The transition from residency to practice is a pivotal moment in every physician’s career. Do you dive straight into practice as a generalist, finally earning a “real” paycheck and regaining some control over your life? Or do you sign up for a fellowship, committing to one to three years of training and deferring gratification for the promise of specialized expertise?
While fellowships typically occur just after residency, some physicians consider taking the step later in their careers. No matter your level of experience, it can be a tough choice as you weigh financial implications against intellectual curiosity and the kind of impact you want to have on your patients.
For some, subspecializing is the only way to practice the kind of medicine you love. For others, the opportunity cost of lost income and delayed family life feels too high. To help you understand your options, we’ll break down the realities of pursuing a fellowship, with insights from your peers in the Sermo community who have been in your shoes.
What is a fellowship and why would a physician pursue one?
A fellowship is an optional period of medical training that a physician may undertake after completing a residency. During this period—usually ranging from one to three years, though some are longer—the physician, known as a fellow, acts as a subspecialty trainee with increasing clinical autonomy under attending supervision. The goal is to gain specialized expertise in a specific branch of medicine.
Physicians’ reasons for signing up for more training after the marathon of medical school and residency are varied. “I believe there are many factors to consider when making this decision, it is not easy at all, but there is no doubt that as part of professional and personal growth, it is a step that we have all considered,” an internist states on Sermo.
Some physicians find a specific organ system or disease process fascinating and want to dedicate their career to mastering it. Others are driven by the desire to perform complex procedures that generalists aren’t credentialed to do. And for many, it’s about career trajectory—opening doors to academic medicine, research or specific hospital leadership roles.
Here is a look at some common fellowships across major specialties:
Anesthesia
- Adult cardiothoracic anesthesia: focusing on anesthesia for heart and lung surgeries
- Obstetric anesthesiology: managing pain and anesthesia for labor and delivery
- Pain medicine: diagnosing and treating acute and chronic pain
Cardiology
- Interventional cardiology: using catheter-based procedures to treat heart disease
- Clinical cardiac electrophysiology: treating heart rhythm disorders
Dermatology
- Dermatopathology: diagnosing skin diseases at a microscopic level
- Micrographic surgery and dermatologic oncology: focusing on skin cancer removal (Mohs surgery)
Gastroenterology
- Gastroenterology (often with a hepatology focus): treating digestive and liver disorders
- Pediatric gastroenterology: specializing in digestive issues in children
Nephrology
- Nephrology: treating kidney diseases and hypertension
- Pediatric nephrology: managing kidney disorders in children
Neurology
- Epilepsy: specialized care for seizure disorders
- Neuromuscular medicine: treating disorders of the nerves and muscles
- Vascular neurology: specializing in stroke care
Pathology
- Cytopathology: diagnosing disease on the cellular level
- Forensic pathology: determining the cause of death
- Hematopathology: studying diseases of the blood
- Molecular genetic pathology: diagnosing disease through genetic analysis
Pediatrics
- Developmental-behavioral pediatrics: managing developmental and behavioral issues
- Pediatric cardiology: treating heart conditions in children
- Pediatric emergency medicine: specializing in acute care for kids
- Pediatric hospital medicine: care for hospitalized children
Radiology
- Abdominal radiology: imaging of the abdomen and pelvis
- Musculoskeletal radiology: imaging of bones, joints, and soft tissues
- Nuclear radiology: using radioactive substances for imaging
Surgery
- Congenital cardiac surgery: correcting heart defects in newborns and children
- Complex general surgical oncology: surgical treatment of cancer
- Hand surgery: treating injuries and conditions of the hand and upper extremity
- Surgical critical care: managing critically ill surgical patients
Pros of a fellowship
Deciding to subspecialize is a trade-off. You are exchanging time now for expertise and future potential. When polled on the main benefit of doing a fellowship, most Sermo members said gaining deeper knowledge in a specific area (41%), followed by higher income potential (22%) and increased employment opportunities (21%). Here’s a more in-depth breakdown of the advantages of completing a fellowship:
Higher long-term earning potential
While not true for every single subspecialty, generally speaking, specialists earn significantly more than generalists over the course of a career. This “specialist premium” can amount to millions of dollars over a multi-decade career. While the pay gap between primary care physicians and specialists has narrowed in recent years in the U.S., it’s still “a sizeable gap,” according to one study.
