By Dr. James M. Dahle, WCI Founder
One reader asks:
WCI Reader Question: “Should I Do a Medical Fellowship?”
“I’m interested in seeing a discussion regarding subspecialization from purely a financial perspective. I’m currently a general surgery resident. Obviously interested in surgical subspecialization but understand your articles must apply to all of medicine and your readers. I have seen this analysis for other specialties but not specifically for surgery.
I’m a 30-year-old surgery PGY3 with $400,000 in student loans. While I understand there is more to the decision whether to subspecialize than finances, I can’t help but think about my loans capitalizing for two additional years (while making the salary of a fellow) and missing two additional years of attending salary early on in my career, which I’m realizing is a critical financial time in my life.”
Fellowship Is Not a Financial Decision
This is a financial blog. And this is a financial post. But the truth is that this decision is not, or at least should not be, primarily financial. It's a bit like deciding whether to have the military pay for your medical/dental school or not. You can run the numbers into infinity, but, except in rather extreme circumstances, the decision should be made primarily based on whether you want to be a military doctor. A decision based on anything else is likely to lead to regret.
It is the same way with choosing a specialty and choosing whether to do a fellowship. Of course, if you love occupational medicine and plastic surgery equally, you should be a plastic surgeon, but I think those types of situations are rare. I did not choose my specialty primarily based on its financial benefits, and I don't think you should either. Certainly, my “mid-range” specialty in terms of pay and competitiveness was more than adequate for me to become financially successful despite several less than optimal decisions along the way.
Longevity Matters Most
The truth is that the best financial decision you can make with regards to career, specialty, subspecialty, and type of practice is to choose the one that you can do the longest. Even if it pays a little less or it takes a little longer to get there, you're going to come out ahead—especially when you take compound interest, an earlier start, and our progressive tax system into account. But let's just run the numbers while ignoring those two factors to demonstrate my point.
Is it better to be an orthopedic surgeon and make $500,000 per year for 10 years or a family practice doc and make $200,000 for 30 years?
$500K * 10 = $5 Million
$200K * 30 = $6 Million
Clearly avoiding early burnout is pretty important financially. Consider my good friend the Physician on FIRE who retired in 2019 at age 43. Assuming an anesthesiologist makes $400,000 a year and a typical one works until 65, he left $400,000 * 22 = $8.8 million on the table. That's four times as much money as most docs retire with.
So the most important financial issue with regard to specialty and subspecialty choice is whether that choice will lead you to choose to work longer because you like the work more. If it does, it is likely to be beneficial no matter what the numbers say.
The Effect of a Delayed Start
The emailer outlines well the effects of a delayed start. In emergency medicine, one can do a three-year residency or a four-year residency. Those of us who went to three-year programs refer to that fourth year as “the $400,000 mistake.” That's not a technically accurate statement, but it's close enough. You see, you don't actually take home $400,000. Maybe $100,000 is really just your tax bill. And that PGY4 received some sort of salary, perhaps $60,000 these days. So maybe it's really a $240,000 mistake.
But wait, there are some other benefits besides just starting to make the big bucks earlier. You can refinance your loans and then start paying them back. You can start investing and capture tax-advantaged space the delayed doc will never get back and reap the benefits of an extra year of compound interest. You also have more time to build a practice and get your income up during your longer career. It is hard to quantify all of those things, but they probably push it back toward a $300,000-$400,000 “mistake.”
Do Fellowships Pay?
Yes, but most medical Fellowships Don't increase income. What a lot of people don't realize, however, is that doing a fellowship doesn't usually increase your income. Obviously, there are exceptions, but they are just that—exceptions to the general rule. First of all, most fellowships don't increase pay. Look at all the subspecialties of pediatrics, internal medicine, and emergency medicine. Nephrology. Immunology. EMS. Toxicology. Ultrasound. Wilderness Medicine. Even in surgery, specializing may mean lower or similar pay. Surveys have shown that the average pay for colorectal surgeons is below that of general surgeons.
Yes, there are some specialties that come with significantly better incomes but usually much worse lifestyles. I'm thinking cardiology, GI, and critical care. But many docs (and their families) are surprised to see that one to three more years of training doesn't equal any increased pay.
To make matters worse, a fellowship-trained doc is far more likely to be working in an academic role rather than private practice. It should not surprise anyone to find out that academic docs are often paid less than their non-academic colleagues for doing more work.
