to brachial plexus surgery, as turtleboard notes this is highly specialised surgery. The surgeons at the TMC who do this are a team of plastics and pediatric neurosurgeons. However, upper limb specialists are often orthopods, although the fellowships are open to those with plastics/general/neuro training.

Hope this helps.

 

[Chris Seattle]

I think New York would be a hectic place for a residency. I am aware of the stringent requirements of ortho residencies. I certainly don't have ortho tunnel vision and just am just as likely to get into 3rd year clinical rotations and find out really whether surgery is something I am cut out for, not pun intended. Linguistically it was a convenient phrase though. Fatigue makes people say strange things.

Anyway, my background is in oncology / immunulogy research and I would consider doing an M.D. / Ph.D. if research salaries would actually make the extra years worth it. I guess you have to endure that schedule based on some humanitarian purpose and although that would be a considerable factor, it would not drive me to ignore other avenues of generating resources to take care of my family.

My gratitude for all who have answered my questions

 

[turtleboard]

While there are some MD/PhDs who do carry clinical practices with hefty research, the lot of them stick with the lab and forego a clinical career. A career in research might bring you a little over $100,000 a year, but no one ever goes into research for the money.

The only advantage with heading into one of those MD/PhD programs is the free med school tuition, but you're talking about four to six extra years of education. Though a PhD might help you land an impossible residency to get, I wouldn't do it for that reason either.


Tim W. of N.Y.C.

 

[Detroit Rock City]

Your concern with money is disconcerting, considering you are not even in medical school yet. Every resident I know that has not paid their loans back yet defer throuought their residency. All this means is more interest. 90,000 borrowed over four years and deferred for 3 of residnecy comes out to close to 120,000. Interest starts the day you take the loan!!!
If I took this job solely for the $$ I'd have shot myself many times just last week. You are worrying about being able to afford a family on a residents salary? You should worry more about seeing that family. Junior residents in almost every discipline especially surgical fields have minimal free time. Worry about that first!
DRC

 

[turtleboard]

DRC,

I think applicants should have a realistic expectation of what the money's like as a resident, and I don't blame the original poster for being borderline obsessed with cash flow.

I don't think anyone would go into medicine for the money, even if it's as much as a neurosurgeon reportedly pulls in. Medicine's too difficult and the sacrifices too great for any MD's sole motivation to be greenbacks... I hope.

If anyone else out there is concerned with the money issue, go to your state med school and save way more than 50% on your tuition costs.

In New York, for example, tuition at a private med school is about $24,000. At the State University of New York (SUNY) the tuition is a little over $8,000.

Tim W. of N.Y.C.

 

[Chris Seattle]

Obsessed? well, I just have to justify in my own mind why I am going to school and residency for 11 years. I have achieved job satisfaction in most places I have been, however, my desire to become a physician is different. The short term tuition may not be such a huge deal at my state school, the University of Washington. I would hope that I could redirect evryone from the impression that I am obsessive about final salary. I just do not want to be ignorant, and yes the schedule bothers me, but I am going to do what it takes.

 

[FourthTime]

Hi everybody. I'm going to be an MS1 this fall at UTMB and am already starting to think about residencies and fellowships. I have a couple of questions. Where can I find a list of all the types of fellowships that exist? How does pay differ for fellowship training as opposed to residency training? How competitive is it to get a fellowship (compared to residency)? Do fellowhips only exist for IM, or other fields? And finally, is there a fellowship/residency that allows one to do mostly internal medicine, but some time for surgery? I want to do be a doctor who does a little bit of surgery, but don't want the time constraints that the life of a surgeon requires. Much thanks for any responses!

 

[Chris Seattle]

It is a good think to start thinking about residencies and fellowships early. I am certainly not the authority in this area as the above posts show, however, I have been researching it lately and have been increasing in knowledge with regard to these matters. Essentialy through MS1 and MS2 it is a good idea to keep your eyes open for exposure to the primary specialties; Neurology, Cardiology, Othopaedics, etc. Some summer opportunities exist to dabble in these specialties as they each desire to court the best students. With regard to pay, residencies are paid by levels classified from R1 to R7 or R8 depending on the program with the R standing for, of course, resident, and the number signifying the year of duty. R1 salaries range from $25k to $35k per year in my area, and a chief resident at R4 on up may make up to $50k. A standard residency may provide general working knowledge in a field whereas a Fellowship is determined to craft an individuals knowledge of sub-specialties. The pay scale continues to press on in the R5, R6, etc. fashion. Essentially, Fellowships are opportunities to advance into a subspecialty. Sub-specialties and the training Fellowships are available based upon demographic availability. It may be good to determine what other facets of practice are attractive to you, and then examine whether surgery is involved in that area. Best of luck in your pursuits!!

 

[turtleboard]

Congratulations on getting to UT -- which one? The "MB" is for "Medical Branch," isn't it?