“All of my classmates and even residents who followed me in training, who did fellowships, have all retired before me,” writes an internist on Sermo, adding that “they all did really well financially,” despite that “many of them were not the best students or residents.”
More job opportunities and demand
As medicine becomes more complex, the demand for highly specialized care increases in many specialties. If you’re fellowship-trained, that can make you a more attractive candidate for competitive hospital positions.
Ability to perform specialized procedures
If you love procedural work—cath labs, scopes, intricate surgeries—a fellowship is often a must. It grants you the credentials and privileges to perform the work you enjoy most.
Stronger professional reputation
Subspecialists are often viewed as the “expert’s expert.” This can lead to a strong referral base and a high level of respect within the medical community. “If your desire is to pursue just professional [development], i think its the right choice,” writes a family medicine doctor on Sermo.
Access to academic and research roles
If your dream involves teaching residents, running clinical trials or attaining tenure at a university hospital, a fellowship is almost always a prerequisite.
More focused, satisfying clinical work
General practice requires a breadth of knowledge that can be exhausting to maintain. Subspecializing allows you to narrow your focus, potentially leading to greater mastery and job satisfaction.
Cons of a fellowship
While most respondents in a Sermo poll (39%) said that fellowships are “absolutely” worthwhile, 23% said they’re worthwhile only when required, 20% were on the fence, and 11% said they’re not worth it. Physicians who opt to forgo a fellowship may do so for a variety of reasons:
Lower pay during additional training years
Fellows are paid like residents—a fraction of what an attending makes. This means delaying your “real” income for several years. In the U.S., fellows earn an average of $59,022 per year, while general practitioners average $183,230, according to ZipRecruiter data.
Those training years are prime years for compound interest. By delaying your high-income years, you are delaying your ability to aggressively pay down debt or save for retirement. It’s hard to buy a house, start a family, or settle into a community when you are in a temporary training position, potentially in a different city than where you want to settle down.
Higher workload and burnout risk
Fellowship training is rigorous. It often involves high acuity patients, complex cases and demanding call schedules, which can contribute to burnout just as you thought you were nearing the finish line. “For me a fellowship was not worth it because I wanted to stay in the area and have more reasonable hours again,” a general practitioner shares on Sermo. Similarly, a pediatrician cautions that fellowship is “not an easy path and you have to sacrifice a lot.”
Competitive and time-consuming application process
Getting into a fellowship isn’t guaranteed. It requires research, networking, interviews and a competitive application. The National Resident Matching Program (NRMP) in the U.S. reported an 83.5% match rate for 14,620 fellowship positions in 2025. Some specialties are more competitive than others. Specialties like gastroenterology, cardiovascular disease and many surgical specialties consistently have some of the highest fill rates among MD applicants in the NRMP, the American Medical Association reported.
The financial cost of a fellowship: calculating the ROI
A medical fellowship isn’t necessary for financial success, but it can help. However, the math is more complicated than just comparing salaries. To truly understand the Return on Investment (ROI) of a fellowship, you have to look at the opportunity cost of completing one.
Imagine that you just finished an internal medicine residency. You could immediately start working as a hospitalist earning $250,000. Instead, you choose a 3-year cardiology fellowship paying $70,000. Immediately, you’ll miss out on earnings in more ways than one:
- Lost wages: over three years, you have “lost” $540,000 in gross income (the difference between the attending salary and fellow salary).
