A Guide to the Subspecialty Fellowship Subspecialty Fellowship Application Processpp

VCU Internal Medicine Residency ProgramJ. Christian Barrett, MDJ. Christian Barrett, MDDivision of Hematology/OncologyVirginia Commonwealth Universityg y

RoadmapRoadmap• Selecting a subspecialty

• Scholarship during residency – important or not?

• What are fellowship directors looking for?

• The application process• The application process

• Resources

• Questions

Selecting the right specialty for youSelecting 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 advisorsDiscussion with academic advisors− Faculty, program directors− Mentors

• Questions that guide choices …

Selecting the right specialty –questions to answerquestions to answer

• Do you want to focus on ifi t ( di l GI)− specific organ system (cardiology or GI)

− multi-systemic (ID or oncology)?

Do you derive more satisfaction from dealing with • Do you derive more satisfaction from dealing with − acutely ill patients− long-term management of diseaseg g

• Do you enjoy − focusing on a specific disease or set of problems (such g p p (

as a cardiology consultant)− the care of the entire patient (for example, serving as

a comprehensive provider to renal dialysis patients who a comprehensive provider to renal dialysis patients who require long-term care from their specialist)?

Selecting the right specialty –questions to answerquestions to answer

• Do you prefer to have a i t i ti t t− prominent inpatient component

− an outpatient focus?

What kind of patient mix do you prefer (age gender • What kind of patient mix do you prefer (age, gender, problems, setting)?

• What are the “hot areas” for scholarship in the 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?future?

• Are you interested in procedures?

Where geographically do you hope to settle and what • Where geographically do you hope to settle and what is the job market in that region?

Other issues to considerOther issues to consider• Competitiveness of specialty

St t il bl iti fill d th h − Stats available on positions filled through match – www.nrmp.org

− Home institution faculty and fellowship y pdirector

− Program director – honest appraisal of candidacycandidacy

• Importance of “scholarship” and personal commitment to pursuing during residencycommitment to pursuing during residency− Particularly pertinent to cardiology and GI

• Visa issues including time limitations• Visa issues, including time limitations

Self-AppraisalSelf Appraisal• Personal reflection (HONESTY!!!)

− Personal value system• Rank order priorities in life

Compare with the work specific priorities• Compare with the work specific priorities• Reconcile incongruity

− Personal aptitudePersonal 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 fellowshipthe selection process for fellowship

• Prominent for most of the competitive f ll hi d fellowships and programs− Programs may be measured on ability to

produce funded research scholarsproduce funded research scholars− Training grants may be focus of success

and may be primary funding for positions y p y g pin programs

− RRC requirement for accreditation of f ll hifellowships

− Reflective of “spirit of inquiry”

A word on scholarship and its role in the selection process for fellowshipthe 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 − Rare for residents to develop their own research questions

− Most will join ongoing projectMost w ll jo o go g p oject• 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 A word on scholarship and its role in the selection process for fellowship

• In absence of scholarly productivity …− Develop an understanding of academic

l d i tifi i ivalues and scientific inquiry− Be prepared to explain what scholarship

means to youmeans 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…2002 Survey by Cooke et al…• Surveyed FPDs in cardiology, endocrinology,

t t l d h t lgastroenterology and rheumatology

• 330 responses

• Three selection criteria – most important− Clinical performance (PD letter)p ( )− Interview evaluation− Interpersonal skills

• Residency reputation frequently assessed

R h d hi f di l id • Research and chief medical residency important to procedure-oriented programs

Gayed Survey of Cardiology ProgramsGayed 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 directorknown by the fellowship director

Gayed Survey of Cardiology Programs (continued)(continued)

• Important factors continued (most to least important)Performance during an elective at fellowship site− 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 divisionResident at institution with well known cardiology division− Participation in research− Assessment of medical knowledge during interview

P bli ti i t f ll hi− Publications prior to fellowship− Performance on ABIM certifying exam if avail.− US citizenship− USMLE scores

2004 Survey of FPDs and IMPD by Mikhail and BernsteinMikhail 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 BernsteinMikhail and Bernstein

• Top 8 items in order…− Fellowship interview***− LOR from known specialists***

LOR f IMPD***− LOR from IMPD***− University-based residency

Interest in research***− Interest in research***− No H1-B visa− Elective at the fellowship site***Elective at the fellowship site− USLME exam scores

