A Guide to the Subspecialty Fellowship Application Process VCU Internal Medicine Residency Program J. Christian Barrett, MD Division of Hematology/Oncology Virginia Commonwealth University

Roadmap Selecting a subspecialty Scholarship during residency – important or not? What are fellowship directors looking for? The application process Resources Questions

Selecting the right specialty for you Experience in the field – rotations Discussion with specialists Private practice AND academic Faculty, fellows at own institution Discussion with academic advisors Faculty, program directors Mentors Questions that guide choices …

Selecting the right specialty – questions to answer Do you want to focus on specific organ system (cardiology or GI) multi-systemic (ID or oncology)? Do you derive more satisfaction from dealing with acutely ill patients long-term management of disease Do you enjoy focusing on a specific disease or set of problems (such as a cardiology consultant) the care of the entire patient (for example, serving as a comprehensive provider to renal dialysis patients who require long-term care from their specialist)?

Selecting the right specialty – questions to answer Do you prefer to have a prominent inpatient component an outpatient focus? What kind of patient mix do you prefer (age, gender, problems, setting)? What are the “hot areas” for scholarship in the discipline under consideration … if interested in academics, how do you see yourself focusing in the future? Are you interested in procedures? Where geographically do you hope to settle and what is the job market in that region?

Other issues to consider Competitiveness of specialty Stats available on positions filled through match – www.nrmp.org Home institution faculty and fellowship director Program director – honest appraisal of candidacy Importance of “scholarship” and personal commitment to pursuing during residency Particularly pertinent to cardiology and GI Visa issues, including time limitations

Self-Appraisal Personal reflection (HONESTY!!!) Personal value system Rank order priorities in life Compare with the work specific priorities Reconcile incongruity Personal aptitude Assess your competitiveness Assess your specialties competitiveness Reconcile (or at least recognize) potential incongruity

A word on scholarship and its role in the selection process for fellowship Prominent for most of the competitive fellowships and programs Programs may be measured on ability to produce funded research scholars Training grants may be focus of success and may be primary funding for positions in programs RRC requirement for accreditation of fellowships Reflective of “spirit of inquiry”

A word on scholarship and its role in the selection process for fellowship Pursuing scholarly activity Identify research mentor early in training (PGY1 year essential for Cardiology/GI) Rare for residents to develop their own research questions Most will join ongoing project Try to carve out a piece that can be yours Hypothesis-based research more valued than descriptive projects or case reports

A word on scholarship and its role in the selection process for fellowship In absence of scholarly productivity … Develop an understanding of academic values and scientific inquiry Be prepared to explain what scholarship means to you Remain open to becoming excited about opportunities for scholarly activity … emphasize what you are attracted to with regards to scientific inquiry

What do the subspecialty fellowship directors (FPDs) want ?

2002 Survey by Cooke et al… Surveyed FPDs in cardiology, endocrinology, gastroenterology and rheumatology 330 responses Three selection criteria – most important Clinical performance (PD letter) Interview evaluation Interpersonal skills Residency reputation frequently assessed Research and chief medical residency important to procedure-oriented programs

Gayed Survey of Cardiology Programs Surveyed cardiology fellowship directors Important factors (most to least important) Negative comments or hints of problems in IM PD letter Personal comments from IM PD Personal aspect of interview Letter of recommendation from cardiologist known by the fellowship director

Gayed Survey of Cardiology Programs (continued) Important factors continued (most to least important) Performance during an elective at fellowship site Rank order in the residency class Genuine interest in research Being a graduate of a US medical school LOR from nationally known cardiologist Resident at institution with well-known cardiology division Participation in research Assessment of medical knowledge during interview Publications prior to fellowship Performance on ABIM certifying exam if avail. US citizenship USMLE scores

2004 Survey of FPDs and IMPD by Mikhail and Bernstein Surveyed 562 responding FPDs (of 1,088 sent) 81.3% of responders were university-based 18 items to rank order

2004 Survey of FPDs and IMPD by Mikhail and Bernstein Top 8 items in order… Fellowship interview*** LOR from known specialists*** LOR from IMPD*** University-based residency Interest in research*** No H1-B visa Elective at the fellowship site*** USLME exam scores

