Residents in a Room

Episode Number: 47

Episode Title: To fellowship or not to fellowship

Recorded: January 2023

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VOICE OVER:

This is Residents in a room, an official podcast of the American Society of Anesthesiologists, where we go behind the scenes to explore the world from the point of view of anesthesiology residents.

I think I have developed myself into a marketable individual without having done fellowship.

Pursuing a fellowship doesn't matter what speciality or subspecialty you want to train in, just have clear goals. That's the most important thing.

I think over the past year I've entertained every single fellowship out there.

And you almost feel like you're letting people down by not doing one.

I am going to be a generalist. Tbd where. Tbd doing what.

DR. ANNA EID:

Welcome to residents in a room, the podcast for residents by residents. I'm Anna Eid and I'm a CA2 and I'll be your host for this episode. Today day we've invited two anesthesiologists to talk to us about why they did and didn't do a fellowship and what they've learned from their experiences. Let's meet our guests first, our speakers, Drs. Anwar and Reardon. Welcome.

DR. BRITTANY REARDON:

Thank you for having us here today.

DR. MUHAMMAD FAROOQ ANWAR:

Good morning, everyone. Thank you for having us.

DR. EID:

And now, my fellow residents

DR. KIM AUT:

My name is Kim Aut. I'm a CA3 here at Vanderbilt.

DR. CHRISTY HENDERSON:

Hi, everyone. I'm Kristie Henderson. I'm a CA 1to here at Vanderbilt as well.

DR. AUT:

Great. Let's get going. Dr. Anwar, you did a fellowship, but. Dr. Reardon, you did not. Can you both tell us about your experience and how you made your choice?

DR. ANWAR:

Just a background for me. I'm an anesthesiologist and a chronic pain physician, an assistant professor of anesthesiology at Duke Anesthesiology Department. I kind of always knew during residency that I wanted to take the academic route, and I was specifically interested in chronic pain, which is a field where you don't get a lot of significant exposure during the residency. So I knew if I wanted to practice outpatient interventional pain, then I need additional training for that. So that was part of my reasoning among other reasons, that includes interest in academics, fellow training and research as well.

DR. REARDON:

So my name is Brittany Reardon. I am an assistant professor of anesthesiology and an associate program director at Mount Sinai West Morningside in New York City. I decided not to do fellowship ultimately, and I had kind of a long list of reasons for that decision. You know, I didn't have a particular field that I was very passionate about. I didn't see myself as a pediatric anesthesiologist. I didn't see myself necessarily as a cardiac anesthesiologist. I wasn't interested in pain or ICU. And as residents and doctors, we kind of are always on this hamster wheel where, you know, you're in college and you're like, I have to get into medical school and you get into medical school and you're like, I have to get into the best residency I can. And you get into residency and you're like, okay, I have to keep training. I have to do fellowship now. I was a chief resident at the time and I had a lot of leadership roles and I felt a lot of pressure where I thought, I think I have to do fellowship. And after talking with a lot of people and reflecting about it, I ultimately decided not to do fellowship. A lot of factors played into this. I had the unique opportunity to stay at my home institution, which was an academic center in New York City, so I was able to still maintain access to the type of job I wanted without doing fellowship. And then I also had a lot of student loan debt. And so I kind of had to consider if I wanted to go into practice and start making an attending salary or not. And then ultimately I had to just figure out if I had another path in academic medicine that did not involve my fellowship training, which I sort of did, which was medical education. So those were kind of the things that I thought about while I was making this decision.

DR. EID:

Thank you. What do you both see as the pros of fellowship training?

DR. REARDON:

I do think that having fellowship training makes you more marketable. I don't think that there's any way to debate that. If you specifically want a career in academic medicine, doing a fellowship helps you obtain future roles such as like a head of an OB division, the head of a regional division. When you're looking for jobs in the private practice arena, I do think it makes you more marketable to say that you do have fellowship training and I do feel like it gives you a clinical niche. So for me I do a lot of head and neck anesthesia, which you don't need a fellowship for, and I've sort of made that my clinical niche. But I had to sort of be thoughtful about that because I didn't have an inherent clinical niche because I did not do a fellowship.

