The journey through medicine can feel, at times, Sisyphean—a repetitive and never-ending task. Physicians within a gastroenterology training program have completed a minimum of 11 years after high school before beginning gastroenterology fellowship, with a constant “restart” at multiple stages. Each new milestone requires acquisition of completely new knowledge and skills. It is understandable that everyone would feel “enough is enough” as they near the completion of fellowship and look forward to joining the workforce. Yet, an additional year of fellowship, with its accompanying challenges and rewards, is alluring to many trainees.
Navigating the decision of whether to pursue an additional year of training is challenging for fellows, as it requires the balance of intellectual curiosity with familial and financial needs. The following is a framework for trainees to use when considering an additional year of post-graduate training.
There are myriad “fourth-year” fellowship positions to consider. Options include (but are not limited to) interventional endoscopy, bariatric endoscopy, third space endoscopy, transplant hepatology, inflammatory bowel disease, esophageal disorders, small bowel/nutrition, and pancreatology. Importantly, both whether a trainee intends to pursue an additional year of fellowship and what type of fellowship are fluid decisions. For example, most interventional endoscopy trainees did not intend to pursue this path at the onset of gastroenterology fellowship (Gastrointest Endosc 2012;76[5]:939-944).
Before considering the benefits of an additional year of training, it’s instructive to first consider why a trainee might want to avoid that additional year of training. First, “matching” is not a given! Within interventional endoscopy, there are more applicants than positions every year. For example, in 2020, there were 121 applications for 71 positions (Gastrointest Endosc 2021;93[6]:1207-1214.e2). So, unfortunately, many applicants will not be able to match into their dream position. Furthermore, there are limited advanced-year positions in each region of the country. If you are required to be in a certain location for personal reasons, identifying a fellowship can be particularly stressful. The additional year of training also tends to be very busy. For example, interventional endoscopy fellows have reported high weeknight and weekend call requirements for their programs (Endosc Int Open 2021;9[3]:E338-E342). Other barriers to pursuing additional training include deferring a full salary for an additional year and, in some cases, delaying starting a family.
Interestingly, a majority (71.9%) of interventional endoscopy fellowship graduates believed it was challenging to find a satisfactory job (Gastrointest Endosc 2021;93[6]:1207-1214.e2). Whether reducing career options by “subspecialization” is a barrier to pursuing training is unclear.
Although this might sound very negative, fourth-year positions are very popular for a variety of reasons. First and, in my eyes, foremost, it is an honor and privilege to have focused expertise. After pursuing an additional year of training, you are tasked by your peers to manage some of their most complex cases. The additional training also makes you a valuable peer to industry, consulting on device and pharmaceutical development. If you have an interest in innovation, this focused expertise allows you to have a leading clinical edge when it comes to being an “inventor.” Finally, many of us were drawn to medicine for the ability to teach the next generation of clinicians; subspecialization emphasizes that aspect of our career, as subspecialists often have the most consistent teaching interaction with trainees. This teaching isn’t just local but may occur around the world as you get invited to share your perspectives at conferences.
Putting this all together, how do you decide whether pursuing an additional year of training is right for you? The two most common reasons, in my opinion, to pursue a fourth-year fellowship are that you want to be the “last stop” for patients suffering from complex illness, and you are deeply committed to a single disease state (eg, esophageal motility disorders or cirrhosis). Perks that come with subspecialization don’t generally drive the choice but can help solidify it. These perks include that, if you love teaching and being more involved in national societies, you will have many opportunities. In the end, only you can decide whether you want to be a “generalist” or “subspecialist.” We need expertise in both—it’s up to you to choose!
This article is from the October 2025 print issue.