My cousin Nathaniel was diagnosed with type 1 diabetes when he was only 11 months old; just a few years later, his younger brother Isaac was also diagnosed. I grew up watching these boys play across the street from my house; I held their hands, riddled with needle pricks, to cross the street that separated our houses. Announcing my intention to become a pediatric endocrinologist elevated me in the eyes of my family from a 17-year-old to a saint. Explaining what an endocrinologist was in response to the question, “What do you want to be when you grow up?” made me feel sophisticated and smart.
My certitude would have quickly vaporized in the face of calculus-based physics, gross anatomy, and 30-hour shifts in the pediatric intensive care unit had I not had a deep fascination with endocrine physiology and a feeling of belonging within the field. Still, I gave every specialty a fair shot as a student and a resident — how else can one get excited about holding a retractor for hours on end? — but as soon as I could articulate my interest, I also sought mentors in endocrinology to encourage me.
Determine Whether a Fellowship Is Right For You
As a clinical fellow, I adore teaching residents and medical students, and I am often asked how I chose my path. If I’m not asked, I volunteer the information because I’m evangelical about getting others interested in pediatric endocrinology. However, regardless of a person’s specialty interest, I do have some tips to offer for anyone considering a fellowship:
1) You won’t make as much money as your friends in the “real world”, at least not just yet. Embrace this now so another year of PGY-something pay will be easier to take.
My sister accepted her first job as a registered nurse in Mississippi with a starting salary that is higher than any I’ve had after 14 years of training post-high school. My husband and I have yet to achieve the “American dream” of owning a home because training has made us nomads. Assuming that I am missing out on the average primary care pediatrician’s salary, the opportunity cost of my fellowship will be in the six-figure range.
I won’t make more money or work fewer hours than a primary care pediatrician when I finish — in fact, I might bring home less money for more work unless someone develops a lucrative procedure to lower hemoglobin A1c levels of diabetes patients to replace the non-reimbursable hours I spend counseling patients. However, I’ve made these kinds of determinations before — the opportunity cost of not becoming an interventional cardiologist or a neurosurgeon is millions of dollars. The feeling of purpose and fulfillment in my work, though, is priceless.
Prospective subspecialists have to be careful to keep proper perspective: most fellows earn a salary that puts us in the top 1% of the wealthiest people in the world. My friends in primary care are paying back their loans now to the tune of thousands per month while I continue to defer the mountain of medical debt I have incurred as the interest keeps accruing. But, I am satisfied to have never had to explain to my cousins Nathaniel and Isaac that I was ignoring the shortage of pediatric specialists for their condition because of financial motivations.
2) After gaining autonomy during residency, you will be back under an attending’s supervision as a fellow, and you probably won’t like it for very long. You will yearn for the freedom of making your own decisions. However, the first time you see a child who is not a “horse” or even a “zebra” but a “purple plaid unicorn” for whom only a case report exists, you will be thrilled for the silver hair of your attending. You will continue to soak up knowledge at hospital conferences, national meetings, and grand rounds. And you will continue to value being a lifelong learner; the feeling of complete self-sufficiency as a young pediatrician is an illusion, anyway, if the conversations I have with my peers newly in practice are an indication.
3) You won’t have to do primary care anymore, but unfortunately, you won’t get to do primary care unless you seek out occasions once you begin your fellowship. Yes, ADHD medication titrations, sports physicals, and chronic abdominal pain are now a distant nightmare. You will be vomited upon approximately 99% fewer times as a specialist. (The calculus might be different if you were to choose gastroenterology, but toting an orchidometer in your pocket isn’t for everyone, either.)
On the other hand, you will have approximately 99% fewer crayoned landscapes and fewer framed photos of your patients. The buck no longer stops with you. You will start to forget the differential diagnoses for immunodeficiencies unless, of course, you are an immunologist or you are studying for boards. This may or may not make you feel less like a “real doctor.”
I solved this conundrum by identifying my favorite aspect of primary care (continuity and building relationships) and was pleased that my chosen specialty offered the same opportunities. Some of my co-residents realized that they were most energized following the intellectual and emotional challenges of a critical care or emergency room shift; others found their greatest joy in an endoscopy or catheterization lab.
One of my closest friends gets to be a detective every day as an infectious disease specialist and almost has the AAP’s Red Book memorized. A particularly unflappable friend is gifted with brilliant neonatal physical exam skills and now works in the NICU; his face lights up when he talks about his tiny patients. My favorite attending in adolescent medicine was fluent in the language of troubled teens. Other physicians I’ve encountered felt pleased with their ability to actually understand renal physiology or the blood clotting pathway, and these are rare talents that cannot be wasted.
Decide Which Career Path
Once you understand what you are giving up and what you are gaining, you might wonder how on earth to decide which career path to choose.
Some questions to ask yourself:
Do you want to run a private practice someday? This may be entirely possible if you are an allergist but less so if you want to study rheumatology. Some fellowship choices automatically mean that you will be tied to a teaching hospital and the victories and defeats associated with academic life.
Do you enjoy research, as in really enjoy it? If so, then you will adore the devoted, mentored time to answer a problem. Plan wisely for this time, and be honest with yourself about your goals. Don’t pretend to like something just to please a mentor or to increase your perception of job security. If you’re not passionate about or even interested in your research, your lackluster performance will seal your doom, not to mention the lost patients you could have helped had you been more self-aware. Begin reading the literature in your desired field. Where are the gaps? Did you take care of a patient who had a catastrophic event due to medication error and want to improve doctor-patient communication? Why on earth does that protein work in some patients who carry a genetic mutation but not in others? Are you perplexed by the lack of a vaccine for a certain virus? Do you wonder why the childhood obesity epidemic continues to snowball rather than plateau? Fellowships aren’t just for pursuing a specialty; general pediatrics research questions abound, as do training programs that help participants learn to answer them systematically. But if you hate research, and 2 years of time devoted to answering a clinical basic science or translational science problem sounds like medieval torture, then consider a different course.
Would a fellowship help you to serve a patient population better? Perhaps you are a hospitalist who would like to become an expert in nonaccidental trauma. Maybe your area is devoid of those skilled in pediatric palliative care. Like me, you might identify an area within your own field that needs addressing.
As I searched for a research project, I met a very accomplished mentor in adult lipidology whose personality complimented mine well. Children with dyslipidemias were crowding his practice. His lab employed methods familiar to me; I was delighted to learn that perhaps when I was in college, all those hours I spent indoors on lovely, spring days, waiting on gels to run weren’t a waste of time after all.
I am now learning a new trade as I complete my fellowship in pediatric endocrinology that will allow me to obtain a second board certification while meeting a specific need. In academic climates, becoming more marketable and flexible always is a tremendous bonus.
Those of us who work in medicine are all too familiar with the fragile nature of life and have many moments to examine our motivations for entering our chosen field. I was diagnosed with melanoma as a second-year resident; I lost a close friend to cancer right before I finished residency; and I held my daughters in my arms for the first time just a few months ago. I was on call during my first year of fellowship when Nathaniel was diagnosed with Addison’s disease. Because of my training, I was able to advise the emergency physician on the dose of stress steroids that helped save my cousin’s life.
These experiences, both jubilant and poignant, offer us the chance to crystallize our goals and help ensure that we are on the right track. So when I go to sleep in my rented condo with a pager on my nightstand, I sleep peacefully until the first call, knowing that I have chosen the perfect career for me. I hope that everyone who reads this article can know the same satisfaction.