The number of anesthesiologists applying for fellowships after graduating from residency has grown substantially over the last 20 years. From 2017-2020, the percentage of anesthesiologists completing their residency and entering fellowships more than doubled. Fellowship participants will be primed to take on the most complex, interesting cases throughout their careers. Yet, many claim that fellowship training has little impact on the likelihood of employment. Nearly all 2020 anesthesiology fellows (96%) found employment in their specialty, as did 95% of anesthesiology residents who completed training in 2020 ( Entering a fellowship also means sacrificing a year’s worth of income, not to mention potential relocation and extended training. Given such a massive uptick in fellowship training, some wonder about the implications on anesthesiologists’ careers and on the profession at large.

Certain hospitals are requiring fellowship training to be hired for specialty cases. Moreover, the American Board of Anesthesiology (ABA) continues to offer more subspecialty certifications, some of which require relevant fellowship training. These certifications could make a physician a better candidate for specific roles or even be required by hospitals in some instances. “We are seeing jobs where anesthesiologists are going to be doing cardiac cases, increasingly looking for applicants with a cardiac fellowship training. A lot of the specialties have required extra board certification,” said Srikanth Sridhar, MD, FASA, Associate Professor, Vice Chair for Quality of Anesthesiology, and Assistant Vice President for Healthcare Quality and Safety at McGovern Medical School at UTHealth Houston. This has contributed to mounting pressure for young anesthesiologists to apply for fellowships. Completing a fellowship post-residency can open the door to new opportunities, but it also has drawbacks for physicians eager to get their careers under way.

Dr. Sridhar engaged in a debate about the pros and cons of entering into an anesthesiology fellowship at last year’s ASA annual meeting. Dr. Sridhar has been an anesthesiologist at the UTHealth Houston for 11 years. At the debate, Dr. Sridhar countered the idea that fellowships are essential for anesthesiologists.

The decision to continue his career without undertaking a fellowship wasn’t one Dr. Sridhar made lightly. After wrestling with the idea for some time, he was able to get board certified for pediatric anesthesiology anyway – a certification that now requires a fellowship. Initially instituted in 2013, the ABA subspecialty certification in pediatric anesthesiology did not require fellowship training until 2016.

“I decided not to, mostly because I wasn’t sure that I wanted to practice primarily pediatric anesthesiology. I knew I wanted to be in academic medicine, so if I had subspecialized in pediatrics, I pretty much would have done all pediatrics all the time instead of having a mix,” recalled Dr. Sridhar. He still feels that opting not to do the fellowship afforded him more variety in his career. Dr. Sridhar was able, however, to practice some part-time pediatric anesthesiology and eventually obtain his board certification. At the time, the ABA considered physicians with experience practicing pediatric anesthesiology to be eligible for their certification. The ABA no longer allows anesthesiologists to gain board certification for pediatric anesthesiology without fellowship training.

Today’s new graduate anesthesiologists need to consider fellowship requirements as they finish their residencies. Not all ABA subspecialty certifications require a fellowship. Moreover, the ABA certifications offer a grace window after they institute the necessity of a fellowship for eligibility. Qualifying physicians with enough experience have a few years to obtain certification before a fellowship is mandated.

The ABA instituted a grace period as a way of letting physicians – who may have been practicing in their subspecialty for years – obtain new certifications without having to go back and perform a fellowship. In doing so, this allows the ABA to reward on-the-job experience while still emphasizing the need for fellowship training. This option allows physicians to segue into a subspecialty after employment with a variety of clinical experiences. Moreover, practicing in a mixed model setting may give younger anesthesiologists more exposure and a better idea of the subspecialties to pursue.

Despite benefitting from the ABA’s grace window, Dr. Sridhar sees fellowship requirements for board certification as a positive: “They want people who are board certified in a subspecialty to be formally trained to do that subspecialty. So, I think that’s actually a positive.” While segueing into a subspecialty from general anesthesiology is possible, fellowship training offers unique advantages and experience.

A fellowship offers the opportunity to spend an entire year getting in-depth, unique experiences in a highly specialized field. Those with a defined interest within one area of anesthesiology can use a fellowship to distinguish themselves from other anesthesiologists. Being fellowship-trained allows a more sophisticated level of unique clinical insight. Specialized perspectives and depth of experience help to create dynamic caregiving teams that improve patient safety.

Moreover, while delayed income may give pause to many finishing their residencies, some fellowships allow for higher earning potential. Obstetric anesthesiology is a growing field with a lot of promise, for both physicians and patients. With maternal mortality on the rise in both developed and developing nations, the demand for anesthesiologists with obstetric subspecialty training will continue to rise (Indian J Anaesth 2021;65:43-7). The American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM) have also contributed to the demand for anesthesiologists with obstetric subspecialty training. In recent years, ACOG and SMFM outlined a ranking system for obstetric and maternal health care offered by hospitals. The top two tiers incorporate subspecialty-trained obstetric anesthesiologists into their staffing requirements.

Ultimately, a lot goes into the decision to pursue a fellowship. Beyond professional considerations, fellowship training is accompanied by income sacrifice, potential relocation, extended training, and oftentimes intimidating workloads. These are worth serious consideration at the beginning of one’s career. Today’s physicians are lucky that fellowships are now an option at times other than the early years of one’s career. After gaining some experience, physicians may steer their practice in a different direction or aspire toward certain positions. “We’ve had people who practice for one to five years and then go back and do a fellowship because they wanted to switch gears or want more expertise,” confirmed Dr. Sridhar. “That door is never closed.”

Fellowship training offers real opportunities and benefits to physicians, care teams, and patients alike. However, the pressure on graduating residents to enter one may be unduly high. “You shouldn’t feel like you absolutely have to do a fellowship just for the sake of doing a fellowship or just for the sake of getting extra training. It should be a personal choice that progresses you toward a goal in your practice,” said Dr. Sridhar.