2004 Survey of FPDs and IMPD by Mikhail and BernsteinMikhail and Bernstein

• The next 10 items …− PublicationsPublications− US Medical School− US Citizen− Research experience− Research experience− Chief residency

− Phone call from IMPD− Well-written personal statement− LOR from attendings outside of specialtyg p y− Applying during residency− Extracurricular activities

2004 Survey of FPDs and IMPD by Mikhail and BernsteinMikhail and Bernstein

• Cardiology and Gastroenterology vs others− Rated considerably higher…

• PublicationsResearch experience• Research experience

− Rated considerably lower…• Elective at the fellowship siteElective at the fellowship site

2004 Survey of FPDs and IMPD by Mikhail and BernsteinMikhail and Bernstein

• University vs. Community-based f ll hi fellowship programs…− Rated higher by university programs…

University based residency• 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 AppointmentsThe Match 2009 Appointments• 1067 certified programs participated

969 filled (91%)• 969 filled (91%)• 98 unfilled (9%)

• 3075 certified positions available• 2940 positions filled (96%)• 135 positions unfilled (4%)

4563 applicants enrolled and certified• 4563 applicants enrolled and certified• 2940 matched (64%)

• US allopath graduates 85% matched• Osteopath graduates 52% matched• Foreign graduates 51% matched

The Match—2009 AppointmentsThe Match 2009 Appointments• Gastroenterology

− 361 positions/153 programs• 1.9:1 applicant to position ratio• 96% filled (70% with US grads & 21% non-US)96% filled (70% with US grads & 21% non US)

• Cardiology− 718 positions/169 programs718 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 AppointmentsThe 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)97% filled (51% with US grads & 32% non US)

• Rheumatology− 179 positions/97 programs179 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)

The Match—2009 AppointmentsThe Match 2009 Appointments• Endocrinology

− 213 positions/112 programs• 92% filled (50% with US grads & 35% non-US)

N h l• Nephrology− 374 positions/142 programs

• 94% filled (35% with US grads & 56% non-US)• 94% filled (35% with US grads & 56% non-US)

The application process –ERAS and NRMPERAS and NRMP

• ERAS – www.aamc.org/erasF 2009− For 2009

• Allergy and Immunology• Cardiology• Critical Care Medicine• Endocrinology• Hematologygy• Gastroenterology• Geriatrics• Hospice and Palliative CareHospice and Palliative Care• Infectious Diseases• Nephrology• Oncology• Oncology• Pulmonary Medicine• Rheumatology

The application process –ERAS and NRMPERAS and NRMP

• NRMP – www.nrmp.orgA f 2009− As of 2009

• Allergy and Immunology• Cardiologygy• Critical Care Medicine• Endocrinology

Gastroenterolog• Gastroenterology• Hematology and Oncology• Infectious Diseases• Pulmonary Medicine and Critical Care• Rheumatology• Nephrology• Nephrology

The application process:The Match 2009 timelineThe Match 2009 timeline

• Late June – Fellowship applicant materials available for downloadmaterials available for download

• July 1-Dec 1 to compile application through ERAS fellowships systemthrough ERAS fellowships system

• mid-Nov – select programs to which to transmit applicationstransmit applications

• Jan 7, 2009– ERAS Fellowships opens to fellowship programsfellowship programs− NOTE: individual programs set deadlines

after which they will no longer accept li iapplications

The application process - timelineThe application process timeline

• Jan-April – interviews occur

• April 8, 2009 – ROL submission begins

• June 3 2009 – ROL submission ends at 9PM• 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

lli d i i rolling admission process

The application process - timelineThe 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

H O N M− Heme-Onc runs Nov-May

ERASERAS• ERAS Fellowships Applicant Site

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

ERAS – how it worksERAS how it works1. Contact the ERAS Fellowships Document

Office (EFDO) to obtain “electronic token” Office (EFDO) to obtain electronic token to access the ERAS system• EFDO is the “deans office, central processing , p g

office” for fellowship applicants

2. Register on the MyERAS website once obtain token

3. Complete common application form; submit supporting materials (originals only) directly to EFDO

4 S l i i 4. Select programs; assign supporting documents to specific programs

5. ERAS receives notice of completed application and transmits documents to application and transmits documents to programs

