Residents in a Room

Episode Number: 71

Episode Title: Ask the Fellowship Directors

Recorded: January 2024

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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 anesthesia residents.

I think the one thing that's important when you're looking for a fellowship is to really find the people that you really want to spend time with.

The trend that I see currently is a lot of private practice groups, and obviously academic groups are becoming more subspecialized.

Your career in medicine doesn't have to have a rigid trajectory. It is okay to be flexible. It is okay to adapt, and it's okay to change your mind at some point during your journey.

DR. JONATHON BURNS:

Welcome to Residents in a Room, the podcast for residents by residents and today hosted a terrific group of fellowship directors. I'm Dr. Jonathan Burns, a CA3 at Kettering Health Dayton in Dayton, Ohio. After residency, I'll be going to the University of Kentucky for a cardiothoracic fellowship. I'm joined by three fellowship directors who are here to give us a peek behind the curtains and share their knowledge. To get us started, let's meet our guests.

DR. STEPHANIE WOODWARD:

Hi, I'm Stephanie Woodward. I'm the OB anesthesia fellowship director at Vanderbilt University School of Medicine.

DR. ROYA SAFFARY:

Hi, my name is Roya Safari. I'm a clinical associate professor at Stanford, and I'm also the associate program director of the new Healthcare Administration Leadership and Management Fellowship.

DR. MARIAM SARWARY:

My name is Mariam Sarwary. I am the associate program director for the Regional Anesthesia and Acute Pain Medicine Fellowship at Stanford.

DR. BURNS:

I have so many questions for you, but let's start with the obvious question: to fellowship or not to fellowship. There are many pros and cons to consider, but in your experience, what considerations are most essential?

DR. WOODWARD:

I think that you want to think about what your future practice is going to look like, and think about what's important when you're considering what that future practice is going to look like. Is it really important for you to live in a particular geographical area? Is working in academics really important to you where you're working with learners like residents and medical students, or is working in like a high volume center going to be really important? When you're thinking about a fellowship, I think that you need to think about, well, if I am going to live in a small rural area, am I like, what kind of fellowship would I want to do that's really going to bring a benefit to that patient population? And then if you're going to live in a large city, is a fellowship going to make you be a more competitive applicant so you can potentially get a better job.

DR. BURNS:

And what's your input, doctor Saffary?

DR. ROYA SAFFARY:

Yeah, I agree with everything that Dr. Woodward said. I would add to follow your passion. What is it that's really exciting to you and something that you really want to pursue and go after that?

DR. WOODWARD:

I think that one thing that's important when you're looking for a fellowship is to really find the people that you really want to spend time with. A lot of the subspecialties end up being extremely collaborative, and you do a ton of time practicing your, like, interdisciplinary communication skills. And so finding the group of people that you really do want to spend a genuine amount of time with and develop those relationships with. I love my OBs. And then I also, at Vanderbilt, have a wonderful team of crnas and residents, and we even have SRNAs on our service, and we all work together to provide really good health care for incredibly sick patients. And that is where I thrive. And I love the people that I work with. And I think your goal should be to truly find somewhere where you are just going to enjoy not just the topic, but also the people that you work with.

DR. BURNS:

And follow up question how necessary is a fellowship, and are there any subspecialties where it's more or less important to have a fellowship?

DR. SARWARY:

That is a wonderful question. I think the necessity of a fellowship really comes down to the individual themselves and the future practice they see themselves having. Me personally, I chose regional because I wanted the opportunity to practice outside of the operating room. As much as I love being in the OR, regional gave me the opportunity to come and do procedures outside and work with patients in that manner. So if that's something you find yourself wanting to do, if you find that the pediatric population is very attractive to you, if you like going on bypass or anything with this within an individual subspecialty that calls to you, then it might be for you. Whether or not you need to do a fellowship, I would say it has been has been changing. Um, back when I applied to regional, um, it wasn't as necessary. A lot of private practice groups were still practicing regional without being regional trained. However, the trend that I see currently, and some of the other guests here can speak to, is a lot of, um, private practice groups and obviously academic groups are becoming more subspecialized. So for example, here at Stanford, only OB be trained anesthesiologist can be on LND. And same with regional. Only our regional trained attendings um provide uh, regional services here at Stanford. So I do see a trend of kind of anesthesia becoming more and more subspecialized.

