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Doctors completing multiple residencies/fellowships

Guest Kirsteen

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Guest Kirsteen

Hi there,


Is there an increasing prevalence of doctors who choose to complete multiple fellowships and/or residencies in order, perhaps, to expand their marketability in certain health care centres? This summer, while on elective in Toronto, I met a fascinating and brilliant guy who had completed a residency in anesthesia, then another in internal medicine and finally, a fellowship in critical care. He could be, and was, deployed in many critical care areas of the hospital and seemed quite happy to share his handsome oeuvre of expertise.


Granted, my observation was biased by the fact that I was working in a quaternary care setting, in an urban centre, thus one might expect that there would be more competition for good jobs and perhaps more concomitant requirement for folks with a broad array of skills. However, is this phenomenon of doctors completing multiple residencies and/or fellowships becoming more common? I get the feeling, abutted by the rumours that a PhD is now de rigeur for an urban faculty position, that a greater volume of credentials and skills is corrlated with a greater opportunity for urban health care jobs. Anyone have any insights?




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Guest Ian Wong

The short answer is no, not really. Most people doing a second residency, at least in my short experience, are those who got disillusioned with the original specialty and want out.


Dual residency sounds good in theory, but is rough in practice. A good example of why can be found in Med/Peds, which is a dual residency offered only in the US (not in Canada) in Internal Medicine and Pediatrics where you become board certified in both. The problem is that when you go looking for jobs, the vast majority of jobs out there for new graduates are going to be in a group practice. Most groups out there just don't do both, so if you wanted to do Med/Peds, you'd either have to go solo, or find a group of Med/Peds docs.


Very few people are ready to commit to a solo practice immediately out of residency (let alone solo practices in general because of the difficulty in covering both on call responsibilities as well as your overhead).


Right out of residency, you have no money to build a practice with, and you usually still have tons of educational debt. You also likely don't have a good idea of how to run an efficient private practice, nor have good business skills yet (since you don't get taught that in residency).


The problem is that if you are Med/Peds trained, then it doesn't matter that you have Peds training if you go in with a group of internists. If you go in with a bunch of pediatricians, none of them see adults and can't take your call, nor will they be willing to cover your clinic patients during your days off. In order to survive, you'd need to join a group with both pediatricians and internists, and have enough of each that the group can effectively use you to split call and cover clinics in both specialties. Such groups are hard to come by.


It's for that reason that most Med/Peds folks end up working predominantly in either Medicine or Pediatrics, but not both. Once you've done this for a few years out of residency, the referral patterns in the community will be stuck in such a way that it'll be hard for you to add the second specialty to your practice. Worse yet, you might find that your skill set has atrophied enough that you don't feel comfortable adding that second specialty into your practice.


With Anes/IM/Critical Care, that's not a big switch since both Anes and IM residencies make you eligible for critical care fellowships, so the skill sets are basically complementary. However, I bet you this guy probably doesn't do all three at the same time. ie. Runs gas in the OR on Mondays, admits from the ER and rounds on IM inpatients and sees IM patients in clinic on Tuesdays through Friday, and covers the ICU on the weekends.


It's just too difficult to dabble in multiple fields, hard to find other partners who can take your call and see your patients, and is very inefficient as far as potentially doubling your overhead, call burden, and commute times.


The other huge factor is that you will run into funding issues from the government if you are going after a second residency. You need to figure out a way for your residency program to have the cash to pay your salary and take care of the administrative costs of having you in the program. There's all sorts of re-entry programs and money from rural communities for this, but getting a second residency isn't as simple as just submitting another CaRMS application.


Luckily for us med students and residents, there's been enough of a screwup in the predictions regarding physician supply and distribution that we'll always be able to find jobs without having to do a second residency or fellowship. It may require you to move outside of the big city in some cases, but getting employment as a Canadian-trained physician in Canada shouldn't be an issue for most (maybe can't say the same about foreign-trained physicians at the moment).



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Guest UWOMED2005

That anaesthesia/internal med/ICU combination is perhaps THE one combination I would expect to be common.


ICU fellowships can be accessed through internal medicine, anaesthesia, and (more recently) surgery. I've heard arguments as to why anaesthesia or medicine would be the better route - anaesthesia gives you better training in procedures, airways, etc. But IM gives you more experience with wierd and wonky diagnoses. . . which sometimes end up in ICU.


If someone were REALLY keen on ICU, I could see an argument for doing both residencies. But it's not necessary, and the reality is most of us when we hit residency just want to get out.

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