I am one of those lucky souls who actually likes their job. Since I completed my pediatrics residency two years ago, I have been working in urgent care settings. What’s not to like? I get to see a wide variety of patients, I’m always learning something new, and I get to finish my encounters with a high-five from an overeager toddler. If you’re a general pediatrician like me, that’s the dream. But just as all good things must come to an end, I see the beginning of the end. I see the scourge of the pediatric urgent care fellowship.
These fellowships advertise that residents today lack the exposure and training for the fast-paced world of urgent care. And like any good bureaucracy, the solution reached is another layer of bureaucracy. Basically, they’re asking you to buy a motorcycle because your car needs an oil change. If truly large numbers of pediatric residents are not receiving appropriate training work as general pediatricians, the correct solution is to fix residency, not just add another layer of training.
This added layer of training will significantly add to the cost of pediatric training. From application fees, to travel for interviews, to moving costs and then to trainee salaries — this all makes training more expensive. This at a time when the cost of medical school is not decreasing, and pediatrician compensation is not increasing. While it seems intuitive that extra training will lead to increased compensation, many pediatric subspecialists know better. (I can imagine the infectious disease physicians nodding along as they read this). This also doesn’t take into consideration the inevitable cost of boards testing which includes not only the test itself, but the study materials and time required to study for, travel to and actually take the test.
Some who read this may wonder if this is all about money. To this, I have two answers:
First, I don’t think of myself as particularly money-driven — I am a general pediatrician after all — but I also don’t claim to be a saint. I live in America, where I have student loans I need to pay off, retirement to save for and at some point, I will likely have to replace my 2008 Toyota Yaris. Not considering the financial implications of this development would be irresponsible of all of us and potentially punishing to a generation of new pediatricians.
Second, if the end goal for all of us is to best improve care for our patients, it’s not clear to me that fellowship training is the solution. By its very existence, this fellowship encourages less, not more, urgent care training in general pediatrics residency. Furthermore, fellowship is a gatekeeping exercise, unintentional though it may be. Some will receive this information and training, and others will not. Limiting the number of physicians who receive this training may, in fact, be worse for patient care.
Potential solutions that would be both less burdensome to pediatricians and beneficial to patients include reexamining and adjusting residency training as well as online training. Could all or even a substantial portion of pediatric urgent care fellowship be instead produced as e-learning modules? Could those modules also count for CME credit, which would further encourage their use? Instead of numerous ongoing costs, could these modules be made available at a reasonable price?
There would be several benefits to such a program. First, it would allow pediatricians to continue to live and work where they choose without incurring another financial burden. In addition, it would make this training available to many more providers and, therefore, even many more patients. These benefits would also not be limited to urgent care patients. Patients seen by primary care providers, for example, may also benefit from such training. And we should note that many of these patients will increasingly be seen by mid-level providers such as NPs and PAs. Developing a pediatric urgent care fellowship implies that pediatric residency is inferior training to NP and PA training. Again, if we believe this to be true, the priority must be to fix residency.
So if we accept that pediatric urgent care fellowship would increase the cost to physicians without an equal benefit, and if we accept that it’s not at all clear that patients would be the beneficiaries, then we are left with one question: Cui bono? Who benefits?
The benefits will go to those collecting application fees, paying physicians at a discount, and those who sell both expensive exams and their study materials.
At this point, you may ask, why does any fellowship exist at all? The truth is, I don’t know. I am not a rheumatologist or a gastroenterologist. I certainly can’t speak intelligently about improvements in rheumatology or gastroenterology training. Much of medical training is done because that’s how it’s been done so that’s how we do it. It’s tautological. As a practicing pediatric urgent care physician, I can say with some confidence that a fellowship is not the answer. Of course, additional training can be beneficial, but we must weigh the cost as well as the benefits, and the cost is just too high.
The continued fellowship-ization of general pediatrics practice depends on us sitting by and doing nothing. So talk to your colleagues, your current or former program director and — most importantly — the residents. We need to fix the problem, not create a new one.
Ron Yalon is a pediatrician.
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