DR. BURNS:

Have you had any experience with residents who came to regret their choice, and if so, why? Is there something we can learn from others, something we should know to look out for?

DR. SARWARI:

To be honest, it's very, very rare to run into a resident who has regretted it. However I do remember as a resident some fellows had trouble finding the specific jobs they wanted. For example, if they were pediatric trained, they had trouble finding, uh, positions that were for, you know, peds only. And same with, uh, some of our chronic pain fellows had trouble finding chronic pain only positions in the vicinity. So that's the only thing that comes to mind. And I think eventually all of those fellows got settled. But initially coming out some of the certain subspecialties depending on the market at the time, might have a little bit more trouble finding a job. That's the only thing that I can think of.

DR. WOODWARD:

The other thing that I feel like I've seen is that someone does a fellowship, or on the flip side, doesn't do a fellowship, and then the goal, their life goals ultimately change throughout their career, and they end up changing course and deciding either to go back and do a fellowship or to stop practicing the subspecialty that they spent a year or two gathering just based on, like circumstantial things. But, um, I also have not encountered a particular resident that, like, really regretted doing a fellowship. I feel like people are overall very glad about the knowledge and the education that they received. And ultimately it's going to make you a stronger, smarter, better physician, even if you're not necessarily practicing that specialty for the rest of your life.

DR. SAFFARY:

I personally also have not encountered a resident or fellow who has regretted their choice. However, I can see that happening. While fellowship is really a valuable path for many, it's not always the right choice for everyone. So some people may feel almost pressured to do a fellowship to be more marketable. And I think that's when, um, deep self-reflection and talking to others about their experiences is really important before committing. That way, you can ensure that this is really aligning with your goals, with your interests, and also with your lifestyle. Um, and the other thing is to remember that it's okay to change your mind. I know nobody wants to stop doing something or, um, going back on their commitment, but your career in medicine is not going to have a very rigid or doesn't have to have a rigid trajectory. It is okay to be flexible. It is okay to adapt, and it's okay to change your mind at some point during your journey.

DR. BURNS:

So let's say you're a resident who is undecided about whether to do a fellowship or not. What advice would you give them? Are there any specific resources you would suggest or any tips you can pass on to our listeners?

DR. SARWARY:

I think the advice I would give is the advice they give to, um, med students who are choosing a subspecialty where I recommend speaking to individuals who are in the subspecialty, and really asking what the bread and butter for that subspecialty is. Um, so obviously rotating with them to get a sense for yourself, what is the day in day to day really look like? Because sometimes we have a, um, impression or a vague idea of what it may be like to be a regionalist, for example, when in reality majority of my time might be spent, um, doing something else. For example, I came, you know, to fellowship and, um, a lot of the fellowship, I expected to learn a lot about regional procedures. Um, but a lot of it was also leadership based and gaining skill set and learning how to develop an acute pain service, for example. And so thankfully that was something I was also interested in. But if that's not, then, um, being a little bit more, um, thorough with the programs you apply to and with those who have completed the fellowships there to get a sense of what the day to day and the overall, um, goals are of that fellowship.

DR. SAFFARY:

I think also taking time to reflect on your career goals and your lifestyle preferences and overall, your long term aspirations is really important. Like Dr. Sarwary said, you should talk to mentors. You should talk to, um, current fellows, current attendings, and sort of gain insight about what that fellowship is really about and if that aligns with your personal and professional goals. You should also take into consideration the financial impact, the time commitment, and whether the additional year or years of training really align with what your ultimate career and life goals are. Um, and again, it's okay to take time to make that decision. Um, it's ultimately your career, your life, and you should make the decision that's best for you.

DR. BURNS:

Do you have anything to add, Dr. Woodward?

DR. WOODWARD:

I think that that's everyone's had a really good point. And I think that what you want to think about when you're thinking about if you're going to do a fellowship or not going to do a fellowship, you need to remember that all of the subspecialties within anesthesia are going to be pretty distinctly different from each other, but in a lot of the subspecialties, there's going to be the opportunity to be a generalist. So for example, I'm an OB anesthesiologist. I spend 50% of my time on labor and delivery, and then I spend about 25% of my time doing inpatient, um, anesthesia and 25% of my time doing ambulatory anesthesia, where I still get to do all kinds of interscalene blocks, or I get to do spinals for hips and knees. And so there is a lot of flexibility within our field to be able to do a broad spectrum of lots of things.

