Unit III: Fellowships in Family Medicine

We family physicians pride ourselves on maintaining a broad scope of practice with a varied and diverse patient population. However, there are good reasons to consider a fellowship program or other type of specialized training and fellowships are increasingly popular. A study from 2014-2015 showed that nearly 20% of family medicine residents indicated they intended to pursue a fellowship and most did, in fact, enroll. Over 50% of residents pursued Sports Medicine, Geriatrics, and Obstetrics fellowships. We hope this section opens your eyes to the many additional educational options available to family physicians after residency.

Fellows vs Fellowships

Before diving in, a few clarifications in terminology are needed:

• A fellowship refers to an additional formal training program after residency, and
• A physician-in-training is called a fellow.

Although a bit confusing, the term fellow is also used as an honorary title within a professional medical society. For example, members of the AAFP are eligible for the designation of Fellow of the American Academy of Family Physicians (FAAFP) if they meet certain criteria, indicating that significant contribution to the specialty. You may want to consider becoming a fellow of the AAFP or another professional society after you have some experience in practice. However, this type of “fellow” is not the focus of this section; instead, we address fellowship training programs.

Certificates and Certifications

Certificates and certifications are also confusing, as they are often used interchangeably. After residency, most family physicians pursue board certification in family medicine by the American Board of Family Medicine (ABFM) or the American Osteopathic Board of Family Physicians (AOBFP). Board certification is generally not required to practice medicine (you must only be licensed in your state), but it is often required to obtain hospital privileges, to enroll with some malpractice coverage companies, and to be hired in some practices.

You can also pursue subspecialty board certification after completing an accredited fellowship program and passing a subspecialty-based board exam. These boards are formal subspecialties of family medicine and grant a Certificate of Added Qualification (CAQ). Physicians are then required to maintain board certification in family medicine, along with any requirements or board exams for the subspecialty board certification.

Some professional organizations also offer independent board certification to family physicians, usually after completion of a fellowship program or with evidence of sufficient clinical experience (to be eligible). Sometime they also require candidates to obtain and maintain concurrent family medicine board certification. That said, most board certifications offered by other professional organizations are not formal subspecialities of family medicine itself.

Finally, some CME courses (e.g., colposcopy or dermoscopy) provide recognition of completing a training course; these sometimes provide a certificate, showing you participated in the course and perhaps demonstrated some competency of skills. These certificates can be useful in various settings, but it clearly does not hold the weight of a board certification.

What Types of Fellowships Are Available?

There are 2 types of fellowship programs for family medicine:

• ACGME-accredited fellowships: The ACGME standardizes learning objectives and accredits each fellowship program. Applicants must become board certified in family medicine, apply to the fellowship through the Electronic Residency Application Service (ERAS), and participate in the National Resident Matching Program (NRMP) match. Fellows complete the fellowship and subsequently sit for a specialty board certification exam offered by a professional organization. If this is offered conjointly with the ABFM or AOBFP, passing this exam grants a Certificate of Added Qualification (CAQ), which is a formal subspecialty of family medicine.
  
  
• Non-ACGME-accredited fellowships: These non-accredited fellowships are also very popular and provide additional experience and training in a specialized area. Even within the same field, individual programs may have different objectives, scope of training, and length of program. Many fellowships also provide flexibility, allowing fellows to tailor their educational experience to fit their own unique interests. Applicants do not apply through ERAS or match through the NRMP and there is no CAQ offered through family medicine as a subspecialty. However, as mentioned above, there are other professional organizations that may offer board certification after completion of a fellowship and subsequent board exam; they aren’t subspecialties of family medicine, per se, but they do hold significant weight.

For a quick list of fellowship programs, the AAFP Fellowship Directory is a useful resource. However, be aware that the listed programs can occasionally be outdated or incomplete and there may be additional fellowships programs.

Why do a Fellowship?

Residents often develop an interest in a particular patient population or field within family medicine, but may not have gained sufficient experience or expertise during residency. Additional training can enhance career satisfaction and flexibility, as well as improve marketability in job searches. A fellowship lends additional credibility when advocating for particular populations, performing research, teaching, or pursuing leadership roles. For those interested in academic medicine, fellowship training is highly valuable for family medicine faculty. Some positions (ie, medical director of a hospice organization or of an addiction treatment program) may require fellowship training and certification.

Why Not to Do a Fellowship?

A fellowship may be unnecessary for your future career, since residency should have trained you broadly; you can also gain additional knowledge and skills by individualized learning, CME activities, and shorter intensive training programs. Some physicians are concerned about student loans and other expenses, and wish to avoid spending yet more time and money in further training. However, if you truly want to do a fellowship, don’t let debt alone deter you--most loans can easily be deferred for another year or two.

When Does Application and Fellowship Training Occur? 

You can do a fellowship at any time after residency; however, the easiest time is probably before you have established your own practice and adjusted to a higher salary. It can also be easier to defer loans or continue income-based repayment directly after residency. Fellowships are generally full-time, but some may allow for concurrent faculty positions or other employment.

If you decide to pursue a fellowship directly after residency, you should review the timeline for application early in PGY-3 since most programs start in the summer or early fall. Some fellowship programs utilize the NRMP match systems and are extremely competitive. As with residency, you want to foster mentoring physician relationships and obtain good letters of recommendation—the earlier, the better. To gain insight into the fellowship program of interest and have a better chance at matching, you may wish to pursue an elective rotation at that site.

ACGME Accredited Fellowships With CAQ

There are currently seven ACGME-accredited fellowship programs with CAQs offered through the American Board of Family Medicine (ABFM). More information about the following programs can be found at the ABFM:

• https://www.theabfm.org/added-qualifications
• https://www.theabfm.org/caq/index.aspx

CAQs conjointly offered through the ABFM include:

• 1. Adolescent Medicine
• 2. Geriatric Medicine
• 3. Hospice and Palliative Medicine
• 4. Pain Medicine
• 5. Sleep Medicine
• 6. Sports Medicine
• 7. "Designation of Focused Practice” in Hospital Medicine (This option is not technically a CAQ, but is listed under the same category)

The American Osteopathic Board of Family Physicians (AOBFP) offers the same CAQs listed above, with the exception of Adolescent Medicine and Hospital Medicine. They also offer three additional CAQs:

• 8. Addiction Medicine
• 9. Correctional Medicine
• 10. Undersea and Hyperbaric Medicine

1. Adolescent Medicine Fellowship

Adolescent Medicine is an important and growing field, focused on the management of complex adolescent health issues within the context of their biological, psychological, social, and cognitive changes: primary care, reproductive and sexual healthcare, disorders of puberty, eating disorders, behavioral health, chronic illness management, genetic disorders, chronic fatigue and/or chronic pain syndromes, substance abuse, school health, foster care, juvenile justice system care, sports medicine, global health, and transitional care. Some specialists see teenagers exclusively or integrate this population into a broader set of clinical responsibilities, while some combine clinical care with teaching, research, and policy and program development.

There is a shortage of Adolescent Medicine specialists. Academic health centers and children’s hospitals are seeking specialists to teach, conduct research, and/or provide consultative and primary care for adolescents. Other opportunities include: (1) government and public health positions on the local, state, and federal level (program development, leadership, policy, clinical care); (2) school health, juvenile justice, and military medicine; (3) adolescent subspecialty care in large multi-specialty physician groups or adolescent private practices; and (4) industry.

A career in Adolescent Medicine is generally conducive to a healthy work-life balance. Communication with adolescents and their families may occasionally arise outside of normal clinical hours, as with any clinical practice. Many specialists provide consultation to pediatricians and other subspecialists. They may also be consulted in the hospital, but the majority of adolescent care is provided in the outpatient setting. The field typically allows for flexibility based on areas of interest, expertise, and desired practice settings.

➢Fellowship and CAQ

Adolescent Medicine fellowships are 2-3 years in length. There is roughly a 50-80% fill rate of the approximately 55 spots for family medicine at nearly 30 programs nationwide. Almost all Adolescent Medicine fellowships participate in ERAS and the NRMP Matchduring fall of PGY3. The AAFP has a listing of Fellowship Programs but should be double-checked since programs change. The Society for Adolescent Health and Medicine (SAHM) and the American Medical Association’s AMAs) Residency and fellowship database, FRIEDA, seem to have very current fellowship information.