2004 Survey of FPDs and IMPD by Mikhail and Bernstein The next 10 items … Publications US Medical School US Citizen Research experience Chief residency Phone call from IMPD Well-written personal statement LOR from attendings outside of specialty Applying during residency Extracurricular activities

2004 Survey of FPDs and IMPD by Mikhail and Bernstein Cardiology and Gastroenterology vs others Rated considerably higher… Publications Research experience Rated considerably lower… Elective at the fellowship site

2004 Survey of FPDs and IMPD by Mikhail and Bernstein University vs. Community-based fellowship programs… Rated higher by university programs… University-based residency US medical school graduate No H-1 visa Rated higher by community programs… Elective at the fellowship site Personal communication from the IMPD

The Match—2009 Appointments 1067 certified programs participated 969 filled (91%) 98 unfilled (9%) 3075 certified positions available 2940 positions filled (96%) 135 positions unfilled (4%) 4563 applicants enrolled and certified 2940 matched (64%) US allopath graduates 85% matched Osteopath graduates 52% matched Foreign graduates 51% matched

The Match—2009 Appointments Gastroenterology 361 positions/153 programs 1.9:1 applicant to position ratio 96% filled (70% with US grads & 21% non-US) Cardiology 718 positions/169 programs 1.8:1 applicant to position ratio 99% filled (63% with US grads & 27% non-US) Hematology/Oncology 449 positions/121 programs 1.7:1 applicant to position ratio 97% filled (54% with US grads & 35% non-US)

The Match—2009 Appointments Pulmonary/Critical Care 410 positions/124 programs 1.5:1 applicant to position ratio 97% filled (51% with US grads & 32% non-US) Rheumatology 179 positions/97 programs 92% filled (47% with US grads & 32% non-US) Infectious Disease 300 positions/123 programs 1.2:1 applicant to position ratio 89% filled (48% with US grads & 37% non-US)

The Match—2009 Appointments Endocrinology 213 positions/112 programs 92% filled (50% with US grads & 35% non-US) Nephrology 374 positions/142 programs 94% filled (35% with US grads & 56% non-US)

The application process – ERAS and NRMP ERAS – www.aamc.org/eras For 2009 Allergy and Immunology Cardiology Critical Care Medicine Endocrinology Hematology Gastroenterology Geriatrics Hospice and Palliative Care Infectious Diseases Nephrology Oncology Pulmonary Medicine Rheumatology

The application process – ERAS and NRMP NRMP – www.nrmp.org As of 2009 Allergy and Immunology Cardiology Critical Care Medicine Endocrinology Gastroenterology Hematology and Oncology Infectious Diseases Pulmonary Medicine and Critical Care Rheumatology Nephrology

The application process: The Match 2009 timeline Late June – Fellowship applicant materials available for download July 1-Dec 1 to compile application through ERAS fellowships system mid-Nov – select programs to which to transmit applications Jan 7, 2009– ERAS Fellowships opens to fellowship programs NOTE: individual programs set deadlines after which they will no longer accept applications

The application process - timeline Jan-April – interviews occur April 8, 2009 – ROL submission begins June 3, 2009 – ROL submission ends at 9PM June 17th, 2009 – Match Day at noon Subspecialties and programs not joining the match follow similar timeline but may have rolling admission process

The application process - timeline Allergy and Immunology Similar timeline with match on May 29, 2009 Pediatric subspecialties Spring Match runs Jan-June Cards, GI, Nephrology, and Pulm Fall Match runs August-Dec Critical Care, Rheum Heme-Onc runs Nov-May

ERAS ERAS Fellowships Applicant Site http://www.aamc.org/students/erasfellow/start.htm Specific program information Process information Form downloads Resources Addresses for letters

ERAS – how it works Contact the ERAS Fellowships Document Office (EFDO) to obtain “electronic token” to access the ERAS system EFDO is the “deans office, central processing office” for fellowship applicants Register on the MyERAS website once obtain token Complete common application form; submit supporting materials (originals only) directly to EFDO Select programs; assign supporting documents to specific programs

ERAS receives notice of completed application and transmits documents to programs Examining boards receive and process requests for score reports Programs contact ERAS PostOffice daily to download application materials

The application components Curriculum Vitae (CV) Automatically generated if ERAS Merideth to discuss next week Letter from Program Director Letters from faculty Personal statement Board scores

