Choosing Fellowship
By Amy Lynn Sorrel Texas Medicine July 2015

As Medicine Becomes More Specialized and Competitive, Career Decisions Become More Complex

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Tex Med. 2015;111(7):39-45.

By Amy Lynn Sorrel
Associate Editor

Before she became a fellow in maternal-fetal medicine at The University of Texas Medical School at Houston, Hind N. Moussa, MD, worked for five years as a general obstetrician-gynecologist. "I had a great job. My practice grew. But I really wanted to go back [into training] and felt like I could do more for high-risk patients."

Having referred many of her patients hours away for subspecialty care — or filled in gaps when she could by providing some tests they needed immediately — Dr. Moussa also knew there was a shortage nationwide of maternal-fetal medicine specialists. 

"Science is exploding. There's information and mission fields we didn't have before, like genetics and stem cell treatments, and ethical questions about what to do with all this technology now that we have it and whether we are using it the right way. We're not in a time when general practitioners can do everything," she said.  

In fellowship, the member of the Texas Medical Association Resident and Fellow Section saw an opportunity to serve a population of patients in need of more specialized care and to ensure the long-term viability of her practice. 

"There's a lot of competition to have a better job and a better lifestyle and be competitive for good jobs," Dr. Moussa said. "But money isn't the only driver. We spend three years on our fellowship. That's three years of lost income. So you also have to think about whether this is something you can live with as a career and something you love, because it is still very demanding." 

Subspecialties Grow

Dr. Moussa is among many physicians who go on to hone a subspecialty through fellowship training. In 2015, a record-setting year for fellowship appointments followed what was the largest Main Residency Match to date, according to the National Resident Matching Program (NRMP). (See "The Age of Subspecialization.")

As with residency, educators emphasize that wherever fellows train they tend to practice, making retention critical to an adequate physician workforce. As subspecialties grow, however, some question whether the trend is also narrowing access to needed general care, for example, primary care, general surgery, general obstetrics, or general psychiatry. 

The NRMP Specialties Matching Service, the nation's largest fellowship match process, encompassed more than 3,600 programs across 56 specialties — with more than a dozen new specialties joining in the last few years. Programs filled nearly 90 percent of the 8,500 positions available, and 80 percent of programs filled all of their positions. Because fellowship matches occur throughout the year, the data are for matches conducted in 2014 and early 2015 for appointments beginning in July. 

Those numbers reinforce years of TMA advocacy for investments that ensure a steady physician supply in a state facing shortages across specialties, says Christian Cable, MD, a member of the TMA Council on Medical Education and director of the hematology-oncology fellowship at Baylor Scott & White Health in Temple. "All postgraduate [medical] education is growing, and has been growing, and what we are seeing now is fellowship catching up with residencies. It's in our best interest to find room for all of our high-quality graduates or we risk losing them to other states."

While there are a number of reasons residents and established physicians go on to pursue fellowships, educators also search for ways to match up subspecialization growth with access-to-care needs. With general and primary care in just as high demand, "it's a question that deserves serious conversation," Dr. Cable said.

The 2015 legislature added $53 million to the state's graduate medical education (GME) budget, but none of the money would go to fellowships. Most of it would expand or fund existing, unfilled entry-level residency slots in primary care and specialties, with the possibility of adding an estimated 200 new positions.

According to NRMP, more than 9,500 applicants participated in the fellowship match for a total of 8,500 positions, with 78 percent obtaining an advanced training slot. 

Fellowship positions have been on an upward trajectory since 2000, outpacing the growth rate of residency positions, according to the Accreditation Council for Graduate Medical Education (ACGME) Chief Executive Officer Thomas J. Nasca, MD. 

While most of the expansion is in existing specialties such as cardiology and gastroenterology, he says during the past 15 years, a whole new series of subspecialties have cropped up: sleep medicine, hospice and palliative care, and medical informatics, to name a few. 

The total number of specialties and subspecialties certified by the American Board of Medical Specialties grew from 113 in 2003 to 161 in 2015, according to TMA research. 

"By and large, the new subspecialties are the result of scientific advances in particular disciplines and specific patient care needs in the population," Dr. Nasca said. Sleep medicine, for example, emerged out of research leading to new techniques that allow physicians to study sleep patterns, its respiratory components, and the central nervous system, and in turn, make better diagnoses and design better treatments. Hospice and palliative care arose to provide more effective ways to keep terminal patients comfortable psychologically and physically, beyond just pain relief. 

Passionate Pursuit 

For the most part, physicians choose a particular area of expertise based on what they are passionate about, and educators generally counsel them in that direction, Dr. Cable says. Nonetheless, trainees are increasingly cognizant of the technical, financial, and lifestyle pressures facing them in today's workforce.

The decision often starts with graduates choosing a residency program that also has a fellowship in a subspecialty that has piqued their interest. And fellowship program directors tend to be more comfortable with residents from their own residency programs "because you basically have a three-year audition on how they work in interprofessional teams and complex systems, and that's more important than just medical knowledge on a test," Dr. Cable said. 

Thanks largely to medicine's advocacy, trainees don't have to make a lifelong career decision too early, he says, now that the fellowship match got pushed to the third year of residency. Because he participated before the change, Dr. Cable had to decide by the beginning of his second year of residency. 

"I was interested in another subspecialty and had already applied and interviewed. And while I was in an oncology rotation, I fell in love and didn't see it coming. The reason TMA and the council advocated for the change was, we wanted residents to have more time making super high-stakes decisions about what to do the rest of their careers," he said. "Medical knowledge has become so intensely amplified trainees are terrified to have to master it all. An amazing primary care physician knows the 90 percent he or she can do and the 10 percent they have to refer, and has that intuition. But that can be intimidating for a young trainee."