The Adolescent Medicine CAQ is offered conjointly through the ABFM, American Board of Internal Medicine (ABIM) and American Board of Pediatrics (ABP). The board exam pass rate each year is about 80%. Candidates must maintain board certification in family medicine to maintain their subspecialty CAQ certification. The ABFM provides information about the Adolescent Medicine CAQ.

SAHM offers many additional resources and encourages interested students and residents to apply for a travel scholarship to attend the Society’s annual meeting where they can learn more about the field while networking with adolescent health professionals and trainees. Additionally, the AAFP has a “Member Interest Group” on Adolescent Health.

2. Geriatrics Fellowship

Geriatric Medicine began in 1988 in response to the expansion of older populations. Geriatricians provide acute and primary care to patients in a unique season of life, addressing their physical, mental, and psychosocial needs. Clinical skills include comprehensive assessment and functional evaluation of geriatric patients, along with rehabilitation, geropsychiatry, nursing home medicine, clinical ethics, and end-of-life care. Collaboration in decision-making often includes other family members and consideration of healthcare costs and coverage.

There is a great demand for geriatricians. The American Geriatrics Society (AGS) reports a current need for 20,000 geriatricians, but only 7,300 certified specialists exist—and by 2030, over 30,000 will be needed. Because of the need, financial incentives are available in some states for loan forgiveness. Academic geriatric education and research in these populations is also lacking.

Many geriatricians find this population and the patient-physician relationship to be extremely rewarding with high rates of job satisfaction. There are a variety of related practice settings that contribute to satisfaction, including house calls, nursing home care, and a combination of inpatient and outpatient opportunities. Some physicians may integrate geriatrics into other patient populations or exclusively see geriatric patients. The practice can typically be tailored to the personal needs and professional goals of the physician.

Average income for geriatricians appears to be somewhat lower than national family physician averages, perhaps due to the primarily outpatient nature and the fact that fewer patients are seen in a day in order to provide additional time per visit.

The Geriatric Medicine board exam is offered through the ABFM, ABIM (American Board of Internal Medicine) and ABPN (American Board of Psychiatry and Neurology). The board exam pass rates are around 90%. Candidates must maintain board certification in family medicine to maintain their subspecialty CAQ certification. The AGS provides board review material. The ABFM also has information about the Geriatrics CAQ.

3.Hospice and Palliative Medicine Fellowship

Hospice and Palliative Medicine is a growing field given our aging population and the complex array of medical interventions at the end of life. Many patients lack access to adequate palliative care and hospice. Palliative care involves symptom management and quality of life care for physical, psychological, and spiritual suffering. Patients can be of any age and with any stage illness or disease whether that illness is curable, chronic, or life-threatening. A palliative team may include palliative care physicians and nurses; social workers; pharmacists; chaplains; dieticians; physical, occupational, and speech therapists; and volunteers, depending on the needs of the patient and the patient’s loved ones. Hospice care provides more specific palliative interventions for patients who are likely to die within the next 6 months.

The Center to Advance Palliative Care (CAPC) counted 1,400 hospital-based palliative care programs in the US with over 4,300 hospice agencies across the country. There is clearly a great demand for physicians to address the medical needs of patients enrolled in these programs. Careers in Hospice and Palliative Medicine also typically result in high job satisfaction and a rewarding practice, and can be tailored to suit individual personal and professional needs. Specialists can work in inpatient settings, scheduling shifts much like hospitalists, with few overnight calls. Outpatient Hospice and Palliative Medicine physicians can work in a variety of settings, including office and home-based care.

➢Fellowship and CAQ

Palliative Medicine and Hospice fellowships are one year in length. Fellows rotate with physician practices, cancer centers, hospitals, and palliative and hospice programs also learn about regulatory, administrative and leadership responsibilities. There are about 143 participating programs, most of which accept 2-6 fellows a year, with a high fill rate. There are also new fellowship training opportunities in non-residential community-based locations for mid-career physicians. These programs participate in ERAS and NRMP’s Medical Specialties Matching Program. The AAFP has a listing of Fellowship Programs but should be confirmed on ERAS.

The Hospice and Palliative Medicine CAQ board exam is conjointly offered through multiple professional organizations with a pass rate of around 80%. Candidates must maintain board certification in family medicine to maintain their subspecialty CAQ certification. The ABFM provides information about the Hospice and Palliative Medicine CAQ.

There are several organizations that support these physicians, including the American Association of Hospice and Palliative Medicine and the National Hospice and Palliative Care Organization. For some testimonials and additional information, see the AAHPM’s brochure and their FAQs.

4. Pain Medicine Fellowship

Many patients experience acute and chronic pain over the course of their lives, making Pain Medicine an important field of expertise. Currently there is a shortage of pain medicine specialists in the United States. While inappropriate treatment with opiates has led to many problems, untreated or under-treated pain adversely affects the quality of life of many patients. Pain contributes to medical comorbidities and further debilitation, as well as depression, anxiety and substance abuse.

Pain Medicine specialists are consulted in both inpatient and outpatient settings for management of acute and chronic pain of all kinds. Family physicians can become trained in a limited number of interventions and procedures, as well as medical management of various types of pain, but it may be necessary to have partnerships with other specialists for more invasive procedures. There are also positions in academic medicine and research opportunities. The average salary for pain medicine specialists is listed at around $300,000, but this may be more reflective of anesthesiologist reimbursement due to their higher rates of procedures.

➢Fellowship and CAQ

Pain Medicine fellowships are one year in length and provide training in interventional and medical pain management in the inpatient and outpatient setting, often with multidisciplinary team approaches. Fellows rotate in the departments of anesthesiology, gastroenterology, neurology, neurosurgery, oncology, palliative care, physical medicine and rehabilitation, rheumatology, sports medicine, and psychiatry. There can be additional training focused on headache medicine, palliative care, pediatric pain, psychiatric comorbidities, and addiction medicine. This fellowship has a high fill rate, mostly by other specialties with relatively few family medicine applicants. These programs participate in ERAS and the NRMP Match as a subspeciality of Anesthesia. While ERAS does list some programs, the AAFP does not currently list any programs for Pain Medicine on their Fellowship page. Applicants may need to request information to see if a given program accepts family physicians.

The Pain Medicine CAQ was originally made available for family physicians in conjunction with the American Board of Physical Medicine and Rehabilitation but now is offered through the American Board of Anesthesiology. The pass rate is about 75% for the 430 candidates who sat for the exam in 2019 (most were not family physicians). Candidates must maintain board certification in family medicine to maintain their subspecialty CAQ certification. The ABFM also has information about the Pain Medicine CAQ.

The American Pain Society formally closed in 2019 but the American Academy of Pain Medicine continues to be a good resource. The Practical Pain Management site also offers excellent resources.

5. Sleep Medicine Fellowship

Sleep Medicine is an important area for the health of patients, with about 70 million Americans suffering from sleep disorders. Most remain undiagnosed and this reality impacts other comorbid conditions, including psychiatric disorders, metabolic and cardiovascular health, and chronic pain conditions. While most Sleep Medicine physicians come from other specialties, family physicians are also eligible for this subspecialty.

Sleep Medicine specialists typically work within interdisciplinary teams in the outpatient or inpatient setting. There are around 2,500 sleep facilities accredited by the American Academy of Sleep Medicine (AASM) that are covered by specialists who interpret polysomnograms (sleep studies) and make recommendations based on those findings. Sleep physicians may also teach at academic centers, consult in public health settings, serve in research centers, or work in administrative roles. Physicians may continue seeing patients as part of their primary specialty and work in sleep medicine part time.

Sleep Medicine is a growing specialty with a growing need for sleep specialists. The availability of wireless wearable technology for tracking sleep, wireless CPAP (Continuous Positive Airway Pressure) feedback, and telemedicine consultation are extending access to patients. The work hours are typically favorable, since technicians typically manage the overnight polysomnography studies and emergencies are rare. Salaries appear to be comparable to the primary specialty of the physician.

