One important decision to be made near the end of residency is whether or not to pursue fellowship training. This can be a difficult decision as it involves multiple factors. Written with my own fellowship experience fresh in my mind, this article will address background on fellowship training, job market considerations, and benefits of fellowship training.
Fundamentally, a fellowship is meant to develop a particular skill beyond the skills that typically are obtained through residency alone. In 2001 the Committee on Accreditation of Subspecialty Training was formed under the aegis of the Society of Neurological Surgeons to provide guidelines regarding fellowship training and to accredit fellowship programs. The committee established several principles; among the more important of these is that neurosurgical residency alone is sufficient for the competent practice of neurosurgical care. The committee defined a fellowship as postgraduate training of usually one year in duration. The committee also affirmed that “enfolded subspecialty training,” dedicated subspecialty exposure during residency, may provide sufficient experience to allow a greater level of subspecialty expertise than would ordinarily be obtained during residency.
Currently there are more fellowships available than there are residents to fill the spots. According to the AANS fellowship directory, there are 205 fellowships available. Of these fellowships, the greatest number is in spine (42), endovascular and interventional radiology (36), pediatrics (30) and oncology (22). Although the accreditation process has been in place for six years, only 18 fellowships, 9 percent, are accredited, and most of them are in pediatrics.
Job Market Considerations
Of the 43 positions advertised in the September issue of the AANS Journal
of Neurosurgery, 13 mention the desirability of some sort of subspecialty
training. Of these, only seven (16 percent) mention fellowship training as
necessary for consideration, and these were for endovascular (five), pediatrics
(one) and spine (one) positions. Similarly, of the 129 listings in the AANS
Online Career Center, 20 (15 percent) mention fellowship training as desirable,
but only 5 percent require fellowship training, again for spine (three),
endovascular (two), and pediatrics (two) positions, which appear to be the
fellowships most commonly in demand. Furthermore, these “fellowship only”
listings were for private practices, possibly refuting the perception that
a fellowship is more necessary for academic jobs.
There is also an “opportunity cost” associated with a fellowship, namely the loss of a year’s income. For example, assume you finish residency at 35 years of age and that you plan to work 30 years until you are 65. You make $50,000 as a fellow, and then take a job for $300,000 for two years, after which you become a partner making $500,000 a year until you retire. If you invest 10 percent of your income and achieve a 9 percent return, you will save $5,988,518 before taxes. On the other hand, if you take the same job directly out of residency, you will save $6,512,350, a difference of $523,832-one year’s salary plus interest.
The Case for Fellowship Training
There are tangible and intangible benefits to pursuing postgraduate fellowship
training. If you are interested in endovascular neurosurgery, which is not
part of the core neurosurgical curriculum at most institutions, a fellowship
will be necessary. Also, if your skills or exposure during residency to a certain
subspecialty is less than you would like, a fellowship might be a good idea,
particularly if your weakness involves a skill that you will need to be successful
in general practice, such as spine instrumentation. Lastly, despite the job
market as a whole,manyresidents are not looking generally for a job, but
rather for a specific position. In that context, a fellowship may be an absolute
necessity or it simply may differentiate you from other candidates seeking
the same job.
There also are intangible benefits to fellowship training. Besides surgical skills, a fellowship gives you a different perspective, usually from an institution or individual who is a leader in the field, on your chosen subspecialty and often on neurosurgery in general. Other intangible benefits include learning different business practices, work habits, and meeting new people, all of which can be helpful in your career.
In conclusion, the decision to pursue a fellowship involves both quality of life and financial factors. As with all important decisions, knowing your own needs and goals, having the correct information, and understanding the direct or indirect benefits are all necessary for making the decision that will most benefit you.
K. Michael Webb, MD, is a founding partner with NeuroTexas PLLC in Austin, Texas. Send topic ideas for this department to Dr. Webb, Residents’ Forum editor, at [email protected]. The author reported no conflicts for disclosure.
New Residents Area of AANS.org
Fellowships are among the important and often time-sensitive information now
aggregated for residents at www.aans.org/residents. The area offers links to
courses,
grants, AANS benefits, and other topics of particular interest to residents.