Hypothetically, imagine you complete three years of internal medicine residency; working nights, managing complex cases, making real decisions. Then you’re told: To work in the hospital, in the in-patient setting, you must complete additional years of fellowship training.

At that point, a reasonable person might ask: Wait, what was residency for? If three years of supervised, graduated responsibility isn’t sufficient preparation, then either the residency is flawed, or the requirement is arbitrary. What was once an absurd hypothetical has now hardened into policy, leaving many pediatric residents to wonder whether they trained for a profession or merely auditioned for it.

Pediatric residency is three years. Inpatient medicine. Nights. Cross-cover. Discharges. Admits. Codes. Consults. Care coordination. Family meetings.

That is hospitalist medicine.

You graduate. Board-certified. Proven. Ready.

And then you’re told: Not yet.

To do the job you’ve already been trained to do, you must complete two more years of fellowship.

Not because the role has changed. Not because outcomes demand it. But because the rules did.

This is not training. It’s control. The fellowship introduces no new patients. No new knowledge. No added complexity.

Bronchiolitis doesn’t care about your title. The febrile infant takes no interest in your certificates.

It’s the same work, under tighter leash, for half the pay.

This isn’t education. It’s filtered labor.

The fellowship doesn’t confer skill. It confers a badge, one used to exclude those who already meet the standard.

This is not meritocracy. It is a protection racket.

And like any cartel, it benefits the insiders, fellowship directors, academic centers, credentialing authorities, while imposing costs on everyone else.

By the time a physician exits this gauntlet, in her mid-30s, her peers have started families, built careers, purchased homes, exercised agency.

She, by contrast, has spent over a decade chasing a moving target, one that may shift mid-course.

Still, the treadmill runs: Chief year. Fellowship. Sub-fellowship. Complex care. Sedation. Discharge optimization.

Soon, no doubt, a fellowship in febrile infants with good insurance, admitted on Wednesdays.

It’s absurd.

This isn’t about patients. It’s about power. Gatekeeping. Control.

If hospitalists are competent enough to remain in practice, then residency is enough.

And if it’s not, then pull them all back in.

But don’t grandfather yesterday’s workforce while demanding sacrifices from tomorrow’s. That’s not progress. That’s hypocrisy.

If residents aren’t hospitalists by the end of residency, then residency has failed.

If they are, then the fellowship is redundant.

The author is an anonymous physician.