“To pursue a fellowship or not to pursue a fellowship? That is the question.”
Explore This IssueFebruary 2021
Do you need a fellowship to succeed in otolaryngology? Although the decision whether or not to pursue one may not rise to the level of Hamlet’s existential deliberation (with apologies to William Shakespeare), a fellowship can contribute to a physician’s professional and personal satisfaction long after his or her years of medical training are over. What is arguably a bit Shakespearian is the passion for learning that essentially should guide the decision and be the litmus test for undergoing yet another arduous year or two of training that may or may not be used in clinical practice.
For otolaryngologists who want to practice academic medicine, pursuing a fellowship is built into the nature of practicing in a setting where training in a subspecialty is mandatory and clinical research is expected. For those wanting to go into private practice, however, pursuing a fellowship may or may not contribute to their future otolaryngology practice.
If you’re an otolaryngology resident considering a private practice career, how do you decide what the value of a fellowship is to you? Is the value of a fellowship for private practice changing, and does it depend on the type of subspecialty you pursue? The answers to these questions are fundamentally interwoven with the career path you choose.
Deciding with Eyes Wide Open
Robert A. Glazer, CEO of ENT and Allergy Associates, LLP, Tarrytown, New York, underscored the need to weigh the pros and cons of pursuing a fellowship to make a well-informed choice. “You need to have your eyes wide open, [knowing] that [the fellowship] may not necessarily make a difference in your career,” he said.
Glazer emphasized that for those who are interested in going into private practice, completing an additional round of training that most private practice groups don’t require may not make sense. Among the main issues to consider, and a disadvantage for many, is a delayed entry into the job market.
“Everybody at some point has to think of the economics,” said Glazer, highlighting not only the delay in salary a fellowship requires but also personal delays. “Most candidates coming out of residencies are age 32 or 33, and many are thinking about the economics of starting a family,” he said. In addition, a fellowship may not mean a boost in salary; for example, prospective fellowship-trained candidates seeking employment at Glazer’s group are paid the same regardless of their fellowship credentials.
Private Practice Options
All that being said, however, there is room for fellows in private practice. Many smaller practices staffed mainly with general otolaryngologists typically refer more complex cases to academic centers with fellowship-trained physicians, but an evolving market for fellowship-trained otolaryngologists is emerging within the growing number of larger otolaryngology practices. These larger private practice groups or hospital-employed groups employ a full complement of fellowship-trained otolaryngologists who are able to provide a similar level of care to that provided by academic medicine, according to Christopher Le, MD, associate professor, rhinology and skull base surgery, department of otolaryngology–head and neck surgery, University of Arizona College of Medicine, Tucson, Ariz.
My primary motivator for doing a fellowship was that I really liked rhinology and that by completing a fellowship I could hopefully narrow my future practice, to some degree, whether that be in private practice or academics. —Lauren Cass, MD, MPH
One advantage of a fellowship, he said, is becoming an expert in a subspecialty that provides a private practice group and patients a higher level of care not available outside of an academic practice group. “This subspecialty training can increase the productivity and referral base for the private practice group from primary care providers and even other general otolaryngology groups in the community,” said Dr. Le. “Overall, fellowship training in an area that a private practice group is looking to expand will make a residency graduate more marketable compared to a graduate who was not fellowship trained.”
For those who are interested in research, the large private practice group Glazer oversees includes a clinical research division in which there are currently 10 clinical research studies being conducted by both general and subspecialty otolaryngologists. With over 900,000 patients seen each month throughout ENT and Allergy Associates’ network, Glazer said that the practice is ideally situated to perform clinical research using all the patient data it captures.
Glazer does hire fellowship-trained otolaryngologists and typically will place them in a location within ENT and Allergy Associates’ network where their particular subspecialty may be needed. Of the 175 otolaryngologists within the group, up to 65% are general otolaryngologists, with the rest made up of fellowship-trained subspecialists in neurotology, laryngology, rhinology, facial plastics, and sleep. Glazer tries to have a mix of general otolaryngologists and subspecialists in each of the 43 offices within the practice network.
That said, Glazer emphasized that for fellowship-trained subspecialists within their private practice, it will generally take years to build up their specialty focus within the practice and said that they should expect to see a lot of general otolaryngology cases. “Realistically, for example, you can become the go-to rhinologist within a larger group private practice setting, but that would probably take seven to 10 years, at which time your patient population may be between 55%-75% of the subspecialty and the rest a mix of general otolaryngology,” he said.
