The End of Pediatric Subspecialties

[Perrotfish]

I was just looking over the 2014 NRP Fellowship Match statistics: http://www.nrmp.org/wp-content/uplo...gram-NRMP-Results-and-Data-SMS-2014-Final.pdf). While I knew that declining subspecialty salaries and the three year minimum training time had hurt the Peds subspecialties, I had no idea how bad it had gotten. While the specialties that lead to significant hourly pay raises continue to do well (ICU/NICU/Cardiology/Peds-EM/Heme-onc) pretty much every other Peds subspecialty is now looking at 40-60% of fellowship slots going unfilled. Even Cardiology has an increasing rate of unfilled slots. And it doesn't look like this has reached any kind of steady state yet.

I mean, I can't say I blame anyone here. Who in their right mind would subject themselves to 3 years of residency-like abuse for the chance to take a pay cut and lifelong call? Still, though, I have to wonder how long the powers that be will let programs go unfilled before they realize that most of these fellowships should be 1 or 2 years rather than 3? In the meantime I hope no one needs any pulmonology, devo, endocrinology, or nephrology consults.

Any thoughts? Should we be pushing harder to make these fellowships shorter? Pay the fellows more? Should we expect that an increased scope of practice for generalists is the new normal, and just stop expecting/relying on specialists to manage conditions like Autism, severe asthma, and chronic kidney injury?

---

Members don't see this ad.

 

[Easily_Sunburned]

Issue is that compensation is low. Most of us graduate in wicked debt, and pediatrics is reimbursed by (usually) medicaid, which doesn't have all that high reimbursement. So as you mentioned, a lot of the better compensated fields are ones which are more procedural - because the reimbursement is better. Currently rotating with 2 peds nephrologists - for them both, peds nephro represented a pay cut as well as 3 more years of not making money at attending level.

This same issue is becoming a problem in other areas too - geriatrics for instance, in adult medicine - huge upcoming demand, but compensation below that of just doing general internal medicine.

Below is a fantastic article in peds by some folks who dirctly analyzed the cost/benefit of various peds subspecialties - highly recommend.
http://pediatrics.aappublications.org/content/127/2/254.full

Direct copy and paste of the result section:
''The financial returns of pediatric fellowship training varied greatly depending on which subspecialty fellowship was chosen. Pursuing a fellowship in most pediatric subspecialties was a negative financial decision when compared with pursuing no fellowship at all and practicing as a general pediatrician. Incorporating the federal loan-repayment program targeted toward pediatric subspecialists and decreasing the length of fellowship training from 3 to 2 years would substantially increase the financial returns of the pediatric subspecialties.''

At the end of the day, it's about doing what you love. Based on the article I quoted, in applying for peds heme/onc subspecilaty training, I'm probably taking a financial hit of 500 000 - 750 000 over my 'practice lifetime.' But I can't imagine anything more rewarding or more satisfying than this field.

 

[Obnoxious Dad]

The people at the ABP who have mandated three year fellowships including two years of research must be economically tone deaf. They can't seem to absorb the fact that interest keeps compounding on student loans while people are in fellowship. This is one more piece of evidence proving that no one ever went broke underestimating the economic intelligence of physicians.

They also can't face the truth that most of the med school graduates who go into peds are women who emerge from residency at 29 with a ticking biological clock. This must be a difficult concept for the ABP screw balls because, after all, they are merely physicians.

Some might suggest that this three year stupidity will change when a crisis is reached but the crisis was reached years ago. The last time I checked there were 13 states in the U.S. without a single pediatric rheumatologist.

Things don't change because the ABP dim wits are unaccountable. Who elected these people? How are they empowered to make these dumb rules?

 

[Perrotfish]

At the end of the day, it's about doing what you love. Based on the article I quoted, in applying for peds heme/onc subspecilaty training, I'm probably taking a financial hit of 500 000 - 750 000 over my 'practice lifetime.' But I can't imagine anything more rewarding or more satisfying than this field.

I don't begrudge anyone a 750,000 donation to the field of medicine, though I honestly wonder if simply donating $750,000 directly might be more rewarding than doing it via a fellowship. What I though was interesting is how poorly love is filling the subspecialty ranks. I always assumed that, if the ABP was continuing to do this, it meant they had a steady stream of people willing to re-indenture themselves after residency despite the insanely long training and clear financial loss. I was amazed that they are doing this in the face of such enormous non-fill rates.

Some might suggest that this three year stupidity will change when a crisis is reached but the crisis was reached years ago. The last time I checked there were 13 states in the U.S. without a single pediatric rheumatologist.

Things don't change because the ABP dim wits are unaccountable. Who elected these people? How are they empowered to make these dumb rules?

I wonder how long it will take for the fellowships to start breaking off from the ABP. If 60% of pulmonary fellowships aren't filling, can't the pulmonologists simply create a 1 or 2 year non-ABP fellowship, like Genetics or Sports Medicine already does? I can't imagine that academic pulmonologists are willing to do their own notes indefinitely, for the benefit of a different set of academic physicians.

 

[Perrotfish]

Also a follow up question: If you had you choice, which fellowships would you 1 year, 2 years, and 3 years respectively?

 

[Doctorverardoll]

As someone who will be starting Peds Endo fellowship this summer, I can't tell you how many people tried to talk me out of it, but at the end of the day there is nothing else I'd rather be doing. And even in my current residency hometown, it is very difficult for patients to get in and see endocrinologists, leaving PCPs at a loss for when their patients need a little more.
I'm looking forward to 3 years of fellowship, even if it is not a financially "good" idea, as I want to polish my research portion of my CV. That said, I'm looking forward to an academic/research oriented career. I know this isn't for everyone and agree that there should be shorter 2 year fellowships for people who want to be subspecialty clinicians.

 

[MEN2C]

Wait, since when does a heme/onc fellowship pay in peds? It often leads to a LOWER salary than you would have made in general peds.

 

[Siverhideo1985]

It's hard to put a dollar amount into the equation that involves job satisfaction. All these numbers are only a piece of the puzzle, just like going into Peds over Ortho/Derm/Optho/Rads was a big puzzle to be figured out a few years ago. If it doesn't directly lead to financial ruin is it worth it to take a calculated pay cut to do what you enjoy most? You'll be doing it for a few decades afterall. Set your priorities and act accordingly...none of us went into peds because of the big bucks to begin with.

