From Residency to Practice: Getting Started Without a Fellowship


With the practice of neurology becoming more complex by the minute, there’s a lot of pressure on physicians to follow up their neurology residency with even more specialized instruction in the form of a fellowship. Reasons to advance to this next level of training range from the desire (or need) to become an expert in a specified area of practice, to the fear of not being hired for key positions without one.

But not everyone follows the same path, and not every good job requires candidates to have fellowship training. Heather Schweizer, DO, is an example of a successful neurologist whose formal education did not include a fellowship. That’s partly by design—she did review the option but decided against it—but also by lack of design. That is, unlike some of her colleagues and friends who entered medical school with a plan for each stage of their career, Schweizer took a more laconic approach. “I’m not really ‘Type A,’” she said, “So I’m okay with plans changing and trying things out.”

That’s a life approach Schweizer applied to her training path as well. Although she is happily positioned now as the stroke medical director for The Villages Regional Hospital in Florida, she wasn’t even aware of neurology as an area of practice when she first entered her residency at Larkin Community Hospital in Miami. Despite having enjoyed the subject during medical school, neurology as a professional track wasn’t on her radar. “I thought I was going to do family medicine when I went to Larkin,” she said. “I didn’t even know they had neurology in my residency program, and then a spot opened up in my second year, so I decided to apply.”

As luck would have it, Schweizer was entering a newly-evolving program at Larkin, getting in on the ground floor as the hospital was developing its neurology rotations. This gave her and fellow residents the opportunity to provide feedback and help shape the program as rotations were added. Even so, she still didn’t have specific plans for the direction her career would take—she just wanted to continue learning about the subject that had held her attention so well during medical school. Nevertheless, Schweizer began to explore the question of fellowships. Over the next couple of years, she inquired with different attending physicians about the fellowships they’d taken and how they thought their careers had benefited. The answers were mixed, which was enough to give her pause. Some of the attendings told her they don’t use their fellowship training in their work—an answer she found most frequently among the outpatient and general neurohospitalists.

The prospect of having a fellowship “not pay off” was especially daunting to Schweizer. “It was a difficult decision financially because I don’t come from a lot of money,” she said. “I had $400,000 in loans, so to take another year digging into that hole, it had to be worth it for me. But the other problem was that I didn’t have any passion for any subspecialty. I love neurology as a whole.”

Schweizer decided to take her chances on the job market without a fellowship, a gamble that paid off when her former residency chief tapped her on the shoulder to apply at The Villages. Schweizer answered the invitation and soon found herself employed in the largest retirement community in the country, where she discovered there were literally more golf carts than cars on the roads. “They call it Disneyland for adults,” she said with a laugh. She started as a general neurohospitalist, a position she loved immediately for its variety. “I like having a bunch of different things to see on a daily basis,” she noted. “I like the problem solving. I feel like being a neurohospitalist lets you specialize in diagnosis and problem solving, and then you get to send it out for specialists.”

Not long after—a year, to be exact—the stroke position opened and Schweizer jumped on the opportunity. Even though this role would more commonly go to someone with a fellowship in vascular neurology or a related specialty, Schweizer thought she could be a viable candidate. “I felt confident in my education and the knowledge I had already gained from my work,” she said. Schweizer also believes the modest size of the community helped keep her in the running, noting that she might have needed a fellowship to vie for a similar role at a larger facility.

One way or the other, Schweizer got the job and she stepped up to lead the stroke program for a community hospital only one year out of residency. Since the population of The Villages skews old—most residents are over 60 years of age—they have a disproportionately high number of stroke cases to treat. On a typical day, Schweizer says, she will print her consult list and go through the different charts and cases, using her NP to do some of the followup. As a primary stroke center, it’s common to have a couple of stroke alerts to attend to. Otherwise, she finds herself interacting a lot with family members, particularly for patients with delirium and others who come from nearby care centers. On the administrative side, which comprises about 20 percent of her day, she may conduct a stroke meeting with other staff, complete reports, or attend meetings with other departments.

Now that she’s finishing her first year as stroke medical director— and her second year out of residency—Schweizer feels she has more perspective to judge her decision not to pursue a fellowship. “For this position,” she said. “I don’t feel like a fellowship would necessarily help me. This isn’t a large academic institution, it’s a comprehensive center.” As for picking up a fellowship later, Schweizer feels that may not be necessary either. “I think the experience with my position here will be as strong on a resume as a fellowship in stroke would be,” she said. “I may be wrong about that, because different places look for different things. But I just got married and I have a baby on the way, so adding training isn’t something I’m thinking about right now.”

For others weighing the fellowship decision, Schweizer has this advice. “Don’t feel pressure from anybody, whether that’s your residency or your family. You have to step back and look at what you want. For instance, if you’re a general neurohospitalist but then take a fellowship in headache, you’ll have that piece of paper but you won’t necessarily get to do a lot of headache cases.” Rather than taking a fellowship for the money, or to appease someone else, Schweizer advises residents to wait until they know what they’re passionate about. In that way, they can ensure that the year of training pays off in career satisfaction, even if it doesn’t turn out to be lucrative. If that means skipping the fellowship, Schweizer is proof that a successful career can evolve without the extra training. “I’m very happy with the choice I made,” she said.

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