➢Fellowship and CAQ

Sleep Medicine fellowships are one year in length and clinical training includes normal sleep physiology and sleep disorders, including narcolepsy, sleep walking, nightmares, as well as other conditions negatively impacting sleep, such as obstructive sleep apnea, restless leg syndrome, and chronic pain. Fellows learn from experts within internal medicine, pediatrics, psychiatry, neurology, pulmonology, and surgery. Research into sleep-related conditions is also emphasized. This fellowship participates in ERAS and NRMP. There is an 86% match rate for the almost 200 fellowship slots at over 85 programs. The AASM is a good resource for further learning.

The Sleep Medicine CAQ is offered through the AASM, and cosponsored by 5 specialty boards, including Anesthesia, Family Medicine, Internal Medicine, Neurology, Otolaryngology, Pediatrics, and Psychiatry, with a pass rate of 89%. The ABFM provides more information about the Sleep Medicine CAQ. Candidates must maintain board certification in family medicine to maintain their subspecialty CAQ certification.

6. Sports Medicine Fellowship

The Sports Medicine fellowship provides specialized training in traditional athlete evaluations, orthopedic care with joint reductions, splinting and casting, ultrasound-guided joint injections and percutaneous needling, exercise rehabilitation, back-pain management, preventive and occupational medicine, and cardiovascular fitness. Fellows may also gain expertise in osteopathic manipulative techniques.

Sports Medicine is an ever-growing field focused on the care and well-being of active persons. Although many may perceive sports medicine physicians as those seen on the sidelines of athletic events, in reality the field of sports medicine aims to care for patients of all ages and activity levels. Many physicians may wish only to broaden their musculoskeletal and preventative medicine training as they plan for their primary care-based practices. Others may pursue a full-time position with an elite-level professional sports team, an academic setting or choose to practice only musculoskeletal-based medicine in conjunction with an orthopedic group.

The ability to tailor one’s practice to a unique set of skills is enhanced with a Sports Medicine fellowship. Salaries for Sports Medicine trained Family Physicians are typically above the average for a board-certified Family Physician, but vary widely based on practice style and location. The ability to perform ultrasound-guided examinations, injections, and other procedures may allow for a potential increase in revenue generation.

Sports Medicine physicians often report high levels of work satisfaction since it is primarily an outpatient practice and often can be tailored to the preferences of the physician. Team physicians, however, may end up with atypical schedules and travel, including across state lines, which may require multiple state licenses in some situations.

➢Fellowship and CAQ

Sports Medicine fellowships are usually one year in length, although some fellows pursue further graduate training thereafter. This fellowship utilizes ERAS and NRMP. It is fairly competitive; 2017 data showed a 96% fill rate for 254 spots; over 80% of US grads successfully match. To increase exposure and knowledge, you should rotate with Sports Medicine trained physicians and take Sports Medicine electives during residency training if possible. Becoming competitive may also involve pursuing opportunities with local sporting event coverage, participating in research projects, and attending national conferences hosted by the American Medical Society of Sports Medicine (AMSSM) or the American College of Sports Medicine (ACSM). A list of Sports Medicine fellowships may be found at www.amssm.org.

A Sports Medicine CAQ is offered conjointly for Family Medicine, Emergency Medicine, Pediatrics, Internal Medicine, and Physical Medicine and Rehab. The board exam is typically offered in July and November of each year. Pass rates are above 90%. Candidates must maintain board certification in Family Medicine to maintain their subspecialty CAQ certification.

7. Hospital Medicine Recognition

Hospital Medicine is part of the scope of practice of family physicians and is certainly a needed skill set. Some physicians working in hospital settings remain in mixed inpatient and outpatient practices, or combine inpatient with emergency department coverage in locum assignments. However, the increasing complexity, requirements, and time commitment of inpatient care have led to some family physicians pursuing a career exclusively in hospitalist medicine. A 2016 survey found that almost 9% of family physicians identified themselves as full-time hospitalists and that figure now may be as high as 10-15%. Additionally, hospitalist physicians had greater job satisfaction and were better paid than non-hospitalists, but reportedly also worked longer hours. That said, call schedules tend to be more predictable and professional responsibilities tend to end when the hospitalist physician is no longer covering inpatients. This combination may be particularly attractive to graduating residents with a high debt burden or those concerned about the stream of patient portal messages and other outpatient responsibilities.

➢Fellowship and CAQ

Hospital Medicine fellowships are one year in length, except for Academic Hospital Medicine, which may be 2 years. They do not participate in ERAS or NRMP. Unlike the other CAQ fellowships, Hospital Medicine Fellowships are not ACGME-accredited. Focus in training includes core clinical competencies, such as inpatient procedures, intensive care, and the full scope of inpatient management. There is also training in healthcare systems, leadership skills, research, and quality improvement. These skills, which may not be fully developed during standard residency training, can allow for professional advancement and leadership roles of complex clinical and non-clinical teams and effective healthcare delivery. More information about current fellowships can be found at the Society of Hospital Medicine. The fellowship listing offered by the AAFP may not be current, but the AAFP does have an active Member Interest Group in Hospitalist Medicine

A designation of “Recognition of Focused Practice of Hospital Medicine” (RFPHM) is offered through the ABFM after sitting for an exam. The exam itself is offered through the American Board of Internal Medicine (ABIM), and is available after the fellowship or after reaching a certain threshold of hospital encounters. More information on the exam can be found at the ABIM.

Note: the exam is called a “Focused Practice,” rather than a board certification. The ABFM accepts the exam for the recognition, but does not title it a “CAQ” to avoid any implicit or explicit requirement of obtaining this recognition. This could limit family physicians who wish to pursue hospitalist medicine after residency, but choose not to pursue fellowship training or subspecialty board certification. Therefore, the RFPHM allows the recognition of those who have completed the fellowship or those who have met the practice requirements and subsequently sat for the exam. At the same time, it avoids setting an expectation of this recognition for all hospitalist physicians, allowing any family physician to practice as a hospitalist.

AOA CAQ Fellowships

The American Osteopathic Board of Family Physicians (AOBFP) offers the same CAQs as ACGME, with the exception of Adolescent Medicine and Hospital Medicine. They also offer three additional CAQs:

• 8. Addiction Medicine
• 9. Correctional Medicine
• 10. Undersea and Hyperbaric Medicine

8. Addiction Medicine

There are significant gaps in medical education about learning to manage controlled substances and substance-use disorders. More people die from substance overdose than any other accidental cause and the life expectancy for adults in America has decreased, largely related to deaths from alcohol and substance use. Fellowship training in Addiction Medicine provides expertise in diagnosing and treating a variety of substance-use disorders and their comorbidities, providing a robust understanding of the standard of care in treating people whose lives have been affected by substance use.

Typical fellowship tracks in Addiction Medicine involve patient care in many settings: outpatient clinics, hospitals, residential programs, opioid-treatment programs, community mental health centers, and other settings. Patient care also extends across a variety of populations and across the lifespan and this broad patient care experience will be familiar to family physicians. Most Addiction Medicine fellowships have hours similar to other ambulatory care positions, with rare after-hours calls. Specialists in Addiction Medicine often become medical directors of residential-treatment facilities, opioid-treatment programs, or inpatient consultation programs. They may also take academic positions or pursue other primary care positions and integrate addiction care.

➢Fellowship and CAQ

Addiction Medicine fellowships are typically one year in length, or 2 years, to provide research or administrative training. Currently there are 81 ACGME-certified fellowships in North America. More information is available at the American College of Academic Addiction Medicine (ACAAM). This program participates in ERAS, but does NOT participate in NRMP.

Note: Addiction Medicine is separate from Addiction Psychiatry, although there is substantial overlap in training. Addiction Psychiatry fellowships are only available to physicians who have completed psychiatry residency training, whereas Addiction Medicine fellowships are open to any board-certified physician.

Board certification in Addiction Medicine has historically been based on building significant clinical experience in the field, as well as passing the board exam. This so-called “practice pathway” does not require a fellowship. However, starting in 2025, all physicians will be required to complete an ACGME-accredited fellowship to become board-certified. More information can be found at the American Board of Preventive Medicine. For osteopathic physicians, Addiction Medicine is a subspecialty of family medicine, and board exam information is available here.