This is anecdotal, but I have a few PICU hospitalist friends who finished residency, worked for 2-3 years while they had 1-2 children and are now going back to applying for PICU fellowship. They had kids, paid off a large chunk of loans by living frugally and making a nice salary and are still going into the field that they love most. Grueling, yes, but which part of medical education wasn't?

 

[Perrotfish]

It's hard to put a dollar amount into the equation that involves job satisfaction. All these numbers are only a piece of the puzzle, just like going into Peds over Ortho/Derm/Optho/Rads was a big puzzle to be figured out a few years ago. If it doesn't directly lead to financial ruin is it worth it to take a calculated pay cut to do what you enjoy most? You'll be doing it for a few decades afterall. Set your priorities and act accordingly...none of us went into peds because of the big bucks to begin with.

This is anecdotal, but I have a few PICU hospitalist friends who finished residency, worked for 2-3 years while they had 1-2 children and are now going back to applying for PICU fellowship. They had kids, paid off a large chunk of loans by living frugally and making a nice salary and are still going into the field that they love most. Grueling, yes, but which part of medical education wasn't?

I guess I have a hard time understanding how anyone expects the benefits of a non ICU/ED Peds fellowship outweighs the associated misery, even independent of the financial aspect of it. To me, there are 4 pieces to the puzzle: lifestyle during training, lifestyle after training, job satisfaction, and finances. From that perspective I can understand a PICU fellowship: you lose lifestyle during training, but gain lifestyle after training (shift work) and improve your total financial outlook, so if you find the job satisfying I can absolutely see doing it. The fellowships that aren't filling their spots, though? You're losing money (to the tune of 1/4th your lifetime earnings), you submit yourself to 3 more years of relentless indignity, and you agree to take a huge hit to your lifestyle by agreeing to a lifetime of call and holiday coverage. How satisfying can a job be that you'd give a million dollars, three years of your life, 5-10 hours a week after training, and every other Christmas until you retire for the sake of doing it? How is anyone willing to do that even independent of the million dollars?

As you said, medical education is all grueling. To me, though, that's a reason to get off the ride as soon as possible.

 

[jlm013085]

I didn't think people went into peds for money, I thought it was about helping children. If we wanted to make money we should have chosen something else. Regardless of how much money we lose over a lifetime we will all live better than 99% of the population. Do what pleases you, help families and just be grateful to be physicians

 

[Easily_Sunburned]

I didn't think people went into peds for money, I thought it was about helping children. If we wanted to make money we should have chosen something else. Regardless of how much money we lose over a lifetime we will all live better than 99% of the population. Do what pleases you, help families and just be grateful to be physicians

Agree. No one goes into peds for the money. I can't imagine anything more rewarding than this career. And, as you so rightly pointed out - even the lowest estimates of a pediatric salary, say in the 150 000 range / year, is still an amazing salary. Yeah, you probably aren't gonna own a yacht or a ferrari - but the people who do own yachts and ferraris don't get to experience the joy of helping kids get better, or in my case (hopefully, fingers crossed for the match!) get to help them beat their cancer. Some things, you can't put a monetary value on. Peds subspecialties are one of those things.

 

[McGillGrad]

Our society values money as a goal. That's what confuses people when peds residents pursue financially detrimental subspeciality training.

What we should value is quality of life (not quantity of goods), quality of your friends and peers (not the number, thereof) and use money as a means to an end (and not an end in-and-of itself.)

Yes, I am going into Peds ED, but if I had a passion for infectious disease then that's what I would purse, despite the pay.

 

[Perrotfish]

Our society values money as a goal. That's what confuses people when peds residents pursue financially detrimental subspeciality training.

What we should value is quality of life (not quantity of goods), quality of your friends and peers (not the number, thereof) and use money as a means to an end (and not an end in-and-of itself.)

Yes, I am going into Peds ED, but if I had a passion for infectious disease then that's what I would purse, despite the pay.

1) Quality of life, beyond money, is part the issue here. Its not just a pay cut. Its a pay cut, perpetual call, and 3 more years of misery. That 3 years is especially important because it is 100% within our power to change, today. That ID fellowship could be 1 year long starting tomorrow, and there would be no more shortage and (since almost 2 years of the fellowship is research) no change in the quality of the graduates. Heck, at one year I might consider doing it just to add to my skillset as a hospitalist.

2) The people who would prefer not to pay you try to make you feel guilty about wanting money, deriding your paycheck as an obsession with nicer cars, boats, rolexes, and other such rubbish. If you're an idiot you certainly can use money for that, but what money really is about is time. Money is what you trade the minutes of your life for, and the better your exchange rate the fewer minutes you need to trade away. Money is the evening that you can't spend with your children because you were working, its the vacation you couldn't take with your wife, and its the chance to retire at 50 that you can't take advantage of. Honestly when I see someone pursuing a Pulm fellowship, just like when I see someone buying a Rolex, I feel like they don't comprehend the value of what they're trading away.

3) I think we, as a profession, need to start getting past the idea of that sacificing our time and money to the medical system necessarily helps patients. You are not saving children when you volunteer to be in a fellowship system that doesn't compensate us. You are enabling a 'non-profit' hospital that would prefer to pay part of your salary to their ever growing administrative budget, an academic oligarchy that would like to use you as an indentured servant for three more years, and a government that wants to promise care for everyone but which doesn't want to take the political risk of taxing anyone to provide that care. The children aren't the ones benifiting from your sacrifice. If you want to give money to children, save up your money and given it to an actual charity. Alternatively improve the quality of your care in a way the hospital can't profit from (expand your work day so you have more time per appointment despite seeing the same number of children, do research and quality improvement, devote more time to studying and self improvement, etc).

4) Again the point of this thread is not how confusing it is that people are pursing financially detrimental subspecialty training. The point of this thread is that people are not pursuing financially detrimental subspecialty training. When there are fellowships where 60% of programs aren't filling, that seems like a pretty clear sign that people aren't finding fellowship all that satisfying.

 

[jlm013085]

The research drives the effectiveness of these specialties. The clinical part sustains/treats patients until the research gives us the next step in providing exemplary care to pts. So it takes people who sacrifice their "lifestyle" to give us the clinical know-how. Please stop using lifestyle as part of your argument, I say that in the most respectful way possible. And these pts are benefiting from our sacrifices

 

[Perrotfish]

The research drives the effectiveness of these specialties. The clinical part sustains/treats patients until the research gives us the next step in providing exemplary care to pts. So it takes people who sacrifice their "lifestyle" to give us the clinical know-how. Please stop using lifestyle as part of your argument, I say that in the most respectful way possible. And these pts are benefiting from our sacrifices

1) Research would still happen without forcing fellows to do years of it. It would just happen after fellowship, and it would be performed by people interested in it, who are pursuing careers based partially around research (academic medicine).

