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 – www.nrmp.orgwww.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

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—2011 Appointments 1090 certified programs participated 965 filled (89%) 125 unfilled (11%) 3177 certified positions available 3002 positions filled (94%) 175 positions unfilled (6%) 4454 applicants enrolled and certified 3002 matched (67%) US allopath graduates 87% matched Osteopath graduates 59% matched Foreign graduates 56% matched

21. The Match—2011 Appointments Gastroenterology − 383 positions/157 programs 1.67:1 applicant to position ratio 95% filled (69% with US grads & 19% non-US) Cardiology − 729 positions/168 programs 1.5:1 applicant to position ratio 99% filled (59% with US grads & 28% non-US) Hematology/Oncology − 458 positions/124 programs 1.7:1 applicant to position ratio 98% filled (53% with US grads & 32% non-US)

22. The Match—2011 Appointments Pulmonary/Critical Care − 417 positions/122 programs 1.35:1 applicant to position ratio 97% filled (47% with US grads & 32% non-US) Rheumatology − 184 positions/102 programs 1.2:1 applicant to position ratio 89% filled (49% with US grads & 33% non-US) Infectious Disease − 314 positions/128 programs 1:1.1 applicant to position ratio 85% filled (46% with US grads & 36% non-US)

23. The Match—2011 Appointments Endocrinology − 233 positions/115 programs 1.46:1 applicant to position ratio 92% filled (47% with US grads & 37% non-US) Nephrology − 380 positions/146 programs 1.26:1 applicant to position ratio 91% filled (27% with US grads & 56% non-US)

24. The Application Process Select programs to which to apply − See individual program application process ERAS and NRMP participating? Program specific deadlines − You must ensure you meet all of the program prerequisites and institutional policies regarding eligibility for appointment Things to consider in selecting programs… − Career and academic goals − Geography − Your talents, abilities and competitiveness − Size of program and applicant pool

25. ERAS ERAS Fellowships Applicant Site − http://www.aamc.org/students/erasfellow/start.htm − Specific program information − Process information − Form downloads − Resources − Addresses for letters Cost (check/money order, VISA, MasterCard) − $100 for 1 st 10 programs − $10/programs 11-20 − $15/programs 21-30 − $25/programs 31 and more

26. ERAS – how it works 1.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 (215) 966-3040 https://www.erasfellowshipdocuments.org support@erasfellowshipdocuments.org

27. ERAS – how it works 2. Register on the MyERAS website once obtain token 3.Complete common application form 4.Submit supporting materials (originals only) directly to EFDO 5.Select programs and assign supporting documents to specific programs a. Allow a week for delivery b. Be aware of program application deadlines with this delay in mind

28. 5.ERAS receives notice of completed application and transmits documents to programs 6.Examining boards receive and process requests for score reports 7.Programs contact ERAS PostOffice daily to download application materials

29. The application components Curriculum Vitae (CV) − Automatically generated if ERAS Letter from Program Director Letters from faculty Personal statement Board scores (USMLE and COMLEX) Medical school transcripts Medical Student Performance Evaluation (MSPE)

30. 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 15 th If ERAS, need ERAS cover letter and waiver If non-ERAS, need envelopes/labels and stamps

31. Letter from faculty Recommend that letters come from faculty within discipline to which resident is applying − Research mentor OK even if not in the chosen subspecialty 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

32. 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”…

33. 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

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

35. 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

36. 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

37. 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 in which most interested first Pre-match calls − OK to have PD or institutional rep call on behalf of applicant - ? impact

38. The application process – ERAS ERAS – www.aamc.org/eras − For 2010 Allergy and Immunology Cardiology Critical Care Medicine Endocrinology Hematology and Oncology Gastroenterology Geriatrics (JULY cycle) Hospice and Palliative Care Infectious Diseases Medical Genetics (JULY cycle) Nephrology Pulmonary Medicine Rheumatology

39. The application process – NRMP NRMP – www.nrmp.org − As of 2010 Allergy and Immunology** Cardiology Critical Care Medicine Endocrinology Gastroenterology Hematology and Oncology Infectious Diseases Medical Genetics** Nephrology Primary Care Sports Medicine** Pulmonary Medicine and Critical Care Rheumatology

40. The Application Process: The Dec Cycle Application Timeline July 1, 2010 – Can obtain token and MyERAS site open to download and begin work on applications − May also apply to July cycle programs July 1-Dec 1 to compile application through ERAS fellowships system November 15, 2010 – Can begin to select programs and to transmit applications December 1, 2010 – ERAS Post Office opens for programs to begin downloading applications − NOTE: individual programs set deadlines after which they will no longer accept applications

41. The Application Process – The MSMP Match Estimated Timeline* January 5, 2011 – Registration for NRMP opens Jan-April 2011– Interviews April 6, 2011 – ROL submission begins at noon June 1, 2011 – ROL submission ends at 9PM June 15 th, 2009 – Match Scramble Day at noon Subspecialties and programs not joining the match follow similar timeline but may have rolling admission process Estimated dates based on prior year. Check NRMP for actual dates once posted.

42. Match Day BE PREPARED − Have copes of all documents ready to go Watch emails from OEA as date approaches Do not schedule vacation for that day Come to office immediately if do not match for assistance

43. The application process - timeline Allergy and Immunology − Similar timeline with match in May 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

44. 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 statisitcs 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

45. 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???

46. Questions