Monday, April 1, 2013

MiM Mail: Delay fellowship?

Hello! Longtime reader here! I am a third year Medicine resident at a notoriously grueling program in the southwest (which I love and would choose a thousand times over if I had to do my Match again...) on the brink of finishing my residency. I am heading into a Chief Resident year which should be a nice break - at my program we are junior faculty, paid as such but only attend for two months and have 10 months of administrative and educational work. I am mom to one lovely 9 week old baby girl. My husband is not in medicine and is currently a stay-at-home dad. I'm struggling in my decision of when and whether to pursue fellowship, and here's why...

As an intern I fell in love with critical care. I loved the fast pace, the gratification of seeing a septic shock patient turn around in hours, loved working with a big team of folks to bring someone back to health. I even liked the end of life issues and family discussions. I liked the idea that even when I had nothing in the way of medical treatments to offer I could still help the patient (and more often, the intubated/sedated patient's family) come to terms with the end of life. I did a block of Pulmonary Consult at our large tertiary referral center and found the physiology and multisystem diseases that involve the lungs very interesting as well.

I'm not sure what happened this year - if I just got tired and burned out (we have 4 ICU blocks a year, still have 30h resident call q4, minimal outpatient stuff) - but I grew tired of the same old thing in the ICU. I got annoyed when families wanted their 85 year old grandfather with two primary cancers and septic shock to be a full code. I got tired of the overdoses and alcoholics in DTs we see at our county hospital coming in night after night, their self destructive behavior the reason for thousands of our taxpayer dollars being spent to dry them out, extubate them, and discharge them to homeless shelters or broken homes to continue their substance abuse. Even some of the pulmonary sub-specialty patients started to annoy me; most of them are in and out of the hospital frequently and have been sick all their lives with congenital heart and/or lung disease and have the "sick person" mentality.

After slogging through months of call while pregnant and finally having my baby girl here with me - the thought of heading into fellowship after my Chief year makes my stomach turn. I am so tired of being a resident! The toddler inside me is stomping her feet and wants to be the BOSS already and stop having to run everything by an attending all the time. I'm tired of 80 hour work weeks. I'm exhausted.

I am considering taking a year to work as a hospitalist and consider my options. On one hand - hospital medicine pays enough for us to live comfortably, in my opinion (I did not grow up with much and neither did my husband) and the moonlighting opportunities in my area would enable me to very easily make an extra $50K by working three very easy nights a month. Scraping along on $50K as a fellow for three more years makes me feel sick...and we want more kids - it would be way easier to do that as a hospitalist than a fellow in a program with 3 or 4 fellows per year.

On the other hand - in my heart of hearts I fear general hospital medicine will not be enough for me. I want to be a specialist - someone who is consulted to assist with a sick and complicated patient. I like pulmonary medicine and while I would probably not do critical care full time or even half time, I wouldn't mind keeping a toe in the water in an academic Pulm/CC position - a few consult months, a few inpatient ICU months, etc. I can't imagine doing any other fellowship if I do specialize, I think Pulm/CC is it for me. And I fear if I go the hospitalist route I will never go back to do my fellowship.

Any ideas? Is it better to do fellowship now when my kid(s) are young? Should I just gut it out a few more years and get through it? If I wait to do fellowship, my kid(s) will be older - won't they miss me more? But I can't stomach the thought of doing a fellowship now. Would love to hear the perspective of you brilliant ladies :)


  1. What about a one year break to work as a hospitalist and then do your fellowship. My two years of research in the middle of residency definitely have prolonged things, but my sanity required it. Residency is long and hard and grueling. Take the year and come back renewed and refreshed and hopefully re-excited about critical care medicine.

  2. "They" say "you'll never go back" meaning you'll never want the fellow salary, fellow work, fellow lifestyle after experiencing being an attending. But who are "they"? Negative nellies. I went straight through and had my first kid during fellowship and my second shortly after...because I thought I knew I could never go back. I absolutely would go back, if my Husband would let me, and do a second fellowship - but alas, no.

  3. You have more options than you think!

    Here's an example: I'm a renal fellow, and entered fellowship immediately after residency BUT I've reorganized my years such that this year (as a "first year") I'm primarily doing research. So I've had a chance to catch my breath (and catch up on sleep/laundry/life) before diving into a strenuous clinical year.

    I say do the fellowship, if that's where you're called to be. I bet you'll feel much more sanguine about work/life/everything after a mellow chief year -- and after your baby is, you know, sleeping.

  4. You have senioritis. What frustrates you is not unique to pulm/cc but I medicine itself. Hospitalists are not immune to the woes you mention. Think of life in 5 years, not in 5 months. Chief year will be a nice break, but don't loose site of the prize. A specialty affords you options and as momma the more options the better. Flexibility in fellowship may be on your side depending on where you go. That flexible schedule may make it easier for you too during your child bearing years. I had my baby 4 years after residency (EM) and I didn't do a fellowship but appreciate flexibility. No matter what do what makes you happy. Beware of any decision though just 9 weeks post partum. If I had made major decisions then I think I would have ended up a stay at home mom! 10 months later, a fantastic nanny and a supportive husband I'm making this working mom situation work! Good Luck!