2) As pharmaceutical companies have proven again and again, there is no reason that you can't be compensated, and live a reasonable life, while performing research. No one needs to sacrifice their lifestyle to advance care. Research is only built on sacrifice when no one is willing to invest in it. The problem is no one is going to invest in something they can get someone to do for free.

 

[jlm013085]

Fair

 

[yup.]

1) Research would still happen without forcing fellows to do years of it. It would just happen after fellowship, and it would be performed by people interested in it, who are pursuing careers based partially around research (academic medicine).

2) As pharmaceutical companies have proven again and again, there is no reason that you can't be compensated, and live a reasonable life, while performing research. No one needs to sacrifice their lifestyle to advance care. Research is only built on sacrifice when no one is willing to invest in it. The problem is no one is going to invest in something they can get someone to do for free.

Sure. But if you don't learn to do research as a fellow, when are you going to learn it? There is about zero chance that a practicing physician, without protected time for research, will teach themselves how to perform research and then advance their field of choice. Fellowship provides protected, paid time for research and research training and even grant applications. Sure, it's not well paid. But it's paid. If you use that time to learn how to do research, you might advance your field of choice, and might even like it.

The ABP, then, has taken us from zero likelihood of performing research to some non-zero number by requiring that we perform research in fellowship, and providing us with protected time to do so. I agree with them that it is a good way to advance pediatrics. Should we be paid better? Maybe. But my quality of life as a fellow in a very much non-lifestyle specialty is way better than it was as a pediatric resident.

 

[Obnoxious Dad]

Sure. But if you don't learn to do research as a fellow, when are you going to learn it? There is about zero chance that a practicing physician, without protected time for research, will teach themselves how to perform research and then advance their field of choice. Fellowship provides protected, paid time for research and research training and even grant applications. Sure, it's not well paid. But it's paid. If you use that time to learn how to do research, you might advance your field of choice, and might even like it.

The ABP, then, has taken us from zero likelihood of performing research to some non-zero number by requiring that we perform research in fellowship, and providing us with protected time to do so. I agree with them that it is a good way to advance pediatrics. Should we be paid better? Maybe. But my quality of life as a fellow in a very much non-lifestyle specialty is way better than it was as a pediatric resident.

I am very sure that you are a sincere well meaning physician but your post is as economically tone deaf as the policies you defend. The fact is pediatric subspecialists in rheumatology and pulmonology aren't available to treat patients in many areas. They aren't available because it takes too long to train and fellows are forced to give up approximately $180,000 in after tax earnings to pursue a three year fellowship. What good is the science if there is no one around to deliver it?

It doesn't matter that you aren't as miserable as you used to be. The issue is that practicing general pediatricians, especially those pediatricians who are family breadwinners, are much better off than they would be if they pursued a fellowship. This is why the match rates in endocrinology, rheumatology and nephrology hover around 60%

 

[yup.]

Obnoxious Dad,
The way I see it, the opportunity cost of fellowship can be offset either by decreasing that cost - by decreasing fellowship length or paying better - or by paying subspecialists better.

I see no reasonable argument for weakening fellowship training yet presented in this thread. And I think the survey answers of current and recent fellows shows pretty wide agreement with my position. You brought up rheumatology, so here is a link to their survey results: https://www.abp.org/content/pediatric-rheumatology-survey-results

I do see a strong and cogent argument for paying pediatric subspecialists better, which you drove home nicely by pointing out that patients can be adversely affected by the limited availability of subspecialists.
However, I didn't think that was the point of the thread, so I didn't address it.

It is easy to check the results for other subspecialties of interest once you follow the link.

This is an interesting discussion. And the survey results are of course biased because the people who really think the training is too long are less likely to pursue it.

 

[Perrotfish]

Obnoxious Dad,
The way I see it, the opportunity cost of fellowship can be offset either by decreasing that cost - by decreasing fellowship length or paying better - or by paying subspecialists better.

I see no reasonable argument for weakening fellowship training yet presented in this thread. And I think the survey answers of current and recent fellows shows pretty wide agreement with my position. You brought up rheumatology, so here is a link to their survey results: https://www.abp.org/content/pediatric-rheumatology-survey-results

I do see a strong and cogent argument for paying pediatric subspecialists better, which you drove home nicely by pointing out that patients can be adversely affected by the limited availability of subspecialists.
However, I didn't think that was the point of the thread, so I didn't address it.

It is easy to check the results for other subspecialties of interest once you follow the link.

This is an interesting discussion. And the survey results are of course biased because the people who really think the training is too long are less likely to pursue it.

I would make the argument that eliminating the research component of fellowship is not weakening fellowship, unless the fellowship graduate is going to make research the focus of their career. If (as now) the majority of fellows go out and either primarily or exclusively treat patients, then 'bundling' research training with fellowship training is just creating a useless cost. That cost has to be borne by someone: whether its us, or the taxpayer, or the patient, someone pays for the useless training. While I think that physicians shouldn't be expected to bear the costs of this training exclusively, I have a hard time justifying why anyone should pay us extra to compensate us for 2 years of research training, when we mostly don't go on to become researchers.

So what should we do instead? I would suggest two possibilities:

1) We could split the training. 12-18 month fellowships that train people to practice, then 1-2 year research programs as resume builders for people who want to go into academia and focus on research. The minority of fellows who plan to make a career primarily out of research can pursue it.

2) Alternatively, and this is what I would suggest, is that we could skip the formal training program for research. The worst thing that has happened to medical training is the growing acceptance of the idea that all training needs to occur in a formal, miserable, authoritarian training program. In every other profession people are hired for jobs knowing that they are going to learn skills on the job. Our nurses, NPs, and PAs continue to prove that medicine is not the exception to this rule. You do not need 2 years as an indentured peon to learn to do research. You just need to get hired for a job that blocks out time for research and expects you to do it. Maybe a job with several promotions and more senior physicians that act as your bosses (like every job in academia).

You have a college degree. You have a doctoral degree. You have three years of training in addition to the doctoral degree. You are, without even starting fellowship, qualified to do research at any level. Don't sell yourself short.

