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numbERs

Are Fellowships Worth It? Not Really

Belanger, Tom MD

doi: 10.1097/01.EEM.0000804948.07297.5b
    FU1-13
    Figure:
    EM fellowships, opportunity costs, jobs
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    Figure

    Opportunity costs and incentives affect our decisions and their outcomes for a career in emergency medicine. As I wrote in October, many large entities are shaping the destiny of emergency medicine, all of which possess large repositories of valuable data. Making the right data public to all emergency physicians will level the playing field by allowing individuals to appraise costs and benefits accurately and make the best decisions possible. (EMN. 2021;43[10]:27; https://bit.ly/3A5k8ps.) A review of the collected data would help emergency medicine better answer if a fellowship is worthwhile.

    My survey used online anonymous data collection and received 473 responses. A total of 103 respondents were currently in EM fellowship training, 136 had previously completed a fellowship, and 234 had never done an EM fellowship. (Table 1; numbers vary because seven respondents did not specify a type of fellowship.)

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    Calculating the Cost

    Opportunity costs are the total costs incurred by taking one action instead of its alternative. A simplistic choice between doing a fellowship in your chosen EM subspecialty and practicing without this fellowship has many different types of costs: Some are measured in dollars (the income you may give up during fellowship, for instance), some are measured in hours (the extra time you might spend at work), and some are measured in promotions.

    The time at which these costs are accrued matters; a cost paid upfront is more costly than one paid at a later date for several reasons. Thought of another way, $100 today is worth more than the promise of $100 a decade from now, even after adjusting for inflation. (Economists call this time preference; read more at https://bit.ly/2Y3eSFw.)

    I translated the costs into dollars to standardize the costs across type and chronology for ease of comparison. A fellowship in emergency medicine is best thought of as a large upfront cost with a possible marginal benefit progressively accrued in the future.

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    I first calculated the initial monetary sacrifice by finding the difference between the hourly pay during a fellowship and the hourly pay of an attending who had never done a fellowship to calculate the opportunity cost of each fellowship. This difference was then multiplied by the number of hours a fellow typically worked in a year, which was then multiplied by the number of years of the fellowship program. This total was compounded by 10 percent annually for the duration of a typical physician's remaining career.

    The rationale for using this quite large amount instead of only the smaller amount likely to be saved is that these things still hold value and this value still diminishes (if only for the reason that putting these things off may mean you never get to enjoy them) even if newly-minted attendings chose to invest their increased earnings on private jets and top-shelf liquor or simply choose to work fewer hours and spend time with family.

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    I calculated the pay difference between fellowship and non-fellowship-trained physicians over each year to see if this cost was eventually offset. This pay difference was compounded, but each subsequent year of earnings was compounded one less time than the year before.

    The Results

    I limited my analysis in this article to the five most popular subspecialties to avoid drawing conclusions from anomalous data. (Graph 1.) Hourly pay generally seems to be better for those not trained in a subspecialty, but the hourly difference diminishes across the most popular subspecialties (EMS, ultrasound, and critical care). (Graph 2.)

    The calculations are unforgiving. You generally forgo the potential for millions of dollars of lifetime yield by choosing to do a fellowship in emergency medicine. This may seem drastic, but remember that a fellowship is a large upfront cost, and its effects grow over time. Future yield would need to be very high to compensate for this loss, and, as you can see from the numbers, the future yield is often negative, which only further exaggerates the cost.

    Some good news can be found for those having completed a fellowship, however: They do see significant intangible gains. Physicians who have done a fellowship are about twice as likely to have an administrative role (41.2% for fellows v. 20.5% for non-fellows) in their organization as those who have not. Those who completed fellowships also consider themselves to have far more power, locally and within the specialty of emergency medicine, than those who have not. (Graphs 3 and 4.)

    The Real Costs

    This methodology was not intended to perform a perfect calculation on the yield of an EM fellowship, and it is not a condemnation of choosing to subspecialize in EM. Rather, my goal was to lay bare the real costs of deferring income in emergency medicine.

