Author + information
- Joshua Kiss, MD∗ (, )@MountSinaiHeart@joshkissMD,
- Benjamin Bier, MD@BenjaminBier and
- Michael Healy, MD
- ↵∗Address for correspondence:
Dr. Joshua Kiss, 1190 Fifth Avenue, GP1 Center, Box 1030, New York, New York 10029-6574.
Many factors contribute to the decision to apply for a cardiology fellowship. A prospective fellow must consider his or her research and clinical interests, practice goals such as private practice versus academic medicine, lifestyle considerations, and other issues. A more recent development is the consideration of whether to proceed directly from residency to fellowship or to delay one’s application while working for 1 or more years as a hospitalist. For many residents, such a decision is wrought with concerns, including the burden of transitioning to a new job in a new place for a short period of time. Additionally, a significant concern for many applicants is the impact that time spent as a hospitalist could have on their candidacies for fellowship. More specifically, applicants are often apprehensive that programs might question their passion for cardiology and that applicants could be penalized for time “away” from formal training. Contrary to these concerns, time spent as a hospitalist prior to starting fellowship can be quite valuable. Hospitalist experience can be advantageous in many ways, including easing the logistical challenges inherent to applying for fellowship and arranging interviews, adding financial stability, increasing clinical acumen and skills, improving clinical decision-making, and providing the opportunity to build an academic portfolio. In this page, we seek to examine each of these considerations in turn.
Applying for cardiology fellowship is a time- and energy-intensive process. Prospective applicants must rotate in cardiology and its subspecialties, obtain letters of recommendation, write a personal statement, complete a complicated application, and eventually traverse the country for interviews. As a resident, this must all be accomplished in the midst of busy and tiring clinical rotations, research projects, outpatient clinic, and other responsibilities. Many residencies also require their residents to determine their own coverage for these responsibilities when scheduling interviews, which can be challenging and lead to burdensome exchanges of coverage time. In contrast, most hospitalists are scheduled for shifts over 180 days, often in a “7 on, 7 off” pattern, allowing for plenty of nonclinical time to finish the applications and to interview in a much less stressful manner (1).
As noted by Dr. Ole-Petter Hamnvik in NEJM 360, some legitimate concerns exist with regard to the impact of delaying fellowship on the application process. While serving as a hospitalist does not keep an applicant away from clinical medicine like time spent doing research or even the primarily administrative focus of a chief resident year might, programs will expect an explanation for the decision in one’s personal statement and during the interview. This might include discussions of why the decision was made, how an applicant spent his or her time, and how time as a hospitalist would help as a fellow and during a career in cardiology. Interviewers might also question whether an applicant will have difficulty transitioning back to life as a trainee, particularly if he or she has been in practice for several years (2). There are numerous challenges inherent to life as a trainee, including lower salary and increased professional demands. Delaying training increases the likelihood that an applicant will experience these challenges at a phase in life when he or she is attempting to form long-term romantic relationships and/or considering having children. Although this is a highly personal issue that varies with each individual, it can potentially affect one’s long-term decisions regarding career goals and additional training after general cardiology fellowship.
Some applicants might be concerned about the opportunity cost of delaying the “beginning” of one’s career. According to this argument, a hospitalist salary is very often less than that of a starting cardiologist, so it is possible that delaying practice by 1 year will have a net negative financial impact. According to Medscape, the average internal medicine hospitalist salary in the United States in 2018 was $256,000, while the average cardiologist salary was $423,000; this would vary significantly, of course, for each individual (3,4). In 1 pre-fellowship hospitalist year, however, the average hospitalist salary is significantly greater than that of a fellow and can not only outpace the difference between that of a hospitalist and cardiologist, but can also offer significant financial stability obtained by paying off loans and funding savings and/or retirement accounts. The net positive interest and yields of these maneuvers earlier in one’s career create greater compounding returns and are often not possible without a bolus of funds earned during a hospitalist year. This can allow an applicant to be much more comfortable about his or her financial future when entering fellowship than a similar applicant at the end of residency.
In our experience as hospitalists at Beth Israel Deaconess Medical Center in Boston, New York University Langone Medical Center, and the University of California-San Francisco, the advantages of a hospitalist year significantly outweigh any possible downsides. For example, candidacy for a fellowship position can be significantly strengthened. As opposed to creating questions about one’s dedication to cardiology, the delay can provide opportunities to publish multiple papers, develop stronger relationships with letter writers, engage in numerous cardiology-related and other academic activities, and win awards that enhance an applicant’s CV much more than someone interviewing as a third-year resident. Additionally, some applicants do not feel prepared to undergo the application and interview process again as a second-year resident in the midst of demanding clinical rotations a mere 2 to 3 years after doing so for residency; delaying the application can thus provide a psychological benefit. Furthermore, delaying fellowship application can allow an applicant to align his or her schedule with that of a partner or spouse to apply together for the next stages of their respective careers and coordinate a potential move to a new location.
An often overlooked—and possibly the most important—benefit of time as a hospitalist is an opportunity to develop as an individual, as a physician researcher, and as a clinical decision maker. Having served as hospitalists gives applicants the opportunity to mature in their clinical decision-making via independent practice, which can differentiate them from traditional applicants. Although there may be challenges in transitioning back into a trainee role from that of an independent attending physician, the comfort and independence developed in a variety of clinical situations as a hospitalist can provide fellows with confidence in making autonomous decisions. This includes triage decisions and consult advice as well as leadership and teaching of residents and team members.
The sprint to a career in cardiology from college through medical school, residency, fellowship, and subspecialty fellowship is arduous. Although any delay in completion of subspecialty training can have personal and financial impacts that may challenge some applicants, time as a hospitalist can be rewarding for a future cardiologist in many ways. Taking some time as a hospitalist to develop as a physician and as an individual can allow future cardiologists to enhance their professional maturity, financial security, and clinical acumen as well as augment their personal health and wellness.
- 2019 American College of Cardiology Foundation
- Piturro M.
- Hamnvik O.-P.
- Levy S.
- Peckham C.