Is Fellowship the Best Pathway After Residency?
Point
Medical practice is a lifelong learning process, but does extending formal training into fellowship make sense for all podiatric residents? Here the author delves into the existing research that suggests that fellowship training is a choice that can yield long-term benefits for the right candidates.
By Elizabeth Ansert, MA, DPM, MBA
The pursuit of fellowship training is a topic that will likely cross the mind of every podiatric student or resident at some point in their early careers. For some, this extended training is merely a fleeting thought, while others devote significant time to the decision. Those individuals thinking of fellowship often seek advice from others in the field. I have been privy to arguments both for and against completing a fellowship, including considerations related to compensation and clinical confidence. Some contend that fellowship is an unnecessary commitment if “your residency is good.” In my experience, it seems that those who favor fellowship are those who have pursued it. It can be challenging for prospective fellows to know what to do or whom to listen to on the subject.
Is Fellowship Training The Best Choice For Everyone?
So when asked the question of, “Is fellowship the best pathway after residency?” my answer is … maybe. I contend it can be a best pathway for some, perhaps even many. While fellowship training in podiatry has become more commonplace, I believe that any pursuit of advanced or specialized training should not be expected of everyone. Being forced into an additional year of training simply for the benefit of stating you are fellowship-trained is not a valid reason to pursue this type of course. It should also not be a substitution for anyone who may feel that their residency training did not meet their expectations. Adding this additional year of training without a genuine desire for it often will put unnecessary stress and strain on that individual without any true benefit. However, a year or two of advanced and specialized surgical training can be immensely beneficial to those who truly desire to pursue it.
What Does The Current Evidence Reveal About Choosing To Pursue Fellowship?
Thankfully, some recent studies may provide some clarity and concrete evidence for young podiatrists to consider when making the decision of whether or not to pursue fellowship training. First, research from other specialties outside of podiatry found an overall benefit of fellowship training. This data from other subspecialties supported that fellowship training leads to more competent surgeons, better outcomes, and fewer complications.1-3 Two additional studies found that fellowship-trained surgeons had better outcomes and fewer complications than those not fellowship-trained.4,5 Similarly, those who were fellowship-trained exhibited improved surgical learning curves.6
In the podiatric literature, Summers and colleagues conducted a subjective survey to determine the pros and cons of pursuing fellowship training within the field.7 For fellowship-trained podiatrists, the decision to pursue fellowship primarily stemmed from beliefs regarding extended training, marketability, and financial benefit. For non-fellowship trained podiatrists, their decision had to do with disinterest and delayed income. The fellowship-trained group reported increased specialization, training, mentorship, confidence, and better job opportunities due to their training. On the contrary, the non-fellowship trained podiatrists noted that starting their jobs sooner and earning increased income earlier in their careers was of great benefit.7
Interestingly, the same study asked the respondents to indicate their satisfaction with their decision. One-hundred percent of the fellowship-trained podiatrists related complete satisfaction with their decision, compared to 76.1 percent of the non-fellowship-trained podiatrists.7 When asked to retrospectively examine their decision, only a little over half of the non-fellowship-trained respondents stated that they would not pursue fellowship. While this study compares both aspects of the debate from a subjective perspective, the authors concluded that more concrete data on perceived and actual benefits of pursuing fellowship was necessary.
In a different study, Rushing and team set out to help tackle identifying the actual financial benefits of fellowship.8 In their study, fellowship-trained podiatrists responded to a survey to determine their annual income. The team then compared the results of this survey to data available from the American College of Foot and Ankle Surgeons compensation survey of the corresponding year, and calculated a net present value for both groups. This study found that the net present value for fellowship-trained podiatrists at 30 years was $4.2 million dollars. The net present value for non-fellowship trained podiatrists at 30 years was $3.03 million dollars. The net present value and cumulative net income difference over thirty years was $1.2 million dollars and $2.5 million dollars, respectively. Additionally, most of the fellowship-trained respondents worked at an orthopedic group. The authors of this study concluded that the initiative to pursue fellowship was an acceptable financial investment that would positively affect future income.
While this is very encouraging for those who want to pursue a fellowship, I personally participated as lead author for a similar study which specifically looked at female fellows. We expanded on the idea of the financial implications of fellowship from the above study and applied it to only female fellows.9 The idea of the study was to determine if fellowship would allow female podiatric physicians to have more equal compensation to their male counterparts. Unfortunately, the study found that female fellows lost about $500,000 net present value compared to female colleagues who did not pursue fellowship training. Specifically, the net present value and cumulative net income difference over thirty years were -$492,159.00 and -$820,000.00, respectively.