DR. ANWAR:

Yes, I agree with Brittany. I think some of the pros with fellowship depends on obviously what you're looking for, what kind of job market you're looking for. Yes, a lot of private practices. It's it makes you more marketable for that. But especially if you're going for an academic practice being subspecialty, certified. And if you have board certification, obviously you can get more leadership roles. If you want to become like a program director, maybe you want to you want to contribute more to that fellowship. So you could do that. Obviously it boosts your resume as if you want to get into more research associated positions. And at the same time, I think some of the people, depends on what their interests are and what sort of fellowships, sometimes coming out of residency they may not feel that comfortable. I've had some residents and fellows tell me that as well, that, oh, I felt like I wasn't ready to just go out and be on my own. And they take that fellowship years sometimes to get more comfortable because a lot of fellowships you could actually act as a junior faculty. So I think if you're not really interested in specific speciality, that's one of the pros as well.

DR. HENDERSON:

And on the flip side, what are the cons of doing a fellowship and taking that year?

DR. REARDON:

Any time that you are going to defer a year of an attending salary is a con. This is something I think a lot of doctors have to think about. Unfortunately, because the cost of medical school is very high and some people have debt coming from college and medical school. And so a lot of people think like, oh, the financial incentive to become an attending is very strong. So I do think a con of fellowship is that you sort of lose a year of an attending salary. Sometimes I think doing fellowship doesn't necessarily get you more financially in a job. I think maybe like the differential is not huge in anesthesia, and I honestly could be wrong about that. But from most academic practices that I've seen, the increase for doing fellowship is kind of small. And I think that there's different reasons to do fellowship. If you're doing the fellowship for the wrong reason, that obviously would be a con as well.

DR. ANWAR:

Yes, I agree with Brittany. Obviously, just know the reasons why you're doing a fellowship. I don't think financially, especially in today's market, any fellowship is somewhat better than the other. There's a lot of demand for general anesthesiologists out in the market, and sometimes you could be specialty kind of like bound to one specialty if you're trained in that. So I've seen a lot of that. I don't know if I would necessarily call it a con because at the same time, I've seen a lot of fellowship trained people come back to just being general anesthesiologists. Obviously, you do lose a year of clinical practice, so you have to factor that into if you're going to make the switch after doing the fellowship, just being in the OR sometimes it could be challenging.

DR. AUT:

The landscape has changed in large part because of this shortage of anesthesiologists. We can earn more money sooner if we skip a fellowship and go straight to the O. and do general anesthesia. Dr. Reardon, you already touched on this a little bit. How much did money weigh in on your decision? And how much do you think it should weigh?

DR. REARDON:

I think it definitely should be something that you think about. If you're passionate about pursuing pediatric or cardiac anesthesiology or OB anesthesia. By all means, I don't think you should say to yourself, oh, can I afford to do a fellowship or not? But I think if you are sort of leaning between doing no fellowship and then participating in some sort of fellowship training, then I think that's when you can kind of weigh in finances as part of the package. You know, doing one more year of training is not going to make a massive difference in your finances. So I definitely think it's something that should be kind of looked at when you're deciding whether or not to do one. Not if you're like, I don't think anyone should be taking a step back and saying, Oh, I definitely can't do this because I can't afford to do it, if that makes sense.

DR. EID:

Do you think people ever go back and do a fellowship later on after being an attending for a while?

DR. ANWAR:

I think in my personal experience, I've seen people do the other way around. Most of the time they'll do a fellowship and then go back to just practicing general anesthesia. But it's definitely not an uncommon thing. Sometimes your interests do change. Depends on what kind of job you initially signed into. People don't necessarily end up liking the lifestyle or the jobs, and sometimes they find a niche that they want to be specialty trained in. Or sometimes people may find certain weaknesses. For example, if somebody started to do more cases in a private practice and there are a lot of lot more cardiac cases and depending on the kind of residency training they had, if they think that they like cardiac or on the other hand, they lack the expertise to deal with those patients, sometimes I've seen people go back and pursue that fellowship and then just try to do those cases more often.

DR. HENDERSON:

And since applications to fellowships are pretty early on in a two year as an intern or a CA1, what advice would you give to them about doing during residency If they're thinking about doing a fellowship?

DR. REARDON:

As an associate program director, I have a lot of these conversations with the residents at our institution. The fellowship applications do have to be an extremely early I know our program and I'm sure many other programs across the country make an effort to give you exposure throughout your CA1 one year. When we're making our box schedule for the CA2 year, we encourage people to let us know what they're thinking regarding fellowship so that we can get them that early exposure to help them make a decision. So picking what kind of field you want to go into is one aspect after you sort of decide whether or not you want to do fellowship. And then a lot of conversations that I have with the residents are kind of, What do you want your life to look like in the next five years? Where do you see yourself working in the next ten years? Like, what are your goals? Someone says to me, Brittany, I really just want a great private practice job. I'm looking to be more of an administrator and I'm not really worried about having a clinical niche that might be someone. I say, Okay, well, maybe then you don't do fellowship and maybe you pursue some sort of credentials in an administrative route.