So if you're trying to justify a fellowship for financial reasons (and you shouldn't), be sure that
- The subspecialty is actually paid significantly more than the specialty, and
- The subspecialty isn't going to force you into an academic role.
Running the Numbers
The basic calculation here weighs the cost of fellowship against the increase in pay. There are a lot of unknowns here (interest rate on loans, investment accounts available, cost of disability and malpractice insurance, tax brackets, time value of money, etc.), but we can make some reasonable assumptions, ignore a lot of minor factors, and make a few general statements.
Let's say the cost of your fellowship is $250,000 per year. Most of this is opportunity cost. Let's say someone is considering a two-year fellowship and the doc will work for 25 more years (including the two in fellowship). How much more, after-tax, does that subspecialty have to pay to be worth it?
One more comment before we do this calculation. In my experience, intraspecialty pay variation is far more impressive than interspecialty pay variation, but I don't know what else you can do other than use averages for a given specialty when running these numbers a priori.
All right, the two docs live the same lifestyle but the fellowship-trained doc can invest a little more each year thanks to her higher earnings. How much more does she need to invest each year to overcome that $500,000 ($250,000 * 2 years) opportunity cost over 23 years? Let's use the payment function from Excel and say both docs need $5 million to retire in 23 years and will earn 8% a year on their investments.
Fellowship Trained Doc =PMT(8%,23,0,5000000) = $82,111
Non-Fellowship Trained Doc =PMT(8%,23,-500000,5000000) = $33,900
Basically, the specialist needs to make $48,000 a year more after-tax to come out ahead.
If we use the same assumptions but make it a three-year fellowship, the number is $74,000 per year. A one-year fellowship is $24,000 per year.
Are there specialties that meet these numbers? Absolutely. For both medicine and pediatrics, cardiology, GI, and critical care will hit these numbers, at least on average. For general surgery, vascular and thoracic should both get you there. But trauma, burn, colorectal, breast, oncology, etc? Probably not.
It doesn't really matter, though, because as we've seen above, you shouldn't be making this decision primarily on financial grounds. If you can't pay off your student loans and have a very nice life on any type of surgical subspecialist's income, you have a spending problem, not an earning problem.
Besides, many generalists have discovered that building their practice by working smarter and harder will provide an income similar to that of a subspecialist without the opportunity cost. Yes, $400,000 in loans is a big hole to start your life in, but you don't have to stay there long. Check out this recent comment posted on the blog:
So, Should You Do a Medical Fellowship?
Most of the time additional training does not make sense financially, but if the subspecialty pays significantly more than the specialty and you plan to have a lengthy career, it could be justified. But the truth is that if you applied this analysis to medical or dental school itself, most of those who are intelligent and hard-working enough to get through this long training pipeline would be ahead financially if they had simply applied those efforts to starting and running profitable businesses right out of college instead. So while this is a fun exercise, just like running the numbers on the military HPSP “Scholarship,” I wouldn't bother.
I'd make the decision primarily on non-financial factors.
What do you think? Did you choose to subspecialize or not? What were the financial ramifications of your decision? Do you think this should be a financial decision? Why or why not? Comment below!
[This updated post was originally published in 2019.]
Interesting article. I would say I respectfully disagree with the notion that some medicine sub specialties comes with “much worse lifestyles.” That is a broad generalization that is often not accurate. It all depends on your practice setup and the type of work you like to do. In cardiology (non-invasive) you can easily set up hours very similar to a primary care doc if functionalize things and find a good group of partners.
Sure, but then again easier hours and non-invasive = less pay. You will not be hitting the numbers the invasive guys hit.
It’s interesting. Regarding the lifestyle piece, no matter what you specialize in, if you expect to make substantially more money you typically have to pay a sacrifice in lifestyle unless you’re more business minded than medicine minded and you scale your practice wisely
Hard to argue that SOME docs have much worse lifestyles by using an example of one doc that doesn’t. All I know is I call cardiologists, even non-invasive ones, a lot after hours. As a general rule, the more I call you from work, the more your lifestyle sucks.
that’s why you’re better off on outgoing side of these phone calls haha. For Peds subspecialties peds EM, GI and cardiology would produce the biggest jump in salaries comp. to Gen Peds
Starting peds EM salary is $220k, give or take, starting Gen Peds- 120K
Good article. The financial aspects are clearly important but do what you love.