While this was a surprising revelation, the authors attributed this difference to many the female fellows participating in this study being newly out of training and having less time to build increased salaries than others. Still, this brings into question whether female podiatrists may see a disadvantage if they decide to pursue fellowship.\
Concluding Thoughts
The decision to pursue a fellowship is a very personal one. It requires the consideration of many factors, such as desired specialized training pathways, or potential impact on family life. The literature suggests that even one’s gender plays a role. Each physician needs to weigh all their options and personal considerations when determining if fellowship is the right path. They must understand that it is not a task taken lightly, and many sacrifices are necessary to achieve this goal.
In my opinion, fellowship should not be utilized to substitute for perceived poor residency training, or simply to gain a title. Instead, fellowship is the best path for podiatric physicians if they desire to build on their knowledge and residency training. However, if a physician does decide to pursue fellowship, the literature notes several subjective and objective benefits. Overall, an increase in ability, confidence, and financial compensation are at the heart of these benefits. While fellowship may not be for everyone, it can be a rewarding and fulfilling best step in a podiatric physician’s career.
Dr. Ansert is a third-year podiatric surgical resident at St.Vincent Hospital in Worcester, MA.
Counterpoint
Although fellowship training plays an important role for the right individuals, in this piece, the author contends that it should not be a primary expectation for all. Instead, she points out logistic and practical challenges to this way of thinking and advocates for continued improvement of residency training programs.
By Sandra Raynor, DPM, FACFAS
An ongoing topic of discussion among podiatrists is, “Should the profession push to have more fellowships available as well as become an expectation for most new podiatrists?” Alternatively, should the emphasis be on improving existing residency programs, such that they provide a more consistent and comprehensive foundation for entry into the field as skilled practitioners? Let us consider these alternatives and some of the underlying issues. As we do so, I contend that although fellowship may be a viable and fruitful choice for some, but most certainly not the only or necessarily the best pathway after residency. Our profession does itself and our young members a disservice by fostering a culture that suggests otherwise.
Challenges and Pitfalls of Fellowship Training as a Standard Expectation
If a practice or other entity wishes to offer an American College of Foot and Ankle Surgeons (ACFAS)-approved fellowship, of which there are currently about 52 in the US, that entity must carry out numerous, diverse procedures and meet several other criteria.1 With an annual graduating cohort of residents, in my observation being in the range of 500+ individuals, unless the criteria were significantly relaxed, there are inherent mathematical constraints to closing that 10-times gap. Thus, this discrepancy also poses a clear barrier to fellowship training being a standard “expectation” among new residency graduates.
Of course, fellowships also encompass an additional year of training and education, which could impose significant financial, personal, and family hardships after already undergoing four years of podiatric medical school and three (or more) of residency. Given that, in my experience, many podiatry residents today are older and have already taken an additional year or two to complete a Master’s program before podiatric medical school, the cumulative costs, time, and the number of location changes could represent a significant deterrent to those considering entering the profession if fellowship becomes an expectation rather than a choice.
On the other hand, fellowships can provide increased surgical exposure and experience in specialty areas such as sports medicine, trauma, diabetic care, pediatrics, etc. Thus, I also fully support striving to establish greater fellowship availability for those who are interested and able to undertake them. While I support improving fellowship availability, it is important to recognize that if hosted within the same hospital system as a podiatric residency program, as a practical matter, additional fellowships could at times impact the collective opportunities to participate in procedures.
Furthermore, as fully licensed practitioners, the clinical or surgical role of a fellow is more variable. Without federal support, as exists for residency positions, there are also funding and compensation issues that arise that could preclude otherwise eligible entities from creating fellowship tracks.
Should The Focus Return To Maximizing Residency Training?
Across the medical profession, residencies serve as our primary post-graduate training. Many residents gain a broad set of diagnostic and surgical skills, becoming well-prepared for board certification, to join or start a practice, or step into a fellowship. However, it is no secret that the podiatric residency experience can vary substantially. Potential variations I have observed include how tightly the residents are integrated into consults, rotations, and procedures, along with the frequency and level of complexity of these cases. Participation in other case management activities as well as formal resident-focused briefings also play a role.