But you know, if someone tells me, I live in a big area like New York City and I want to work in an academic center and I want to be the head of a division, and that's their goal, then it's more clear that they should do fellowship training. There are some institutions where, like if you're not fellowship trained and you're a large academic center, it would be very challenging for you to get a job. And this kind of went back to what I was saying is that I sort of had the opportunity to have a job in an academic center. And so that was something that weighed into my decision. But I always tell residents that they should kind of consider all of those things.

It's very challenging to make a decision in your late twenties and early thirties that kind of projects out your career, but having career conversations with the residents and kind of pulling out of them, what they see for themselves in the future I think is the best way to help make decisions about fellowships and give them that kind of insight that you're kind of making a decision now that will impact you much later on.

DR. ANWAR:

I agree with Dr. Reardon. The only thing I would add is obviously not all residency programs offer the same kind of subspecialty experience. So if you're interested in a specific fellowship, then you want to have that down sooner than later, and then you want to seek opportunities, even if it's outside your program, if it's something your program doesn't offer, then you want to seek opportunities outside your institution. Try to go rotate with those people, do outside rotations, look for mentors who would be writing letters for you? I mean, again, any good letter, it's a blessing. But at the same time, I think it just increases your chances maybe slightly more if you have a letter from that specially trained anesthesiologist. And also you can identify mentors earlier on in that field. And some of these mentors will even continue to support you after your residency program as well. No matter where you end up for the fellowship.

DR. AUT:

Are all fellowships created equally or are some more essential than others in order to practice in certain subspecialties? Are some fellowships clinically relevant, while others more relevant for leadership or other career priorities?

DR. ANWAR:

We would never, I guess, say that none of the fellowships are essential. Obviously, they all offer a breadth of clinical experience, which sometimes, depending on the residency program, you may or may not have that experience during your training. But at the same time, there are the fellowships are all just like you said, they're not all created equal because if we talk about obstetric anesthesia or regional anesthesia, again, depending on your training, you may have had a breadth of exposure to regional anesthesia or OB anesthesia. And I don't know if it'll make sense for you just from the status of like getting more clinical experience if you want to do that fellowship. But it may make sense for you more if you are looking for a leadership position in that subspecialty or you want to be a leader in that specialty, you want to do more research. But at the same time, again, and I'm talking from personal experience, like any kind of training, like a chronic pain fellowship or for certain programs, a cardiothoracic fellowship, you may or may not have had a lot of experience during your residency training. So obviously in those cases, I think you want to pursue a fellowship if you want to primarily practice in that arena.

DR. REARDON:

I completely agree. There are definitely fellowships that are going to expand your clinical knowledge base and then there are fellowships where your clinical knowledge base will be expanded, but not to the same extent. And I think you put it beautifully, like for me, at my program that I trained at, we do so much regional anesthesia that I had my regional bloc numbers by my intern year. So for me, if I had decided to do a regional fellowship, I wouldn't have said to myself, Gee, I don't really feel comfortable doing regional anesthesia. I would have said to myself, Hmm, I think I want to be at the forefront of research. I think in the future I see myself as the director of regional anesthesia or a fellowship director. That would have been more the decision making, whereas if I decided to do cardiac, I would have said to myself, you know, I don't necessarily feel comfortable clinically right now in my stage of my career performing cardiac anesthesia without a fellowship. Right. Same for pediatrics, same for ICU, same for pain. So just because though a fellowship is not going to enhance your clinical performance doesn't mean that you shouldn't do it. It totally just depends on what your overall goals are. If you want to be a cardiac anesthesiologist, there's no way around that, right? You've got to do the fellowship. If you want to be the head of an OB division, you probably should be OB trained.

So like I was saying earlier, it's difficult because sometimes people don't necessarily project that far in the future what they want to do and what their goals are. So I think if you take anything away from this podcast, it would probably be that to start reflecting on what you want your life to look like. And you know what's kind of challenging? Because at the end of residency you may be a single person or just gotten married or you may want a family in the future or you may not, and all of these things kind of are going to go into what your day to day life is going to look like. Like I've heard a lot of people, for example, say, Oh, I would really like to do pain because then I won't be so beholden to the OR schedule. I don't know if that works out, but know but these are just things that people say. But that's something where someone has reflected on what they kind of want for themselves and for their life in the future. And so I think that that's what you need to consider when you're picking.