 

[Obnoxious Dad]

Obnoxious Dad,
The way I see it, the opportunity cost of fellowship can be offset either by decreasing that cost - by decreasing fellowship length or paying better - or by paying subspecialists better.

I see no reasonable argument for weakening fellowship training yet presented in this thread. And I think the survey answers of current and recent fellows shows pretty wide agreement with my position. You brought up rheumatology, so here is a link to their survey results: https://www.abp.org/content/pediatric-rheumatology-survey-results

I do see a strong and cogent argument for paying pediatric subspecialists better, which you drove home nicely by pointing out that patients can be adversely affected by the limited availability of subspecialists.
However, I didn't think that was the point of the thread, so I didn't address it.

It is easy to check the results for other subspecialties of interest once you follow the link.

This is an interesting discussion. And the survey results are of course biased because the people who really think the training is too long are less likely to pursue it.

There is one tiny problem with that survey. They didn't survey the opinions of graduating pediatric residents who failed to apply for fellowship. If they had I suspect the respondents would have said the training is too long and they have their own kids to feed.

The best argument that this three year requirement is nonsense is the paucity of American MD grads applying for fellowships in nephrology, endocrinology, pulmonology and rheumatology.

 

[jlm013085]

Either way, whether or not they reduce the length of fellowships, these kids still need these services

 

[yup.]

Thanks for the replies. As the only fellowship trained participant in the thread, I want to balance out the opinions a little bit.

I would make the argument that eliminating the research component of fellowship is not weakening fellowship, unless the fellowship graduate is going to make research the focus of their career. If (as now) the majority of fellows go out and either primarily or exclusively treat patients, then 'bundling' research training with fellowship training is just creating a useless cost. That cost has to be borne by someone: whether its us, or the taxpayer, or the patient, someone pays for the useless training. While I think that physicians shouldn't be expected to bear the costs of this training exclusively, I have a hard time justifying why anyone should pay us extra to compensate us for 2 years of research training, when we mostly don't go on to become researchers.

So what should we do instead? I would suggest two possibilities:

1) We could split the training. 12-18 month fellowships that train people to practice, then 1-2 year research programs as resume builders for people who want to go into academia and focus on research. The minority of fellows who plan to make a career primarily out of research can pursue it.

2) Alternatively, and this is what I would suggest, is that we could skip the formal training program for research. The worst thing that has happened to medical training is the growing acceptance of the idea that all training needs to occur in a formal, miserable, authoritarian training program. In every other profession people are hired for jobs knowing that they are going to learn skills on the job. Our nurses, NPs, and PAs continue to prove that medicine is not the exception to this rule. You do not need 2 years as an indentured peon to learn to do research. You just need to get hired for a job that blocks out time for research and expects you to do it. Maybe a job with several promotions and more senior physicians that act as your bosses (like every job in academia).

You have a college degree. You have a doctoral degree. You have three years of training in addition to the doctoral degree. You are, without even starting fellowship, qualified to do research at any level. Don't sell yourself short.

Saying that most pediatric subspecialists primarily provide patient care, while true, obscures the many that also participate in research. Furthermore, fellowship is not 1 year clinical 2 years research. It provides protected time for research, yes (hopefully), but fellowship also provides ongoing clinical training, even when not on service - call or clinic, not to mention teaching - for all 3 years.
Finally, I'll only speak for myself here, despite prior research experience I was absolutely not trained to do research "at any level" prior to my fellowship (I'm not sure what you mean by that, or why you seem to believe the MD or residency provide research training). The opportunity to address that weakness was one of the reasons I chose my particular program.
So your proposals would weaken both clinical and research abilities of future fellowship grads.
Is a weaker pulmonologist or rheumatologist better than none? Maybe. But is weakening fellowship training the best solution to not filling training programs? I don't think so.
BTW I have never been an indentured peon. Well, OK, maybe on 2 services in residency. I am sorry that your residency experience has been so miserable.

There is one tiny problem with that survey. They didn't survey the opinions of graduating pediatric residents who failed to apply for fellowship. If they had I suspect the respondents would have said the training is too long and they have their own kids to feed.

The best argument that this three year requirement is nonsense is the paucity of American MD grads applying for fellowships in nephrology, endocrinology, pulmonology and rheumatology.

I specified that issue with the survey when I gave the link. But when it comes to evaluating training programs, wouldn't you think people who had actually undergone the training might have just a little more insight than those who haven't? I'm sure we all have a tendency to view our own training with rose-colored glasses. But those surveys - across specialties, and across training/experience levels of respondents, overwhelmingly support my opinions about the length and structure of training. And I can't think of any better group to survey. General pediatricians are simply not qualified to evaluate training they have not undergone.

If "the best argument that this three year requirement is nonsense is the paucity of American MD grads applying for fellowships in nephrology, endocrinology, pulmonology and rheumatology," then why are other fellowships of the same duration filling? You know why. It's because the ones that fill have some benefit to balance out exactly the same opportunity cost.

Again, there are 3 options here: decrease opportunity cost by 1. shortening (weakening) fellowships or 2. paying fellows more, or 3. make life better for pediatric subspecialty attendings, in order to overcome the opportunity cost. Weakening fellowships apparently appears to be an attractive option to some people who have not done fellowship training, but not to almost anyone who has or is a current fellow. Paying fellows more across the board is unlikely, as it is determined by the programs, and so won't decrease overall opportunity cost. And kids can be fed on current fellowship salary, let's not get too dramatic. So the remaining option of overcoming training opportunity cost by paying subspecialty pediatricians better is the only logical choice. I still haven't seen any reasonable arguments to the contrary.

You are welcome to your opinions, and of course we all need to weigh our own personal cost/benefit analysis when choosing our own training path.

 

[Obnoxious Dad]

Thanks for the replies. As the only fellowship trained participant in the thread, I want to balance out the opinions a little bit.

So the remaining option of overcoming training opportunity cost by paying subspecialty pediatricians better is the only logical choice. I still haven't seen any reasonable arguments to the contrary..

You are not merely "the only fellowship trained participant in this thread", you are also a dreamer and utterly devoid of economic intuition.

The compensation of fellowship trained pediatricians isn't going to improve appreciably because too many of their patients are medicaid recipients. Medicaid budgets are exploding throughout the country. In the year 2030 it is expected that Medicaid will account for 30% of the state budget of Wisconsin. Are we going to pay the pediatric pulmonologists more by throwing the incontinent demented 90 year old geezers out of the nursing home?