When you're thinking about like, okay, well, do I want to do an OB fellowship? Do I want to do a regional fellowship? Do I want to do a peds fellowship? There's a couple different ways in which you can kind of break it down. So number one, do I want to be in private practice when I finish or do I want to be in academics? I think thinking about the differences between those things can help guide you to help make a better decision. And just because you're going into private practice, like Dr. Sarwary, was saying, you can be more marketable if you have a fellowship. You also potentially have this additional skill set which will allow you to be a leader within your private practice. So we've had a couple of fellows go through my program in the past couple of years who have gone on to be the OB anesthesia section chief within their private practice, giving them the opportunity to really create change and safe environments for patients to be able to have labor analgesia and anesthesia, which I think is like really cool. And it's a way in which you can translate your fellowship into a private practice.

You should also think about whether or not you really enjoy clinic, and if a clinic setting is good for you, and then you really want to look at the lifestyle of the attendings around you. And ideally, if you know any of the attendings at other institutions within that subspecialty. So for many of the OB anesthesiologists, I know we do a lot of shift work. There's pros and cons to shift work. Right. But you know what time you're going to get off mostly every day. Today, my sign out was at 5 p.m., and I was home or leaving for home at 515 once my sign out was complete, which was, for me, a really nice to have that kind of predictability within my life. But that's definitely not going to be the right choice for everybody. Um, so thinking about all the different aspects of like, do you want to do overnight call, do you want to have to do weekend and holiday call? And like, what is the frequency of those calls and talking to different attendings like you talk to a cardiac attending in private practice in Louisville and one in New York, and see if their lifestyles, even though they're going to be a little bit different, kind of match with what your future goals are going to be.

DR. BURNS:

So going off of that, once.

So going off of that, once one knows a fellowship is in their future, what's next? Are there any specific resources that are available to provide help with researching and narrowing down the options on which fellowships to go for, or to apply to?

DR. WOODWARD:

If that fellowship that you're excited about applying for is available at your institution, I think the first resource you can utilize is going to be the fellowship program director for that particular fellowship. They often know exactly which website is going to have the list of programs, and how many fellowship slots might be available. And then from there you can also, I know that, for instance, SOAP has a list of all of the fellowships on their kind of like community page called Trade Wing, um, where you can figure out like which programs have fellowships and how many spots there are. And I'm sure that other fellowships have a really similar program for being able to help people decide, like, well, where should I apply? Then you want to start to kind of think about like, is there a particular, um, location that's going to be really important for me to live in or cities that I really do or do not want to live in? And then you can start to narrow your list from there. You also want to make sure that the program just feels like the right fit. So sometimes I encourage residents to apply to a couple different programs and then during the course of their interviews, be able to see like where they feel like they're going to get both the best education and overall have the best experience.

DR. BURNS:

What do you have to add, Dr. Sarwary?

DR. SARWARY:

Going off of what Dr. Woodward said, I think a lot of the subspecialty annual meetings will have open houses for the fellowship programs, which is a wonderful opportunity for you to meet all the leadership in the different programs and learn more about each. And then I know Stanford, as well as some other programs, also have virtual open houses, um, prior to the application season. So it's an opportunity for you to log on through zoom and ask us questions and get to learn more about our programs. So those are two opportunities for residents to better get a sense of each program.

DR. BURNS:

So now that you decide on what fellowship you want to go into, how many fellowships should one apply to? Is it dependent on which subspecialty a resident is going into?

DR. SAFFARY:

I think that really depends on the subspecialty you're applying to. It also depends on the competitiveness of the programs you're considering, and it really depends on where you see yourself. Is there a specific area that you're focusing in on? Are there specific programs or types of programs that you're interested in and how competitive you are as an applicant? Based on that, I think the best way forward is to sit down with your program director and discuss how many programs would be the ideal number to apply to.

DR. SARWARY:

I think it is a very personal decision for each resident. It goes for how badly you want to pursue that fellowship, and I just want to give a plug for sometimes it's okay to let the cards kind of fall as they may. And what I mean by that is this is my own personal experience. I loved regional, um, you know, there's a financial hit you take going into fellowship. And so for me, it came down to I knew the locations I wanted to end up with. I knew that I wanted to practice regional long term, but I wasn't willing to go just anywhere for it. So if I happen to get in where I wanted, great, I would pursue it. But if I didn't, then I was totally fine being a generalist. And so that's that's an option that may work for most. You don't have to kind of be all or nothing. You can kind of see, um, how things pan out. And so that might impact how many, um, places you apply to. I know it's an additional year of training. Some people are okay with being moved for that one year to a different location, being away from family and friends, etc. and for other people it may not be worth it. Um, as much as they love the subspecialty. So just again, personal decision. If you are gung ho on going to a subspecialty, then of course apply um, broadly, especially now that most of them, at least regional, recently joined the SF match. And so it's a match now as opposed to open applications. And so the more you apply to the better chance of matching.