If there is a subspecialty that you love, do it, a few more dollars in the bank at retirement won’t matter if you practice in a field that makes you miserable.
While certain subspecialties will direct you towards academic/ hospital positions, others will enhance your opportunities to get a better private practice job. There is no one size fits all.
Know thyself and know thy field.
With respect to general internal medicine, I am concerned that the entire field will be taken over my lower paid nurse practitioners. Witness the 15 docs at urgent care centers that were fired and replaced by NPs.
I did two things that extended my training and cost me money in the long run while I was finding myself.
The first was first going into general surgery residency (for the wrong reasons) and after pgy2 decided it was not for me and switching to radiology. Lost a year there as I was credited one as a transitional year.
The second was doing an interventional radiology fellowship for 1 year after residency. My current practice (which I’ve been at since 2006) does not have any interventional work at all (except minor procedures which general radiology does anyway like FNA and MRI breast biopsies). So that year of additional training in the grand scheme of things was truly a wasted one financially (interventional radiology docs do make more than general though).
In the end I figure the timing was more important as I would not have lucked into my current job because there would not be a position open if I was 2 years ahead. So the delay may have resulted in this current practice where I have a much better lifestyle then most in terms of hours and geographic arbitrage.
Let’s combine both conversation- doing a fellowship in the military! Tox doesn’t have it’s own AOC code so you’re still paid as an ER doc (others like critical care may see a pay raise, especially relative to IM). Military fellows get paid their military attending pay from their base specialty during training, but wind up owing additional time afterwards, usually either 1 year for one year or 2 years for one year (which delays getting the post-obligation bonuses, though if you wait until your obligation is up to grab the fellowship you can sometimes get those bonuses too). Also while in military training you can’t moonlight, which is part of that “I’m willing to work harder for more pay” intraspecialty difference.
Still a bad financial decision but I’d make it again.
Good points but counter-argument for the absolute merit of getting an IR fellowship.
I was a frustrated surgeon that did not enjoy the absolutely abusive surgical residency that I entered into and therefore chose Radiology to get away from the malignant nature of surgical graduate medical education.
The comparatively benign residency allowed me to do a lot of other things in my life that I wanted to by allowing me more time for it.
However, I got extremely sick of sitting next to an attending physician who would dictate to me what I should transcribe and felt like a glorified scribe more than a doctor for most of my radiology residency.
IR was the beacon of hope that allowed me to stay in medicine lest I just give it all up and run for the hills. It had the perfect amount of procedural medicine for me. Usually short, swift procedures and limited protracted patient contact.
I enjoy every bit of it except the unwelcome dumps from other services, but that’s ok too compared to being the hamster in a wheel turning out studies like my diagnostic colleagues..
Eventually, I got to the point where I could stand reading enough diagnostic studies to keep people happy and do IR procedures in a mixed private practice model while earning very well.
If I did not do my IR fellowship, my job security would not be what it is since I don’t have the zeal that my diagnostics colleagues do to read studies all day long and as a result, my productivity is not what theirs is.
However, keeping a hospital contract hinges on the IR arm of a practice and therefore, I should be able to carry on through my career to the chagrin of some of my colleagues, and get to the point where I can hopefully ride out into the sunset a rich man.
I may be wrong but I think the difference might be more then you calculated. It does not seem that you included the extra 2 years of work in the non fellowship doc in the equation. It would not change your point but just enhance it. Unless I misunderstood your assumptions.
This is a very valuable post. I know several people who have gone on for further training with the justification of higher salary. This just shows how significant it has to be to break even.
Yea…I am not sure he calculated this correctly at all.
If you invest 68K a year for 25 years (you skipped 2 years of fellowship) then you can reach 5 million at 8%…
If the other dude/dudette did 2 year fellowship he/she would have to invest 82K for 23 yrs to get to 5 million
thats per year diff of 14K and thatd be something like 35K of income based on 37% marginal.
No, I didn’t skip them. That’s where the $500K came from. And I specified these are after-tax amounts.
No, I included it in the $500K the non-delayed doc starts out with. So from that point forward, it’s 23 years for both of them.
For Psychiatry, Child and Adolescent tends to pay more by perhaps $25,000 per year, as does Geriatric Psych. Both of these cost you an extra year, but seem crucial choices to work out: see young people or see old people.
