By Dr. Charles Patterson, WCI Columnist

Two years out of training, while enjoying a lovely summer evening with my young family, I received a text message out of the blue from a residency mentor. It was great to hear from him—he had always been the type of physician and gentleman that I had aspired to be. The reason for the text was quite random—he was looking for a recommendation on a Willamette Valley Pinot Noir, a topic about which I am very happy to feign expertise and render a pretentious opinion.

After the scripted pleasantries and joyful banter, he incisively asked when I was going to fellowship. It struck a nerve.

Residency (newsflash!) is hard. At the time we went through it, my wife and I were young, our marriage was new, and we were experiencing the simultaneous growing pains of first-time parenthood and the foundation of careers in medicine. Although I had planned on subspecialization, the toll of the training lifestyle weighed heavily on our little family, and we agreed to take some time in between pipelines to settle and establish some real or perceived sentiment of competence.

Life was indeed more enjoyable after residency: we had integrated nicely into a community we loved, our family was growing and thriving, and we were fortunate to be enjoying good health of mind, body, and spirit. Work was work—a task that seemed a satisfactory trade of time for income—but it lacked the personal and professional fulfillment that can contribute magnificently to a life well lived.

I was surprised by my visceral reaction to the mentor’s question about fellowship. It seemed more than a Siren call; rather, it was received (whether intended or not) as a calling to something greater. The implications for our family, our careers, and our quality of life in training and beyond were profound. After weeks of scrupulous inner dialogue, I broached the idea with my wife, expecting an incredulous laugh and a Dikembe Mutumbo-style rejection. I was floored by the swiftness with which she responded: “We need to do this.


Conceptualizing Fellowship

No one enters training so that one day they might continue to be a trainee. We are enticed at first, idealistically, by the beauty of the field and the intellectual stimulation it engenders. But how often do students and trainees take the requisite time to explore what their life will look like after residency and fellowship? How many lay down a strategy for achieving contentment through a harmonious integration of personal and professional endeavors? Do we, as a culture of medicine, help our learners think through their plans for financial independence, for physical and mental health maintenance, for spiritual or philosophical enrichment, or for overcoming faults and finding joy through relationships and experience? I would posit that we have, to our shame, decried such “soft niceties” as outside of our scope, ignoring that what sounds sexy and awesome when you are 27 may be a hellish nightmare when you are 37.

One of the benefits of training after a period in the working world is this: I had tasted the good life; knew what life could look like; and with carnal knowledge, made the bed that I would lay in. We had settled into our modest primary care attending income, and I was now pushing (gasp!) my fifth decade. I had a sense of what fellowship would demand and what the pace of the career would entail afterward. To the most detailed extent possible, I planned for how my priorities could change with each season of life.

My wife and I talked, imagined, then talked some more. We mused and overthought, walking through contingencies ranging from chronic illness to burnout to lawsuits. It was a discernment process. Not unlike bringing a child into the world, a career shift of this magnitude is an exciting venture of best-laid plans. And as with all things, we set our expectations low and agreed to take the plunge together.

The financial implications of fellowship are practical in nature. By this, I mean that there are two ways of rectifying the income loss (opportunity costs) that come with the added years of training. In the first place, if one makes significantly more as a subspecialist, then one can obviously make up the difference with enough time, prudent savings, and investment. The second: accounting for the years of lost income would be the potential for bolstered career longevity and productivity as a result of increased job satisfaction.

Making the financial case for further training was made easier by a review of literature which described the actual costs and benefits of specializing. While there is little credence to geographic arbitrage, benefits negotiation, retention incentives, and field saturation, there is a plethora of basic information published on physician income to help inform the decision.

In my case, the specialty of choice was both more lucrative and intellectually engaging. Based on Medscape surveys and conversations with colleagues across the country, annual compensation for the subspecialists in my desired field was typically 20%-25% higher than those in general practice. And even if the compensation wasn’t higher, I felt that my longevity in practice would be more robust. God bless the general pediatricians of the world. While I probably wasn’t the worst of those, for practical reasons (pace, nature of practice, academic interest), it just wasn’t tenable for me to stay in that position for the long term. The money involved was, to a large degree, knowable, and that is an important, if sticky, consideration.

Money, though a critical aspect of the decision, is by no means a be all end all. It says quite a bit if one is willing to take a haircut so they can subspecialize. What proves more difficult is predicting the fulfillment associated with said career five, 10, 20, or even 40 years after training. Medicine is tough. Life is hard. Circumstances change. Maybe you don’t want to be in the OR when you’re 50. Maybe pulling a 48-hour shift is less tenable when you’ve got adolescents skulking about the house unsupervised. Perhaps being beholden to a large HMO becomes the moral equivalent of a daily ocular papercut.

For us, the fulcrum in considering these impossible questions was an agreement to regularly (yearly and as needed) examine and resist the career creep that can erode the time that is the lifeblood of our family.

More information here:

Should I Do a Medical Fellowship?

My Spouse Is Quitting Medicine


The Oldest Trainee in the Hospital

It ended up taking several more years to begin fellowship, thanks in part to a lovely deployment and a very unique Match process. While it was unnerving to be back in an academic center after such time, the cobwebs seemed to dust off after a bit of attention. As it happened, feared atrophy in inpatient acumen was, in reality, a trial in reintegrating into systems processes and resource management, as opposed to lost or outdated subject matter understanding. One of the worthy criticisms of our monolithic GME complex is that we have become very good at creating great trainees, who in turn must become great attendings once they have graduated. I don’t have a fix for that. But I am grateful for the four years of solo practice and for the opportunity to learn what patient ownership really feels like. Experience is an excellent teacher.

too old to be training

I am the oldest trainee in the hospital, older even than several of the attendings. Perhaps it's the receding hairline or the palpable decay that comes with fatherhood, but there is more than an age gap that separates me from my fellow trainees. They sure seem smarter and more adept than I am (or was when I was in their position), but I must confess that I don’t envy them. We all share a fear of what comes next. But this is not my first rodeo, and I am acutely aware of what success and failure look like. The learning curve is as steep as ever, but great challenges are great because they are only surmountable with full exertion. No matter the outcome, I chose this path with a greater understanding than most.

More information here:

The Moderate-Income Physician



Having completed a significant portion of training, I periodically reflect on whether I would do it again. The answer is absolutely yes, and I am incredibly grateful that I did it and that I am on this path. It's an arduous and intimidating time of life, but let's face it: we're lucky to have problems such as these.

Would my wife and kids do it again? I don’t know; I’m afraid to ask. The general consensus, depending on the day, is that this has been a manageable set of challenges that have promoted healthy growth (one of the residents who received this answer told me that my response was “corporate.” I didn’t know whether to laugh or cry). But the truth of the matter is that this has been hard. We chose the more strenuous trail. And because of that, we are stronger and more resilient. We own our decision and are grateful for the opportunity. We are blessed to say that, in our marriage and in our family, each year has been more fulfilling than the one prior.

That is as true now as it ever was. This career evolution has contributed to that success, and it is our intent to keep it that way.

Have you thought about going back to training after a stint in the so-called real world? Have you already gone down that path? Was it worth it? Would you do it again? Comment below!

The views expressed in this article are those of the author and do not reflect any official position of the Department of Defense or the US government. These writings are not authorized, approved, or endorsed by any of the above entities.