Fork in the road: Should you pursue fellowship or go straight into practice?
Key Takeaways
For physician trainees, fellowship means increased training and specialization, but deferred peak earnings.
Clarity on career goals, financial outlook, and debt load can help inform the decision on whether to seek a fellowship.
Physicians can familiarize themselves with other doctors’ journeys before making their own decisions about fellowship.
If you’re like the typical physician-in-training, you’ve spent about 4 years as an undergraduate, another 4 years in medical school, and then anywhere from 2 to 7 years in residency.[] Along the way, an estimated 73% of you amassed student-loan debt, and your median education debt load is about $200,000.[]
Time and money make the prospect of spending another 1 to 3 years in fellowship a decision that trainees should consider carefully.[] Should you pursue fellowship, or go straight into practice? The right decision will be unique to each physician, but there are some common factors worth weighing.
Begin with the end in mind
When considering if fellowship is right for you, it helps to begin with the end in mind. In the case of two physicians who spoke to MDLinx, one knew the ultimate end goal was a specialized surgical career, and the other knew that balancing work with a thriving relationship was important.
Robin Friedman, MD, is a colorectal surgeon with Valley Health System in New Jersey.
Dr. Friedman knew her subspecialty was the right choice for her, and she knew fellowship was a requirement.
“I’ve wanted to be a colorectal surgeon since my first year of general surgery residency,” said Dr. Friedman. “I found the field to be filled with pleasant, compassionate, and light-hearted surgeons. That was very attractive to me.”
Related: Choosing your fellowship: How do you find the right fit?Clarity on goals was also a driving factor for Jayram Pai, MD, an emergency medicine physician with Brown Emergency Medicine in Rhode Island. Dr. Pai’s wife, who specialized in pediatric emergency medicine, was facing a mandatory fellowship.
“It was easier to find a job rather than to try and coordinate two different program matches,” he said. Eschewing fellowship also allowed them to avoid a long-distance relationship, he added.
Dr. Pai, an assistant professor at Brown’s Warren Alpert Medical School, also suggested that if going into a competitive academic-based practice is a priority, “having a fellowship can give you a niche that makes you a more competitive job candidate.”
Effect on future earnings
Of course, economics can be an important part of fellowship considerations.
Regardless of fellowship decisions, physicians spend a long time in training—time when their lay peers are progressing toward maximum earning potential and (hopefully) saving money for rainy days and retirement.
According to the jobs site Indeed.com, the average US medical fellow earns approximately $47,000 a year.[] Indeed derived its estimate using data from fellows in cities across the US. For comparison purposes, the most recent Bureau of Labor Statistics data puts the average American’s annual salary at around $57,000.[]
On the surface, additional education may not seem like a prudent financial move, especially when you consider that in 2023, the average US physician earned $352,000, according to Medscape.[]
However, future earnings in a subspecialty may offset the immediate cost of a 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,” wrote Dr. James Dahle, founder of the White Coat Investor.[]
However, this analysis generally does not hold up for medicine in general, Dr. Dahle added, as most physicians have the intelligence to succeed in other, more lucrative industries.
Dr. Friedman said that future earnings didn’t factor into her decision.
"In the grand scheme of things, 1 to 3 extra years is nothing. We spend so much time [in training] that you shouldn’t settle for anything other than your dream specialty. "
— Robin Friedman, MD
Debt load
Education debt may also factor into any fellowship decisions. On the surface, deferred earnings may mean deferred elimination of that debt.
According to Dr. Pai, the pandemic deferment of student loan payments took some of the financial pressure off his decision making. And according to Dr. Friedman, passion for her profession was the priority.
“It's best to be happy doing what you love than to have a higher income [in] a few years,” she said.
Also factoring into any fellowship decisions should be potential eligibility for the Public Service Loan Forgiveness Program (PSLF).[] Let’s say you’re a physician pursuing a fellowship in pediatric sports medicine, and all of your top fellowship choices are nonprofit entities that would qualify you for PSLF.
Under PSLF, you would be making income-adjusted payments during your fellowship, all of which could count toward loan forgiveness. These qualifying payments would continue if, after your fellowship, you continued to work for an eligible employer.
Suddenly, debt load becomes less of a consideration—but you have to begin with the end in mind.
Ask around
The application process is lengthy—that's one of the reasons fellowship isn’t a decision to be taken lightly, nor is it one that can be made at the last minute. Before physicians make any decisions, they can talk to their peers, attendings, and perhaps the head of their residency program. They may also want to seek feedback from the people who have walked the career path they are considering.
Both Dr. Pai and Dr. Friedman appear to be content with their choices. Both are new parents who are enjoying their families and careers. Dr. Pai will soon make a career move to New Jersey, and Dr. Friedman continues to love the rigor of compassionate care and cancer prevention.
“I don’t think I would do anything different,” Dr. Friedman said.
What this means for you
Logistically, it’s impossible to make a rushed fellowship decision—the application process is too lengthy. Physician trainees can use this natural break to do their due diligence and determine whether fellowship is aligned with their career goals, earnings outlook, debt load, and desired life outside of practice. Quizzing peers and superiors about their experiences will also be helpful.