I lucked into a geriatric psych job in 2001 after getting a bit burned out in General Psych after only 7 years in practice. I did not need a fellowship for this job, my best one ever. It lasted 11 years and I earned a pension worth 2/3 of the max social security amount.
I’m glad I didn’t try to go back and do a one year fellowship in 2001. Fellowship pay back then was about $50,000 and I made $200,000 as an inpatient geriatric psychiatrist (with only general psych training) at that time.
I’m sure it varies a lot by specialty, but in Psych it’s not a financial decision for the most part. The other more obscure fellowships in psych don’t really pay extra.
I can attest to the statement that you may not necessarily more as a sub-specialist than a generalist.
I chose my sub-specialty (pediatric anesthesia) based on my fascination with the subject matter primarily. It also didn’t hurt that the fellowship was 1 year so little lost opportunity cost there.
One thing that I see is that subspecialists (at least in anesthesia) seem to be more in demand. Employers are looking for more candidates who have the fellowship training and board certification in the subspecialty. Maybe that can translate into a higher income or more job security.
Regards,
Psy-FI MD
Definitely an interesting read. I imagine a lot of this is specialty specific. For pathology, there are a lot of folks doing 1-2 fellowships, but I’ve seen surveys that employers prefer someone to hit the ground running out of training; the fellowship certificate doesn’t weigh that heavily. I know a few folks who have gone from path residency straight into a job, but I feel that path residency lacks a lot of good independence that would enable most people to do this. I’ve sat through a discussion on this topic at a national meeting, and it seems to be a nationwide issue. I’m curious if radiology has similar problems.
I’m a bit biased because at least one of my fellowships pretty much got me my job even though I will be signing out general surgical pathology.
I chose my subspecialty (pediatric anesthesia) based primarily on my love for the subject matter. I can pretty much attest to the sub specialization not earning much more than a generalist salary. Fortunately, the fellowship in anesthesia was 1 year so there was not nearly as much opportunity cost.
One thing I have been noticing is that employers are looking for subspecialists. They want to see the subspecialty fellowship training and board certification in the specialty. That may translate into a higher income or job security.
Regards,
Psy-FI MD
Fellowship improved my skills a lot more than just residency. I can anticipate problems before they happen. I am lot more proactive than reactive. My life is not so much stressed as I have seen and managed a lot harder stuff. People come to me to ask. I get a lot more respect from other physicians and they value my opinion. Definitely less burn out and more happiness in my life.
I have more job security as there are only few of me doing the work. In fact I got my current job due to my fellowship. Its easier for me to get another job due to my fellowship. I may be limited due to my fellowship where I can work (as not every place does what I do) but than I can have a my pick as well. More jobs want me than my colleagues. Its easier for me to find a good group due to my fellowship.
My work is actually easier than my colleagues as my volume is lower (though I cant predict when it will end). I have more downtime, sometimes I can even workout for 10-20 minutes while at work during these downtime. My colleagues cant. I can plan vacations while at work during these downtimes.
I will definitely do the fellowship again if I have to redo it.
I can only speak for radiology, and sometimes it depends on the subspecialty and where we are in the job cycle.
In general, having a fellowship makes you more attractive as a candidate for a wider variety of jobs post training. Some practices will not look at you without a fellowship and most job postings specify which subspecialty trading or experience is required.
How this translates financially is murky as many of the less desirable jobs in less desirable locations pay better. That said, having the fellowship (and the additional training) is always valuable and gives you the greatest opportunity to call your shots.
Seconding this comment as a radiologist-in-training.
//he left $400K * 22 = $8.8 Million on the table. That’s four times as much money as most docs retire with.//. The average doc retires with 2.2 million? Seems low to me…Are you including the house and the office practice in that?
That number is probably about right. 1/4 of docs in their 60s aren’t millionaires. 1/4 have >$5M in net worth. The rest are in between there.
It is hard to say an exact average at the time of retirement from the surveys I have seen, but the $2M ballpark is reasonable. I read that only 19% over 65 have $5M so that is more like one in five. But only 10% of those in the 50-64 age group have $5M and a lot of doctors retire before at 65.
Wait so I am confused about your calculations
You state: How much more does she need to invest each year to overcome that $500K ($250K * 2 years) opportunity cost over 23 years?….
In your PMT function, the 82K for the non-fellowship doc is the INVESTMENT he/she is making to reach 5 million. The 500K is just the gross income lost as “opporunity cost”…should that be the -500K in the next guys’ PMT function? shouldn’t that be more like 82X2 = -164K input?