You can find a listing of fellowships and residencies at the AMA FREIDA website: www.ama-assn.org/freida

Pay during fellowship is usually a bit higher than residency, but no where near six figures if that's what you're wondering.

Fellowships vary in competitiveness depending on the particular program, but they're generally more difficult to snag than a residency.

Fellowships exist in IM, General Surgery, Ortho, FP, etc. -- so, no, not just IM. Anyone who does major surgery goes through a surgical program and, hence, lives the life of a surgeon. The closest lifestyle to the kind you describe is being a surgical subspecialist (i.e., orthopedist, ENT, opthalmologist, or urologist). These guys tend to have the life that you describe, where they spend their mornings operating (which can be infrequent depending on their case load) and afternoons in their offices.

Tim W. of N.Y.C.

 

[kimberlicox]

Just wanted to add a couple of words in addition to the excellent advice gievn by Tim and Chris. If you are interested in procedural work, consider Gastro or Cardio fellowships after an IM residency. In addition, Interventional Radiology, Anesth also do lots of procedures. I would also add Plastics onto the list of surgical subspecialties with lots of procedures but a slightly better lifestyle than General Surgery.

Hope this helps...

 

[Chris Seattle]

Excellent suggestions. An Interventional Radiologist might be a nice mix, Anesthesiologists might have the surgeon schedule but I don't know any so I am speaking from ignorance (forgive me), the Invasive Cardio may be a mix of patient interaction and surg, Gastro might have lots of endoscopy and not so much of the cut and paste stuff, but who knows...It's too bad that the Plastics have declined in popularity/demand/compensation over the last few years although in the MidWest region they are still doing well...

 

[FourthTime]

Thanks for everyone's great information. One more question. What are people's opinion about OB/GYN? It seems to have surgery and primary care as well as take on some social issues as well. Also, I'm a male, so how does that influence my ability to be successful in this field?

 

[Neurogirl]

Just a few thoughts on OB-GYN and Anesth as those are the other two fields that I seriously considered.

OB-GYN is a great field for those who want to be surgeons but don't want the lifestyle. However, as we all know, babies come into this world when THEY'RE ready so your schedule can, at times, be pretty grueling. Whenever I mentioned the bad hours, everyone told me not to worry about it because lots of OB-GYNs share call and end up delivering each others babies. Even though more and more people are doing this, the patients don't like it (how would you like to have your baby delivered by a stranger?) and I knew I wouldn't like it either. However, it's a very fun specialty and the money is great. Unfortunately, unless you're willing to be very mobile, it's becoming more and more difficult for male OB-GYNs to find good positions. At the same time, women entering the field are courted and have their choice of jobs. No, it's not fair, but women tend to want female physicians for their OB-GYN needs.

Anesth is also a terrific field but I think it's one of those areas that you either love or hate because 99% of your time is spent monitoring CRNAs (depending on where you end up practicing, you might not even get to do any but the most complex cases), and doing pain management, while the other 1% is white knuckle time, ie., crisis management. And you have to be comfortable going from 0 to 100 in one second flat! The main disadvantage of Anesth is the increasing autonomy of CRNAs. The big advantages are the hours (usually 6-7 am til 3-4 pm...unless you're on call) and the money (many make as much as surgeons).

 

[FourthTime]

Thanks Neurogirl:
Well, I do really want to incorporate surgery, but I don't want the lifestyle. That's why I was considering OB/GYN. I gues the whole gender thing is a negative for me. Anyway, I wanted to ask your opinion (or anyone else's) about orthopedics. I know it's competitive, but I've read (scutwork.com) that the lifestyle is less grueling than other surgical specialties. Can't someone do a "little" surgery and have a life too? Any thoughts are most appreciated.

 

[Neurogirl]

Well...no. Haven't you heard the old surgical resident's joke? One resident to another: There's only one thing wrong with q2 call...you miss half the interesting cases! hehehe. In general though, I agree with Tim in that if you want to be a surgeon, but without the lifestyle, you should consider OB/GYN, ENT, Opthal, or urology. When you say "a little surgery", how much do you mean? Most specialties utilize at least a few proceedures. Even in Neuro, I'll get to do LPs and nerve biopsies. Also, while it's nice to have a specialty in mind, you really need to be open to all the specialties, at least until you've done a few of your 3rd year rotations. I can't tell you how many people ended up changing their minds by the end of the 3rd yr.

Regarding ortho, the ones I know are just as busy as general surgeons. It's probably less stressful than general surgery only because they tend to have fewer emergencies and lower operative and post-op mortality.

 

[Chris Seattle]

I just want to thank all those who have responded to this thread. The discussion has been very beneficial to me.

 

[kimberlicox]

IMHO orthopods don't have particularly great hours - they do a lot of trauma, and that often happens after hours! OTOH, its a lot of fun.

I agree with Neurogirl - more family/lifestyle friendly true surgical specialties are ENT and Ophtho and I'd still include Plastics. Remuneration may have dropped but they still make more than most internists or general surgeons.

