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Subspecialty Fellowship Training

by Philip Masters, MD, FACP
Director, Clinical Content Development

During the second year of residency training, most trainees start to make a decision about whether to pursue a fellowship immediately after their residency. This is an important decision because whether you are considering fellowship application may affect scheduling of rotations and other activities during the rest of your residency, particularly to accommodate program visits and interviews. Others may choose to defer this decision to a later point in their residency, although this will mean that there will be a gap between completing your residency training and the start of a fellowship. Some individuals find this attractive as it provides an opportunity for a year (or more) of practice experience prior to starting more advanced training.

All internal medicine fellowships participate in the subspecialty match offered through the National Residency Matching Program (NRMP). The Match opens for submission of applications around the start of the third year of residency with interviews occurring until mid-November when rank lists must be submitted. Match day for subspecialty fellowships is in early December of your third year, approximately 6 months before the start of the fellowship program.

When considering whether to pursue fellowship training, it is important to consider these questions:

  • Do you have a deep interest or fascination for a particular subspecialty area?
  • Does deep mastery of a more limited content area appeal to you?
  • Would you be satisfied clinically to care primarily for patients with problems within a particular subspecialty area?
  • If a subspecialty is primarily consultative, does that role appeal to you?
  • Are you interested in performing procedures associated with some subspecialties?
  • Are there lifestyle or financial advantages to a subspecialty career that are important to you?

Unfortunately, the decision about whether to pursue subspecialty training occurs relatively early in residency training and is therefore often made with limited information. Many residents make a decision on a subspecialty career based primarily upon their subspecialty hospital experience or association with an exciting role model. Be sure to gain ambulatory or community experience in the subspecialty that interests you before making a career decision as this will better reflect what subspecialists in that area do away from inpatient or academic settings. 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.

It is also important to not pursue subspecialty training primarily because you do not find the practice options for general internal medicine (such as ambulatory or primary care) appealing. Pursuing subspecialty training is a major career and life decision, and should therefore be based upon your overall personal and professional goals and not primarily on excluding other career options. Many trainees who are undecided choose to delay the decision about subspecialty training and take the opportunity to work in one or more areas of general internal medicine to clarify whether they truly want to subspecialize.

Additionally, it is important to consider the practical landscape of fellowship training. Some subspecialty areas are more popular and therefore more competitive than others, and this may influence your decision making. Practical information about the number of fellowship training slots is available on the American Board of Internal Medicine website and from individual subspecialty societies.

If you do choose to apply for fellowship training, it is important for you to assess your qualifications and seek to optimize your credentials for fellowship training. First and foremost, it is critical that you do well in your general medicine residency program. Your overall performance evaluation in your residency and recommendations from your program director and program leadership are one of the most influential parts of the fellowship application. It is also important to find a mentor in your institution in the subspecialty area in which you are applying. Different fellowships have unique requirements and expectations, and it is extremely valuable to have guidance from someone who knows that particular system well. This person and others within the subspecialty division at your institution will likely be helpful in ensuring that your training and experience during residency will position you well for fellowship application in that area.

You may also wish to visit or perform an elective rotation in a particular institution where you are interested in applying. While not usually necessary, this may provide both you and the program with additional information and perspective about your interest and qualifications for training. Lastly, it is important that you interview well (see the article in this series on Tips for the First Interview). Factors such as performance on the USMLE, US citizenship, and completing a residency program with a specific institution are much less important to fellowship program directors. If these are concerns for you, discuss them with your residency program director and subspecialty mentor who may be helpful in addressing them.

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