Not sure I am following your calculations here.
What aren’t you following?
Fellowship Trained Doc =PMT(8%,23,0,5000000) = $82,111
Non-Fellowship Trained Doc =PMT(8%,23,-500000,5000000) = $33,900
The payments are how much has to be invested each year to make up for that $500K that the non-delayed doc starts out ahead.
8% is the interest rate, 23 years is the term/period/NPER, -$500K is the amount the non-delayed doc banked while the other doc was in fellowship, the $5M is the end target.
If you want to do your own calculations and change the assumptions, knock yourself out. That’s why I showed my work.
Oh I see what you are doing. 500k after tax for the non fellowship doc. Got it. Didn’t understand that in the article but appreciate the explanation.
The assumption is that all of 500k is in the bank though (since 5i mllion is in retirement account) but that is not practical – the working two years and having 500k “banked” as retirement after tax somewhere.
Then write your own post if you don’t like mine. Do your own calculations with the numbers you like. 🙂
The idea is that their net worth is $250K/year higher for being an attending and not a fellow. Some of that is lower student loans, some is a smaller mortgage, some is more home equity, some is retirement contributions etc. As explained in the post.
No need to get defensive. Idea is fine, your calculations are needlessly steering to wrong conclusion. Run it with 100-150K “opportunity” cost, since thats a linear 8% on that money YoY which I’d find more reasonable in this context.
You didnt explain that in the post, instead you used all of 500K as starting investing hole for the fellowship trained doc which is incorrectly applied.
And no – 250K / year is income, not NW. Aren’t you famous for touting income != NW? Come on.
Not gonna argue further.
Why argue at all? Why not just do your own calculations the way you prefer they be done? I showed my work so you could use it or modify it as you see fit. I disagree with your assertion that my calculations are wrong or that they lead to the wrong conclusion.
I appreciate that you stressed that a fellowship is not purely a financial decision, though obviously this is a financial blog so that’s the focus.
One other financial factor is job security. I’m in EM. With more non-physician providers taking jobs, having a fellowship (I’m ultrasound), makes you more attractive to employers. If jobs get more scarce, the ones who stand out and can provide more to a department than just clinical skills will get those jobs.
My decision to do a pain fellowship was entirely professional interest and lifestyle-driven, but the increased pay ceiling is nice too. Way easier to make mid/high 6 figures in pain than general anesthesia.
I am a general internist who did a chief year 26 years ago. While it was likely not the smartest financial decision, it was one of the most important years of my career. I had a whole year to read and teach. In the end, I opted out of the pulmonary/ critical care fellowship I had matched into and entered into the practice where I have thrived for 25 years. I really found my passion for medicine in that year. I agree with the WCI, finding your vocation can’t be all about the money.
Agree that medical students should think about the financial implications of their specialty choices. They should also consider fellowships. Choose Cardiology vs ID, not just “internal medicine and figure out fellowship later.”
Why are the docs illustrated as only practicing 23 years? If the financial reward for doing a fellowship is higher income later, then truncating the working career would lead to a lower payoff. If the docs are, say, 30-35 when they finish training, depending on age entering med school and the length of training, then they should have 35-40 years of practice. Cutting out the last 12-15 years, likely to be the highest income period, would be a terrible financial decision. Assuming they would do this weights the analysis against the fellowship.
There are plenty of cardiologists and GI docs in private practice. Their fellowships did not push them into academics. There are plenty of academic proceduralists who make private practice money. By leveraging the trainees, often they can do more cases than their private colleagues. They would take a pay cut if they spend a lot of time teaching or doing research, but not everyone in academic jobs does any of that.
Just because you’re working to 70+ doesn’t mean most docs will. I picked 25 years because it gets a doc to 60 from age 35. If you don’t like my assumptions, use your own. I showed my work and you can change it as needed for your purposes. Obviously the longer you work, the lower the difference must be.
“…if docs are 30-35…they should have 35-40 years of practice…”
That has you working at 70-75 years of age. My entire focus since age 50 has been how to retire by age 58-60.
There are so many things I want to do besides work. Most men have their “decade of decline” from age 70-80. You might consider the average age at death in your planning.
In May, we will walk the Camino from Portugal. I can only get about 11 days off, so we will do the last 120km. If I were retired, I’d do a longer trek across the top of Spain.