- Interest on debt: during those three years, your student loans are likely accruing interest. That $212,000 debt pile (the average education debt for medical school graduates) is growing while you are making minimum payments on a fellow’s salary.
- Time value of money: that $540,000 you didn’t earn is also money you couldn’t invest. In the stock market, that capital could have compounded significantly over 30 years.
However, once you become a cardiologist, your salary might jump to $500,000+ (the specialists’ salaries range from $386,000 to $615,000 in the U.S., per Glassdoor data). You are now earning $250,000 more per year than you would have as a hospitalist. In this scenario, it might only take two to three years to “break even” on the lost wages, and over a 30-year career, the cardiologist will come out millions ahead.
But, not all fellowships offer this boost. Some subspecialties— like those in pediatrics or infectious disease— may offer only a marginal salary increase compared to general internal medicine, meaning the financial ROI might not be worth it. Some specialties may even come with a lower salary, such as in academic, research, or low-reimbursement clinical roles. For instance, pediatric endocrinologists in the U.S. have a median salary of $251,000 vs. $255,000 for general practitioners, per Glassdoor data. In these less common cases, the financial return of the fellowship can be limited, but still make sense to pursue if the decision is driven by passion, intellectual interest, or lifestyle considerations and not profit.
Many Sermo members believe the benefits of doing a fellowship outweigh the up-front loss. In a poll, 44% said loss of income and debt matter, but not as much as other things, and 32% said it’s a minor consideration compared to career satisfaction. That said, 18% believe that the opportunity cost of a fellowship is the most important factor to consider.
Are medical fellowships paid?
Yes, fellowships are paid positions. However, you are paid at a PGY (Post-Graduate Year) training level, which is funded by a combination of Medicare (GME funding) and institutions in the US. While fellows make a livable wage, it is far from the market rate for a board-certified physician.
The decision to take a fellowship may feel like more of a sacrifice for some than for others, an OBGYN on Sermo points out. “The economic reason is one of the most important, along with postponing certain life events… each person must assess that for themselves,” they write.
One rheumatologist and Sermo member is content with their decision to pursue a specialty despite any short-term financial implications. “I have been doing rheumatology for decades and never regretted it,” they reveal. “..Loving what you do should be at least as important as financial considerations.”
Are fellowships worth it? Final thoughts from the Sermo community
It’s useful to compare fellowship vs general practice income, but that’s not the only metric that matters in making your decision. Feedback from the Sermo community suggests that long term salary potential, intellectual curiosity and the ability to “settle down” sooner should also factor in.
In a Sermo poll, physicians were generally happy with their decision, whether they pursued a fellowship (48%) or decided not to (28%). Only 7% regretted doing a fellowship and 13% regretted not doing one when they had the chance.
“I’m happy with my decision not to subspecialize and therefore not to have received any scholarship for that purpose,” wrote one family medicine doctor reflecting on their decision. A maternal-fetal medicine specialist expressed “satisfaction and gratefulness” for their fellowship.
Generally, Sermo members believe that whether a fellowship is “worth it” will depend on your individual circumstances and interests. They’re worthwhile “if this is your goal professionally,” according to a rheumatologist, “if it gives you resources, experience, or connections that clearly move you closer to your professional or academic goals,” according to an endocrinologist or “if the subspecialty truly excites you and aligns with your long-term vision,” in the words of a general practitioner.
How to decide if a fellowship is right for you
There is no universal “yes” or “no” to the question of fellowships. The value cannot be measured by salary alone; it is a complex calculation involving long-term financial security, intellectual challenge and achieving a lifestyle that’s sustainable and fulfilling.Ideally you won’t make this decision in a vacuum. You need data and the honest truth from people who have walked the path before you. The Sermo community has a wealth of candid, peer-vetted data, and the chance to ask questions, discuss options and learn from people who have walked in your shoes. Join Sermo to connect with physicians across 96+ specialties, and find clarity on which fellowship path is right for you.
