A CONVERSATION WITH SIDHARTH V. PURAM, MD, PHD
Since 2000, the number of medical and surgical resident graduates seeking subspecialty training has nearly tripled, and many now view the five-year otolaryngology residency as a gateway to subspecialization. Why go into a fellowship, and what are the benefits and impact of the decision from the perspective of a current fellow?
What considerations played the largest roles in your decision to follow the fellowship path?
In my experience, it was a question of depth versus breath or, as another way of saying it, a decision between being general versus specialized. Residents must consider whether they enjoy the full scope of the specialty or want a narrow scope of practice. I realized that I had a passion for treating head and neck cancer. I happened upon otolaryngology by chance and did not even realize it was a surgical field until my third year when I was exposed to it. However, those experiences really shaped my decision to not only focus on otolaryngology but to further narrow my scope. I decided that the head and neck cancer subspecialty is where my interests and passions really were – seeing those patients, talking to their families, and watching some survive cancer was something I enjoyed. As I saw more and more cases and my exposure deepened, it drove me further towards the subspecialty. As I spoke with leaders in the field about these interests, it became clear that I would need a fellowship to realize my professional goals.
What suggestions would you give to a resident considering an ENT fellowship?
Ideally, you should try and figure out as early as possible your interest in otolaryngology when you are rotating through all the services in years one and two. Even as a medical student, once you know ENT is the specialty you are interested in, try to figure out if you want to take the next step and subspecialize. It is a big decision that will impact your professional life, so investigate where your passion lies, and that will guide the decision about whether to pursue a fellowship. An important confirmatory step is to immerse yourself as much as possible in those areas, validate your choice, and make sure you are comfortable with it. In my third year of residency, I was trying to figure out what I wanted to do and realized that I enjoyed basic cancer research and head and neck cases. I spoke with my mentors and colleagues and tried to figure out what type of career path matched my interests. Can I do it? Do I have the skills I need? Is this a specialty where I will fit in? These are all question that went through my mind as I continued to validate my choice. I started engaging in opportunities to meet others in my chosen subspecialty, presenting at conferences, speaking to other residents, research, and just trying to gain more information on the available programs. The key is information gathering and being honest with yourself about your goals, interests, and desired lifestyle.
From your perspective, what are the benefits from pursuing a fellowship?
I would say there are three main benefits for going into a fellowship. For me, the opportunity to work and practice in an academic institution was key. A fellowship made my candidacy more attractive to potential employers. Secondly, if you are interested in a more narrow focus versus general practice, a fellowship is a good option after residency. In a more general practice, you don’t have as much control over your scope of practice, and for me that was important. In addition, an advantage of a fellowship is immersing yourself in a field you love and developing the depth of knowledge by focusing on reading the primary literature of the field and understanding everything in that subspecialty. A fellowship gives you confidence, strength, and the skills to handle the most complex and toughest cases. Looking forward, it means that you will shape thinking and influence the field throughout your career.
One practical note: If you are planning on going into an academic setting, starting salary with a fellowship will be higher. I would estimate $50,000 to $75,000 more. It is important to remember that this does not apply to private practice, but rather, the higher salary is for a candidate looking to start in an academic setting having completed a fellowship versus a candidate wanting to remain in academic but have a general practice.
What are the cons and challenges to a fellowship?
If you go straight into practice, you spend less time in training and can hit the ground running. Your practice will generally grow faster than in an academic subspecialty setting, and you will have more control over your schedule. A fellowship really precludes you from doing a little of everything, some of which I enjoyed but others which I didn’t. For example, by choosing head and neck, I gave up seeing pediatric cases, sinus surgery, and everything in between. General ENT also allows you to continue to do everything you did as a resident in terms of the types of cases and patients and typically doesn’t involve a heavy research focus.
What type of work-life balance can you expect? How does it differ from residency and private practice?
It is important to understand that your fellowship year will be a very busy time. How busy really depends on the nature of the fellowship. Overall, I found my work-life balance was much better than residency. In most cases, fellowship is just one year, which makes it manageable (neuro-otology is the only fellowship that is two years). In that short time, you have to try and get as much as you can out of the experience, which is not easy.
However, once you are out of the fellowship, you may have a lot more control over your schedule, especially in an academic setting rather than private practice. It is a different type of stress to see a full schedule of patients each day versus combining time for research with patient care. In an academic setting, there is often more flexibility and time to attend meetings, do research two to three days a week, and have more control over your schedule.
What advice can you give a resident planning on applying for a fellowship?
One piece of advice is to do your fellowship in a different environment than your residency. Try and find a program that differs either in practice model, part of the country, or institutional culture, to name a few. I went from one type of culture in an urban setting to Ohio State University, which really emphasizes autonomy and resident education. This was different from my prior experiences and gave me additional opportunities to teach residents who are more independent.
The other important piece of advice is that once you do a fellowship, you are really committed to staying in that field. It is really important to understand what you are getting into as you will be dedicating your professional life to that subspecialty. Be honest about your goals and priorities. Be sure to pick the right area and fellowship. Over time, I have become more convinced that I selected the right field and estimate that 80 percent of my learning will be reflective of my fellowship. That one year’s experience has really shaped and defined me, and I am grateful for having found the right place and program.
That brings up the question, how did you find the right place?
The most important factor for me was the interview process. I went to as many programs as possible and really spoke to the residents, fellows, and faculty. I solicited advice from my mentors, analyzed the institution’s culture, and asked some frank questions to everyone I met. I also spoke with people in the field. I probed into how much of my time was spent on education or primarily focused on service. Was I going to take general calls for all the attendings, or was this an institution that they wanted me to focus on my learning and preparing for cases? I wanted to make sure that I was not doing a lot of busy work, and I asked what the expectations were of the residents to solicit unfiltered information. Keep in mind that fellowships can be very competitive as they only have one slot, and if you are the second best candidate, you may still be out of luck. As a result, compared to residency, it is a bit harder to get the exact program you want; however, in most cases, getting a position in the specialty (at a fellowship program) is a bit easier.
Are there any resources you suggest?
Find a good mentor who is in the subspecialty. Talk to them about what they like about it, what they don’t like, and why they went into the field.
Know the logistics of applying to plan early, and keep in mind different programs may have different deadlines. Plan in advance as it takes time to get effective letters of recommendation. Keeping track and setting aside your vacation days is important as you will have to use them to attend interviews. Budgeting for $5,000 to $10,000 for airline tickets and hotels requires some planning too as you pay all these expenses out-of-pocket in the vast majority of cases.
Sidharth V. Puram, MD, PhD – Head and Neck Oncologic Surgery Fellowship, The Ohio State University (2018-2019)
