Fellowship vs Attending: What’s the Difference?

September 26, 2022
Every year as residency comes to an end, many decide between doing a fellowship or starting practice as an attending. It’s an individualized decision that hinges on professional goals and personal circumstances. The roles fellows and attendings serve are different in structure and purpose. If you’re approaching a similar decision, here are a few key distinctions between being a fellow vs attending to ensure you’re informed and can choose what’s right for you.

Key difference #1: Training

The biggest difference between a fellowship vs attending is a fellow is still in training while an attending completed their training and is practicing independently. To become a fellow, you first must complete a residency teaching broad skills relevant to your field. Then, you work with and learn from attendings who completed the same fellowship to gain expertise in a narrower subspecialty.

For example, cardiologists complete an internal medicine residency first to learn how to manage a wide breadth of medical conditions. Then, they complete a cardiology fellowship to gain expertise specifically in cardiac diseases. Of note, while usually viewed as the next step after internal medicine, pediatrics, and general surgery residencies, fellowship options exist after almost every residency including dermatology, anesthesiology, and psychiatry.

By contrast, an attending is no longer training but also no longer further subspecializing. They completed all of the requirements to work within their field and are functioning without the oversight of another physician. If you completed a general surgery residency and elected to start practicing without a fellowship, you would be able to do the core operations you learned through your training. Importantly, however, you would not be qualified to do more specialized procedures like transplants or certain pediatric operations without the additional experience that comes with fellowships in transplant or pediatric surgery.

Simply put, a fellowship may add multiple years to your training before you can start working on your own. The advantage, however, is the skills it will give you to become an expert in your specific field.

Key difference #2: Job responsibilities

The responsibilities of a fellow and an attending also differ. The structure and duration of fellowships vary by type, but they usually involve both research and clinical or surgical components. Most fellowships that follow an internal medicine or pediatrics residency frontload patient care duties. You will spend most of your first year doing inpatient hospital consults and establishing a panel of clinic outpatients before transitioning to primarily focusing on research. While surgical fellowships naturally include more surgical time, they often also follow this general format. What’s different as an attending is your schedule is less regimented and more flexible. In addition to caring for patients, you’ll also have more freedom for medical education, research, or administrative projects.

In addition, because attendings practice independently while fellows are still training, fellows collaborate with attendings when providing patient care. For example, attendings and fellows commonly work together on services for hospitalized patients. In this context, a fellow will often see a patient first and develop a treatment plan. Then, they see the patient again with the attending who signs off on that plan or modifies it as needed. This allows the fellow to learn from the attending and gain the skills to eventually also practice on their own.

On the outpatient side, fellows may be supervised by a more senior physician and treat a panel of patients. This ensures safe and effective patient care while allowing fellows to have autonomy in anticipation of when they become attendings.

Key difference #3: Application process

The fellowship application process is similar to the process for residency and involves sending your CV through an interface like the Electronic Residency Application Service (ERAS), interviewing at programs, and finally being matched to an institution. You have control over the process insofar as you submit a ranking of programs in order of your preference, but the matching algorithm ultimately will determine where you’re placed.

On the other hand, securing employment as an attending more closely resembles the job application process in other industries. Rather than through an application service, you directly communicate with prospective employers who may review your CV and cover letter. After receiving job offers, you can weigh the strengths of different options and choose one rather than being matched to one.

Key difference #4: Compensation and benefits

Your pay as a resident or fellow rises incrementally the further you are into your training. However, the compensation for fellows is similar to that of a resident, and only a fraction of an attending’s pay.

Fellows and attendings may also have differential access to other benefits. For example, attendings may have a percentage of annual retirement account contributions matched by their employer, but this may not be the case for trainees.

Nevertheless, while the benefits and pay you receive may be important, it ideally shouldn’t be the only one. Don’t let the prospect of a higher salary in the near future hold you back from pursuing a career you will love in a slightly more distant future.

In summary

Briefly restated, the ultimate distinction between these two paths is an attending has finished training while a fellow has not. Some attendings practice in more general fields like internal medicine or general surgery, while others did a fellowship to practice in narrower fields.

If you’re nearing the end of residency and thinking about these options available to you, think about your career goals. If you hope to have a broad scope in your practice, becoming an attending out of residency streamlines the path. Conversely, if you love a niche area of patient care, you should consider doing a fellowship. Consider what you want to do with your life and identify the best path to make that dream a reality.

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By Michael Stephens, MD


Get a little more clarification

How do I choose a PA specialty?
If you haven’t started PA school yet, try getting hands-on medical experience (like as a scribe or medical assistant) in a field that interests you to make sure it's the right fit. While going through your clinical year of PA school, reflect on your experiences during rotations:
  • What subject gets you excited just thinking about it?
  • Do you feel a sense of purpose at the end of the day during a particular rotation?

Keep in mind that a negative experience during a rotation, such as poor organization or preceptorship, doesn’t mean you shouldn’t pursue that specialty. Ultimately, being in a fulfilling role is what's important.

Learn more about different PA specialties with the Is this the right PA specialty for you? series.
How do I get my first PA job?
During a rotation, if you’ve decided you'd like to work in that particular field, there are a few ways you can get your foot in the door:
  • Make your interest in the specialty clear to your preceptor and any attending staff you work with.
  • Show your commitment to the specialty and your desire to actively participate. This will open up the conversation for recommendations on additional resources (like helpful textbooks), and it can give your preceptor time to contact colleagues who may be hiring.
  • Do your elective or preceptorship with the clinician or facility you would like to work at.
  • Consider joining professional associations for your specialty to network with other PAs and learn more about the field.
For other tips, such as how to tailor your CV and cover letter to a specific position and what questions to ask in an interview, read How to Get Your First Job After Passing the PANCE.
How can I become a cardiology PA?
During the clinical year, get an elective in cardiology and consider shadowing a cardiologist on your days off. Spend some time with the telemetry technicians to pick up on common ECG variations.

Read Is Cardiology the Right Specialty for You? for more info.

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