Hope this helps.

 

[turtleboard]

The orthopod I worked with this past summer had GREAT hours. Two cases in the morning every other day followed by about 7-10 patients in the afternoon (mainly post-op follow-ups). Fridays would be a half day with no surgery in the morning, 2 or 3 patients in the afternoon. Work week started on Tuesday.

Tim W. of N.Y.C.

 

[kimberlicox]

Originally posted by turtleboard:
The orthopod I worked with this past summer had GREAT hours. Two cases in the morning every other day followed by about 7-10 patients in the afternoon (mainly post-op follow-ups). Fridays would be a half day with no surgery in the morning, 2 or 3 patients in the afternoon. Work week started on Tuesday.

Tim W. of N.Y.C.

I stand corrected - or perhaps I should clarify. In my academic world and mind, I narrow mindedly only thought about orthopods practicing at academic medical centers - places which tend to include a fair bit of call (lessening, like everything, as you gain seniority) and trauma action. At my school the orthopods tended to operate more and later hours than anyone else - especially on weekends (and I was right there along side, hankering for some drilling action!

.

 

[turtleboard]

But this was an orthopod who was an academic orthopod (oxymoron, anybody?

) and was actually chief of the service at a major hospital center in New York.

Fancy!

Tim W. of N.Y.C.

 

[FourthTime]

Wow! You guys are giving me a lot of insight. Thanks again. OK, so now I want to get people's advice on what type of residency is good for someone who wants to do the following:

1. See patients most of the time (50-80%); devoting as much as 50% of that time to surgery and the rest primary patient contact.

2. Teach at an academic institution for some portion of time (20-30%)

3. Perform/oversee/engage in research (possibly) for about 10% of the time. This one I'm not sure about. I probably feel the least strong about this, but would like to do it if I could.

4. Serve as a consultant/stakeholder for the development of public policy that affects the types of patients I see (ie. influence populations-based medicine) for about 10% of the time.

Given this scenario, can anyone give me their opinion on what type of medicine would best suit me? I realize that I still need to experience all the rotations to find my "passion," but I'm so excited about starting med school in the fall that I can't help but to think ahead! Thanks again.

[This message has been edited by FourthTime (edited 02-14-2001).]

[This message has been edited by FourthTime (edited 02-14-2001).]

 

[kimberlicox]

Originally posted by turtleboard:
But this was an orthopod who was an academic orthopod (oxymoron, anybody?

) and was actually chief of the service at a major hospital center in New York.

Fancy!

Tim W. of N.Y.C.

I stand corrected x two! I would suggest that since he is the Chief of Service his hours do tend to be less than residents or junior faculty, but we may just have had different experiences. True, I rarely saw the Chief of Ortho in the OR after hours or on weekends (except for major trauma/difficult cases) when it was largely the residents doing the cases and taking the call. At any rate, depending on what Chris & Fourthtime are looking for, the residency will be a bit longer on hours and greater on surgery than perhaps he is interested in!

 

[GGale]

Hi. I was just wondering if ortho is the best jumping off point for somone who wants to do predomiantly trauma surgery? Would plastic surgery be better?

 

[turtleboard]

Well, there are actually trauma fellowships available for general surgeons. They're not listed in FREIDA for whatever reason, so here's a couple of links you may want to try:
www.aast.org/fellow.html www.trauma.org/resources/fellowships/fellowships.html

There are trauma fellowships available to Orthopedists, but that would relegate you to doing ortho trauma (hip fractures and that sort of thing).

It's really interesting. As an undergrad I had the opportunity to work with the top orthopedic trauma surgeon in the world (well, at least he thought he was...

) -- yes, he's in New York City.

W.

 

[turtleboard]

4th time,

It's always been my observation that those MDs who end up in administrative positions were, more often than not, internists by training. Look up the president or dean of your med school and find out what he does. I'm almost positive he's probably NOT a surgeon and most likely an internist.

I don't know why this is so, but it may be because there are just so many internists and surgeons tend to love the OR more than anything else.

Why not look into general surgery? There are surgeons who do the things you describe, but it really depends on how far you want to take your career. Not all surgeons are hard core OR-types who live and breathe surgery -- they don't tend to be at the top of their field, but that's not what you're necessarily looking for.

W.

 

[FourthTime]

True. I've thought about general surgery. I'm just really concerned about the lifestyle. I don't want to work 90 hour work weeks forever. I want to spend time with my family too. Is this possible with gen. surg?

 

[richierich]

Trauma....
Yes you can do fellowships in Trauma, Ortho -trauma, ect..... but I have been told that it is not necessary to do a fellowship esecially if you do your Gen Surg at a large level 1 trauma center. I had inquired because at one time I had smelled too much of my dry erase markers and was a little loopy.

Hope this helps,

Richard

[This message has been edited by richierich (edited 02-24-2001).]