In 2013, we trekked 120km through the Peruvian Andes to a Machu Picchu on a two week trip. There was no one on the trail out in the boonies over age 60.
70-75? Working full time? Not me. If I’m intact and fully functional at that age, I will certainly feel very lucky. I’m almost 56, take only one medicine (Nexium) and swim several days a week at lunch. I swam a 5000 meter open water swim this year and ran a 10 mile road race after training all spring and summer. Still, realistically, I hope to live to be 85, and the last couple might very well be marginal.
The mid 70’s are not the years to start your retirement. Take a look at folks in their 70’s and 80’s. Few are trekking the Camino.
Im makes around 200000. Gi and cards in a good market over double that. In a great market triple. Market and Loan repayment big salary factor
Will have two mil in under ten years at this rate living on half. Thanks
There’s a reason I singled out those two specialties in the post.
Thanks for posting this timely article! My wife and I were just having multiple conversations this week about the pros and cons of pursuing a fellowship.
I am currently leaning towards a fellowship, and these numbers/calculations (although only a single component of the whole decision to do a fellowship) do help put into context what an extra year or two will look like from a financial standpoint.
Many thanks!
People who have lots of other things to do and don’t care so much about money can retire early and keep themselves occupied. I like to hike. But I would not spend hundreds of thousands of dollars to be able to take a particular hike. Nowhere near important enough to me. I have great hiking within a short drive of home. I would not consider going to another country to take a hike. Not only not worth the money, not worth the time it would take to drive to the airport to start the trip.
However, this article was not about traveling the world hiking. This article was about the financial implications of doing a fellowship.
To the extent that the financial payoff of a fellowship is higher income, only coming after a delay of 1-3 years, then truncating the working life reduces that payoff. It is like delaying Social Security. You take zero benefit when you are first eligible and gamble that you will live long enough for the higher payments starting at 70 to make up for that loss.
If you apply that thinking to fellowship training you find that the longer you work the better the higher income fellowship looks- financially.
You don’t delay SS if you don’t expect to make it to 70. You don’t do a fellowship for financial reasons if you expect to retire before it pays off. You don’t make an investment that will pay off in 10 years if you will need the money after 5 years.
It is more worthwhile to point this out for those fellowships than it is to do an analysis based on a short career and conclude that it does not pay off.
The difference in income required with this analysis depends in part on the value of that extra money invested during the first few years of practice when the alternative would have been doing a fellowship. If you assume a high rate of return, then it is harder for the higher income later to catch up. With current valuations, many would say that 8% is an optimistic return projection. I use 1% real for my retirement planning for a balanced portfolio. One could argue for something higher, but 8% nominal with inflation at 2% creates perhaps an artificially high hurdle.
This is a good outline of how to think about the financial implications of fellowship. It is just the conclusion that I find far too broad.
I know plenty of docs who work past 70. Some from prior generations, some recently, some working now. It seems the median retirement age for physicians is around 65. Somewhat later for cardiologists -who may be doing just what was postulated, taking advantage of their higher incomes to extract more value from their extra training. This means that about half of physicians practice past age 65. Not the impression one would get from all the shock and awe about someone planning to work a few years past that age. Keep in mind that at least some of those who retire at 65 or younger are forced to do so by ill health or reverses in their practices and you expect that more than half of those who have a choice continue working past this age.
Isn’t it fun that you get to run your own numbers? Think my term is too short? Lengthen it. Think my return is too high? Lower it. Come to your own conclusions.
As far as retirement age, the average doc retired at 70 in 1980, at 67 in 1995, and 65 in 2016. So yes, half of docs are practicing past 65. Not sure all of those are doing it willingly though, but there are likely some who retired before 65 who didn’t do so willingly either.
https://www.wallstreetphysician.com/physician-retirement-age/
Maybe 75 is the new 55?
Lots of people over 60 run marathons and climb mountains. Maybe some of those people you saw on the trail were older than you thought.
https://www.runnersworld.com/trail-running/a21998984/73-year-old-sets-western-states-record/
https://www.runnersworld.com/news/a20849297/70-year-old-becomes-oldest-to-complete-292-mile-badwater-double/
This specific question has actually been answered for general surgery using NPV and published in peer reviewed literature.
https://www.ncbi.nlm.nih.gov/m/pubmed/27930278/
To sum it up, CT, pediatric, transplant, and vascular all adding to your NPV (baseline defined as the end of residency with MGMA average salary over the next 34 years).