I would also like to make the point here that this two years of research added to the clinical year is just one more example of the way that the good old USA takes it in the shorts for the rest of the world. Why are Americans always expected to shoulder the world's medical research burden? On a per capita basis we spend almost four times as much as the Canadians spend on basic medical research. Why? Are there three year pediatric fellowships in Europe? How much time do you spend reading research papers coming out of the European Union? The support of this research apparatus is one of the reasons that US medical care costs are so much higher than the rest of the world

 

[yup.]

You are not merely "the only fellowship trained participant in this thread", you are also a dreamer and utterly devoid of economic intuition.

The compensation of fellowship trained pediatricians isn't going to improve appreciably because too many of their patients are medicaid recipients. Medicaid budgets are exploding throughout the country. In the year 2030 it is expected that Medicaid will account for 30% of the state budget of Wisconsin. Are we going to pay the pediatric pulmonologists more by throwing the incontinent demented 90 year old geezers out of the nursing home?

I would also like to make the point here that this two years of research added to the clinical year is just one more example of the way that the good old USA takes it in the shorts for the rest of the world. Why are Americans always expected to shoulder the world's medical research burden? On a per capita basis we spend almost four times as much as the Canadians spend on basic medical research. Why? Are there three year pediatric fellowships in Europe? How much time do you spend reading research papers coming out of the European Union? The support of this research apparatus is one of the reasons that US medical care costs are so much higher than the rest of the world

oh come on. There are actually valid arguments to be made in support of your opinion. Ad hominem and (other) red herrings aren't valid.

 

[michigangirl]

I would make the argument that eliminating the research component of fellowship is not weakening fellowship, unless the fellowship graduate is going to make research the focus of their career. If (as now) the majority of fellows go out and either primarily or exclusively treat patients, then 'bundling' research training with fellowship training is just creating a useless cost. That cost has to be borne by someone: whether its us, or the taxpayer, or the patient, someone pays for the useless training. While I think that physicians shouldn't be expected to bear the costs of this training exclusively, I have a hard time justifying why anyone should pay us extra to compensate us for 2 years of research training, when we mostly don't go on to become researchers.

So what should we do instead? I would suggest two possibilities:

1) We could split the training. 12-18 month fellowships that train people to practice, then 1-2 year research programs as resume builders for people who want to go into academia and focus on research. The minority of fellows who plan to make a career primarily out of research can pursue it.

You have a college degree. You have a doctoral degree. You have three years of training in addition to the doctoral degree. You are, without even starting fellowship, qualified to do research at any level. Don't sell yourself short.

Late to the party, but agree with Yup on all points. Perrotfish, you bring up some interesting thoughts above. I COMPLETELY disagree with the last sentence though. If you want to do crappy, "doctor science" then yes, you can do research at any level. Good science means strong training in how to do good science. Which means fellowship training and field work. Or an MPH, or Ph.D. in clinical investigation or a basic science area. But, if research is not in your future....

I do agree that perhaps there should be tracks in fellowship to fill the clinical gaps in the community. But one should do the SAME amount of clinical time that is currently required-- just concentrated something in between 1-2 years. Can just eliminate the research time, and it is assumed you are limiting yourself to working in a non-academic center.

Bottom line, the only reason to do this is to fill a public health need. Not to make fellowship less miserable. Most fellows find their complete fellowship experience valuable to their personal career development and goals. If making 40-50K/year for an additional 3 years isn't in the cards for you, then there are other options.

 

[Obnoxious Dad]

I do agree that perhaps there should be tracks in fellowship to fill the clinical gaps in the community. But one should do the SAME amount of clinical time that is currently required-- just concentrated something in between 1-2 years. Can just eliminate the research time, and it is assumed you are limiting yourself to working in a non-academic center.

Bottom line, the only reason to do this is to fill a public health need. .

This is the point. In many places clinical needs are not being met.

Surveying people who made the choice to pursue a fellowship tells you absolutely NOTHING about the people who choose not to pursue a fellowship in the lowest paying fields in medicine. Graduating residents at pediatric programs who choose to pursue general pediatrics immediately are the people who need to be convinced that they should hang around for another three years to take a pay cut. They are the people you need to survey.

 

[Homunculus]

fascinating read. and a lot of passion.

i'm a pediatric subspecialist. i make more than gen peds. i'm a little confused about parrotfish's claim of more call and crappier life. i did the gen peds thing for 4 years, and if i had to do it any longer i would have gouged my eyeballs out. subspecialty call is a thousand times better than gen peds call, and the clinics are incomparable. the approach and style is totally different. even if the salary was the same, the decreased volume of patients and increased interest factor would have been worth it to me.

salary figures are always off for peds subs. so many of them are academic affiliated you have to read between the lines. no academic peds sub is practicing at 0.8 to 1.0 FTE-- everyone likely has time allotted to research, teaching, or other admin duties. the private peds subs make more than their academic counterparts but (obviously) are motivated to work more.

i feel similarly about the research aspect. the problem is that it is not a 1 year + 2 year model-- research is done throughout the 3 years. simply getting a research study through an IRB may take up an entire year. you can't reasonably do anything of note in a year. possible yes but not probable. the second reason (and the reason they will always have it) is that there is a number of people who don't expect to want a career in research who for whatever reason enjoy it and stick with it. luckily those people exist for those of us more on the clinical spectrum.

a solution to me is a 3 year traditional model or a 2 year clinical model. some of the research can be shaved off, but you aren't sacrificing the whole enchilada. but then you have to ask yourself what is shaving off a year doing? is that one year *really* a make or break thing for people interested in subspecialties?

personally i don't think they should be adjusting much. the fact of the matter is you need good gen pediatricians out there, and some people (for whatever reason) aren't cut out to be subspecialists anyway. i've yet to run into anyone who really really wanted to subspecialize but didn't because it was 3 years. life as a fellow is multitudes better than that as a resident, and like what has been mentioned before it's not like they are paying peanuts. (for full disclosure, i was military peds subspecialty trained so my fellow pay was identical to my peds attending pay so i say that without having done it)

bottom line to me is there are benefits to being in demand (even if not directly reflected in salary), and shortages should not lower standards. if that argument were true we should start knocking years of residencies, too-- which due to work hours restrictions will never happen. in fact, because of the even stricter work hour restrictions residents today have *fewer* clinical hours under their belts than ever before-- which would argue against shortening fellowships since they'll need the time for clinical exposure.