DR. BURNS:

Can you talk about the what the application process is like and specifically give us some insight into what it looks like from your end? What are you looking for? Is there anything specific or any specific things that make you more or even less interested in a candidate?

DR. WOODWARD:

The application process is going to vary depending on the fellowship that you're going into. So people who are applying to cardiac fellowship are going to be a little bit different than the people who are applying to OB and regional and PEDs, and people are going to kind of match at different times depending on what subspecialty you're going into. You'll really want to talk to your program director and just do a little bit of research on the website. Most of the subspecialty websites will have something on the fellowship that specifically says like, oh, we participate in, for example, the SF match system, and then you'll be able to be able to figure out when your applications are going to be open and when the ranked list is due and the match day is.

DR. SAFFARY:

So I can talk specifically about the application process for the HOME fellowship, the Health Administration and Leadership and Management fellowship. Um, this is going to be the first year that we are recruiting for that fellowship, and next year's fellow will be the first one here at Stanford. Um, it's a little bit different from the purely clinical fellowships. Um, so what we are looking for are candidates that do demonstrate strong clinical competence, but also leadership potential and a really genuine interest in health care administration and policy. We want a solid foundation in medicine, but also an interest in improving systems of care. And candidates who are passionate about leadership roles, whether that's been through previous administrative experience, committee involvement or just initiatives to improve patient care or the health care environment. Um, our application process is outside of the match. So we require a personal statement that makes it clear why you are interested in, um, a health care leadership program. And it should include sort of your vision for your career in this space and how this fellowship will help you in your career and also aligns with your goals. And finally, being able to demonstrate that you are able to work within an interdisciplinary team, you have a forward-thinking approach to healthcare challenges and are really committed to making a broader impact on healthcare is what we're really looking for.

DR. SARWARY:

My input on the application process is that if you're even, um, subtly, if you will, considering, um, applying for a fellowship, uh, prep your application. Because it's very easy to withdraw your application or not rank, for example, once you interview with people and kind of drop out of the match. But it's kind of harder the other way if you haven't prepped your application and then last minute decide. So if you even have an inkling, I think the limiting factor is usually the letters of rec. So get those requests out early. If you've already rotated on the subspecialty, um, have them ready and available. And should you change your mind, it's not the end of the world, but at least you're ready. So that's my recommendation that even if you're, um, remotely thinking about it, just prep the application. Most of the stuff is in your hands. Personal statement, short answer questions, etc. so you can probably turn those out faster. But usually the limiting step is the letters of rec. So make sure to give your letter writers adequate time to prepare those for you.

DR. BURNS:

Thank you all for sharing about that. I know the application process can be a little bit nerve wracking for applicants. Are there any myths or misperceptions about fellowships that you'd like to dispel? What do residents get wrong about fellowships?

DR. WOODWARD:

I think one of the most common things that I hear is, well, you don't need a fellowship in order to practice OB anesthesia. And while that can be true in some circumstances, it's not going to be true in all circumstances. So depending upon the market in which you ultimately want to get a job, there may or may not be a job available where you would be able to take care of obstetric patients within the the market that you're working in. So if you're going to a market where there tend to be a lot of academic medical centers that, like Dr. Sarwary was saying that like at Stanford, you can only do OB anesthesia if you are an OB anesthesiologist. That would not be, you couldn't move then to that area and expect to be able to work on labor and delivery if you did not have that fellowship training available. I also think that if you are aiming for a job in which you want to be a leader in the field, either in the subspecialty field as a whole or within your private practice, that the fellowship can really add value to the patient care that you provide. And overall, it's an extra year of training and learning from a variety of different people who have a lot of information to share and teach you and to teach you to be a better teacher for both your patients and any learners underneath you.

