Postponing the Fellowship to Pursue a Practice or Research Opportunity
October 2002
By Bonnie Darves
Editor’s Note: “Traditionally, it may only be a few days or even hours between leaving residency and starting a fellowship. Reasons to extend the transition time include resolving massive debt load, achieving work-family balance, coping with career and location indecision, and gaining some ‘real world’ practice experience. Obtaining an advanced degree, engaging in volunteer work, or simply taking leisure time that was unobtainable during training may reinvigorate the prospective fellow. Time off also allows for the pursuit of activities in organized medicine and political advocacy for the profession.”
— John A. Fromson, M.D., Chairman of the Department of Psychiatry at MetroWest Medical Center
For a variety of reasons — ranging from practical considerations to career indecision or competitive factors — many residents are pursuing short-term practice options or research before starting their fellowship.
It used to be almost a given that residents who were planning to pursue a fellowship would get on the fast track and stay there. They would go straight from medical school into residency, and then, within days or weeks of completing their residency, pack up and head to the location where they would continue their specialty training.
That is changing. Today, a growing number of residents are taking a “breather” of sorts before starting their fellowships. It’s not uncommon to see young physicians fresh out of residency signing on for international medical relief opportunities, working as locum tenens or hospitalists, or taking a year to do research in an area of interest.
The trend is so new that no hard data is available on the number of residents taking the training hiatus. Todd Dickinson, assistant director of public policy for the Association of Program Directors in Internal Medicine, says that his organization “hasn’t tracked the trend” or collected data to determine the extent to which it’s occurring. But residency program directors and chief residents say that, anecdotally at least, the movement is apparent.
“I haven’t done any formal research, and I don’t have objective numbers that show this, but from an observational perspective, that certainly appears to be the case in our program,” says Kelly Kieffer, M.D., director of the internal medicine primary care residency at Dartmouth-Hitchcock Medical Center in Lebanon, N.H. “Taking time off before fellowship seems to be a more common phenomenon now.”
Ari Berman, M.D., an internist and chief resident at Boston Medical Center in Massachusetts, concurs with Dr. Kieffer. “It’s a huge trend at BMC. I would say that the majority of residents here are now taking time off [from training] before they start their fellowships. I’ve heard a lot of stories about people traveling for a few months and then moonlighting for six months. Others are doing international work or becoming hospitalists in community hospitals four days a week.” Also figuring in the equation is the demand created by the relatively new residents’ work hour rules, which went into effect last July. Now that a resident’s work week cannot exceed 80 hours, hospitals are scrambling to find adequate coverage, and are turning to hospitalists, physician assistants, and nurse practitioners to ease attending physicians’ workload.
For Frantz Hastrup, M.D., the year between completion of his residency at Boston Medical Center and the start of his fellowship has been both productive and personally gratifying. The internist, who plans to become an academic pulmonary attending and will start his fellowship at the Combined Harvard Pulmonary Fellowship program in July, has spent the year in three pursuits: working as a hospitalist at Quincy Medical Center in Massachusetts and covering for physicians on vacation, traveling the world, and catching up on sorely needed leisure time.
“It’s been a great year. I have had a lot of time for myself and made a little income, so the residency hardships seem a little more remote,” Dr. Hastrup says. “I think it’s a very good thing — working at my own pace and having a bit of leisure time. And it has been a lot easier to find jobs than I expected it would be.” Between the hospitalist jobs, which Dr. Hastrup describes as “educational and satisfying work,” he managed to fit in three long-envisioned trips to Asia, Europe, and the Caribbean.
Now ready to embrace the challenges of his fellowship, Dr. Hastrup has no regrets about his “breather” year, and recommends the strategy to other young physicians who are feeling particularly spent after residency. “It seems a lot of my friends from residency are doing the same thing, and they’re really enjoying it,” he says.
The trend toward pursuing a short-term job in the hospitalist field is becoming more prevalent, Dr. Kieffer notes, because the demand for inpatient physicians has increased dramatically in recent years. She says that such positions are readily available in both academic sites and community hospitals, and that the work can be both a “potential bridge” between residency and fellowship and a way to gain valuable practice experience. Another popular option is spending a year in an acute care practice setting as a “stand-in” physician, covering for doctors whose schedules are overloaded or who need relief for other reasons.
Family considerations are also a factor in some physicians’ decision to put off a fellowship. Today, many residents already have a family or are starting one, and some choose to take a break in active training to adjust to those responsibilities. In two-physician families, the “split shift” is becoming more common: one spouse starts fellowship training while the other works, and the second spouse begins the fellowship a few years later.
If residents are stepping back from the beeline or taking more time to chart their career course, the obvious question becomes: Why? The reasons are varied, ranging from philosophical considerations, such as indecision about an ultimate career choice, to pragmatic concerns, such as adding a buffer to the bank account before the reality of educational debt hits home. With the average medical school debt load now exceeding six figures, the prospect of working for a few years to pay down some of that debt can be appealing, notes Dr. Kieffer. And for residents who plan to start a family, the salary increase provided by an active practice position, even if it’s short term, may become an imperative.
