A Guide to the Subspecialty Fellowship Application Process

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.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—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 • 1.5:1 applicant to position ratio • 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 – 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

25. 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

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 • http://www.aamc.org/students/erasfellow/start.htm • 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/email 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 • 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

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 • 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

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)