DR. EID:

Thank you. I would love to ask you guys about combined fellowships and what your thoughts on are about those.

DR. ANWAR:

So I can talk from a second hand experience. At our institution, being a big academic center, they have certain combined fellowships. I think one of the most popular one is ICU and cardiothoracic anesthesia. So I think it's a good idea if you really want to specialize in that area, like if you want to practice or you want to spend most of your clinical time in a surgical ICU taking care of post cardiac surgery patients, then I think the combined fellowship is an excellent idea and it does give you the breadth of experience. And at the same time, I think the other part of the thing is, other than the time commitment, obviously you have to spend extra time doing that. The other thing is people sometimes don't want to be limited to just one field and they want to go out and explore some of the other stuff as well. So I think in that sense it also works out.

DR. REARDON:

Yeah, I don't have much experience. I only know of people who do the combined cardiac and ICU fellowships. Again, most likely people who are planning to work in big academic centers like Duke, who have very high cardiac volumes and very large robust ICU. So I think that's particularly niche.

DR. HENDERSON:

And Dr. Reardon, since you have so many career conversations with residents, I was wondering which fellowships do you think are most popular right now and why?

DR. REARDON:

I don't know about other people's institutions, but for us it ebbs and flows. Like a few years ago, everybody did cardiac and then right now it seems like everybody really likes regional. I think it just totally depends. Also, we only have a random sampling of 15 people of the entire country and we're in like the Northeast in New York City. So I'm not sure it's the best sample to kind of comment on. But I do think usually in my experience, regional and cardiac are the two most popular that people like to go into. I could totally see why for both. Both will provide you great training for sure.

DR. AUT:

Would you make the same choice if you guys could go back in time and decided all over again?

DR. ANWAR:

I think so. For me, I'm just beginning my career. I'm just a few months out of fellowship, so obviously I haven't had a chance to sit back and think, okay, would I do anything differently. But definitely, I think at this point I still have a lot to learn and a lot to incorporate into my practice. And I feel like I'm in that phase where where I have to expand my practice and still trying to find my niche. And Dr. Reardon may have different answer for that.

DR. REARDON:

Honestly, I'm very happy at my institution and with the job that I have and I have no plans of leaving. The one thing I will say that I worry about is if I ever did like relocate or have to get another job, I wonder if my prospects would be more limited not being fellowship trained or if the fact that I was an experience attending would sort of like make up for that, so to speak. I do think that in academics I have had to work harder at taking on other leadership roles and finding my own clinical niche that isn't related to fellowship training. So that's also something to consider. So if you want to do a research project and you're OB trained, you're like, Great, I'll do an OB project. But like for me it's like, okay, I have to sort of think outside the box a little bit, work a little harder to figure out what I want to do. But I think if you have a vision for what you want, your, your clinical practice to look like, and if you're interested in other things, like for me, medical education, now I'm involved with the medical school, I think I have developed myself into a marketable individual without having done fellowships. So in short, I have no regrets on not doing fellowship. I took some good vacations and I'm just kidding. So I think that ultimately I would make the same decision again.

So I know that we are kind of wrapping up the show and we've answered a lot of questions that we've received from you guys. But for our residents who are with us here today, if you guys want to speak a little bit about where you are in the decision-making process and kind of what your thoughts are or if you have any additional questions for us, we'd love to hear from you guys.

DR. AUT:

I'm a CA3 and I last year was really on the fence about whether or not I was going to do a cardiac fellowship. I loved the patient population. I liked the big cases. I liked all the procedures. And I thought doing another year of training with critically ill patients with the cardiac population would only make me a better anesthesiologist. I also was a little leery about doing a whole other year of training. I ended up going to medical school as kind of a nontraditional student, and so I was already older than a lot of my classmates and already had a kid and was kind of excited just to be done with training. And so I was really on the fence about it and talked to a lot of mentors. In the end, my perfect dream job popped up in the perfect city that my husband and I wanted to settle down in, and I decided that if I had done a cardiac fellowship one, I wasn't sure that that perfect job would still be there for me. And secondly, I didn't know that I would really get to use any of those extra cardiac skills I picked up for my dream job. So I ultimately decided not to do a fellowship and just signed with a practice where we wanted to live, doing all the things that I want to do and I feel like I'm really excited for it and everything worked out perfectly.