9. Undersea and Hyperbaric Medicine

Undersea and Hyperbaric Medicine primarily focuses on prevention of injury and disease due to ambient pressure changes. This requires extensive training and experience in diving medicine, altitude sickness, treatment principles and practices involving hyperbaric pressure chambers, and management of various kinds of burns and wounds. Physicians primarily work in hospital settings where hyperbaric pressure chambers are located, although patients are not necessarily admitted.

➢Fellowship and CAQ

Undersea and Hyperbaric Medicine fellowships are one year in length and are ACGME-accredited. They do not participate in ERAS or NRMP. Fellowships are integrated within a variety of specialities, including anesthesiology, emergency medicine and surgery. No fellowships are listed on the AAFP website, but 11 fellowship programs are listed at the Undersea and Hyperbaric Medical Society.

Board Certification is offered through the American Board of Preventive Medicine (ABPM), conjointly with the AOBFP. Allopathic physicians can take the board certification directly through the ABPM, but it is not a CAQ of the ABFM. The American College of Hyperbaric Medicine has further resources and you can become a “fellow” of this organization if you meet the criteria.

10. Correctional Medicine

Correctional Medicine physicians provide medical care for incarcerated persons. This population often receives inadequate primary and preventive health care. Obstetrical and sexual health care remains lacking and incarcerated patients often present with complex medical concerns, including substance use disorders, psychiatric complaints, acute and chronic infections, wound-care needs, and higher rates of chronic disease. Family physicians are perfectly equipped to serve as Correctional Medicine physicians. We can provide holistic care during their time of incarceration as well as continuity of care with community-based primary care physicians and specialists. Knowledge of legal issues is important and some correctional physicians are asked to serve as expert witnesses. Advocacy for incarcerated patients is so crucial.

➢Fellowship and CAQ

Correctional Medicine fellowships are two years in length and some provide a concurrent MPH degree. If an MPH is already obtained, programs may be shortened to one year. These fellowships do not participate in ERAS or NRMP. Programs are not listed in the AAFP Fellowship search, but can be found through regular internet searches.

Board certification for osteopathic physicians is conjointly available through AOBFP. However, for allopathic physicians, there is now a Certification process through the National Conference for Correctional Healthcare. The exam is inexpensive and can be taken online from any location. The American College of Correctional Physicians has endorsed the exam and also provides additional professional resources. Finally, there is an extensive physician blog website, called Jail Medicine, that may be useful for learning more about the practice of medicine among various correctional populations.

Non-CAQ Fellowships

There are a much larger number of fellowships that do not provide CAQs or result in formal subspeciality status within family medicine. However, some fellowship programs do encourage or expect fellows to pursue board certification through a separate professional organization. With a few exceptions, these fellowships programs are not ACGME-accredited and are subject to considerable variation and flexibility. You should carefully research each individual program to confirm it meets your learning goals.

Fellowships on the AAFP Fellowship List include (but not limited to) the following:

1. Addiction Medicine (see CAQ through AOBFP)
2. Behavioral Medicine
3. Clinical Informatics
4. Community Health
5. Correctional Medicine (see CAQ through AOBFP)
6. Diabetes Medicine
7. Faculty Development (Academic Medicine)
8. Global Health
9. Headache Medicine
10. Health Policy
11. HIV Fellowship
12. Homeless Healthcare
13. Integrative Medicine
14. Medical Humanities
15. Neuromuscular
16. Obstetrics
17. Population Health
18. Preventive Medicine
19. Primary Care Ultrasound
20. Research
21. Rural Medicine
22. Urgent Care
23. Value-based Care
24. Wilderness Medicine

1. Addiction Medicine (see AOBFP CAQ Fellowships)

2. Behavioral Medicine/Mental Health

Behavioral Medicine includes behavioral and mental health, psychological interventions and psychiatric medications. While this field is a core part of family medicine residency education, physician specialists in behavioral medicine provide advanced skills in complex behavioral and mental health concerns, especially in settings where referral options are limited. Behavioral Medicine specialists are equipped to integrate behavioral health into primary care settings, including coordination of care with clinical pharmacists, care coordinators, and social workers. They evaluate and treat complex psychiatric illnesses, complex neurocognitive care concerns, such as autism and ADHD, and may also teach and perform research in academic settings.

The fellowship is one year in length and applicants should be board-certified in family medicine. These programs are not ACGME accredited. There are a number of behavioral health fellowships listed under “other” on the AAFP Fellowship List. Direct online searches may reveal more options and some may be listed under other names, such as “Mental Health Fellowships.” There are currently no direct board certification options. Programs may combine Behavioral Health with other training programs, such as an Integrative Health Fellowship, allowing board certification in Integrative Health.

3. Clinical Informatics

Clinical or Medical Informatics is a growing and important field. According to the American Board of Preventive Medicine (ABPM), “Physicians who practice Clinical Informatics collaborate with other health care and information technology professionals to analyze, design, implement and evaluate information and communication systems that enhance individual and population health outcomes, improve patient care, and strengthen the clinician-patient relationship. Clinical Informaticians use their knowledge of patient care combined with their understanding of informatics concepts, methods, and tools to: assess information and knowledge needs of healthcare professionals and patients; characterize, evaluate, and refine clinical processes; develop, implement, and refine clinical decision support systems; and lead or participate in the procurement, customization, development, implementation, management, evaluation, and continuous improvement of clinical information systems.

This fellowship is two years in length and open to board-certified or eligible family physicians. It is not ACGME-accredited. There are a handful of programs participating in ERAS available to family physicians, and this fellowship does not participate in NRMP. Starting in 2022, all physicians will need to complete a fellowship prior to being eligible for subspeciality board certification in Clinical Informatics. However, it’s also possible to sit for the exam if a similar training program has been pursued (e.g., a master’s degree in biomedical informatics, health sciences informatics, or a National Library Science fellowship). The board exam is available through the ABPM. The American Medical Informatics Association provides an up-to-date list of fellowship programs and extensive information and support for practicing physicians in Clinical Informatics. There are videos describing the field and an annual conference provides additional resources.

4. Community Health

Family medicine has a vital role in Community Health, meeting the needs of marginalized or underserved communities. The impact of social determinants of health and health care resource distribution affects health care delivery in a myriad of ways. Knowledge and skills in community health improve health care and advocacy within marginalized communities.

Fellowships are one year in length and train physicians to practice medicine with a greater understanding and integration of the social determinants of health. Fellowship programs emphasize health promotion to communities with limited health access and/or health literacy, including mental health, substance abuse, and infectious disease management. Fellows learn how to partner effectively within local communities to gain trust and cooperatively pursue solutions through community resources. Research into novel ways to deliver effective care is often part of the fellowship, along with advocacy and leadership training. This is not an ACGME-accredited fellowship, it does not participate in ERAS or NRMP, and there is no board certification at this time. However, some programs may be extended to incorporate a master’s degree in public health, health systems science, or clinical leadership.

Note: These fellowships may be named primary care transformation fellowships, public health fellowships, or may be included within another fellowship, such as global health, health disparities, leadership, mental health, or urban health. The emphasis may differ slightly, depending on the goals of the fellowship.

5. Correctional Medicine (See AOBFP)

6. Diabetes Medicine

Physicians specializing in Diabetes Medicine manage complex cases of diabetes, including complications of diabetes, such as foot ulcers, retinopathy, and nephropathy. Knowledge of effective pharmacotherapy includes starting and maintaining insulin therapy as well as use of concentrated insulin therapy, use and interpretation of Continuous Glucose Monitors (CGM), insulin pump initiation and maintenance, inpatient management for complex cases (e.g., hypoglycemia, DKA, HHS, pre-operative and post-operative cases), and care of pregnant patients with pregestational or gestational diabetes. Specialists may work closely with a team of other professionals comprised of pediatric endocrinologists, podiatrists, primary care physicians, obstetricians, ophthalmologists, maternal fetal medicine specialists, certified diabetes educators, nurses, pharmacists, and psychologists. Some specialists are also trained in Obesity or Lifestyle Medicine and integrate weight loss clinics.

