The decision to pursue fellowship after residency training offers physicians the chance to sharpen a specific skill set and grow a niche knowledge base. Does the extra training with fellowships—typically adding one to three years of graduate medical education (GME) training—correlate with a bump in one’s long-term career earning potential?
That financial consideration is just one among many that residents can and do ponder as part of their choice on whether to enter practice or continue their training. Others include their passion for a given subspecialty or their vision for how they see their physician career unfolding.
On the financial side of the fellowship training choice, a peer-reviewed study examines that question through the lens of general surgery residents.
According to the study, published in the Journal of Surgical Education general surgery residents who pursued subspecialty fellowship training saw the extra years of training yield varying results for their overall career income. In many cases, the researchers found, the opportunity cost of added fellowship training means that career earnings may not surpass those of surgeons who enter general surgery practice directly after residency.
How should resident physicians who are considering going the fellowship route weigh the impact of those years on their career earnings? Data and firsthand insights from physicians offer insight.
Are post-general surgery fellowships worth it?
The research team behind the study of general surgery fellowship paths used a net-present value metric to measure the total value of a surgeon’s career earnings, adjusting for the time value of money. They examined whether the general surgeons started practicing immediately after residency or pursued additional fellowship training, taking extra years to train at a lower salary figure and further delaying the chance for retirement saving to compound over time.
Across 10 general surgery paths studied for physicians who enter private practice after training, the researchers found that only a few surgical subspecialties offered positive value for fellowship trainees, with cardiothoracic, plastic and pediatric surgery offering the best chance for a long-term career earnings boost even with two extra years in training.
On the other side of the coin, subspecialty paths which yielded a negative net-present value—the least likely paths in which fellowship training would benefit long-term career earnings—included breast surgery, surgical oncology, trauma, colorectal and transplant fellowships.
The net-present value calculations for surgical subspecialties in academic practice largely mirrored those seen in private practice, with almost all fellowships yielding similar financial outcomes across both settings. One noteworthy difference came in vascular surgery. When done in an academic setting vascular surgery retained a positive net-present value only when additional research years were avoided.
The financial return on investment (ROI) for fellowship training varies based on post-training practice setting. With academic physician roles typically paying less than those in physician private practice settings. Researchers also found that taking extra time out of residency or fellowship to do research can reduce a surgeon’s net career earnings.
“Trainees may assume that additional subspecialization will be rewarded with additional compensation,” the study’s authors wrote. “In many cases, this is an incorrect assumption and does not factor in the academic-development time needed to match to a fellowship program, the variance in hours worked per week based on specialty or the average salary of each subspeciality.
“While trainees must consider personal interests, desired practice setting, nonclinical interests including research and education, geography and other factors in their career choices, these data confirm that subspecialty training does not often result in a financial ROI.”
What about nonsurgical specialties?
The study’s focus on general surgery paths is notable because surgical fields are among the training paths that require the most time in GME. Still, certain aspects of the data—such as delayed earnings, opportunity cost and the impact of practice setting—can be applied broadly as residents consider fellowship training opportunities.
Now an assistant professor in New Mexico, David Savage, MD, PhD, did a three-year hematology-oncology fellowship following his internal medicine residency.
"I enjoyed internal medicine a lot, saw that getting to focus on oncology and kind of being an expert in one little domain would be very satisfying to me,” said Dr. Savage, an AMA member who serves on the AMA Council on Medical Education.
The delayed earning potential of subspecialization came with extra opportunity cost for Dr. Savage, who spent nine years on an MD-PhD track during his undergraduate medical education.
"For me, this subspecialty was one I saw as most compatible with a research career, because I could be really focused in one tight area and I could do research with it,” he said.
When Dr. Savage accepted a fellowship position in hematology-oncology, he “knew it was going to delay starting a faculty job by another three years, and that is a tough trade off, but I was willing to make it."
Biggest hit is to retirement savings
One of the major areas in which income is lost in longer training paths, per the study, is retirement savings. Few GME programs offer matches for retirement contributions. Further, each additional year of training at a lower salary means a delay in contributing significant amounts to retirement accounts. The forgone opportunity for compound interest over the course of a career can have a substantial effect on long-term financial outcomes.
Amid a seven-year vascular surgery residency program in Massachusetts, AMA member Tiffany Bellomo, MD, is now in the second of two research years following three clinical years. She has found that the protected research years offered by her program allow for moonlighting, which helps compensate for the lost time in the market that is essential for building long-term retirement wealth.
“By entering an integrated program that is set up with both a streamlined path to fellowship and dedicated research years, I gained financial flexibility,” said Dr. Bellomo, a finalist in the 2025 AMA Research Challenge. Dr. Bellomo has taken the money she made from moonlighting and put the maximum amount into retirement savings vehicles such as her 403(b), Roth Individual Retirement Account (IRA), Health Savings Account (HSA), and a 529 plan for her niece.
“One of the biggest threats to physician financial well-being is burnout, and financial freedom allows doctors to make the choices that they really want to make,” she said. “If you have put yourself in a good long-term financial position, you can say no to additional responsibilities, positions that do not inspire you, and even a job if it does not benefit your satisfaction.”
Dr. Savage knows of physicians he trained with in fellowship who worked to make up forgone early career earnings by making higher salaries as oncologists in physician private practice, as compared with academic roles. Still, professional satisfaction, Dr. Savage said, is what should be at the root of one’s decision to pursue fellowship.
“I've seen people who choose not to do a fellowship because they want to go ahead and start making an attending salary, then they get five or six years in and they've just kind of done the same thing day in and day out ... and they were never super passionate about it, but they certainly enjoyed having the stability of a stable income. If those people want to pivot, it’s much harder at that point.”
