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Subspecialty Fellowship Training

by Patrick C. Alguire, MD, FACP
Director, Education and Career Development, ACP

At the beginning of your PGY-2 year, a conscious decision about fellowship training should be made. If you decide to pursue subspecialty training, this is the time to make contacts with programs to obtain information and set up interviews. Most residents will interview after December of their PGY-2 year. This should be kept in mind when arranging your PGY-2 schedule. You will want to use elective time to interview, and you may actually wish to arrange a clinical rotation at the fellowship site.

Some programs abide by the subspecialty match offered through the National Residency Matching Program (NRMP), but many do not. Check with the NRMP to determine which programs participate, and read the content related to the guidelines and timetable. Program and Applicant Agreements are available in December for a fellowship start date in July, 18 months later. Strict adherence to the timetable is required, and no exceptions are allowed. This site also has useful information on which programs filled and did not fill through the match.

While it is possible to enter fellowship training after a few years of practicing general medicine, it is not commonly done. The reasons will be your reluctance to forego a lucrative practice income in exchange for a fellowship stipend, possibly relocating, and the bias of fellowship directors against candidates not directly out of residency programs.

To assess if fellowship training is for you, analyze your motives for going into a subspecialty.

  • Do you have a deep love or fascination for the specialty area?
  • Do you enjoy the role of consultant?
  • Do you enjoy performing procedures?
  • Are you fascinated by the hospital-related problems?
  • Does deep mastery of a restricted content area appeal to you?
  • Do you respect and admire the subspecialty faculty?
  • Would a subspecialty career offer you important lifestyle or financial advantages?
  • Are you entering subspecialty training because you disliked your general medicine hospital clinic experience?

Many residents make a decision on a subspecialty career based solely upon their subspecialty hospital experience or association with an exciting role model. Be sure to gain outpatient experience in the subspecialty that interests you before making a career decision. Many residents are disheartened by the ambulatory experience, finding the types of problems seen in that setting unappealing, and subsequently reconsider their career direction.

Also, try to have contact with more than one role model before making career decisions; looking at the subspecialty from many points of view can avoid uninformed choices.

Do not make a decision to pursue subspecialty training because you disliked your general medicine hospital clinic. If this is the case, inquire about a clinical rotation in a practitioner's office to get a more realistic view of ambulatory general medicine.

It's equally important to consider the job market. Ideally, you would like the luxury of many employment options upon finishing your training, but in reality the job market is getting tighter for many graduating fellows. It will be worthwhile to review the annual report by the AMA on the job seeking experiences of graduating residents and fellows.

Before you embark on the process of applying to a fellowship program, assess your qualifications and take action on those you can improve. The best information available on desired applicant qualities comes from a survey of cardiology fellowship directors by Dr. Gayad. It is unknown whether we can generalize the results to other fellowship programs, but they probably reflect the general attitudes of most fellowship directors. Listed below are qualities and other factors important to fellowship directors, ranked from the most important to the least important:

  1. Negative comments or hints of underlying problems in letter written by internal medicine program director
  2. Personal comments by the internal medicine program director
  3. The personal aspect of the interview
  4. Letter of recommendation from a cardiologist known by the fellowship director
  5. Performance during an elective at the fellowship site
  6. Rank order in the residency class
  7. Genuine interest in research
  8. Being a graduate of a US medical school
  9. Letter of recommendation from a nationally known cardiologist
  10. Doing a residency program at an institution with a well known cardiology division
  11. Participation in research prior to the fellowship program
  12. Assessment of medical knowledge during the interview
  13. Publications prior to fellowship
  14. Performance on the ABIM certifying examination if available
  15. US citizenship
  16. Performance on the USMLE

Based upon this data, a number of recommendations can be formulated. The first and foremost is do well in the general medicine residency program. Second, interview well. See the article in this series on Tips for the First Interview. Get a well-written letter of recommendation from the program director and your reference cardiologists (See Letters of Recommendation. Whenever possible, arrange in advance an elective rotation at the institution that interests you the most. This will require planning your elective rotation in advance of your interviewing. As a resident, find a mentor in your institution and get involved in research. Also, worry less about the factors that are ranked lowest in importance to fellowship directors, including performance on the USMLE, US citizenship, and completing a residency program with a well known division of cardiology.

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