Do I Really Need This Fellowship?

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Dear Boss,
I am just starting my final year of residency and while I know I want to practice community emergency medicine, I am thinking that I should do an ultrasound fellowship to help me get the best community job out there. Do I need a fellowship?
Fellow Wanderer

Directors Corner by Michael Silverman, MD 

Dear Boss,
I am just starting my final year of residency and while I know I want to practice community emergency medicine, I am thinking that I should do an ultrasound fellowship to help me get the best community job out there. Do I need a fellowship?
Fellow Wanderer

Dear Wanderer,
Whether it’s a fellowship in ultrasound, administration or toxicology, there are a myriad ways to boost your experience and credentials after a residency. But just because you can doesn’t mean you should. Here are a few factors to consider.

Consider Your Motivation
First and foremost, a fellowship needs to be about the desire for further education and training and your commitment to a sub-specialty. If your motivation is simply to make yourself a better job candidate, you’re going down a path that will lead to frustration and dissatisfaction. Having said that, if the fellowship helps you find the “right job,” then it may be the right thing to do.  If you want to develop an ultrasound program, establish yourself in the field of ultrasound or pursue a career in academics, this may be the right niche to accomplish those goals.

Consider the Environment
In an academic setting, being fellowship trained may make it easier, both by underlying skill set and credentials, to develop the research niche that you need to secure grants and move your career forward. This can be particularly true in areas such as toxicology, EMS, and international health, all of which really rely on the academic model to sustain a career and allow time for research and contribution to the specialty. Ultrasound, for example, is still relatively new to the community practice—after all, there are lots of old timers like myself (those out of residency more than 10 years), who had little to no ultrasound training during residency. We are still trying to catch up with technology, which means that almost any young attending with ultrasound experience will be able to make an immediate contribution to their group and quite possibly find themselves as the director of ultrasound in the group right out of residency.

Consider the 5-Year Plan
Ask yourself where you want to be in five years. If the answer is to be a clinician with exceptional ultrasound skills or to be using ultrasound in cutting edge clinical scenarios, a fellowship may help you reach your goal. On the other hand, dedicated time during your final year of residency and continued CME after residency may also get you there. If your goal is to be your group’s ultrasound director, you may be able to achieve that by taking an interest in your group’s ultrasound program by teaching and reviewing the studies done by your colleagues without a fellowship as well.

Consider the Sub-Specialty

Ten years ago, an EM graduate could get involved in administrative issues shortly after residency because there was a lack of interested, qualified candidates, and because administrative issues lend themselves well to on-the-job training. As the specialty has evolved, getting an administrative position through on-the-job training isn’t as easy as it was then and an administrative career can definitely be advanced by completion of an administrative fellowship. The interest and skill set for a leadership position in ultrasound today is similar to where the potential for administrative positions was 10 years ago. That means, working to further your skill set as an attending will separate you from your colleagues. Additionally, working with your chairman to advance your groups ultrasound program (training, review, indications, and performance) will further advance your standing in the group. I know several fellowship directors who, like me, have supervised a fellowship without completing one. While fellowship may be necessary in some sub-specialties of emergency medicine, I don’t think ultrasound is one of those—yet.

Employers Consider the Whole Candidate
When it comes to being an attractive job candidate, there are many ways to define “best job” for a newly minted attending. However, I’m not sure that any community chairman will have “fellowship training” on a pre-req list when they look at candidates. Most of the chairmen I know who hire for the “best jobs in town” still look to recruit on personality, ability to work with colleagues, nursing staff and patients, and quality of care. Sure, a fellowship might make you more attractive on paper, but it wouldn’t compensate for a failure to fulfill the basic needs of the department or if you have a history of causing problems with the nursing staff.

Consider the Cost
Ask yourself what specific skill set will you develop in a fellowship that can’t be developed elsewhere. You need to weigh that value against the financial impact of a fellowship. How will the dollars and cents impact your family and financial needs? How much will you make in your first year? $250,000?  If so, this may be a $250,000 mistake. How much interest will accrue on your educational and personal debt? Do you want to wait another year to buy your family a house or a new car? You need to take some time to analyze the long-term impact of the additional time spent. The overall benefits must equal or outweigh the negatives.

Mike Silverman, MD is the chairman of emergency medicine at Harbor Hospital in Baltimore and is on the faculty at the TeamHealth Leadership Academy.

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