Recently on Twitter, I found myself in a spirited debate. I argued that unaccredited, extra years of clinical training in hematology-oncology — a bonus year focusing on lymphoma, breast cancer, or bone marrow transplant — are a “scam.” Some disagreed, but it’s a conversation we need to have.
The debate, of course, is bigger than hematology-oncology. Medical training is getting longer. Twenty years ago, you could get a job after a residency in radiology, but these days you need not one, but two fellowships.
Cardiology rarely ends after 3 years. There are extra years in electrophysiology, interventional, structural, imaging, prevention, and more. You’ll be lucky to be done in 8 years (including residency).
My friend finished neurosurgery residency and a fellowship in 7 years, and he counts himself lucky to have found a job. Some of his colleagues took 9 years (extra fellowships). And, a friend from medical school found herself in 11 years of training to do cardiothoracic surgery.
I am a hematologist-oncologist and spent 10 years getting there (4 for medical school, 3 for residency, and 3 for fellowship). Since I started working and paying back my loans, I have taken care of patients with solid cancers, hematologic malignancies, benign hematology concerns, and folks undergoing bone marrow transplant — a.k.a. the full range of hematology-oncology.
But things have changed recently. A number of fellowships have emerged. An extra year to focus on lymphoma, bone marrow transplant, or gastrointestinal oncology. I have no doubts that one can spend years learning more about any disease — what I do doubt is whether these extra fellowships, which often are paid far less than attending wages, are a good thing.
I think there are eight reasons why we as doctors must reform or boycott these bonus years.
1. It won’t stop with 1 more year. One of the fallacies is that “just 1 more year” is all it takes to be prepared for the job of an attending. But what starts with an extra year to focus on breast cancer, will quickly become 2.
Why not add a research component? Soon we will be talking about 3 years. As I discuss below, the finances only incentivize more years. The truth is that eventually one will be an attending, and there will inevitably be things one learns on the job.
No amount of training can avert that. For example, in the documentary “Jiro Dreams of Sushi,” Jiro’s 50-year-old son is an apprentice in his 85-year-old father’s restaurant eager to one day graduate to master chef. There is such a thing as too much training.
2. Longer training means more money for hospitals and less money for doctors. A recent study calculates that a single neurosurgery resident earns $345,000 for the hospital. This is three to four times their annual salary.
When a New Mexico residency program lost accreditation and 10 residents, the hospital had to hire 29 midlevels to do their work. When Hahnemann declared bankruptcy and sold the residency in auction, the residency alone was acquired for $55 million. That hints at how lucrative residents are.
In short, the more advanced the trainee, and the more clinical time they work, the more money hospitals make. If hospitals can justify paying doctors a fellow’s wage, they will. This incentive means training will only get longer, not shorter — it’s a form of wage exploitation.
3. Longer training makes medicine a profession for kids of the wealthy. We already struggle in medicine to train kids who come from poor families. A third of medical students come from families in the top 5% of income, and less than 5% come from the bottom 25%. Extending the years it takes to earn a faculty salary makes it increasingly hard to pursue medicine for trainees who need to earn money to send to parents, siblings, or grandparents. It is hard enough to earn one’s first real paycheck at age 32, let alone 42. If we continue to extend training, we increasingly make medicine a profession for young aristocrats.
4. Longer training hurts women. Both men and women are victims of longer work hours and more years in training, but women are particularly affected. Research shows that longer work hours meant women were less likely to pursue fields such as surgery. Women in medicine face unique challenges balancing career and family and may truncate training to have a family.
The risk with extending the number of years to become a bone marrow transplanter or a lymphoma doctor is that this may further make these male-dominated fields. That is bad.
5. Longer training periods mean cruel parental leave policies. At some point, some people may have children. The amount of time available for leave is already inadequate for full faculty members, but trainees often get less time. More training means less time for parents to bond with children.
6. If we don’t participate in voluntary fellowships, they won’t become mandatory. One reply I received is that these fellowships are voluntary and just provide options. The trouble is that all expansions in training begin as voluntary programs that quickly become mandatory. That’s why training has expanded. If instead, doctors refuse to accept these low-paid fellowships, they will go extinct. Moreover, voluntary doesn’t mean something cannot also be exploitative. For example, payday loans are voluntary, but they prey on the vulnerable.
7. What’s the alternative? Some argue that had they not pursued these extra years of fellowship, these doctors would have a different job or not be successful, but that is not right. The counterfactual — what would have happened were it not for the fellowship — is usually not a different career. It is much more likely to be on-the-job training. This means a hospital hires a junior person to attend on the transplant service, and gives them some guidance or senior attending mentorship for a few months before cutting them loose. This has been the principal method of training for decades.
8. Many support these fellowships, and run these fellowships, but did not attend these fellowships. A grand irony in this space is that many proponents of these extra fellowship years did not themselves train in these fellowships. Moreover, they run these fellowships. They are in an impossibly conflicted position — advising trainees to fill their programs, and not to simply try for a job — rather than encouraging on-the-job training, which is the way they themselves entered their careers.
We face a choice: reform or boycott these fellowships.
Option A: Integrate the curriculum and laudable training aspects of these advanced fellowships into the first year of on-the-job training for junior faculty. If we truly seek justice, we could go further and move fellows of all types out of the postgraduate year salary scales and onto full-fledged faculty scales with commensurate benefits during their entire fellowship period.
After all, fellows are often board-certified, fully licensed internists/surgeons/pediatricians/radiologists. Re-organizing the entire fellowship system and pay scale would obviate the cruel and unusual situation of advanced/additional fellowships.
Option B: Until these reforms occur, I will advise all trainees — no matter what fields they pursue — to do the least number of clinical years needed before starting as attending. It is simply a way for hospitals to transfer income from you to them, and as an alternative, find a different institution — perhaps one with less of a brand name — willing to sponsor some on-the-job training.
Vinay Prasad, MD, MPH, is a hematologist-oncologist and associate professor of medicine at the University of California San Francisco, and author of Malignant: How Bad Policy and Evidence Harm People With Cancer.
Last Updated October 12, 2020