Although debt load may figure in the postponement, more often the issue is indecision or concern about choosing the best path, say some program directors. “I think a lot of it is that some residents are still figuring out what they want to do — they’re struggling with that a bit,” says Merle Sande, M.D., director of the internal medicine residency program at the University of Utah School of Medicine. “People want to be a little clearer about where they want to go [with their careers] before starting a fellowship.” Dr. Sande notes that he is even seeing the trend among some medical students, who are stepping off the fast track during medical school to do volunteer work in Africa or other countries where the need is pressing.
The trend toward taking time off before a fellowship is less pronounced in specialties such as surgery, but some residents are punctuating those years with special research projects or other pursuits. John Potts, M.D., program director in surgery at the University of Texas at Houston Medical School, says that many of his residents take time out during their residency to do a year or two of research. “Sometimes it’s to help bolster their fellowship applications. Other times they’re doing that out of true scientific interest,” says Dr. Potts, president of the Association of Program Directors in Surgery. “Some of the residents have not been exposed to science before and they want to try it — to learn some basics and see if they would enjoy it as a career.” He adds that the number and types of surgery fellowships available to general surgery residents — about 70 percent of those residents do complete a fellowship — has increased substantially in the past two decades, which may contribute to physicians’ taking longer to decide on a career path.
Some of the newer programs — in such areas as transplantation, surgical oncology, and peripheral vascular surgery, for example — are proving popular with young physicians.
Burnout, personal considerations may be factors
Dr. Berman thinks that in many cases, the purposeful delay has to do with a combination of factors. For one, fellowship applications are due in the beginning of a resident’s junior year, when many feel they’ve just gotten started and haven’t had enough exposure to subspecialty areas to make an informed decision about a fellowship. Others, he says, “are just too tired” to tackle the fellowship application process at that stage in their training. “Some residents find they’re just busted through — from going to college, medical school and residency — and they feel it’s important to take a step back and reevaluate what they want to do with their careers,” Dr. Berman says. The current malpractice crisis may also figure in the postponement. Some residents may rethink their original career choice to avoid a specialty in which premiums are skyrocketing, or revise long-term plans by opting for a geographic region that hasn’t been as hard hit by rising premiums.
Dr. Kieffer agrees with Dr. Berman’s assessment of the application-deadline dilemma. She thinks many residents are reluctant to “jump into the fellowship process” until they’re more certain about what they want to do. “Making a decision [about a fellowship] when you’re not far past your internship is a challenge for a lot of people. They want to make sure they have chosen a specialty that is going to make them happy,” she says.
On the marketplace front, there is the issue of stiff competition in certain fellowship programs. Many residents who are competing — or will eventually compete — for scarce spots or highly competitive programs are choosing to boost their resumes by either doing research after residency or gaining practice experience. In cardiology and gastroenterology in particular, Dr. Berman notes, competition has gotten so stiff that some physicians choose to do research, obtain a master’s degree in public health, or join in a research project. “Many residents see this as a way to boost their resumes,” he says.
Residents who are concerned that a hiatus from active training might make it appear that they aren’t committed to their careers need not worry. As the practice of postponing the start of a fellowship becomes more prevalent, many employing organizations are deciding that it’s actually a wise move, because physicians who take longer to decide on a career are likely to be happier with their ultimate choice. In addition, many hospitals and practices are willing to be flexible with physicians who want to work for a few years before starting a fellowship, so long as physicians make their intentions clear at the outset.
“I think it’s actually a good thing, and we are willing to hire a physician for only two years when we know the physician plans to do a fellowship” says David Nyman, the physician recruitment coordinator at St. Vincent Hospital in Green Bay, Wis., who also manages recruiting for an affiliated 160-physician multispecialty clinic. “That way, we can both ‘try out’ each other, so to speak — and we’ll bank on the fact that the physician will want to come back after the fellowship.” In some cases, especially with high-demand specialties, hospitals or practices may even be willing to subsidize physicians during the training period, if they agree to return after they complete the fellowship. “That is becoming more common now. If hospitals know they’ll need people in a certain specialty a few years down the road, and the physician has worked out well, they do what they can to try to keep them,” he says.
Regardless of the reason residents are choosing to delay the start of their fellowships, two things are clear: The decision isn’t affecting physicians’ future career prospects adversely, and fellowship slots aren’t going unfilled. Finally, the delay may be a good move if it ensures that young physicians are able to make better-informed decisions about both the type of medicine they wish to practice and the setting in which they prefer to work.
NOTE: The author, Bonnie Darves, is an independent health care writer based in Lake Oswego, Oregon.
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