Choose Your Passion
Once you’ve decided to pursue a fellowship, decisions should fundamentally be about your passion for learning. The topic of your fellowship should be something that resonates deeply. “Pick something you’re truly passionate about,” said Rakesh Chandra, MD, MMHC, professor of otolaryngology–head and neck surgery, Endowed Directorship for Leadership and Educational Development, Vanderbilt University Medical Center, Nashville. “Whether you serve in that capacity in your academic department and/or your community, that’s what matters the most.”
Dr. Le advises residents that a genuine interest in a particular subspecialty is the most important consideration when pursuing a fellowship. “I always ask my residents whether they would be happy practicing general otolaryngology for their entire career or if there’s a subspecialty area they really gravitate toward,” he said.
Although some subspecialties in otolaryngology are more conducive to academic medicine, others may flourish in private practices, said Dr. Le. For example, fellowship training in head and neck oncology/microvascular reconstructive surgery would more likely lead to practicing in an academic setting that would offer more career support, including access to clinical trials and collaboration with other fellowship-trained colleagues and residents. Other subspecialties requiring fellowship training, such as facial plastics reconstructive surgery, may be more conducive to private practice, given the freedom a private practice allows for more control over advertising, purchasing and distribution of cosmetic products, and reimbursement for cash pay procedures and surgeries without the academic medicine’s arduous approval process.
According to Dr. Le, one subspecialty that’s always in demand in both private practice and academic medicine is neurotology. “The high demand might be due to a combination of limited fellowship positions and graduates each year and decreasing exposure or comfort of graduating residents with otologic surgery compared to past generations of graduating residents,” he said.
Perspective from a New Fellow
Lauren Cass, MD, MPH, an otolaryngologist with Kaiser Permanente in Clackamas, Ore., who graduated in 2020 with a fellowship in rhinology, sinus, and skull base surgery and now practices in a large physician-owned multispecialty group setting, said her first priority when considering a fellowship was asking herself what she wanted to get out of it.
I always ask my residents whether they would be happy practicing general otolaryngology for their entire career or if there’s a subspecialty area they really gravitate toward. —Christopher Le, MD
“My primary motivator for doing a fellowship was that I really liked rhinology and that by completing a fellowship I could hopefully narrow my future practice, to some degree, whether that be in private practice or academics,” she said.
Dr. Cass cited additional benefits to pursuing a fellowship. “Perhaps you feel like you didn’t get enough exposure or practice in a certain area of the specialty but know that the specialty will make up a big part of your practice,” she noted. In addition, a physician fellow can offer expertise in a specialty area that a private practice group may be lacking. “Some groups may be looking for a competitive advantage and want to advertise fellowship-trained physicians,” she said.
Dr. Cass, who also has an interest in clinical research and a background in public health, emphasized that pursuing a fellowship gave her additional time and access to clinician-researchers so she could gain more robust experience in clinical research. Although she considered some academic jobs following her fellowship, she chose to practice with Kaiser Permanente, specifically Northwest Permanente, because it offered her a position that fulfilled her goals to practice more rhinology in a preferred geographical location. She also underscored the fact that Kaiser Permanente, although not academic based, is more similar to a health or hospital system-based practice than a traditional private practice group.
Dr. Cass also noted some of the disadvantages of a fellowship, including not being able to practice in your trained subspecialty if you choose to practice in a small group or in a major metropolitan area where the market for specific subspecialists is saturated. “In underserved areas, there may be more of a need or opportunity for your subspecialty, but you may also find yourself doing a lot of non-subspecialty work because there are fewer otolaryngologists in general to meet the general needs of the community,” she said.
She also pointed to the economic disadvantage, saying that fellows give up a year or two of significantly more pay than a starting salary for a practicing physician, and, like Glazer, noted that many residents are ready to settle down and begin working after long years of medical and residency training.
Overall, said Dr. Cass, residents need to be honest with themselves about what kind of career they want to pursue and what will really make them happy. “Ultimately, the needs of the group you join will largely dictate the type of practice you have regardless of what you see as your ideal practice, at least when you’re starting off,” she said, adding that the needs of the group will be dictated by its type, geographic location, and the particular landscape of the workforce at the time.
Whether or not to pursue a fellowship in otolaryngology is a choice made based on careful considerations of your personal and professional aspirations. Fundamentally, the choice to pursue a fellowship should be made on the strength of the passion you have for the subspecialty, taking into account the time it will take to become an expert in a subspecialty you may or may not use in your future career. Physician-owned group practices may offer a fellow-trained otolaryngologist a niche in their practice for taking on cases in their trained subspecialty, but it may take years to develop a subspecialty practice within the group.
Mary Beth Nierengarten is a freelance medical writer based in Minnesota.