As rates of diabetes increase, diabetologists are in high demand and therefore there has been an expansion in diabetes fellowship programs, as well as programs seeking fellowship-trained faculty. After achieving specialty recognition, physicians should seek to be reimbursed at specialist rates. Primary Care Diabetes Fellowship Programs: Developing National Standards: https://clinical.diabetesjournals.org/content/early/2020/09/25/cd20-0055

Fellowships are one year in length and completion allows the fellow to identify as a “Diabetologist” or as “Fellow Trained in Diabetes.” You must be board-eligible or board-certified in Family Medicine to apply. Currently there are five programs: Duke Southern Regional AHEC, East Carolina University, Ohio University, Touro University California, and the University of Colorado.

There is currently no single board exam for this fellowship. Graduates may sit for exams to obtain the following certifications: Board Certified-Advanced Clinical Diabetes Management or Certified Diabetic Educator with the Certification Board with the Association of Diabetic Care and Education Specialists. Another option is sitting for the American Board of Obesity Medicine, which may have some additional training requirements. However, the American Diabetes Association is working towards formal board recognition as a medical specialty; this recognition is anticipated to be available sometime after 2025.

7. Faculty Development (Academic Medicine)

Academic Medicine is a rewarding and challenging career. Faculty positions may be in a medical school, a residency program, or both, but involve far more than provision of good clinical care. Mentorship, education/teaching, and leadership skills are needed, along with the ability to understand and develop effective curricula, based on ACGME and other requirements. While residents learn a great deal about teaching during residency, there are important specialized skills a fellowship can further develop.

Fellowships are usually one year in length, although some may be extended for master’s programs or additional research training. Fellowships vary significantly in how they are structured. Some one-year fellowships require relatively brief (4-6 weeks) on-campus time; the rest of the program may be completed remotely. Skills developed include teaching and curriculum development, theories and styles of medical education, mentorship, evaluation, remediation of learners, research design and implementation, leadership development, administration, critical review, scholarship, and professional writing. Specific clinical skill sets interesting to the fellow or needed by the program may also be developed. A fellowship can also serve as a networking platform and provide more structured learning. While much of this material can be learned “on the job” in a teaching position, a faculty-empowering fellowship is designed to thoroughly equip those pursuing academic medicine as a career. Opportunities for better academic positions with higher salaries will more likely be available to the fellowship graduate than to the physician directly out of residency.

Academic fellowships are not ACGME-accredited and do not participate in ERAS or in the NRMP. Applicants need to be board certified in family medicine. Some options are available through the AAFP Fellowship List (under “other”), but more are likely to be found through direct online searches. There are no board certifications involved in Academic Medicine fellowships, but some of them integrate master’s degrees in medical education, public health, or research.

8. Global Health

Global Health attracts considerable interest from physicians-in-training and can be a fulfilling career. There are many ways to practice global health: directly providing medical care, medical education, research, and/or some combination of these activities through bilateral partnerships.

Fellowships are one to two years in length, carry no ACGME-accreditation, and do not participate in ERAS or NRMP. There are significant variations between programs because their focus and educational programming are considerably different. For example, many of these programs require travel abroad and/or they work with underserved or international patient populations in the US. Some focus on practical clinical skills in low and middle income countries (LMICs), while others focus more on academic development, research, or public health education. The AAFP maintains an excellent list of resources and offers summaries of all current global health/international medicine fellowships, as well as courses and contacts to begin your journey in the field of Global Health (the AAFP Fellowship List may not yield the best results).

There are no board certifications in Global Health; however, you can sit for board certifications in Tropical Medicine, Traveler’s Medicine, HIV Medicine, or complete a certificate through the Institute for International Medicine (INMED) or another equivalent program (listed elsewhere in this document). Evidence of some sort of certification is useful, especially if practicing overseas.

The AAFP has a Global Health Member Interest Group and an annual conference, the Global Health Summit, which may be helpful for discerning if a global health fellowship is right for you. You can review the core educational competencies here: AAFP Curriculum Guidelines.

9. Headache Medicine

Headache medicine is an important field for diagnosing and managing complex pain from various kinds of headaches. Specialists may work in interdisciplinary teams, including ophthalmologists, oral maxillofacial surgeons, OBGYNs, pain management specialists, physical therapists, plastic surgeons, neurologists, neurosurgeons, and sleep specialists. Settings include inpatient and outpatient centers, along with infusion centers. Specialists perform procedures including nerve blocks, transnasal sphenopalatine ganglion blocks, and botox injections.

Fellowships are one year in length. They are not ACGME-accredited, although some may be accredited through the United Council for Neurologic Subspecialists (UCNS), but they do not participate in ERAS or NRMP. The AAFP Fellowship List includes a few options under “other,” however, the American Headache Society lists 40 Headache Fellowships and the UCNS lists 45 fellowship programs. Some are only available to neurologists, not to family physicians, but it’s worth exploring these sites for additional opportunities.

The UCNS offers a certification exam after completing a UCNS-accredited fellowship.

10. Health Policy

An understanding of health policy can be extremely valuable for physicians who want to effectively advocate for change within health care systems, and more broadly, at the intersection of community health, public health, and governmental regulations and programs. Knowledge of, and skills in, health policy allow for advancement into leadership positions, research roles, and many non-clinical positions that affect health care delivery and social determinants of health.

Fellowships are 1-2 years in length, are not ACGME-accredited, and do not participate in ERAS or NRMP. There is a great deal of overlap with community health, public and/or population health fellowships, and other leadership-development fellowships. Some “fellowships” are intended to be integrated alongside other full-time employment opportunities and provide training and mentorship. Some fellowships can be found on the AAFP Fellowship List in “other;” while more fellowship opportunities can be found by doing direct online searches.

11. HIV

HIV treatment is an important skill set for some family physicians, particularly those interested in infectious diseases, global health, urban health, correctional medicine, or public health. There are numerous opportunities for CME and other training in HIV medicine described in non-fellowship training areas of this chapter; however, formal fellowships can be particularly helpful for establishing HIV clinics and patient panels, inpatient management, academic medicine, and advocacy. Often the scope of practice also involves Hepatitis C management.

Fellowships are 1-2 years in length, are not ACGME-accredited, and do not participate in ERAS or NRMP. Applicants must be board certified or eligible. Fellowships can be found at HIV Medicine Association (HIVMA) and American Academy of HIV Medicine (AAHIVM).

Certification is available through the AAHIVM and provides a specialist designation.

12. Homeless Healthcare

According to the "State of Homelessness: 2020 Edition", over half a million Americans are homeless on any given day. Unsurprisingly, patients who are homeless or who experience severe housing insecurity receive inadequate medical care. Experts in homeless health care provide acute and chronic care management, including chronic disease, reproductive care, and wound care management. They address communicable diseases such as tuberculosis, HIV and Hepatitis C. Specialists provide trauma-informed care, psychiatric and behavioral health interventions, substance use and addiction medicine, and chronic pain relief. They also respond to many other social needs (as they are able), providing resources to support housing, employment, food security, and other determinants of health.

There appears to be only one fellowship program in homeless medicine, but other programs (such as Urban Health and Community Health Fellowships) address many of these same issues and populations. This fellowship doesn’t participate in ERAS or NRMP and has no board certification opportunities.

13. Integrative (Complementary/Alternative) Medicine

Integrative health utilizes both conventional and alternative methods to promote holistic healing and wellness. Many reputable health care centers and academic institutions have integrative medicine physicians who address chronic pain, other symptoms of chronic medical issues, and behavioral and mental health needs. Expertise includes nutritional health, botanical and other supplements, Chinese medicine, mind-body wellness (i.e. yoga and meditation practices), acupuncture, and other alternative pain management strategies.

Most Integrative health fellowships are one year in length, but some have short on-site training sessions followed by online learning that can be integrated into a standard full-time clinical practice. Research and other academic training may be incorporated as well. These fellowships are not ACGME-accredited and do not participate in ERAS or NRMP. Some fellowships are listed on the AAFP Fellowship List and others may be found on the ABPS or by direct online searches. After completion of a fellowship or other training program, the American Board of Integrative Medicine (ABOIM) exam is available through the American Board of Physician Specialties.