Letter from Program Director One of the most important components of the application Emphasizes performance within the program Articulates unique characteristics of the applicant, highlights scholarly activities Important to comment on the candidate’s potential for scholarship and an academic career Recommend requests submitted by October 16th If ERAS, need ERAS cover letter and waiver If non-ERAS, need envelopes/labels and stamps

Letter from faculty Recommend that letters come from faculty within discipline to which resident is applying Should articulate resident’s performance Emphasize importance of scholarship potential Avoid sending more letters than requested May be value in requesting from “national expert” faculty

Personal Statement Brief is better – aim for one page or less Do not just restate CV content Communicate enthusiasm for discipline Communicate spirit of inquiry Opportunity to discuss projects in which participated – why enjoyed, how involved, etc Findings of project less important than bringing out enthusiasm for scholarly pursuit First do no harm is the “golden rule”…

Personal Statement Avoid Actual findings of a project unless it has yet to be published Approaches in the PS that cast you in less favorable light Poor grammar, awkward sentences Hollow platitudes … “I am enthusiastic about the discipline/research” Say something that supports these points “interesting patient approach” Use sparingly to springboard demonstration of other points Closing doors in PS … not too focused, want to appear excited and attracted to multiplicity of possibilities offered by the discipline and program

The interview Opportunity for applicant to project enthusiasm, uniqueness, inquisitiveness Opportunity for program to critique residents on demeanor and content of answers Candidate should …

The interview – candidates should… Be confident but not arrogant Prepare to ask one to two questions of each interviewer, avoiding topics addressed by brochures, websites or welcome sessions Types of questions asked convey interest Provide concise answers to questions Maintain professional demeanor at all times; remain positive Eye contact and firm handshake is important Remember that interview process begins with first phone call/email interaction Convey genuineness

Commonly asked questions What distinguishes you from other candidates? Why are you interested in this field? This program? Tell me about your research project or interests What areas can you improve upon? What made you decide to pursue or select _______(any item from your CV)? Where do you see yourself in 10 years? What do you like most about your residency program?

Post-interview dialogue May be one of most challenging aspects of the process for the candidate Send follow-up note to each program Thank and point out unique point Email is usually acceptable Avoid generic notes Comments such as “near the top of my list” or “one of my top choices” tells fellowship that program is NOT top

Post-interview dialogue Not-in-match programs post-interview May call residents soon after interview asking for relatively immediate decision Challenge if interviews not yet complete In competitive disciplines without a match, residents should try to schedule programs most interested in first Pre-match calls OK to have PD or institutional rep call on behalf of applicant - ? impact

Resources and Important Websites www.nrmp.org – match information, match data from prior years, timelines http://www.aamc.org/students/erasfellow/start.htm - AAMC ERAS site – ERAS application and supporting resources, timelines, program information http://www.aamc.org/students/cim/ - AAMC careers in medicine website – resources for job applications, interviewing, specialty selection, etc http://www.ama-assn.org/ama/pub/category/2997.html - AMA Frieda website – program and specialty information, program and career statistics http://www.acponline.org/counseling/index.html - ACP career counseling website – includes tips on marketing self, tips for applying to fellowships, etc

Summary Know your deadlines Do not wait until last minute for letters Focus on the consistently important things you can change… Interview skills and preparation LOR from specialist (particularly known) LOR from IM Program Director Fellowship begins day 1 of your intern year!!! With regard to scholarship Interest > Publications > Experience Consider an on-site elective in the subspecialty field???

Questions

The Match—2008 Appointments Cardiology 1,264 applicants for 699 positions/164 programs 99.1% filled (438/550 US grads & 155/714 non-US) Hematology/Oncology 724 applicants for 424 positions/122 programs 98.1% filled (241/312 US grads & 165/412 non-US) Pulmonary/Critical Care 569 applicants for 374 positions/121 programs 96% filled (182/206 US grads & 177/363 non-US)

The Match—2008 Appointments Gastroenterology 622 applicants for 325 positions/150 programs 96.3% filled (230/319 US grads & 83/303 non-US) Infectious Disease 344 applicants for 283 positions/118 programs 90.5% filled (138/155 US grads & 118/189 non-US) Rheumatology 251 applicants for 165 positions/95 programs 92.1% filled (84/98 US grads & 68/153 non-US)