Should I specialize?

[zeppelinpage4]

Hi guys, been a while since I've posted here but I'm feeling a bit lost and need some advice on what to do after residency. A TLDR version of my history, I needed to take some extra time off to retake Step 3 and do some extra rotations. I was a weaker resident but thankfully I've been able to improve and am now on track to finish residency in the next few months. I'm offset due to my extra time and will be finishing in the Fall instead of June. Due to my history of being slower and generally weaker resident, I'm a bit worried about how I'll fare as an attending in general pediatrics. I do really well on rotations where I can focus in on one area and spend a lot of time on it, getting to know it well. However, the high volume, having to rapidly see patients, and general breath of knowledge that gen peds requires (literally anything can come through the door and be missed) had me questioning if it's really a good fit for me. On top of it, I just haven't found it that rewarding as I rarely get to spend time with patients getting to know them and most of the care if preventative or referring I don't feel like I fixed much.

One of my mentors told me to specialize, and said if I do so, I can see lower patient volumes as a specialist while making the same as general pediatrics or maybe a little more. And I can also feel more confident in getting to know one area of pediatrics very well. Is this true? And is this good reason to consider a specialty?

Right now I'm seriously considering pediatric pulmonology as the patient population seems rewarding to work with, literally helping kids breath and I've had a good amount of experience in it through all my inpatient rotations. However there aren't many threads on it. Overall, how is the lifestyle and salary in peds pulm compared to general pediatrics? I heard it's PICU heavy, so that might be stressful but I don't know if that's common. I honestly want to be in a relatively low stress field, normal hours, but have pay at least equivalent to gen peds or more if that is possible. Are there other pediatric specialties I should look into? Maybe endocrine or rheum?
Allergy and Immunology is too competitive, and I think cardio, GI, NICU and PICU are more intense than I would like. Peds ID and adolescent seemed nice but the salary seems to be lower than gen peds. Due to my history I want to make sure i make the right decision as I faced a lot of burnout and struggled in residency and I don't want to be like that in fellowship or as an attending.

And I'm looking to hopefully do some mix of non-clinical and clinical, I'm really interested in informatics and I know peds pulm can pair well with it too.

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[SurfingDoctor]

Hi guys, been a while since I've posted here but I'm feeling a bit lost and need some advice on what to do after residency. A TLDR version of my history, I needed to take some extra time off to retake Step 3 and do some extra rotations. I was a weaker resident but thankfully I've been able to improve and am now on track to finish residency in the next few months. I'm offset due to my extra time and will be finishing in the Fall instead of June. Due to my history of being slower and generally weaker resident, I'm a bit worried about how I'll fare as an attending in general pediatrics. I do really well on rotations where I can focus in on one area and spend a lot of time on it, getting to know it well. However, the high volume, having to rapidly see patients, and generally breath of knowledge that gen peds comes with makes me have doubts. On top of it, I just haven't found it that rewarding.

One of my mentors told me to specialize, and said if I do so, I can see lower patient volumes as a specialist while making the same as general pediatrics or maybe a little more. And I can also feel more confident in getting to know one area of pediatrics very well. Is this true?

And I'm seriously considering pediatric pulmonlogy as the patient population seems rewarding to work with, literally helping people breath. How is the lifestyle and salary in peds pulm compared to general pediatrics? I heard it's PICU heavy, so that might be stressful. I honestly want to be in a relatively low stress field, normal hours, but have pay at least equivalent to gen peds if that is possible. Are there other pediatric specialties I should look into? Due to my history I'm not the most competitive applicant and I want to make sure i make the right decision as I faced a lot of burnout and struggled in residency and I don't want to be like that in fellowship or as an attending.

Thanks! And I'm looking to hopefully do some mix of non-clinical and clinical, I'm really interested in informatics and I know peds pulm can pair well with it too.

Well first off, outside of PICU, NICU and Cardiology, none of the sub-specialties will make more than General Pediatrics, so just consider that up front. However, to be honest, those can be more competitive sub-specialties and having to repeat rotations and fail a Step exam are red flags. I'm not saying its impossible, but it is pretty unlikely.

If you need extra time, you can work in a clinic where you set the expectation that your patient load is lower. Though you should realize that in many professions, it's eat what you kill (which is bad phrasing I realize), but if you see less patients you get less compensation.