14.Medical Humanities and/or Medical Ethics

Medical humanities focuses on the humanistic aspects of medicine throughout the entire continuum of human life and experience, but specifically on the dignity of the human person; an understanding of health, wholeness and suffering; and the patient-physician encounter. Literature, culture, and narrative ethics are foundational to this field. Some medical humanities focus on the intersection of medical history, racial and ethnic perspectives and experiences, as well as persons with disabilities or those living on the margins of society.

There are a variety of one year fellowship programs that address medical humanities, medical ethics or both. These skills may be helpful in academic settings and in scholarly activity. These fellowships do not participate in ERAS or NRMP and there is no board certification exam.

15. Neuromuscular

Neuromuscular specialists care for patients with complex neurological disorders, i.e., Alzheimer’s and Parkinson’s, muscular dystrophy, multiple sclerosis and post-stroke disabilities. Nearly all specialists are neurologists but there are opportunities in a few locations for osteopathic family physicians to pursue this training.

The “fellowship” is actually a residency in its own right, but a family medicine residency must first be completed so, in that sense, it functions as a fellowship. It is one year in length, is ACGME-accredited, participates in ERAS, but not in NRMP. Emphasis in training includes clinical and didactic education, along with clinical research. There is only one fellowship listed on the AAFP Fellowship List and is only available to osteopathic family physicians who are board certified or eligible. There are other fellowships listed on the American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM) website, but these are not available to family physicians.

Fellows may be eligible to sit for the board certification exam from the American Board of Psychiatry and Neurology (ABPN), but this is unclear.

16. Obstetrics

There is a huge need for family medicine obstetrical care, especially in rural and underserved areas. Access to high quality obstetrical care within one’s own community improves maternal and neonatal mortality and morbidity. While most family medicine residencies train in obstetrics, not all programs provide surgical management or high-risk obstetrics management. This specialized training can be useful (perhaps essential), if you intend to practice in underserved areas. The AAFP supports surgical obstetrical and cesarean section training.

Fellowships are typically one year in duration; however, some offer a two-year program, which offers the opportunity of obtaining a MPH. The obstetrics fellowship isn’t ACGME-accredited and doesn’t participate in ERAS or in the NRMP application/match process.

Not all of these obstetrics fellowship programs provide the same training. In fact, it’s safe to assume that, just like residency programs, OB fellowships are quite different and offer a wide range of exposure to high-risk OB training, volume of surgical training, scope of practice, and scholarly opportunities. Take the time to carefully review fellowship program objectives and goals and reach out to the program director and graduates to determine if the fellowship is a good fit for you. The AAFP Fellowship List contains some options, however, some programs listed may not be updated or may no longer exist. The AAFP OB Member Interest Group (OB MIG) has been working to compile and update the list of active fellowship programs with the hopes of creating a user-friendly centralized directory. In the meantime, the OB MIG has compiled a spreadsheet that we are updating with a few other colleagues. Link: OB Fellowship Directory. There are no certificates of added qualification (CAQ) through the American Board of Medical Specialties (ABMS), but the Board of Certification in Family Medicine Obstetrics (BCFMO), created in 2009, has gained increasing attention and recognition. The certification through the American Board of Physician Specialties (ABPS) is the only CAQ currently available. A number of fellowship programs include sitting for this BCFMO board exam as part of the fellowship training curriculum. A handful of residency programs are considered to be an OB fellowship equivalent, also allowing graduates to sit for the exam. It's important to recognize this board is not yet viewed as a “privileging requirement” for providing surgical obstetrical care, nor is it widely recognized in the US. Other useful resources include the AAFP OB Member Interest Group (mentioned above) and the FAMDEL email listserv, an email list of the STFM Perinatal Care working group, designed to facilitate communication between group members. This is a great way to build your professional network/contacts and stay abreast of real-time conversations about teaching and practicing family medicine obstetrics. Send an email to “FAMDEL@lsv.uky.edu” to join.

17. Population Health

Population Health has a great deal of overlap with Community Health and Public Health and is sometimes used interchangeably. Technically, however, population health experts tend to focus on outcomes across various populations and through health care delivery systems, rather than addressing inequities and social determinants at the community level.

Fellowships are 1-2 years in length. This fellowship isn’t ACGME-accredited and doesn’t participate in ERAS or NRMP. Training may include a master’s degree in Health Care Administration, Leadership or Delivery Science. There are few Population Health fellowships and these can be found on the AAFP Fellowship List and by direct online searches. Again, there is significant overlap with Community and Public Health Fellowships and there are no board certifications available in Population Health.

18. Preventive Medicine

Preventive medicine is a core part of family medicine; however, the field addresses preventive medicine at a larger scale, including public and population health. Specialists address environmental preventive medicine i.e., physical and occupational health, nutrition, safe water access, and toxic exposures in the environment. Lifestyle medicine, vaccine availability, cancer, chronic disease, addiction prevention and screening, aerospace medicine and other traveler safety, and mental health care are also key areas. Training includes biostatistics, epidemiology, informatics, health care policy and delivery, and research. Fellowships are 1-2 years, are ACGME-accredited, and may include a MPH degree, but do not participate in ERAS or NRMP (residencies in Preventive Medicine do participate, but not fellowships). The AAFP Fellowship List has a few options, however, the ACGME provides more information and fellowship search instructions. Direct online searches will likely provide additional options.

Board certification is available through the American Board of Preventive Medicine (ABPM), under the title Public Health and General Preventive Medicine. There are additional specialty options by the ABPM, including aerospace subspeciality options, many of which are addressed elsewhere (Addiction Medicine, Clinical Informatics, Medical Toxicology, and Undersea and Hyperbaric Medicine). The American College of Preventive Medicine provides excellent resources and CME training.

19. Primary Care Ultrasound

Point-of-care ultrasound (POCUS) and other ultrasound modalities are a useful skill for family physicians. While these skills are increasingly being incorporated into residency training programs, not all residents receive adequate training to utilize them in practice. For those pursuing emergency medicine opportunities or academics, developing additional expertise in POCUS and other ultrasound skills may be beneficial.

Fellowships in Primary Care Ultrasound are one year, are not ACGME-accredited and do not participate in ERAS or NRMP. A growing number of fellowships exist for family physicians, which often run parallel to Emergency Medicine Ultrasound Fellowships. In addition to fellowships, there are extensive CME training opportunities available by various professional and private organizations.

There is no board certification, however, affiliation with several professional organizations may be beneficial, including the American Institute of Ultrasound in Medicine and the Society of Ultrasound in Medical Education.

20. Research

The ability to perform quality research is an important skill for family physicians and may not be fully developed during residency. Research fellowships are 1-2 years, are not ACGME-accredited and do not participate in ERAS or NRMP. Fellows develop skills in research methodology, epidemiology, biostatistics, critical review, grant writing, and presentation of data. Some of these skills may be included in academic or other types of fellowships, or research may be a stand-alone fellowship. Academic or research fellowships are not prerequisites for joining a teaching program, but do provide more flexibility and leverage when asking for “protected” academic time for research and/or other scholarly activities. Distance (online) learning options exist that may allow full-time employment elsewhere. Funding for fellows varies and federal support for these fellowships has fluctuated greatly over the last 2 decades. There are no board certification organizations.

As an example, the Robert Wood Johnson Foundation’s research fellowship is the “Clinical Scholars Program”: https://www.rwjf.org/en/library/funding-opportunities/2020/clinical-scholars.html

21. Rural Health

Family physicians have an option to pursue rural health directly after graduation and a huge need exists for primary care in rural communities. Physicians serve in key clinical areas in rural communities, in both inpatient and outpatient settings, and often cover emergency and obstetrical care. Besides direct clinical engagement, physicians may serve in a variety of leadership positions within the rural community’s hospital and/or nursing homes. In addition, a rural physician may serve as the county coroner, direct the community’s Emergency Medical Services (EMS), and/or serve in various public health advisory roles for schools and businesses. For all of these reasons, health care leadership, business, and advocacy skills are important.

