More residents are pursuing fellowship each year, according to data from the National Resident Matching Program. The decision to opt for additional training—in lieu of going straight into practice—is a personal one. It is also one that residents must make early on in their training as they plot their career course.

A recent resident who opted to skip fellowship and become an attending physician offers his insight on the answers to five questions that informed his decision and could be helpful to other medical and surgical residents.

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After three years as an emergency medicine resident at McGovern Medical School at the University of Texas Health Science Center in Houston, July 1 marked the first day in the emergency department as an attending physician for Jason Lesnick, MD. He opted to go directly to practice—accepting a position in the emergency medicine department at nearby Memorial Hermann Northeast Hospital—instead of pursuing a fellowship position.

“The decision to pursue a fellowship is all about what you plan to do eventually,” Dr. Lesnick said. “For emergency medicine, you don’t need to a fellowship. A lot of my friends who do orthopedic surgery, almost all of them subspecialized, whether they want to do hip or ankle or upper extremity [surgery], there are multiple chances for them to get additional training beyond residency and that’s sort of the standard for their specialty.

Learn the top five factors fellowship program directors look for in applicants.

Training longer will mean you have less time to maximize your income. When pondering fellowship, you should consider your potential income losses by extending training and the potential gains your additional training could yield. Dr. Lesnick noted that physicians are significantly behind the curve when it comes to savings relative to their peers who are typically working and saving some of their take-home pay during the time that doctors spend accruing more debt in medical school.

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Dr. Lesnick has interest in potentially working in C-suite positions down the road, which could be something a physician trains for with a one- or two-year administrative fellowship. Still, he felt much of that experience could be gained outside of a fellowship, and by going into practice his salary is a multiple of what it would have been during fellowship.

“If you do a two-year [administrative] fellowship, they’ll pay for your MBA as well,” he said. “The problem is the cost of an MBA plus the salary you would make as a fellow is still significantly less than what you can make as a community physician. My plan is to get my MBA on my own and that still keeps every option open for me while keeping me from losing a large sum of money potentially available to me.”

Learn how much you’ll spend looking for a fellowship.

In choosing to eschew fellowship, Dr. Lesnick considered geography. He wanted to stay in the Houston area and begin building a life with his fiancée. As a recent chief resident at one of the larger emergency medicine programs in the city, he was confident he could secure an attending position in the area.

“The experience [of pursuing fellowship] is obviously an incredibly valuable opportunity,” Dr. Lesnick said. “The learning that could come from it, the mentorship and connections are very valuable. But, by having done residency in a big city and having worked with people in a large program already, I was looking at it in the sense that I already had those connections. So that aspect was less of a factor for me.

“I was really not interested in moving from Houston right now. I’m very happy here with my fiancée. We didn’t see much of a point in moving for one maybe two years and having to move again after that, eventually. “

Learn how the choice to subspecialize differs by gender.

Deferring income to pursue fellowship means that you are also likely to wait on paying down your loans in any significant fashion. Dr. Lesnick saw that as a con of going for a fellowship position.

By continuing to “live like a resident” while collecting an attending’s salary he believes he can pay down his loans entirely in around two years.

“Loans feel like hundreds of thousands of little weights you carry around with you,” Dr. Lesnick said. “There’s pressure I feel to want to get that done with as soon as possible and by going straight into practice without a fellowship I will be able to do it much faster.”

Learn the three items you should have on your loan-repayment checklist during residency.

Seek out physicians and mentors whose opinions you value and get their input on what additional value a fellowship could offer.

“The most important thing is to talk to multiple people who have been there and done what you want to do and ask them do you think it’s worth it for you to do,” Dr. Lesnick said. “For those who have already done it you can ask would you go back and do it again?”

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Ultimately, Dr. Lesnick said, you shouldn’t skip a fellowship if it’s what you have your heart set on.  

“You have to take a good long hard look in the mirror and ask yourself what are your future goals?” Dr. Lesnick said. “If a fellowship is necessary to reach those goals, you won’t be happy unless you do it. If you are pursuing a career that doesn’t require a fellowship, I would posit that it might not be worth your time.”

With summer application deadlines for several subspecialties looming, make use of FREIDA™—a recently revamped comprehensive AMA tool that captures data on more than 12,000 residency and fellowship programs accredited by the Accreditation Council for Graduate Medical Education. 

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