There are subspecialities which I would consider to be more cerebral and per patient time consuming (which also happen to be less competitive and generate less revenue mind you). ID and Rheumatology come to mind. In addition, Neurodevelopmental and Genetics also fit into those categories. You can beef up the financial reward of the latter though with botox injections if you saw fit.

Pulmonary isn't the most competitive specialty, but because there is a mix of outpatient, inpatient and procedures, you need to be efficient at time management. When you have clinic, it will be booked and you need to see the patients in a timely manner. You should talk to whoever the Peds Pulmonologist is in your hospital system to figure out if you'd be a good fit.

Glad to hear you'd worked through your struggles.

 

[zeppelinpage4]

Well first off, outside of PICU, NICU and Cardiology, none of the sub-specialties will make more than General Pediatrics, so just consider that up front. However, to be honest, those can be more competitive sub-specialties and having to repeat rotations and fail a Step exam are red flags. I'm not saying its impossible, but it is pretty unlikely.

If you need extra time, you can work in a clinic where you set the expectation that your patient load is lower. Though you should realize that in many professions, it's eat what you kill (which is bad phrasing I realize), but if you see less patients you get less compensation.

There are subspecialities which I would consider to be more cerebral and per patient time consuming (which also happen to be less competitive and generate less revenue mind you). ID and Rheumatology come to mind. In addition, Neurodevelopmental and Genetics also fit into those categories. You can beef up the financial reward of the latter though with botox injections if you saw fit.

Pulmonary isn't the most competitive specialty, but because there is a mix of outpatient, inpatient and procedures, you need to be efficient at time management. When you have clinic, it will be booked and you need to see the patients in a timely manner. You should talk to whoever the Peds Pulmonologist is in your hospital system to figure out if you'd be a good fit.

Glad to hear you'd worked through your struggles.

Thanks so much! Yes, I'm definitely taking my competitiveness into the equation as well. I ruled out allergy and immunology very quickly as a result. And PICU, NICU and cardiology I definitely don't want to do as the lifestyle is rough and I don't like the adrenaline and intensity that comes with those specialties. It's not worth the pay increase for me.

And yeah, one of my gen peds attendings said that. Unfortunately, I know in gen peds due to the low reimbursement, you need to see high volumes to keep a practice running. Truthfully, if salary isn't much lower than gen peds, I just want to find a specialty where I might be a better fit and I can do well in. I considered rheumatology but I'll look at genetics. And is botox injection common in genetics? I actually didn't know they did those.

I am hoping to do a peds pulm elective very soon, I'll definitely have an honest conversation with the fellows and attendings about my fit in the specialty. I know I'll be using good time management in all specialties and truth be told I am comfortable with seeing patients in a timely manner. But I do feel that specialties that are a little slower paced relative to others specialties might suit me more than the fast paced ones.

 

[SurfingDoctor]

Thanks so much! Yes, I'm definitely taking my competitiveness into the equation as well. I ruled out allergy and immunology very quickly as a result. And PICU, NICU and cardiology I definitely don't want to do as the lifestyle is rough and I don't like the adrenaline and intensity that comes with those specialties. It's not worth the pay increase for me.

And yeah, one of my gen peds attendings said that. Unfortunately, I know in gen peds due to the low reimbursement, you need to see high volumes to keep a practice running. Truthfully, if salary isn't much lower than gen peds, I just want to find a specialty where I might be a better fit and I can do well in. I considered rheumatology but I'll look at genetics. And is botox injection common in genetics? I actually didn't know they did those.

I am hoping to do a peds pulm elective very soon, I'll definitely have an honest conversation with the fellows and attendings. I expect I'll be using good time management in all specialties and truth be told I am comfortable with seeing patients in a timely manner. But I do feel that specialties that are a little slower paced relative to others specialties might suit me more than the fast paced ones.

I mean it's most common in PMnR and Neurology, but if you're the specialist in congenital hypertonia syndromes and/or kids with a syndrome leading to spastic CP... the families might go to you. But then again, I've seen all sorts of sub-specialties do botox.

https://med.virginia.edu/pediatrics/wp-content/uploads/sites/237/2015/12/200303.pdf

And yes, until you've done a Pulmonary rotation and talk to a Pulmonologist, I wouldn't make life choices regarding that specialty.