Rural fellowships are one year. While only a few opportunities are listed through the AAFP Fellowship List, more are available through direct online searches. These fellowships are not ACGME-accredited, and do not participate in ERAS or NRMP. Clinical skills needed in underserved regions are emphasized, which may not have been fully developed in residency, including emergency department care, behavioral and mental health care, orthopedic management, obstetrical and gynecological management, POCUS, and procedural skills. Fellowships also focus on community health, public health, and academics; some emphasize global health and minority or refugee care. Experiences may also be tailored to the fellow’s needs and interests. There are no board certification opportunities. Additional resources include the National Rural Health Association, which has its own fellowship (unrelated to direct clinical medicine), but may be of interest after physicians have been in practice for some time. The Rural Health Information Hub, the National Rural Health Resource Center, and the Rural Health Policy and Research Institute all have additional resources for learning more about rural health.

22. Urgent Care

Family physicians should be trained to manage urgent care needs through their residency training. However, some physicians may want or need additional training to practice exclusively in urgent care or to run an urgent care business (with additional credentials).

Fellowships are one year and are not ACGME-accredited and do not participate in ERAS or NRMP. Training primarily focuses on additional clinical skills in splinting and casting, other orthopedic and procedural skills, ophthalmology, dentistry, POCUS, radiology, emergency department care, and practice management.

Board certification is available through the American Board of Physician Specialties (also available to those with sufficient urgent care experience, even without completing a fellowship).

23. Value-Based Care

Health care delivery is currently migrating in the direction of “Value-Based Care.” “Value” is defined as the quality of care divided by cost. Improving the quality while reducing the cost is important to provide sustainable health care for all. Residents may not become familiar with this concept and may not understand all the implications of value-based care and how it will impact health systems and clinical care. Knowledge of this approach to patient care and business management will be beneficial for those interested in healthcare leadership and administration.

Value-Based Care Fellowships are two years and include a Master’s degree in Business Administration. Only one option is listed through the AAFP Fellowship List (under “other”). This fellowship isn’t ACGME-accredited and doesn’t participate in ERAS or NRMP. Master’s programs in Value-Based Care or Health Care Delivery Science are also possible, but these would not be paid fellowship positions (unless you can get your employer to cover the costs). There are no board certifications available at this time.

24. Wilderness Medicine

Wilderness medicine entails advanced clinical training to manage emergencies in remote settings and stabilization of severe injuries and illnesses in austere environments: massive trauma; cardiac arrests; fractures; lightning injuries; near-drowning; poisonings from plant ingestions, snakes, or insects; hypo- or hyperthermia; burns or frostbite; and high altitude and deep-sea diving illnesses. Fellows also learn rescue techniques in mountainous areas, white-water rapids, deserts, or other austere environments. Physicians may serve alongside park rangers, travel with adventure groups, or work in research to improve safety or management of wilderness injuries.

Fellowships are typically one year in length, are not ACGME-accredited and do not participate in ERAS or NRMP. That said, the Wilderness Medicine Society (WMS) now offers a peer-review application process of fellowship programs and provides curriculum guidelines. Training includes the skills listed above, but also leadership skills and research. Note: there are other intensive wilderness medicine training courses that are not paid fellowships, but provide a similar level of education.

There is no board certification exam, but there is a “fellowship” status offered by the WMS, after completion of a particular amount of training and experience. There are several other certifications available, including a Diploma in Mountain Medicine and a Diploma in Diving and Marine Medicine, both of which are offered in collaboration with other professional organizations, however, again, these are not board certifications.

Non-Fellowship Certification or Other Training Programs

We cannot cover all non-fellowship training programs available to family physicians; however, there are many additional educational opportunities that can expand skills in clinical care and develop non-clinical skills—and these may open the door to professional advancement and leadership roles within academic centers, health care systems and governmental organizations.

Certified Professional Coder (CPC)

Thorough knowledge of medical coding provides a significant “edge” in practice, by allowing physicians to capture performed billable services. Unfortunately, many physicians under-code for their work, which in turn contributes to physician burnout and frustration in meeting revenue benchmarks. Training in residency is not always adequate for preparing physicians to excel in “real world” practice. Additional training in medical coding can provide advantages when pursuing administrative or leadership positions in group practices or health care institutions. Physician coders can often maximize the entire practices’ revenue by bridging the gap between individual physicians’ coding habits and system requirements. One thing to note is that coding, in general, must be learned, not only coding specific to Family Medicine.

Several certification courses are available, including medical billing, medical compliance, and practice management, offered by the AAPC. The CPC exam is expensive and should not be attempted without thorough exam preparation. Continuing education allows a CPC to remain current in the field as codes and regulations change over time.

Colposcopy Mentorship Program

Frequency of colposcopy may decrease with vaccinations against high-risk HPV, however, it’s an important procedure to evaluate screening abnormalities. Physicians may not always receive adequate colposcopy training and experience during residency. While referral is an option, colposcopy is an appropriate procedure for family physicians and an important area in women’s health. Such skills can be a particular asset to underserved or rural patients, and in global health, where PAP and HPV testing may not be available.

The American Society of Colposcopy and Cervical Pathology (ASCCP) routinely offers an excellent live four-day training course with hands-on experience. For those interested in being mentored and in obtaining certification, physicians then perform 25 colposcopy examinations under an ASCCP mentor over the next 24 months, followed by an exam to obtain the Certificate of Program Completion.

Dermoscopy Certificate

Dermoscopy is an important family medicine skill and a growing area of interest that can be easily integrated into office management. While residency programs may provide some training in dermoscopy, additional training may be helpful to utilize this skill most effectively.

There are a number of ways to be trained in Dermoscopy. The AAFP now provides workshops in dermoscopy during the annual meeting (FMX). There is also an excellent three-day annual course called the American Dermoscopy Meeting. These two options do not provide formal certification, however, it’s possible to pursue training and subsequent certification through international organizations, such as Skin Cancer Courses. It’s unclear if certification would provide any specific advantage to US-based family physicians, since certification isn’t required prior to office-based use, however, it might be helpful in academic settings and/or on your CV.

Eating Disorder Certification

Eating disorders aren’t uncommon and finding specialists able to adequately address these patients’ health needs can be difficult. Family physicians with an interest in treating eating disorders may apply to become a Certified Eating Disorder Specialist (CEDS) through the International Association of Eating Disorders Professionals (iaedp™). While there used to be both traditional and equivalency routes, only the traditional route is currently available. The traditional route requires a minimum of 2,500 eating disorder-specific practice hours accrued within 24 months, under the guidance of an iaedp™-appproved supervisor. Core courses are also required (available online), ongoing CME requirements, an application process (with letters of recommendation), required case studies, and an exam. Some physicians may be able to pursue CEDS certification during a fellowship in Adolescent Medicine.

Fertility Awareness Methods Certification

An increasing number of patients are seeking non-pharmaceutical ways to plan their families and to more fully understand their sexual and reproductive health. Couples experiencing sub-fertility or wanting to achieve pregnancy in a timely manner benefit from having a more accurate and personalized assessment of when ovulation occurs than most standardized apps allow. Physicians can benefit from understanding the charts of patients to assess them for ovulation and luteal phase defects, PCOS, endometriosis, and other sexual and reproductive issues. Training in Fertility Awareness Based Methods (FABMs) has historically been lacking in medical education. Several training options are available for physicians, including an accredited elective for students, residents and practicing physicians. Certification is also available through FEMM, Marquette University and Pope Paul VI Institute program. The International Institution of Restorative Reproductive Medicine (IIRRM) and FACTS about Fertility provides additional education resources for physicians.