But higher performance expectations are quickly becoming a fixture in today's health care system, and some fellows and educators say the advanced training can help prepare physicians for that reality.

Dr. Moussa says this year "every spot filled" in UT Houston's obstetrics-gynecology subspecialties, with an overflow of applicants.

"We have to be competitive. We have to provide good quality care. And everyone — Medicare, Medicaid — is looking at your performance," she said. "With all of these changes, it makes sense to subspecialize to meet all of these new requirements to prove you are providing the best quality care, or you won't receive payment." 

Baylor College of Medicine uses fellowships in part to arm physicians-in-training with the leadership skills to cope with practice pressures, says Angela Siler Fisher, MD, an emergency physician and director of the emergency medicine administration fellowship. As associate chief of operations for emergency medicine at Baylor, she founded the school's Emergency Medicine Administrative Fellowship Program, along with six other emergency medicine-based fellowships.

With a more complex medical system and increasing restrictions on residency work hours, "we barely have enough time to fit all the clinical training in. For that reason, fellowship is focused on the clinical practice, as well as business and administration. Fellowship ensures formalized mentorship to aid in honing leadership skills to be successful in practice," she said. "All physicians, whether in an academic or community environment, are required to understand the business of medicine." 

As Baylor's first international emergency medicine fellow, Jessica A. Best, MD, is looking to translate her experiences in other countries into expanded clinical and leadership skills back home in Texas. She starts her international fellowship in July. "There's a big push now for global medicine to give residents and students a different perspective on medicine and the treatment of patients not only in different systems, but also in limited-resource settings," of which Texas has many, the member of the TMA Resident and Fellow Section said. 

Dr. Best and her young physician colleagues are also well aware of the increasing medical school debt they have accumulated. But money is not their main motivation. 

"Financial reimbursement is better in subspecialty fields. But we are taking a pay cut to pursue our dream," by delaying full-time practice, she said. "People joke and call it the $300,000 mistake, but a lot of us are doing this because it's what we are passionate about." 

Recent studies suggest specialization may contribute to lower physician burnout rates, too.   

Closing the Gaps

Fellowships also help expand the scope of opportunities educational institutions provide and serve as a good recruiting tool for high-caliber trainees and faculty, says Surendra K. Varma, MD, a member of the TMA Subcommittee for Academic Physicians and executive associate dean for GME and resident affairs at Texas Tech University Health Sciences Center (TTUHSC) in Lubbock. 

But he acknowledges those benefits can come to the detriment of less lucrative but equally necessary general care. Often the hospitals that teaching institutions partner with to provide fellowship training "would rather fund a cardiology fellowship than an infectious disease fellowship because [the hospitals] are going to benefit more from procedure-oriented subspecialties." 

At TTUHSC, for example, out of 36 internal medicine residents, only six or eight will remain in primary care, Dr. Varma says. Most go on to choose subspecialties like nephrology, hematology-oncology, or pulmonary and critical care, and all of the school's internal medicine fellowships "are full," he said. 

Educators do not deny the need for subspecialty care, pointing to the Association of American Medical Colleges' most recent prediction of a national shortage of nearly 46,000 to 90,000 physicians by 2025. That includes shortages in primary care and specialty care. Download the full report.  

"But the gap between specialty care and primary care is too high," Dr. Cable says, due largely to an imbalanced payment system that undervalues primary and general care.

The maldistribution also underlies the Institute of Medicine's recent study of the issue and controversial recommendations for reform of GME financing. (See "GME Gamble," October 2014 Texas Medicine, pages 27-31.)

Federal antitrust law precludes ACGME from actively managing the number or type of residency and fellowship positions offered. 

Dr. Nasca says ACGME, one of several fellowship accreditors, has largely responded to the subspecialty movement, having accredited programs in 146 different disciplines — up from 28 in 1981 — and assuring high-quality training in those disciplines. "But in reality, the public does not need as large numbers of subspecialists, as we need generalists, and not just primary care."

The gap could shrink, he says, as ACGME moves to a new model that places more emphasis on demonstrating community need as a part of programs' assessment. (See "Learning Curve," April 2014 Texas Medicine, pages 27-31.) 

"We are struggling to go beyond merely assuring the public of the quality of education to try and understand how potentially helpful or harmful continued subspecialization is to overall clinical care efforts. One challenge is balancing scientific advancements and the delivery of sophisticated services with trying to create a physician workforce that meets all of the needs of the American public in an efficient and effective fashion," Dr. Nasca said. "What's clear is, there is a delicate balance that needs to be struck, keeping in mind graduates are going to practice in the areas where they train. So we are asking programs to ask those fundamental questions: What does the community need? And are we preparing people well to meet the needs of the populations we serve?"

Educators also walk a fine line in counseling their trainees. 

"I knew I could make a meaningful contribution taking care of people at the end of life. Not only would I have been willing to make less, but I would have pursued it, no matter what," Dr. Cable said. "So my message to my students is, if something is your passion and that's how you are going to make a meaningful contribution, then we absolutely need it. If you don't have a passion, the best hours and salary in the world won't make up for it."

Dr. Fisher agrees the primary care and specialty gaps are largely rooted in the physician payment system. But as long as medicine continues to change, access to care will change with it, she says. "Specialization is a good thing because you want experts taking care of you. We're going to continue to see increases in fellowship and, as a result, stronger physician leaders in a position to advocate for their patients in a more meaningful way." 

Amy Lynn Sorrel can be reached by phone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email.

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