 

[zeppelinpage4]

I mean it's most common in PMnR and Neurology, but if you're the specialist in congenital hypertonia syndromes and/or kids with a syndrome leading to spastic CP... the families might go to you. But then again, I've seen all sorts of sub-specialties do botox.

https://med.virginia.edu/pediatrics/wp-content/uploads/sites/237/2015/12/200303.pdf

And yes, until you've done a Pulmonary rotation and talk to a Pulmonologist, I wouldn't make life choices regarding that specialty.

Oh that's quite interesting.

And yes, I haven't made final life decisions on what I'm doing. But, I have very limited elective time, so I'm trying to narrow down to 1-2 specialties for which to do electives in for the next 2-3 months.

 

[Perrotfish]

And yeah, one of my gen peds attendings said that. Unfortunately, I know in gen peds due to the low reimbursement, you need to see high volumes to keep a practice running.

How many patients per day is too many for you? I think you may be overestimating the difficulty of genpeds, and underestimating the pay

 

[FlowLimited]

Inpatient management is a very small part of what pulmonologists (and many other subspecialists) do. As such, it's a poor representation of what it's like to be one. You need to see clinic. The pace, workflow, and even the types of patients you see in clinic are very different from inpatient. I don't know what you mean by pulmonology being "PICU heavy." Most consultants see patients in the PICU because those patients are very sick and often have multiple medical issues. I know many pulmonologists who have no interest in spending more time in the PICU than absolutely necessary and others who avoid it like the plague. I know very few who love it. You can't avoid it, but that's not pulmonology-specific.

 

[DeadCactus]

Do a subspecialty if you love that subspecialty.

Doing a subspecialty because you're worried about the breadth of general pediatrics doesn't make sense. It's like looking at a map of a state and thinking "This is too much, look at all these cities and highways" so you switch to just looking at a map of one city and realizing "Now everyone expects me to know each of these neighborhoods and streets". General pediatrics doesn't man knowing all of pediatrics, it means knowing primary care pediatrics or hospital ward pediatrics. It is a specialty in and of itself.

If you're worried about how fast you will have to see patients, this is more of an issue of job choice. There are relatively relaxed outpatient jobs and crazy busy ones. Also realize, the time will feel less rushed as you stop staffing with attendings and have more support staff to handle things that frequently get dumped on residents in an academic clinic.

By all means explore some subspecialties but it might be worth rotating at a community practice if that's an option for you.

 

[zeppelinpage4]

How many patients per day is too many for you? I think you may be overestimating the difficulty of genpeds, and underestimating the pay

So, in our resident clinic the minimum we are expected to see are 5-6 in the morning and 5-6 in the afternoon (so 10-12/day). I actually do this pretty comfortably. The faster residents in my program can see up to 7 or even 9 in a morning or afternoon. However, I was under the impression that 15-30/day is the norm in gen peds and what I should be aiming to do. One thing I am considering is that in residency, we're slowed down by the fact that residents need to present to preceptors and have the attending also go in and eyeball the patient after each visit, and often times we need to draw up and give our own vaccines. All of this adds time to the visit and I imagine if I'm not needing to present to preceptors or have clinic staff to do things like give vaccines I can go much faster. My actual visit time is usually 10-15 minutes for sick visit, and 15-30 minutes for a well visit with the adolescents taking longer and the standard newborn visits usually being much faster.

I believe what slows me down most is that faster residents can ask questions and talk to parents while they simultaneously do the physical exam. However, I end up forgetting parts of the physical, or forgetting to ask specific questions when I do this. So I always speak to parents and do my screenings first and then finish with the exam.

Most of my time is spent on inpatient rotations, so it's also possible that as I do more and more outpatient clinic I will get more comfortable and gain speed.

Inpatient management is a very small part of what pulmonologists (and many other subspecialists) do. As such, it's a poor representation of what it's like to be one. You need to see clinic. The pace, workflow, and even the types of patients you see in clinic are very different from inpatient. I don't know what you mean by pulmonology being "PICU heavy." Most consultants see patients in the PICU because those patients are very sick and often have multiple medical issues. I know many pulmonologists who have no interest in spending more time in the PICU than absolutely necessary and others who avoid it like the plague. I know very few who love it. You can't avoid it, but that's not pulmonology-specific.

So, I had an adviser (granted he wasn't in peds pulm) who told me if I didn't like my time in PICU, I wouldn't like peds pulmonology. I suppose he was referring to the vented patients and severe asthmatics, but all the peds pulm doctors that I know only come as consultant in our PICU and the PICU attending is still the one doing most of the management. I'm planning on an elective in peds pulm soon, so hopefully I can see the outpatient clinic and get a better idea of the flow and day to day work. Thanks, that's actually really reassuring to here that PICU doesn't have to be a huge part of peds pulm, not more than any other subspecialty at least.