Healthcare Ethics Certification

Competence in Healthcare Ethics is an increasingly important and acknowledged skill set for physicians. Family physicians are often confronted with challenging situations requiring ethical expertise, along with integration of legal advice, social work, and risk management in community and public health. A solid background in clinical ethics facilitates serving on ethics committees or in other healthcare leadership roles. The American Society for Bioethics and Humanities provides education in preparation of certification to be a Healthcare Ethics Consultant (HEC-C). Many universities and some faith-based bioethics organizations offer certification programs but do not have a board exam equivalent.HIV Certification

The medical management of HIV is one of the few areas of medicine to become simpler over the past years. Most people living with HIV/AIDS (PLWHA) in the United States have the disease very well controlled and many are living long enough to be aging. An increasing amount of medical attention is directed towards non-HIV-related issues, including chronic care. For these reasons, family physicians are ideal candidates for providing HIV care. Of the clinicians providing care for the over 1 million PLWHA in the United States, most are in primary care, and 28% of them are family physicians. An estimated shortage of 500 HIV clinicians remains a concern. There are a number of ways to become competent in the medical management of HIV.

1. Conferences: The American Conference for the Treatment of HIV is a practical clinical conference that can be useful for both novice or experienced clinicians. The Conference on Retroviruses and Opportunistic Infections is a much more academic conference emphasizing the latest research. Application to attend is required.
2. Residency-based HIV curricula and/or HIV fellowships (1-2 years): Some residency programs incorporate HIV curricula and patient panels. There are also a number of HIV fellowships available to family physicians, discussed in the fellowship section. The HIVMA and AAHIVM provide more information on these opportunities.
3. Self-directed study: The American Academy of HIV Medicine Core Curriculum (AAHIVM) consists of 16 modules. AAHIVM membership is required. The following should also be considered:

• National HIV Curriculum
• HIV Virtual Patient Clinic
• HealthHIV HIV Primary Care Training and Certificate Program

Certification includes becoming an American Academy of HIV Medicine HIV Specialist (AAHIVS). This does not require a fellowship, but does require:

• Experience (with an option for mentorship for those with limited experience)
• HIV related ongoing CMEs
• Passing an open-book test on HIV Medicine

Lifestyle Medicine Certification

Lifestyle-related, non-communicable disease is a growing pandemic, accounting for nearly 80% of premature death and disability in the US, and as well as excessive costs. Family physicians are being drawn to the growing specialty of lifestyle medicine to help patients restore health—instead of just managing chronic conditions. Lifestyle medicine, as defined by the American College of Lifestyle Medicine (ACLM), is the evidence-based implementation of a lifestyle with a whole food and plant-predominant diet, regular physical activity, restorative sleep, stress management, avoidance of risky substances, and positive social connections as a primary therapeutic modality for treatment and reversal of chronic disease. Team-based care and shared medical appointments are a major component of Lifestyle Medicine practice, supporting the behavior change needed to help patients be successful.

There has been very little medical school or residency curricula dedicated to nutrition and other lifestyle education, as described in the Harvard Law School Food Law and Policy Clinic. The ACLM was founded in 2004 to address the need for quality, evidence-based education and certification in treating and reversing the underlying lifestyle-related causes of chronic disease. The ACLM provides and standardizes curricula and CME for pre-professional and graduate students, residents, and practicing physicians through online and conference learning opportunities. A reimbursement roadmap has recently been published on the ACLM website to assist practitioners in establishing sustainable clinical practice models. There is also a brand-new provider network for patients and practitioners to identify ACLM providers.

Board certification in Lifestyle Medicine through the American Board of Lifestyle Medicine (ABLM) became available in 2017, with an experiential pathway for current board-certified family physicians or an education pathway for residents who graduate from programs that provide a lifestyle curriculum. (While you can sit for your ABLM exam after your residency, your certification will only be issued after you successfully pass your primary board exam).

Note: there are only a few programs:

• Florida State University College of Medicine Family Medicine Residency at Lee Health
• Greenville Family Medicine Residency at University of South Carolina School of Medicine
• Loma Linda University Family Medicine Residency, Preventive Medicine Residency, and Family and Preventive Medicine Combined Residency

CME hours must be completed and a case study must be submitted. The board exam is offered immediately following ACLM’s annual conference, and several other times each year (see ABLM’s website https://ablm.co/). There are also Maintenance of Certification requirements, including a yearly payment, CME requirements, and recertification every 10 years (see www.lifestylemedicine.org for updated information, practice resources, and evidence-based articles).

Medications for Addiction Treatment (MAT) Waiver Training

The opioid epidemic has resulted in a huge need for physicians to support patients with opioid-use disorder. Access to safe treatment options can be a huge asset to your patients and to your future practice, particularly in underserved or rural areas. While a fellowship in Addiction Medicine would provide the most comprehensive training, family physicians may take an 8-hour online or in-person training course through the Physicians Clinical Support System. Completion of this course allows physicians to then apply for a buprenorphine waiver through SAMHSA . Obtaining this waiver has been a legal requirement before being able to prescribe buprenorphine. In addition to other requirements, legal limits have been set on how many patients can be prescribed buprenorphine in the first year after the waiver is obtained. However, check on current legal requirements, since at the time of this writing, information has been released about an exemption for this waiver when treating up to 30 patients in your practice. Note: even with the waiver, a physician is not allowed to prescribe methadone for opioid-use disorder.

STFM Residency Faculty Fundamentals Certificate

STFM offers several excellent online programs and fellowships in faculty development, including a Residency Faculty Fundamentals Certificate. The cost for STFM members is currently around $1000 and the faculty member must set aside time to complete the modules within one year. The online assignments require the faculty member to collaborate with the program director or other faculty mentors and then the assignments are reviewed by STFM faculty. These STFM Certificate courses are organized into modules to address key topics in academic medicine and include ACGME program requirements; competencies, milestones, and entrustable professional activities (EPAs); structure and funding of medical schools and residency programs; billing and documentation requirements; recruiting and interviewing; ABFM rules and requirements; scholarly activity and writing for academic publication; curriculum development, didactic and clinical teaching skills; assessment, evaluation and feedback; and how to support struggling learners. These programs can be helpful for new faculty seeking to develop their skills in teaching and mentoring, as well as to learn about the administrative requirements for medical schools and residency programs. Many programs will support faculty pursuing this option.

Tropical Medicine and Traveler’s Health Certificate of Knowledge

Many patients travel internationally, which comes with exposure to new diseases and other risks. Family physicians are well equipped to offer pre-travel and post-travel counseling and medical attention for US travelers, as well as international travelers within the US. Some family physicians establish travel clinics. Additionally, for those engaging in global health, research, or academic medicine, a deeper clinical knowledge of tropical medicine can be beneficial. The International Society of Travel Medicine (ISTM) offers a Certificate of Knowledge in Travel HealthTM (CTHⓇ). The ISTM also has an online learning resource with CME courses, webinars, and an annual conference. Having a certificate in Travel Medicine can be useful for establishing and advertising a travel clinic, obtaining various travel vaccines, academic advancement, professional development, advocacy and leadership promotion.

Note: the ISTM is an international organization with international standards and differs from the American Society of Tropical Medicine and Hygiene (ASTMH), which offers a similar certificate, called the Certificate in Tropical Medicine and Traveler’s Health (CTropMedⓇ). There are two pathways for obtaining eligibility for the exam: a Practice pathway and a Diploma pathway. Both require CME and international experience. The diploma pathway requires completion of an eligible diploma course in Tropical Medicine. There are about 20 diploma programs in the US and these programs are fairly intensive.

The CTHⓇ may be easier to obtain than the ASTMH because there are no requirements for international work or formal courses in tropical or travel medicine that must be obtained for eligibility for the exam.

Pursuing Another Degree

Many graduate degrees may be useful to family physicians, depending on professional goals and trajectory. Common examples include a Master’s of Public Health (MPH), Master’s in Health Care Education (MHCE), Master’s in Clinical Research, Master’s of Business Administration (MBA), Master’s in Health Care Delivery Systems (MHDS) or Health Care Management, Administration, Leadership or Advocacy, or a Master’s in Bioethics. Some physicians may even pursue doctoral programs in the above programs or in other disciplines. These programs are too diverse to describe in detail in this chapter. However, be aware that there are advantages to additional training, including the ability to develop or consult on public health strategies, population health, advocacy, research, as well as for leadership development of professional roles, including healthcare administration. Some healthcare organizations will pay for the degree requirements or provide protected time to pursue additional skill sets. Many educational programs are designed to allow continuation of physician practice.

For further review and comparison of opportunities, see this website: Master’s degrees for physicians in healthcare administration.