DR. REARDON:

And I think that's a great example of sort of like knowing where you want your life trajectory to be. Things like geography and knowing you need to move or just having a vision of what your dream job is and knowing whether or not you can obtain that with or without fellowship training. Kind of like what you're speaking about is really like the best decision-making process I think you can do for fellowship.

DR AUT:

And I think it's hard when we train at these big academic centers that are really encouraging us to pursue fellowships, and you almost feel like you're letting people down by not doing one. But in the end, I knew I wasn't going to stay here forever and I needed to do what was right for me and my family, and I feel like it ended up working out perfectly.

DR. REARDON:

Yeah, I mean, I felt a lot of the same, not necessarily pressure from our from my chair or program director, but more like pressure from myself because I was so used to always trying to obtain the next thing, which, you know, I think when you're a physician, that's just sort of like what's ingrained in you. And I think taking the time to sort of like stop and evaluate what you want with your life is totally relevant and something that you should be doing and it's something you should be doing even while you're in residency regarding other things besides fellowship.

DR. EID:

I just applied to Cardiac Fellowship cardiothoracic, and I miss you too. And I think over the past year I've entertained every single fellowship out there. One minute I want to be an OB anesthesiologist, then intensivist, then a cardiac anesthesiologist. I just loved all of them. And so I was able to do these rotations twice before making my choice, and I feel that was very helpful. I think everything is super fun the first time you do it and is very captivating. And so doing it again was really helpful and like, why did I really why do I really want to become a CT anesthesiologist? And I found that I love the big cases. I also particularly fond of tea and cardiac physiology in general, so it is really early on. I feel like I was a little bit overwhelmed these past two months and trying to get your letters in and trying to present at a conference and having a wholesome CV, a comprehensive CV for this application. So I would recommend for the CA1s to be able to do their rotations once again as early on as they can if they have a particular interest. And yeah, that was my choice.

DR. ANWAR:

And I would just add to this great conversation, just like Kim and Anna said, I think pursuing a fellowship doesn't matter what speciality or subspecialty you want to train in, just have clear goals. That's the most important thing you should know. Really clear early on why or why not. You want to do a fellowship. And just like Dr. Reardon was saying, yes, there's going to be a lot of clinical or maybe some pressure from your colleagues as well, especially depending on what kind of residency program you're in. But you should not let that dictate your plans. Like I said, a lot of times there's a lot of personal life decisions we have to incorporate as well. And like Kim talked about a couple of things that her family was looking for. And then we talked about people having student loans and things like that. So you really want to weigh all the pros and cons and then make an informed decision on what you want to do. And just be very clear in that thought process, because if you go do end up going for a fellowship, yes, people come back and sometimes they don't necessarily practice in that subspecialty, but at the same time, I think that's a big time commitment or it's only one year. But then. You want to be satisfied and you want to have a satisfactory career. And that is something you're going to be doing for the rest of your life. So just think about it early on and as much as you can before you make that decision.

DR. HENDERSON:

So I am going to be a generalist. TBD where. TBD doing what. But I, similar to Anna, was privileged enough here at Vanderbilt to get to see all the subspecialties once, sometimes twice before last summer. So I was able to kind of evaluate how I felt on each rotation. And similar to Anna, I liked a lot of things the first time, but found some of them draining the second time around. And so I honestly just did an evaluation with myself and recognized which rotations was I most energized by the end of the day and which ones was I truly exhausted. And that kind of helped guide what I was naturally enjoying and wanted to do again and again and again and could see myself doing for decades and still enjoying it. And that was a little bit of OB, a little bit of regional, a little bit of trauma. And after talking to my mentors, it just seemed that a generalist job would fit that role. So now I'm in the phase of networking all over the country, but mostly where I have family back home in Texas and just trying to find that perfect job, just like Kim found. So we'll see where I go.

DR. REARDON:

The job market for anesthesia is so good right now. You know, our residents who are moving directly into who are generalists and are moving directly into various academic places and private practices are getting amazing offers and having a very easy time of finding a very competitive salary and competitive benefits. Definitely, if you are on the fence about fellowship, you may as well take advantage of this time period where things are kind of as promising as they are right now.

DR. EID:

Now that we're concluding our podcast for today, I'd like to thank my co residents, Dr. Henderson and Dr. Aut. I'd also love to thank Dr. Anwar and Dr. Reardon for joining us today and all your insight and advice. We've learned a lot and we hope our listeners did too. Speaking of our listeners, thank you for joining us for another episode of Residence in a Room, the podcast, by residents. Please give the show a follow or a share with a friend and join us again next month. Thank you again for your time.

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