Do a subspecialty if you love that subspecialty.

Doing a subspecialty because you're worried about the breadth of general pediatrics doesn't make sense. It's like looking at a map of a state and thinking "This is too much, look at all these cities and highways" so you switch to just looking at a map of one city and realizing "Now everyone expects me to know each of these neighborhoods and streets". General pediatrics doesn't man knowing all of pediatrics, it means knowing primary care pediatrics or hospital ward pediatrics. It is a specialty in and of itself.

If you're worried about how fast you will have to see patients, this is more of an issue of job choice. There are relatively relaxed outpatient jobs and crazy busy ones. Also realize, the time will feel less rushed as you stop staffing with attendings and have more support staff to handle things that frequently get dumped on residents in an academic clinic.

By all means explore some subspecialties but it might be worth rotating at a community practice if that's an option for you.

Thanks for the insight. This is true, I don't want to put more years into something unless I see myself genuinely enjoying it. I suppose since I wasn't excited by general pediatrics in residency, I'm now considering subspecialties with the hopes of finding something more exciting and also feeling more comfortable with the knowledge base and getting more time with patient. But the map analogy you have definitely changes how I view things. And that' a good point to, being in an academic resident clinic with scutt work is probably much different from being an attending in a clinic. Although, dealing with insurance and billing will be a new challenge with that. That's a good idea, we used to have a rotation option to go to a local practice, I may need to ask if that's still possible to do.

 

[FlowLimited]

So, I had an adviser (granted he wasn't in peds pulm) who told me if I didn't like my time in PICU, I wouldn't like peds pulmonology. I suppose he was referring to the vented patients and severe asthmatics, but all the peds pulm doctors that I know only come as consultant in our PICU and the PICU attending is still the one doing most of the management. I'm planning on an elective in peds pulm soon, so hopefully I can see the outpatient clinic and get a better idea of the flow and day to day work. Thanks, that's actually really reassuring to here that PICU doesn't have to be a huge part of peds pulm, not more than any other subspecialty at least.

I disagree with your advisor and I think most pediatric pulmonologists would as well. ICU ventilator management has very little in common with home ventilator management. Treatment of status asthmaticus has nothing in common with how we maintain long term asthma control. Hopefully you can spend the majority of your elective in clinic so you can see these things for yourself.

 

[MEN2C]

Well first off, outside of PICU, NICU and Cardiology, none of the sub-specialties will make more than General Pediatrics, so just consider that up front. However, to be honest, those can be more competitive sub-specialties and having to repeat rotations and fail a Step exam are red flags. I'm not saying its impossible, but it is pretty unlikely.

I'm in NICU, and this year 25% of programs didn't even fill (most years it is similar). I think you can find a spot. For lots of reasons, people don't really like NICU. 230/238 matched, and I bet the unmatched was because they didn't apply widely for whatever reason (or something a lot crazier than repeating rotations or failing a step exam). The OP doesn't like NICU so it's a moot point, but it's just not competitive.

Source: https://mk0nrmp3oyqui6wqfm.kinstacdn.com/wp-content/uploads/2019/12/417_MRS.pdf

 

[Splenda88]

Get a gen peds job first. If that does not work out, pursue a fellowship.

 

[FrkyBgStok]

Think about your life as an attending. General peds is like any other specialty. 80% of your time, you will be doing (fairly) mindless well child checks that you will be great at. And you will narrow what is important. But this is how all specialties are. I am an EM fellow and my training is focusing on my skills on the breadth as well as the high acuity situations and leading the team. But that definitely isn't 80% of my time. The bulk of my time these days is spent with viral URIs and bronchiolitis. Choose a specialty and it will be the same 80% which you will get excellent at by shear volume.

I once had an attending give me great advice. He was dev/beh and we were talking about the pay difference. I asked how he justified doing fellowship for less money and he said, "fellowship is for those who just can't imagine a life in general peds. I didn't care what it paid, I knew I had to specialize. if you can see yourself in general peds, you absolutely should do general peds." Obviously there are some exceptions but I think, overall, it is good advice and that was how I felt at the end of residency.