DR. SAFFARY:

I think one of the myths is also that you should only be doing a fellowship if you want to stay in academics. As Dr. Woodward said, doing a fellowship, even if you go into private practice, can really enhance your application and your overall career. You can be the standout leader in that field within your group. So I do think it's if you're interested in the field, it's important to apply for a fellowship, whether you go into academics or choose to do private practice. The second point I want to make is the financial impact. I think we all brought up that fellowships do come with a financial impact, but I would urge applicants to look at it as an investment in yourself, and there will be a return on investment further down the road. So even though it's difficult to go through that period while you're in it, just rest assured that it will pay off in the long run.

DR. SARWARY:

One of the ways I like to talk to residents about it, um, is some of the best advice I got as a resident applying to fellowship. My attending told me, you know, Mariam, don't forget that the income loss in your fellowship year will likely. Especially since I was going into regional, not be made up for the rest of your career. Because a lot of the subspecialties—and I guess I can only speak for myself—but a lot of the subspecialties, you don't necessarily, at least in the academic system, make any more than your generalist colleagues. Um, I think the only exceptions may be cardiac and chronic pain. However, for the majority of their subspecialties, uh, especially in the academic setting, we pretty much make all the same amount. But what it comes down to is, for me, that loss of income was worth it because it changed what my day to day as a physician looked like for the rest of my career. And so for me to take that financial hit, it was totally worth it. At the end of the day, I would do it, um, over again because I love the variety. Like Dr. Woodward said, I'm I get to, um, not only be in the main operating rooms, I'm in the ambulatory centers performing anesthesia, doing regional. I'm on acute pain service, and so that variability of my day to day was totally worth it. So just another thing to keep in mind when deciding whether or not to pursue fellowship.

DR. WOODWARD:

And it gives you the opportunity to be able to get into leadership positions both earlier in your career and leadership positions that otherwise just wouldn't be available. So you really get to be someone at your institution who is not only an expert in your field, but also can become a leader in the field.

DR. BURNS:

I have one last question for you all. I'm wondering if there's a specific piece of advice you find yourself giving to the fellows in your programs, most often, anything that comes up again and again.

DR. WOODWARD:

I think for fellows specifically who are looking for their very first job, and this goes for residents looking for their very first job, it's important to remember that your first job is only going to be for a year. And so it doesn't have to be a perfect decision. You want it to be a great fit, but sometimes it's not going to be. And that's okay. It's not nearly as big of a commitment. And so you really want to find a place that's going to help you grow as a doctor and professionally in whatever capacity you've chosen to follow. And that's going to be the most important thing for you.

DR. BURNS:

What advice do you have, Dr. Saffary?

DR. SAFFARY:

I completely agree with that. I would encourage residents and fellows to prioritize finding a program that really aligns with their values, and where they feel a strong sense of belonging. It's really about finding the right fit, and that needs to be both professionally and personally.

DR. SARWARY:

One of the pieces of advice that I give my fellows very early on, when they join us, is to really use the fellowship to tease out whether they want to go into private practice or academics, because I find, um, at least for myself, that was one of the main reasons I pursued a fellowship was to get my foot in the door at an academic institution and try to get a sense, if that's what I wanted my future to look like. So I let them, um, know very early on that the timeline for applying for jobs kind of sneaks up on you, so you don't have as much time as you want. And I encourage them to run the job searching process in parallel to their fellowship. It's very easy to start a fellowship and get lost in the world of clinic and the clinical aspects and the research aspects and the leadership roles, and almost forget about what's going to happen after your year of fellowship. So that's one of my biggest pieces of advice to them is get a sense if academics is for you. Line up some interviews at private practices, um, just in case. And that's what I did as well. I had an inkling that I wanted to stay academic, but I still interviewed with private practices to get a sense of what, um, their day to day looked like. And, um, you know, my goal is to have most of my fellow situated for where they're going afterwards. It decreases the stress at the end of the year, um, leads to a lot of excitement and then gives them enough time to be situated prior to graduation. So that's one of my main things, is just keeping an eye on at the end of the at the end of the year, it kind of creeps up on you.

DR. BURNS:

Well, this has been a really interesting discussion. I've learned a lot and I'm sure our listeners have too. Thanks for joining us, and thanks for our listeners for tuning in. Please join us again for more resonance in the Room, the podcast for residents by residents.

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The ASA Resident Distinction Award is a great way to recognize residents for outstanding work. Consider encouraging your exceptional residents to apply. If you are a resident, take the leap and apply for yourself at asahq.org/RDA.

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