Also included is Ortho and OB/Gyn. Long story short, WCI is dead on—if you are doing a fellowship, it should be for more than just monetary gain.
Interesting. I wonder what sources they used for this article to come up with the ones that don’t add value financially. Just talking about obgyn, from every single survey out there I have seen, mfm and gyn onc on average pay about the same yet they conclude that mfm increases career value and onc decreases it? Is there another criteria other than compensation they r looking at? It would make sense since mfm and gyn onc have different lifestyles. But if it’s purely compensation that’s their focus, how does one reconcile that with the fact that the two make pretty much the same on average?
In my specialty (eyes), lifestyle and work hours generally get worse with more training. The fellowship trained people are the ones who see all the trainwreck patients that I’m not competent enough to manage. Income usually goes up with a fellowship, but it comes at a price.
Coming out of general surgery residency without fellowship, you will probably find a job somewhere, but if you want to be more marketable and want to live in a big city, you will likely need to do some type of fellowships. 1 year of critical care, minimally invasive, colorectal is not a bad option financially.
I’m planning on doing several years of fellowship. I’m interested in psychiatry (3-4 years), and plan to pursue fellowship training in child and adolescent psychiatry (2 years), forensics (1 year), sleep medicine (1 year), and aerospace medicine (2 years).
If I fast-track into child, then I’m looking at 9 years of postgraduate training total! 10 years if I don’t fast-track. Yikes! I don’t know what exactly I want to do yet — I imagine that I will have a main research gig and do some private forensic work on the side.
Although clinical medicine is where the money is at, I find most of it to be rather routine and mundane, especially outpatient medicine. So hopefully a research career will provide me with more excitement because I will be focusing on advances in medicine. And then I can work inpatient on the side because I really do want to work with the severely mentally ill.
Either way, I’m excited that the field of medicine is so wide, broad, and expansive. Sure, maybe I won’t retire at the same time as my peers, but I just can’t say no to all the knowledge that is out there and available!
I’m planning on working at PSLF-qualified institutions during residency/fellowship, and I’m not much of a lavish spender. I’ve already internationally quite a bit, so lavish travel isn’t in the cards for me at the moment. Europe will be here in 20 years! And I can always travel cheaply within the US as well.
And there’s always moonlighting! So I’m not too worried about these loans. Everything will work out!
Thank you WCI for this website! Great information for those that want to take their lives into their own hands!
This happens a lot with med students who haven’t figured out what they want to do with their life yet. They start talking about med/peds, and EM/IM and EM/Peds kind of residencies. Or Gen Surgery plus trauma plus burn fellowships. Most figure it out by MS4 and just do one thing. But those who don’t usually pay a financial price for their indecision. It’s costly to change residencies and there is a cost to every additional year of training. Doesn’t mean it isn’t worth it for you, but the likelihood of you doing both aerospace medicine and forensic psychiatry your entire career is pretty low. Hope you don’t owe $550K in loans, but unfortunately, I often see these two things (career student desires and big student loan burdens) go together.
Sinking that much time and you could complete an elite neurosurgery program followed by a spine or vascular fellowship. The financial payoff would be vastly higher, if you could get in to NS.
Is there such a thing as aerospace sleep forensic child psychiatry? What is the point of training in a wide variety of fellowships with no overlap? This not only makes no sense financially, it makes no sense as a career plan.
That’s a good point. It might be fun to learn, but you won’t learn it very well unless you actually do it.
Good points. It is just fun to learn, but eventually everyone chooses a path. Thanks for your input!
Just wanted to point out that there is definitely an arena for a psychiatrist to do all these fellowships and have a coherent career.
http://jaapl.org/content/early/2019/11/21/JAAPL.003889-20.long
Sleep medicine relates to spaceflight because sleep disturbances and altered circadian rhythms commonly affect astronauts. The linked article demonstrates the niche that forensic psychiatrists occupy in aerospace evaluations. And finally, understanding childhood traumas and treating the psychiatric disorders of children and adolescents will add another dimension of understanding into the mind of the potential astronaut.
Sure, someone who does this may not retire with 5 million dollars in the bank, but it with loan forgiveness and frugal living, I think it would be a worthwhile endeavor. I’m gonna be practicing for like forty years, might as well do something interesting and have fun with it!