 

[zeppelinpage4]

I'm in NICU, and this year 25% of programs didn't even fill (most years it is similar). I think you can find a spot. For lots of reasons, people don't really like NICU. 230/238 matched, and I bet the unmatched was because they didn't apply widely for whatever reason (or something a lot crazier than repeating rotations or failing a step exam). The OP doesn't like NICU so it's a moot point, but it's just not competitive.

Source: https://mk0nrmp3oyqui6wqfm.kinstacdn.com/wp-content/uploads/2019/12/417_MRS.pdf

Oh this is quite surprising. NICU seems to attract some of the strongest residents in my program and I know pay goes up, so I assumed it was competitive across the board as well.

Get a gen peds job first. If that does not work out, pursue a fellowship.

Thanks, this is where i was leaning before. I figured fellowship is always there if I decide to pursue it. But it might be worth giving gen peds an honest shot before going in for 3 more years of training. The only hesitation I had with trying gen peds first is my concern if I can adjust to attending life and a lot of people told me it gets harder to get back into fellowship training after a few years of getting used to being an attending.

Think about your life as an attending. General peds is like any other specialty. 80% of your time, you will be doing (fairly) mindless well child checks that you will be great at. And you will narrow what is important. But this is how all specialties are. I am an EM fellow and my training is focusing on my skills on the breadth as well as the high acuity situations and leading the team. But that definitely isn't 80% of my time. The bulk of my time these days is spent with viral URIs and bronchiolitis. Choose a specialty and it will be the same 80% which you will get excellent at by shear volume.

I once had an attending give me great advice. He was dev/beh and we were talking about the pay difference. I asked how he justified doing fellowship for less money and he said, "fellowship is for those who just can't imagine a life in general peds. I didn't care what it paid, I knew I had to specialize. if you can see yourself in general peds, you absolutely should do general peds." Obviously there are some exceptions but I think, overall, it is good advice and that was how I felt at the end of residency.

That is a fantastic and reassuring piece of advice, thank you. This is true, I'm not the fastest but I do feel very comfortable with well visits, basic screening, and the usual otitis media, gastro, and URI visits. As well as knowing when to refer to a specialist or send to the ED. And I will keep that quote in mind. I don't mind gen peds and like it enough, but I definitely don't love it or feel a strong passion or excitement towards it. I'm hoping to find a specialty that might give be that excitement but it is likely worth giving gen peds an honest try first. Ideally I could find a more relaxed part time job while I get used to it and to see if I like it.. Then once I get more comfortable I can switch to a full time role.

 

[Splenda88]

That is a fantastic and reassuring piece of advice, thank you. This is true, I'm not the fastest but I do feel very comfortable with well visits, basic screening, and the usual otitis media, gastro, and URI visits. As well as knowing when to refer to a specialist or send to the ED. And I will keep that quote in mind. I like gen peds and like it enough, but I definitely don't love it or feel a strong passion towards it. I'm hoping to find a specialty that might give be that excitement but it is likely worth giving gen peds an honest try first.

That is good enough... My impression is that most physician are not passionate about what they do. It's just a nice job that pays the bill and allow one to be financially 'safe'.

I like my job; I DON'T love it or passionate about it. It's a nice job that will get me where I want financially.

 

[zeppelinpage4]

That is good enough... My impression is most physician are not passionate about what they do. It's just a nice job that pays the bill and allow one to be financially 'safe'.

I like my job; I DON'T love it or passionate about it. It's a nice job that will get me where I want financially.

That's actually reassuring to hear, as I'm of that mindset with gen peds right now. I do like the job I do, but the biggest priorities for me are being there for my family, taking care of myself and enjoying life outside of work. So for now, the path that will give me the best income to hours ratio or flexibility in terms of hours and work life balance is likely what is best for me now.

 

[mvenus929]

So, in our resident clinic the minimum we are expected to see are 5-6 in the morning and 5-6 in the afternoon (so 10-12/day). I actually do this pretty comfortably. The faster residents in my program can see up to 7 or even 9 in a morning or afternoon. However, I was under the impression that 15-30/day is the norm in gen peds and what I should be aiming to do. One thing I am considering is that in residency, we're slowed down by the fact that residents need to present to preceptors and have the attending also go in and eyeball the patient after each visit, and often times we need to draw up and give our own vaccines. All of this adds time to the visit and I imagine if I'm not needing to present to preceptors or have clinic staff to do things like give vaccines I can go much faster. My actual visit time is usually 10-15 minutes for sick visit, and 15-30 minutes for a well visit with the adolescents taking longer and the standard newborn visits usually being much faster

Am I the only one who thinks it odd that you have to draw up and administer your own vaccines routinely?