In my opinion, training prior to independent practice should be a systematic and nuanced process that integrates principles and practice towards medical competence, efficient use of and collaboration within a surgical suite, proficiency with various technical equipment, meaningful rotations, and coordination of care with other specialties. This conceivably could and should occur during a standard residency program, and not rely on an additional fellowship. Depending on the residency program, it is possible that the number of attendings and their associated experience can vary significantly.
Some states limit the scope of procedures, as well, and procedure count should not be the only measure of success. Thus, the long-standing question remains, regarding what we can do to minimize the impact of differences between residency programs? How can we empower residents to gain more from the time they are already investing?
Closing Thoughts
These institutional relationships and ongoing years of training are already in place, federally funded, and part of our standard professional process. We know what a good residency program looks like. It is unreasonable for our profession to expect a resident, after perhaps an inadequate residency experience, to have to seek additional training through a fellowship. While we should certainly seek to expand fellowships, I believe our dominant focus should be on facilitating improvements to the existing opportunities in residency to maximize each trainee’s experience.
There are already efforts underway towards this goal as CPME continues revising CPME 320 and 330.2 Undeniably, optimizing post-graduate education of any kind is a challenging, long-range undertaking, conceived by necessity in terms of a 5- or 10-year initiative. However, I think the benefits would be well worth the investments.
Dr. Raynor is a Fellow of the American College of Foot and Ankle Surgeons and is the Director of the Foot and Ankle Fellowship in Indianapolis, IN. She is a founding member of Podiatry Associates of Indiana and is currently the President of the Indiana Podiatric Medical Association, state legislative chairman, APMA PAC representative, and past member of the state licensing board.
Point References
1. Saltzman C. The future of foot and ankle care: training the next generation. Editorial. Foot Ankle Int. 2005;26(4):273-274.
2. Hammond JW, Queale WS. Surgeon experience and clinical and economic outcomes for shoulder arthroplasty. J Bone Joint Surg Am. 2003;85-A(12):2318-2324.
3. Rodeghero J, Wang Y-C, Flynn T, Cleland JA, Wainner RS, Whitman JM. The impact of physical therapy residency or fellowship education on clinical outcomes for patients with musculoskeletal conditions. J Orthop Sports Phys Ther. 2015;45(2):86-96.
4. Johnston MJ, Singh P, Pucher PH, et al. Systematic review with meta-analysis of the impact of surgical fellowship training on patient outcomes. Br J Surg. 2015;102(10):1156-1166.
5. O’Kane D, Papa N, Lawrentschuk N, Syme R, Giles G, Bolton D. Supervisor volume affects oncological outcomes of trainees performing radial prostatectomy. ANZ J Surg. 2016;86(4):249-254.
6. Bianco FJ, Cronin AM, Klein EA, Pontes JE, Scardine PT, Vickers AJ. Fellowship training as a modifier of the surgical learning curve. Acad Med. 2010;85:863-868.
7. Summers JN, Protzman NM, Brigido SA. Foot and ankle fellowship training in podiatric medicine and surgery: a national survey comparison of fellowship trained and non-fellowship trained podiatric surgeons: part 1: subjective. Poster Abstract presented at American College of Foot and Ankle Surgeons Annual Scientific Conference; Las Vegas, NV: February 27-March 2, 2017.
8. Rushing CJ, Ansert E, Hyer C. The financial implications of podiatric foot and ankle fellowship: is another year worth it?. J Foot Ankle Surg. 2021;60(5):964-967.
9. Ansert E, Rushing CJ. The financial implications of being a female fellow: does another year help close the gap? Poster presented at the American College of Foot and Ankle Surgeons Annual Scientific Conference; San Antonio, TX: February 19 – 22, 2020.
Counterpoint References
1. American College of Foot and Ankle Surgeons. Minimal criteria for an ‘ACFAS Recognized Fellowship.’ Available at: https://www.acfas.org/uploadedFiles/Students/ACFAS_Recognized_Fellowship_Initiative/ACFAS_Recognized_Program_Criteria/Minimal%20Criteria%20for%20ACFAS%20Recognized%20Fellowship.pdf. Published 2010. Accessed February 8, 2022.
2. Council on Podiatric Medical Education. CPME 320 and 330 revisions in progress. Available at: https://www.cpme.org/residencies/content.cfm?ItemNumber=29729&navItemNumber=15094. Published April 2021. Updated October 2021. Accessed February 8, 2022.