    The results show that fellows appear to give up significant lifetime earning potential in exchange for potential intangible benefits, including greater administrative roles and a greater sense of power in their communities. A better understanding of the total opportunity costs of this important choice will help EPs decide if subspecializing is right for them. More work can and should be done in this space.

    I built this tool at this time for an important reason: I am concerned that a tight labor market will force residents to choose fellowships over entering the job market. Before doing this, though, residents need to be aware of the lifetime costs, which are potentially large. Many may see increasing numbers of fellows as a good thing for emergency medicine, but this trend may also represent underemployment that could hide the true effects of a tightening labor market.

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    Fellowship N
    Administration 12
    Clinical informatics 5
    Critical care 36
    Disaster medicine 3
    Education 17
    EMS 32
    Health policy 2
    Hyperbaric medicine 4
    Innovation 1
    International EM 8
    Medical toxicology 18
    Pain 8
    Palliative care 6
    Pediatric EM 15
    Research 6
    Simulation 3
    Sports medicine 7
    Ultrasound 40
    Wilderness medicine 9

    The tool has one further purpose, and I will use it in my February column to examine how opportunity costs affect power structures in emergency medicine, and, hopefully, demonstrate how this affects our specialty and our patients.

    Download the raw data, see the yield for the full list of fellowships, and explore the app for yourself at https://bit.ly/numbERsROIsurvey.

    Dr. Belangeris secretary of the American College of Emergency Physicians Locum Tenens section and an emergency physician in McKinney, TX. Read his past articles athttp://bit.ly/EMN-numbERs.

    Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.
    • Tom Belanger, MD5:37:21 PMIt certainly seems that your fellowship was worthwhile! My fear is that people may turn to fellowships in a tough job market; I want them to know what they may be giving up by doing this. But it's wonderful to see that there may also be gains that are missed by a strictly financial analysis.
    • Jon Matson, MD11:12:27 AMDr. Belanger, you area absolutely correct. Doing an EM ultrasound fellowship cost me three-quarters of the pay that I would have otherwise made at the job I left in 2011 to do the fellowship. That is money I will never get back or be able to invest. Doing the EM US fellowship was worth it, however. As an EM graduate in 1998, I had essentially no EM US training as it was just coming on the scene. Though my civilian job had great US coverage, my military experiences in Iraq and Okinawa convinced me that this skillset was an important tool for my desired future endeavor. I did my fellowship with the mindset of going to Africa to teach and to provide direct patient care. I currently serve in Kenya at a mission hospital since 2015 making 1/30 to 1/20 of what I could make in the United States. I do indeed teach and lead an 18-month program that teaches PA-equivalents EM and critical care to fill a giant gap in these areas. There is only one Kenyan trained formally in EM for 56 million citizens. Concerning critical care, there are very few specialists here in that area. Our graduates are running ICUs now. I have an incoming class of 14 trainees starting in January and a current class of 13. Part of their training is to perform ECHOs, evaluate IVCs, and perform e-FAST exams, among other skills. This is important because many hospitals do not have CT scan technology, much less MRIs, available. Though I continue to train these skills, my former students are now training the students too. Our hospital did have two American-trained peds-EM-trained docs, though we are down to one peds-EM doc now. They made a huge impact here in pediatric care, especially peds critical care. They established our peds ICU in conjunction with our very skilled Kenyan pediatricians, and they even helped establish the first EM-peds fellowship in coordination with the major teaching hospital in Kenya. I regret that my age and time will not allow me to do a critical care fellowship. This training is the skillset that I think would make a great impact here and anywhere in the developing world. After critical care-trained personnel, EMs are the de facto critical care docs. And many of the skills learned in the EM US fellowship are part of the critical care training. So it is with some envy that I watch my younger American IM-peds colleague completing his critical care fellowship. So you are correct. Any fellowship will cost the individual money, both present and in the future. But the potential for increased knowledge in one's area of interest and the ability to skillfully impact patients more in the United States and abroad is a fantastic and satisfying accomplishment. Blessings on all my EM colleagues.