The time it takes to precept is real. I see 4-5 pts in a half day in my subspecialty continuity clinic, and I’m not sure I could see more because I end up waiting around for the attending a good chunk of the time. If you’re comfortably seeing 10 pts per day, you could probably quite easily bump that to 15 after graduation once you learn the new system you’re in.

 

[zeppelinpage4]

Am I the only one who thinks it odd that you have to draw up and administer your own vaccines routinely?

The time it takes to precept is real. I see 4-5 pts in a half day in my subspecialty continuity clinic, and I’m not sure I could see more because I end up waiting around for the attending a good chunk of the time. If you’re comfortably seeing 10 pts per day, you could probably quite easily bump that to 15 after graduation once you learn the new system you’re in.

I fully agree, and you're definitely not the only one. It's been a topic of debate at our clinics. The attendings and residents are against having to draw up and give their own vaccines, but due to push back from other staff, and nursing shortages, the residents still have to do it most days unless an extra nurse is available.

And thank you, that's good to hear I'm not the only one finding resident clinics slower with preceptors. Hopefully, it's more likely the clinic workflow with precepting and vaccines slowing me down and not me taking too long with patients.

 

[zeppelinpage4]

My other related question is also how difficult is fellowship compared to residency hours? I know this can vary program by program, and NICU, PICU, cardio, heme/onc are generally much more intense fellowships. But are peds pulm, nephro, or endocrine fellowships generally more difficult than residency or is fellowship life a little better overall?

 

[FrkyBgStok]

you are right that it depends on the fellowship. I am in EM and the hours are exponentially better than residency. The specialities feel better because you are doing what you love and focused on that and not acting as a resident. From what I understand, first year generally sucks for specialties because, while the hours are better, you know nothing so you end up working about the same, but second and third year seems to focus on research and generally way better than residency in every way. PICU and NICU are still going to be relatively harder with work hours but still better than residency.

 

[mvenus929]

My other related question is also how difficult is fellowship compared to residency hours? I know this can vary program by program, and NICU, PICU, cardio, heme/onc are generally much more intense fellowships. But are peds pulm, nephro, or endocrine fellowships generally more difficult than residency or is fellowship life a little better overall?

Endocrine fellowship is 1000% better than residency. Even the roughest schedule doesn't come close to standard residency hours.

 

[zeppelinpage4]

you are right that it depends on the fellowship. I am in EM and the hours are exponentially better than residency. The specialities feel better because you are doing what you love and focused on that and not acting as a resident. From what I understand, first year generally sucks for specialties because, while the hours are better, you know nothing so you end up working about the same, but second and third year seems to focus on research and generally way better than residency in every way. PICU and NICU are still going to be relatively harder with work hours but still better than residency.

That's really reassuring to hear, thank you. My other concern with specializing was if I could go through another 3 years of the same intensity. But I'm glad to hear that in most cases, fellowship is a better experience overall and hours are better.

Endocrine fellowship is 1000% better than residency. Even the roughest schedule doesn't come close to standard residency hours.

That's really nice to hear. I mostly saw the inpatient side of endocrine with DKA, and panhypopituitary patients, so I thought the hours would be more demanding.

It seems in general with the exceptions of heme/onc, NICU, PICU, cardio and maybe GI, the other sub-specialty fellowships are better than residency hours wise. That's another hesitation I had about doing fellowship. Residency was tough, and I honestly don't want to do another 3 years of that same intensity and hours, even if I really like a subspeecialty.

 

[DeadCactus]

The fact is that fellowships have to deal with a reality that residencies don't; trainees in fellowship have an option. A resident has little practical choice but to suck up whatever residency demands and finish. A fellow can pull the ripcord and parachute at any time into a job that pays four times as much for half the work. A few subspecialties are able to push trainees a bit because they offer a financial incentive or attract a crowd who cannot tolerate the idea of being a general pediatrician, but the pressure relief valve of fellowship is far less securely sealed than residency. Fellowships have to make sure they keep the training environment at a low enough level of "suck" to keep from triggering it, particularly in pediatrics where fellowship tends to be a net negative investment. Even the intense fellowships are generally low on scut which tends to make long hours more tolerable.