  5. I imagine that being burned out at the end of a medicine residency is tougher than being burned out at the end of a pathology residency, but I did 5 years of path and 1 year of fellowship all in a row. Fellowship was with toddler and baby and struggling, ending marriage, so I can empathize with being tired. My fellowship was required to get the job I wanted, so there was no choice involved.

    Maybe this was selfish, but it seemed easier to get that block of maternity leave in training (more flexible and less dependents) than to ask it of my future partners. It's not like I took more time than other residents - I was covered for yearly vacation only but it was done in one stretch rather than week spurts, which must have taken a coverage toll. Plus I had this crazed, determined baby timeline in my head that couldn't be deterred. I did not suffer being a fellow during motherhood. Academically, anyway. It was interesting to read that it would be the opposite for you with hospitalist vs. fellowship.

    I highly agree with above - your signs of being annoyed by the aspects of medicine that formerly energized you are probably a symptom of being at the end of training, but even more so, having a 9 week old baby and being at the end of a long gestation! Congratulations but oh my gosh you are so in the weeds of new mommy hood. So glad you have a break/chief year coming up. A little time will bring fresh perspective on where to go next. If you choose the hospitalist year for more financial support and control of your life, you will know in a few months if you need to go back and that experience will give you more to add to a fellowship or more to continue your life in that vein. The fact that you and your husband don't seem to be itching for monetary largesse (in this world of medicine good luck, ha ha), having not had it in the past is a bonus - hopefully you won't be tethered by your salary to your job and can suck it up for another three years if your desires in life demand the challenge.

    I hope you have a few months to make this decision, because time and a little bit older baby and a break year will help. Good luck to you.

  6. I agree with Kim---the things you mention being burnt out on are inherent to medicine itself. I don't think being a hospitalist vs. a CC/pulm fellow will help you avoid those things. And fellowship will usually afford you the luxury of protected research time, enough to actually realize you miss clinical medicine or decide that you do not miss it at all and want to pursue a research-heavy career.
    On the other hand, lots of people take a year off between residency and fellowship---you would apply during your chief year (vs. applying now, right, don't you apply 2 years before starting for your fellowship?). You have a year to set up some sort of work for that year---whether research or clinical---and you can totally spin that during your interviews as somehow enhancing your overall experience so that you enter as a stronger fellow.
    Basically I'm saying you can start in 2 years or 3 years, but if you want to do the fellowship, plan to do the fellowship, and don't leave yourself wondering "what might have been" 5 years down the road when you realize primary care/hospitalist isn't your life's calling.

  7. I think this is one of those cases where you can't go wrong either way so follow your heart. Before my mat leave, I felt quite tired out and more easily frustrated with situations at work, even though in my head I knew that colleagues may just be grumpy because they were having a bad day or administrators did have different priorities or that families of those patients were going through critical situations for the first time so they needed more time and repetitive discussions to come to some conclusions. But later after a break for mat leave, I realized that I was just having less patience because I was tired out myself. My mat leave was a wonderful break and time to regroup and after it, I felt much more energized. Coming back, I've redeveloped my patience and are back to feeling more empathetic and kind to everyone all around - even if there are patients, families, colleagues or system issues that are trying. Gretchen Rubin author of the Happiness Project says that when you are personally happy, you develop a stronger capacity to deal with other people who may not be happy, and that breaks are essential to maintaining your capacity to do that. From your post, to me, it sounds like you need a break, and you need a break of some sort before fellowship. If the mat leave and chief residency year can do that, and you are happy at the end to just continue straight into fellowship, that works. If not, taking a year as a hospitalist sounds great! Don't worry about not going back for a fellowship later - if it's what you want, you will. At my hospital, there are three current ICU fellows (all male) who graduated their residency and then took a couple of years to be attending physicians (e.g. in emergency medicine and internal medicine and anesthesia), pay of loans, buy houses, be with their kids. Then they went back to pursue fellowship some 2,3 or 5 years later - they are the best fellows we have because they are so experienced and can handle so many situations and don't need as much handholding by attendings. They were highly involved fathers and said they found it easier to do their fellowships when their kids were older and in school compared to when the kids were really little. If they had done fellowships while their kids were little, they said their spouses would have had less support and more likely to be hard on their spouses as well. Apparently doing it later also helped the kids develop good academic ethics before they could do homework while their dads studied for ICU fellowships and board exams. Anyways, I can see it being good either way. Hope you'll let us know when you decide what you did do :)

  8. Your senioritis will subside during your chief year. It is better to get things over with and be happier with your job in the long-run. You can do it!


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