-- your friendly neighborhood post PGY years caveman

 

[ThurmanMcMurman]

This is such an interesting topic. I for one went into a super academic residency and realized I loved it but I couldn't afford it- not with my loans ( 300k) not with my parents needing help, and not in the very expensive geographical area in which I was living where my spouses industry is. I got super sad about it, but now I'm just throwing money at those student loans, and that makes me feel better. Maybe I'll go back to fellowship after I have a nice nest egg for retirement, to at least offset the financial negatives of fellowship.

I'm working as a hospitalist, and it's moderately ok. Financially it's great- but I feel like I have more to offer. But it's hard to give up so much money for fellowship. I know an adult ER doc who did a 2 year critical care fellowship and is double boarded. That is crazy! Less training than a PICU/NICU doc.

Are student loan interest rates going up? And overall debt? ( I assume so since undergrad is crazy expensive now). I feel like a lot of attendings in my residency program were a bit judgy about private practice, but I don't know if they had the loan interest rates I have. ( 6.5-6.8%).
Maybe some academic docs get some grant money to help their salaries? Or they moonlight?

 

[SurfingDoctor]

Maybe some academic docs get some grant money to help their salaries? Or they moonlight?

Grant money protects your time so you can do research, it does not boost your salary. In fact, because you see less patients, you generally pull in less overall than academic colleagues who don't do research or have grants. Grant money also isn't just your salary, it's money for your research assistant, post-doc, student, supplies, equipment, electricity, toilets with running water (seriously). At the end of the day, only a portion of the grant is one's own salary. This is a whole other topic, but a reason for people not doing grant funded research is because (besides the general lack of interest among a lot of trainees and other academic faculty), doing grant-funded research provides lower salary, the same work hours (if not slightly more... I come in on weekends and days off) and little recognition from the institution because no matter how much an institution touts the research enterprise, the reality is that research "costs the institution money" (that is a direct quote I've heard from administration, meaning the cost is lost patient revenue at the expense of research). All that being said, I absolutely love my research. I actually enjoy coming into work in my off time (or staying up late at night having a drink and writing grants and papers) and thinking and testing ideas. I can't imagine doing anything else and if my grant funding dries up and I have to go back to just seeing patients... I'll make more money, but I will be less satisfied overall. Anyway, long story short, grant funding doesn't equal better money, it generally means the opposite.

The moonlighting thing, well I know some of my colleagues moonlight to make more money. However, most institutions operate on a margin that doesn't allow for a lot of free time to moonlight. The general gestalt from a non-profit institution's financial standpoint is that it is better to be understaffed and make people work more than to be overstaffed and have people without a job to do. Thus, if you are already overworked or stretched thin, the idea of moonlighting, no matter what the financial incentives, usually don't pull people in. I know many of my colleagues who gladly trade away extra call/shifts that have bonuses attached because sometimes, time has no price.

 

[Putkernerinthehall]

I am very sure that you are a sincere well meaning physician but your post is as economically tone deaf as the policies you defend. The fact is pediatric subspecialists in rheumatology and pulmonology aren't available to treat patients in many areas. They aren't available because it takes too long to train and fellows are forced to give up approximately $180,000 in after tax earnings to pursue a three year fellowship. What good is the science if there is no one around to deliver it?

It doesn't matter that you aren't as miserable as you used to be. The issue is that practicing general pediatricians, especially those pediatricians who are family breadwinners, are much better off than they would be if they pursued a fellowship. This is why the match rates in endocrinology, rheumatology and nephrology hover around 60%

Sorry - really old thread but wondering how things have changed for pediatric subspecialties. Training durations, compensation, prevalence of unfilled fellowships ?

 

[HemeOncHopeful19]

Nope. In fact I thought this was a recent thread and only noticed it was a decade old about halfway through. If anything the rise of the “hospitalist” fellowship has just shown that things will only get worse and not better.

It’s a sad truth but in reality I think there is no coming back from the low salaries in Peds subspecialties. Maybe, MAYBE they will drop the 3 year fellowship stuff if there is ever truly a “crisis” of lack of access, but I think it’s more likely that you end up with cheap midlevels filling the gap. Peds is super popular with NPs to the point that there is actual competition for most jobs.

 

[Putkernerinthehall]

Peds is super popular with NPs to the point that there is actual competition for most jobs.

Thanks. Sorry I couldn't somehow flag it as an old thread. When you say this are you referring to NP's encroaching on Gen Peds or are you more specifically talking about the NP encroachment into Peds subspecialties ? I'm thinking about someday going the PICU / NICU route.

 

[SurfingDoctor]

Thanks. Sorry I couldn't somehow flag it as an old thread. When you say this are you referring to NP's encroaching on Gen Peds or are you more specifically talking about the NP encroachment into Peds subspecialties ? I'm thinking about someday going the PICU / NICU route.

PICU and NICU NPs function as residents essentially. That was true when I was in training 15 years ago, it’s true now and true likely going forward.

As an aside, interestingly, I’ve seen more PICU NP turnover than PICU faculty turnover, which is also relatively high.

 

[SurfingDoctor]

Nope. In fact I thought this was a recent thread and only noticed it was a decade old about halfway through. If anything the rise of the “hospitalist” fellowship has just shown that things will only get worse and not better.

It’s a sad truth but in reality I think there is no coming back from the low salaries in Peds subspecialties. Maybe, MAYBE they will drop the 3 year fellowship stuff if there is ever truly a “crisis” of lack of access, but I think it’s more likely that you end up with cheap midlevels filling the gap. Peds is super popular with NPs to the point that there is actual competition for most jobs.

I assume this is not about PHM because that’s a 2 year fellowship, but this is definitely not going to happen in the higher paid subspecialties, ie NICU, PICU, Cards. The market forces wouldn’t support that kinda of model, because there is less need. The only way a 2 year fellowship works is if you reduce the number of fellowship spots the year the transition occurs. Otherwise you flood the market with double the applicants with no change in available jobs.

In general, the higher paying specialities are becoming increasingly challenging to find jobs at and making the fellowship 2 years instead of 3 is not going to make that better.

 

[Putkernerinthehall]

In general, the higher paying specialities are becoming increasingly challenging to find jobs at and making the fellowship 2 years instead of 3 is not going to make that better.

