Participating in a hospitalist fellowship means a lower income for the year or 2 spent in a program, but the long-term benefits may be worth that sacrifice.
“Fellows may be able to achieve their long-term career goals in a faster way if they make an upfront investment in getting additional skills that can often accelerate them into positions of leadership and responsibility. It does help in a competitive job market,” said Margaret Fang, MD, FACP.
The Society of Hospital Medicine lists more than 60 fellowship programs for hospitalists on its website, with programs concentrated in internal medicine, family practice, pediatrics, and psychiatry, and that number is increasing.
Although most fellowship programs attract candidates who have just completed their residency, they are also designed for physicians who have been away from clinical practice, have limited hospital experience, or want to focus on research or on a new aspect of medicine.
At the Mayo Clinic in Rochester, Minn., the fellowship program has attracted a handful of fellows over the years who have been away from clinical practice for a period of time for various reasons, such as working on a doctoral program. “They have used the fellowship program to concentrate more on the clinical side rather than on the academic side,” said Tamara Buechler, MD, ACP Member, the program's associate director.
A fellowship can also give “protected time and mentorship to develop a research interest that maybe was there prior to fellowship, but the fellow didn't have the time or the guidance to develop that interest as a resident,” Dr. Buechler said.
The programs do also carry some costs, both time and financial, which prospective hospitalist fellows have to weigh when considering whether to devote a year or more to the additional training.
The design, length, and focus of fellowship programs differ among institutions, with some emphasizing clinical practice and others more focused on research. Some offer graduate degrees as part of the training.
Gaining admission to a fellowship program is competitive, with usually only a handful or fewer positions open per institution each year. For example, at University of California, San Francisco (UCSF), where Dr. Fang is associate professor of medicine and current director of the academic hospital medicine fellowship, they generally receive 10 to 20 applications each year and admit only 1 to 3. The program at Texas Tech University Health Sciences Center in Odessa, Texas, receives 8 to 10 applications a year; half of the applicants are invited for an interview and only 2 are accepted into the program.
UCSF's 1-year academic fellowship allows time for fellows to work on quality improvement and patient safety projects and gain skills in research, leadership, and teaching, with a lot of “autonomy and ownership of what they choose to work on,” Dr. Fang said.
On average, the fellows work on 1 to 4 projects over the course of their year, many of which lead to abstract presentations at national meetings and subsequent publication, she said. The focus is not on developing clinical skills. Clinical responsibilities include a month of ward attending and 20 night shifts.
By contrast, the 1-year fellowship at Texas Tech is very clinically focused and concentrates on family and community medicine, with most candidates coming from that department's residency program. “The original architects of the program wanted to offer the fellowship track as a mechanism to make family medicine residents competitive in the world of hospital medicine employment opportunities,” said fellowship program director Arun Mathews, MD, ACP Member.
The 2 fellows admitted to the program each year participate in 6 months of inpatient experience, 2 to 3 months of dedicated ICU rotations, and month-long tracks devoted to quality improvement/hospital administration, cardiology, and a research elective. Patient loads are lighter during the first 6 months of the program, which is dedicated to didactics and problem-focused reading. After that period, fellows carry 75% to 100% of full patient loads to gain experience with triage, management, and efficiency.
Fellows who complete Mayo's program should be able to “run a service of their own with a mid-level provider and clinical assistance by the end of the year,” Dr. Buechler said. The program concentrates on research and quality, education, and clinical work—work that mimics “what it is like to work as a hospitalist. They are working shift work by the end, but they have also had a lot of time to develop both a research project and a quality improvement project,” she said.
Johns Hopkins University in Baltimore offers a fellowship designed for general internists, with the option of a hospitalist area of emphasis, targeting hospitalists who have bedside experience but want intensive research experience and training. Most of the fellowship is devoted to research projects, such as quality improvement efforts or independent research, and 20% of each year is clinical time in a variety of settings. Fellows also earn a master's degree in public health.
“This program was spearheaded by people who are really excited about academic medicine, and I think we really thrive on that. We want to advance the practice of medicine, and we want to be a learning and teaching institution,” said Daniel Brotman, MD, FACP, a professor of medicine and the hospitalist program's director.
Johns Hopkins also has a separate hospitalist fellowship at Johns Hopkins Bayview Medical Center, where 30% of each year in the 2-year program is spent in the clinic. The fellowship emphasizes leadership, medical education, quality improvement, and research, with a greater emphasis on health care systems; no degree is offered.
In addition to existing programs, the Keck School of Medicine of the University of Southern California (USC) and ApolloMed (a health care delivery group) recently announced the launch of a 1-year fellowship in hospitalist leadership. The curriculum will involve 50% clinical training and 50% nonclinical training and include patient safety, quality improvement, care coordination, and the business side of hospital medicine.
Meanwhile, a 2-year fellowship at Duke University in Durham, N.C., is scheduled to begin July 1, 2016, and will focus on academic development and scholarly work for physicians seeking leadership positions in academic hospital medicine. Fellows in the program will earn a master's degree of health sciences in clinical research.
Pluses and minuses
People involved in hospitalist fellowship programs concede that pursuing a fellowship can mean a year or more of financial sacrifice. “You can obviously make a larger salary by going right into being a practicing hospitalist instead of going through a fellowship program,” Dr. Fang said. As with most fellowships, UCSF pays fellows a PGY-4 salary, which averages about $61,300. The salary ranges from $52,483 to over $70,000 at Mayo, depending on the post-graduate year of the participant.
Many young physicians are already saddled with debt and may not be attracted by the low salary of a fellow, according to Jamie Newman, MD, FACP, hospital medicine fellowship program director at Mayo. “Hospitalist jobs for private practice are more lucrative, paying up to 4 times the salary of a fellowship. With a young family and massive debt and available jobs, there is a strong lure to enter the workforce without a fellowship,” he said.
The cost of tuition can be another financial factor, but many programs offer grants and stipends to help. At Johns Hopkins, for example, the fellowship slots are fully funded by federal training grants for the full 2 or 3 years of the program. UCSF covers tuition for its Summer Research Program, an 8-week course involving an introduction to clinical research, and covers additional coursework on an ad hoc basis. Educational grants are also available at Texas Tech.
Institutions that offer these programs aim to be training at least some of their own future researchers, faculty, or hospitalist leaders. “We have several faculty members who were prior fellows; that is definitely our goal,” Dr. Buechler said.
The benefit to the institution may not always be long term, though, if fellows leave after they complete their fellowship. “For a hospital that is understaffed, having residents enter a fellowship in lieu of joining the staff is a mixed blessing,” Dr. Newman said. “It may lead towards academic and administrative productivity, but it takes time and effort training fellows only to have them work elsewhere, leaving staff hospitalist positions unfilled.”
Regardless of where hospitalists decide to apply after fellowships, however, that added experience can definitely be a bonus, according to Dr. Fang. “The majority of the new hospitalists we hire each year are those who have done a hospitalist fellowship or a chief residency year. Having completed that gives them a leg up when being considered for a faculty position,” she said.
Dr. Mathews agreed. “There is a win-win there [for fellows] both on the academic and the professional sides,” he said. “We like to call the hospitalist program a 1-year-long interview for potential candidates.”