6 E i i b d i d 6. Examining boards receive and process requests for score reports

7. Programs contact ERAS PostOffice daily to download application materials

The application componentsThe application components• Curriculum Vitae (CV)

− Automatically generated if ERAS− Merideth to discuss next week

• Letter from Program Director

• Letters from facultyLetters from faculty

• Personal statement

• Board scores

Letter from Program DirectorLetter from Program Director• One of the most important components of the

applicationapplication

• Emphasizes performance within the program

A ti l t i h t i ti f th • Articulates unique characteristics of the applicant, highlights scholarly activities

• Important to comment on the candidate’s • Important to comment on the candidate s potential for scholarship and an academic career

• Recommend requests submitted by October 16thq y

• If ERAS, need ERAS cover letter and waiver

• If non-ERAS, need envelopes/labels and stampsIf non ERAS, need envelopes/labels and stamps

Letter from facultyLetter from faculty• Recommend that letters come from faculty

within discipline to which resident is within discipline to which resident is applying

• Should articulate resident’s performance• Should articulate resident s performance

• Emphasize importance of scholarship potentialpotential

• Avoid sending more letters than requested

• May be value in requesting from “national expert” faculty

Personal StatementPersonal Statement• Brief is better – aim for one page or less

• Do not just restate CV content

• Communicate enthusiasm for disciplinep

• Communicate spirit of inquiry

• Opportunity to discuss projects in which • Opportunity to discuss projects in which participated – why enjoyed, how involved, etc− Findings of project less important than

bringing out enthusiasm for scholarly pursuitpursuit

• First do no harm is the “golden rule”…

Personal StatementPersonal Statement• Avoid

− Actual findings of a project unless it has yet to Actual findings of a project unless it has yet to be published

− Approaches in the PS that cast you in less favorable lightg

− Poor grammar, awkward sentences− Hollow platitudes … “I am enthusiastic about

the discipline/research”p• Say something that supports these points

− “interesting patient approach”• Use sparingly to springboard demonstration of p g y p g

other points− Closing doors in PS … not too focused, want to

appear excited and attracted to multiplicity of possibilities offered by the discipline and possibilities offered by the discipline and program

The interviewThe interview• Opportunity for applicant to project

th i i i i itienthusiasm, uniqueness, inquisitiveness

• Opportunity for program to critique residents on demeanor and content of answers

• Candidate should …

The interview – candidates shouldThe 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 questionsq

• 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 interactionphone call/email interaction

• Convey genuineness

Commonly asked questionsCommonly 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 dialoguePost interview dialogue• May be one of most challenging aspects of

th f th did tthe 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 list or one of my top choices tells fellowship that program is NOT top

Post-interview dialoguePost interview dialogue• Not-in-match programs post-interview

− May call residents soon after interview asking for relatively immediate decisionChallenge if interviews not yet complete− Challenge if interviews not yet complete

− In competitive disciplines without a match, residents should try to schedule atc , es de ts s ould t y to sc edule programs most interested in first

• Pre-match callsPre match calls− OK to have PD or institutional rep call on

behalf of applicant - ? impact

Resources and Important WebsitesResources and Important Websites• www.nrmp.org – match information, match data from

prior years, timelinesp y ,

• http://www.aamc.org/students/erasfellow/start.htm -AAMC ERAS site – ERAS application and supporting resources, timelines, program information, , p g

• http://www.aamc.org/students/cim/ - AAMC careers in medicine website – resources for job applications, interviewing, specialty selection, etcinterviewing, specialty selection, etc

• http://www.ama-assn.org/ama/pub/category/2997.html - AMA Frieda website – program and specialty information program website program and specialty information, program and career statistics

• http://www.acponline.org/counseling/index.html -ACP career counseling website – includes tips on ACP career counseling website includes tips on marketing self, tips for applying to fellowships, etc

SummarySummary• Know your deadlines

− Do not wait until last minute for lettersDo not wait until last minute for letters

• Focus on the consistently important things you can change…

Interview skills and preparation− Interview skills and preparation− LOR from specialist (particularly known)− LOR from IM Program Director

F ll hi b i d 1 f i t !!!• Fellowship begins day 1 of your intern year!!!

• With regard to scholarship− Interest > Publications > Experiencep

• Consider an on-site elective in the subspecialty field???

Questions

The Match—2008 AppointmentsThe 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 AppointmentsThe 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)