Great information, thanks. Any idea on how challenging the job market is for PICU, NICU, Cards ? I mean 5-10% can't find good jobs or like 40-50% can't find good jobs ? I have serious interest in PICU / NICU but want to understand what I'd be getting into employment / compensation-wise.

 

[SurfingDoctor]

Great information, thanks. Any idea on how challenging the job market is for PICU, NICU, Cards ? I mean 5-10% can't find good jobs or like 40-50% can't find good jobs ? I have serious interest in PICU / NICU but want to understand what I'd be getting into employment / compensation-wise.

I can’t say anything about NICU. There’s still a amount of private and community hospitals that employ neonatologists. There none in PICU.

Most of the graduating trainees I’ve seen have been able to find jobs, but the types of jobs and locations are less desirable (hence, why they are available). CVICU had the best job market currently.

 

[HemeOncHopeful19]

I assume this is not about PHM because that’s a 2 year fellowship, but this is definitely not going to happen in the higher paid subspecialties, ie NICU, PICU, Cards. The market forces wouldn’t support that kinda of model, because there is less need. The only way a 2 year fellowship works is if you reduce the number of fellowship spots the year the transition occurs. Otherwise you flood the market with double the applicants with no change in available jobs.

Sorry I meant that I could only see a shortening of fellowships if “doctor shortages” ever became so dire that they needed to induce more people to go into fellowships. I agree it is very unlikely to happen.

Though to play devil’s advocate I’m not sure how much “market forces” really play a role in GME numbers. See EM, Rad Onc for examples where rampant expansion happened despite the lack of a market for it.

 

[SurfingDoctor]

Sorry I meant that I could only see a shortening of fellowships if “doctor shortages” ever became so dire that they needed to induce more people to go into fellowships. I agree it is very unlikely to happen.

Though to play devil’s advocate I’m not sure how much “market forces” really play a role in GME numbers. See EM, Rad Onc for examples where rampant expansion happened despite the lack of a market for it.

Yeah, the doctor shortages aren't going to ever happen in subspecialties. In fact, it's more like over supply.

As to the bolded, GME numbers are specifically divorced from market forces. This is actually by intent. I asked the PD of our program to goes to the national meetings why the other PDs and the ACGME were so oblivious to this. The answer was simple, they weren't. The real answer was more on the nose: "cheap, skilled labor".

So I guess its not so much that the ACGME is contrary to market forces, so much that the people who run the ACGME are very akin to capitalism and know how to best utilize an opportunity when its presented and they pull the string. Nothing left to say to that except:

 

[GoSpursGo]

Just to echo what @SurfingDoctor said, except for PEM and NICU, I would daresay most peds subspecialty markets are pretty poor. In heme/onc, many fellows are needing to do a 4th or even 5th year of fellowship to get a job that isn't a workhorse/hospitalist type gig. The trend is actually towards LONGER training, not shorter, and then you just have to really like your subspecialty in order to make it worth it to you.

I *do* really like my subspecialty, hence why I do it. But I think med students and residents should go into this process with eyes wide open.

 

[Putkernerinthehall]

Just to echo what @SurfingDoctor said, except for PEM and NICU, I would daresay most peds subspecialty markets are pretty poor. In heme/onc, many fellows are needing to do a 4th or even 5th year of fellowship to get a job that isn't a workhorse/hospitalist type gig. The trend is actually towards LONGER training, not shorter, and then you just have to really like your subspecialty in order to make it worth it to you.

I *do* really like my subspecialty, hence why I do it. But I think med students and residents should go into this process with eyes wide open.

Markets for PICU and CVICU aren't good ?

 

[GoSpursGo]

Markets for PICU and CVICU aren't good ?

@SurfingDoctor can comment better, but my understanding is you can get jobs but you may not get them in a highly popular area. He indicated CVICU is better but that’s obviously highly specialized.

 

[mvenus929]

I assume this is not about PHM because that’s a 2 year fellowship, but this is definitely not going to happen in the higher paid subspecialties, ie NICU, PICU, Cards. The market forces wouldn’t support that kinda of model, because there is less need. The only way a 2 year fellowship works is if you reduce the number of fellowship spots the year the transition occurs. Otherwise you flood the market with double the applicants with no change in available jobs.

In general, the higher paying specialities are becoming increasingly challenging to find jobs at and making the fellowship 2 years instead of 3 is not going to make that better.

Some peds hospitalists fellowships (particularly at large academic centers) are 3 years even though only 2 are required to sit for boards.

Yeah, the doctor shortages aren't going to ever happen in subspecialties. In fact, it's more like over supply.

This is probably an oversimplification in some cases. There are more peds endos retiring than entering fellowship, for instance, but peds endo generally costs hospitals money (because it requires a fair amount of support), so a lot of places, the burden falls on general pediatricians to manage--which may or may not be done well. The wait time for our main campus is about 3 months for peds endo and there isn't enough spots for us to see everyone on the timeline that we would prefer they be seen (patients with diabetes, for instance, are more commonly seen every 4-5 months instead of every 3 months). Our health system also covers a very large geographical area, but there aren't enough patients in some areas there to have a peds endo established permanently, so we have patients driving from 4-6 hours away to see us.

 

[GoSpursGo]

Some peds hospitalists fellowships (particularly at large academic centers) are 3 years even though only 2 are required to sit for boards.

This is probably an oversimplification in some cases. There are more peds endos retiring than entering fellowship, for instance, but peds endo generally costs hospitals money (because it requires a fair amount of support), so a lot of places, the burden falls on general pediatricians to manage--which may or may not be done well. The wait time for our main campus is about 3 months for peds endo and there isn't enough spots for us to see everyone on the timeline that we would prefer they be seen (patients with diabetes, for instance, are more commonly seen every 4-5 months instead of every 3 months). Our health system also covers a very large geographical area, but there aren't enough patients in some areas there to have a peds endo established permanently, so we have patients driving from 4-6 hours away to see us.

For these low reimbursement/high workload specialties, what percentage of your salary do you need to bring in through grants?

 

[SurfingDoctor]

Some peds hospitalists fellowships (particularly at large academic centers) are 3 years even though only 2 are required to sit for boards.

