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

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

3. 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 …

4. 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)?

5. 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?

6. Other issues to consider
Competitiveness of specialty
Stats available on positions filled through match –
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

7. 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

8. 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”

9. 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

10. 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

11. What do the subspecialty fellowship directors (FPDs) want ?

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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)

22. 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)

23. 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)

24. The application process – ERAS and NRMP
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

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

26. 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

27. 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

28. 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

29. ERAS ERAS Fellowships Applicant Site
Specific program information
Process information
Form downloads
Resources
Addresses for letters

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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”…

36. 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

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

38. 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/ interaction
Convey genuineness

39. 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?

40. 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
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

41. 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

42. Resources and Important Websites
– match information, match data from prior years, timelines
- AAMC ERAS site – ERAS application and supporting resources, timelines, program information
- AAMC careers in medicine website – resources for job applications, interviewing, specialty selection, etc
- AMA Frieda website – program and specialty information, program and career statistics
- ACP career counseling website – includes tips on marketing self, tips for applying to fellowships, etc

43. 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???

44. Questions

45. 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)

46. 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)