This is probably an oversimplification in some cases. There are more peds endos retiring than entering fellowship, for instance, but peds endo generally costs hospitals money (because it requires a fair amount of support), so a lot of places, the burden falls on general pediatricians to manage--which may or may not be done well. The wait time for our main campus is about 3 months for peds endo and there isn't enough spots for us to see everyone on the timeline that we would prefer they be seen (patients with diabetes, for instance, are more commonly seen every 4-5 months instead of every 3 months). Our health system also covers a very large geographical area, but there aren't enough patients in some areas there to have a peds endo established permanently, so we have patients driving from 4-6 hours away to see us.

To your first point, oof. Requiring 3 years when the board says youre ready in 2 is just rubbing salt in the wound and pathetically out of touch.

As to the latter, yes I was speaking in generality. But, those “shortages” are more easily addressed up by hiring NPs so as the specialists can keep the same patient loads at the same salary without having to deal with high volume, low RVU maintenance. So, it’s still a shortage that is relative and rectifiable by cheaper means.

 

[BigRedBeta]

I can’t say anything about NICU. There’s still a amount of private and community hospitals that employ neonatologists. There none in PICU.

That's not true
.
Having done locums at a few locations, there certainly are private and community hospitals with small PICU's that need staffing and provide critical access for kids in a number of locations. Now are they more likely to be small (6-8 beds) units? Absolutely. Are they going to have a full assortment of subspecialists available to provide consultations? No way. Are you likely to ship anything that is even the least bit high acuity? Probably. Are they likely to be jobs that are appropriate for a new grad right out of fellowship to continue their maturation process as they become a fully competent intensivist? Highly unlikely, though such jobs do exist that have the right volume, acuity, support, and mentorship to be appropriate for someone right out of fellowship.



Off the top of my head of locations with private practice PICU groups - none of which have trainees, and I'm very certain no academic appointments at the bigger locations. Some of these locations require the intensivist to function as a peds hospitalist as well so may be responsible for all the children admitted but none are actually requiring critical care skills.

Alexian Brothers - Suburban Chicago
Central DuPage Hospital - Suburban Chicago (though now an affiliate of Northwestern)
Boys Town Hospital - Omaha
Rocky Mountain Children's - Denver
Medical City Children's - Dallas
St. Vincent's - Evansville IN
St. Vincent's - Billings, MT
Bon Secours - Richmond VA
Palm Beach Children's Hospital - Palm Beach FL
Sommerville Medical Center - outside Charleston SC
Covenant Health Children's - Lubbock TX
Children's Healthcare of Atlanta at Scottish Rite (Emory is affiliated with the Egleston Campus)
Overland Park Regional Medical Center - Suburban Kansas City (on the Kansas side).

Of these, only Dallas, Atlanta, and Denver probably are adequate for a freshly minted attending by having the appropriate volume and acuity. Omaha is in a very weird place right now and may get there depending on what happens with Nebraska Med/Children's Omaha vs Boys Town's appetite for expanding services.

Depending on how you want to slice "academic medicine", the following places have trainees but the attendings have at most adjunct faculty appointments
Both Las Vegas Children's Hospitals (UMC and Sunrise)
Peyton Manning Children's Hospital - Indianapolis, IN
Joe DiMaggio Children's - Hollywood FL

Again, these are just off the top of my head and I'm sure there are others that fit these categories.

There are some groups like Children's Mercy in Kansas City and the group at Rady Children's in San Diego that have academic appointments and trainees but their financials are quite different than a standard academic group. The group in KC was part of a larger group of anesthesia providers in the area for a long time (may still be, though I know there was some drama about that about a year ago) and had a very unique contract. The group at Rady from what I understand is a pure, fee for service based compensation model ("eat what you kill" sounds a bit dark for a PICU group but that's what it is).

 

[SurfingDoctor]

That's not true
.
Having done locums at a few locations, there certainly are private and community hospitals with small PICU's that need staffing and provide critical access for kids in a number of locations. Now are they more likely to be small (6-8 beds) units? Absolutely. Are they going to have a full assortment of subspecialists available to provide consultations? No way. Are you likely to ship anything that is even the least bit high acuity? Probably. Are they likely to be jobs that are appropriate for a new grad right out of fellowship to continue their maturation process as they become a fully competent intensivist? Highly unlikely, though such jobs do exist that have the right volume, acuity, support, and mentorship to be appropriate for someone right out of fellowship.



Off the top of my head of locations with private practice PICU groups - none of which have trainees, and I'm very certain no academic appointments at the bigger locations. Some of these locations require the intensivist to function as a peds hospitalist as well so may be responsible for all the children admitted but none are actually requiring critical care skills.

Alexian Brothers - Suburban Chicago
Central DuPage Hospital - Suburban Chicago (though now an affiliate of Northwestern)
Boys Town Hospital - Omaha
Rocky Mountain Children's - Denver
Medical City Children's - Dallas
St. Vincent's - Evansville IN
St. Vincent's - Billings, MT
Bon Secours - Richmond VA
Palm Beach Children's Hospital - Palm Beach FL
Sommerville Medical Center - outside Charleston SC
Covenant Health Children's - Lubbock TX
Children's Healthcare of Atlanta at Scottish Rite (Emory is affiliated with the Egleston Campus)
Overland Park Regional Medical Center - Suburban Kansas City (on the Kansas side).

Of these, only Dallas, Atlanta, and Denver probably are adequate for a freshly minted attending by having the appropriate volume and acuity. Omaha is in a very weird place right now and may get there depending on what happens with Nebraska Med/Children's Omaha vs Boys Town's appetite for expanding services.

Depending on how you want to slice "academic medicine", the following places have trainees but the attendings have at most adjunct faculty appointments
Both Las Vegas Children's Hospitals (UMC and Sunrise)
Peyton Manning Children's Hospital - Indianapolis, IN
Joe DiMaggio Children's - Hollywood FL

Again, these are just off the top of my head and I'm sure there are others that fit these categories.

There are some groups like Children's Mercy in Kansas City and the group at Rady Children's in San Diego that have academic appointments and trainees but their financials are quite different than a standard academic group. The group in KC was part of a larger group of anesthesia providers in the area for a long time (may still be, though I know there was some drama about that about a year ago) and had a very unique contract. The group at Rady from what I understand is a pure, fee for service based compensation model ("eat what you kill" sounds a bit dark for a PICU group but that's what it is).

I was again speaking more broadly as a comparison to NICU, but I definitely defer to you cause you know that market much better than I.

As a somewhat aside, I thought Mercy changed their model and there was/is an exodus from that place. Maybe that was just a rumor I heard.