APPLYING FOR A FELLOWSHIP IN THE USA

When applying for a residency (in the USA), many of us aspire to eventually pursue fellowships in different subspecialties. Getting into a fellowship can be more difficult than applying into a residency program; it is a process that starts from the time you start residency and involves more hard work and time than just giving and clearing your USMLE exams and applying through ERAS/NRMP.

I will discuss here the general principles of applying for fellowship positions in the internal medicine subspecialties. I am sure that the same principles would apply to the surgical subspecialties as well. My own experience comes from applying for a hematology-oncology fellowship, which along with cardiology and gastroenterology, is currently among the most competitive fellowships in the USA.

The basic rule is that you have to make your candidacy attractive; remember, you are competing with US medical graduates and international medical graduates (IMG’s) with prior experience (MRCP, PhD, MPH etc) for positions which are a lot fewer than the residencies you applied for. For example, according to the 2002 statistics (from the American Medical Association), there were 21,136 residents in accredited internal medicine residencies compared to 1,999, 1,058, and 991 fellows in cardiology, gastroenterology and hematology-oncology programs respectively (you can divide these numbers by three to get a rough estimate of the first year positions available every year in the respective specialties). Furthermore, for various reasons that I will not divulge into, fellowship programs are being downsized and getting more competitive to get into every year. 

Start Planning Early

If you are interested in doing a fellowship, you have to start planning even before you apply for residency. As IMG’s, we are at a disadvantage; the type of training we receive in medical school cannot be verified by program directors here. Our ‘medical school transcripts’ do not have the information they are looking for, it is arduous to call and get in touch with deans/principals to verify the ‘accomplishments’ we mention in our resumes and there is no way they can verify our medical school standing (for them, AIIMS, New Delhi and Medical College, Jhumri Tilyya are usually the same). To make up for these deficiencies, the first thing that we can do is get into a good and well known residency program. People do get fellowships after doing residencies in ‘community’ programs, but it becomes easier if you are in an ivy league or a ‘university’ program where there are more opportunities for research, the faculty is ‘well known’, and there is a chance you will get absorbed into a fellowship position in the same institution. For example, this concept is similar to applying for a residency after graduating from say the ‘Harvard’ medical school versus an osteopathic medical school (for those of you not familiar with the US medical education system, these schools grant a DO (Doctor of Osteopathy) degree and are generally considered to be not as good as the regular medical schools). So study hard, get good USMLE scores and get into a good residency program (good ‘community’ or a ‘university’ program). If you choose to do residency in a ‘community’ program, as a lot of us do for various reasons (H1B visas being the most common), you can still get a good fellowship position provided you plan ahead of time. A lot of ‘community’ programs impart excellent training, have fellowships, have opportunities for research, or are affiliated with ‘university’ programs where you can do rotations or hook up with some one to do research or get recommendation letters from.

Once you start your residency, get settled and then start focusing on which fellowship you want to pursue. Fellowship applications are sent out in the beginning of your second year of residency. As most of us are here on different visas, unfortunately we don’t have the option of delaying our fellowship applications (as some US grads do – they take a year or two off after completing residency to do research before applying for a fellowship). We have to start our fellowship right after we finish our residency and usually cannot take a break (there are some options though, and I have listed them below). So, the earlier you can decide which subspecialty you want to pursue, the earlier you can start your research and identify mentors in that field.

Identify a Mentor

Unlike India where getting into MD/DM courses is strictly on the basis of merit in an entrance exam, a number of variables are looked at when you apply for a fellowship in the USA. One of the important factors is recommendation letters. So identifying a good mentor in the beginning of your residency is crucial. The mentor should be someone who is easily approachable, readily available, is willing to write a good letter of recommendation, and might make a few phone calls when the time comes for you to apply. Usually, mentors are from the same specialty as the one you are interested in (makes sense!), and often can give you guidance for research. Don’t go after somebody just because s/he has a ‘big name’; s/he may not be always available, may not have the time to get to know you well and hence may not be able to write a good letter of recommendation. Remember, an excellent letter from some one not as well known will be better that a mediocre letter from someone who is a stalwart in that specialty. 

Research

Your accomplishments in research are also very important. You are not expected to be a Nobel Prize winner or have an extensive list of publications. But you should be actively doing something. Most program directors understand that the internship is too busy and short a time to complete a project and publish. They are looking for people who are motivated enough to be taking out the time and effort to pursue research despite their hectic schedules. So don’t worry if you lack extensive prior research experience, don’t have a PhD or an MPH degree – work hard during internship to set the foundation for your research which you can at least mention in your CV and talk about during the interview. Again, research does not have to be ground breaking lab research, even retrospective clinical studies, case reports etc will be appreciated.

Apply Early

Again, I cannot emphasize this enough. Fellowship programs have limited spots. Once the interview slots are filled out (most programs interview around 3-5 candidates for each position), the applications mostly start going into a pile of trash. So apply on time, the earlier the better.

Talk to Your Peers

Learn from the experiences of your seniors, both US medical grads and IMG’s. It is always better to learn from other peoples mistakes. And your seniors can tell you about the advantages and disadvantages of different programs, what to expect during interviews and who to contact for research projects and good recommendation letters.

Don’t Get Discouraged

For those who unfortunately cannot get into a fellowship during their residency, an option is to practice as an internist, settle your visa issues, and then apply for a fellowship. I know of many people who have taken this route and then come back to do a fellowship. Try to remain in touch with your residency mentors during that time period and try to keep in touch with the concerned subspecialty (attend related conferences, do research, etc).

Though the prospect of applying and getting into a fellowship is getting more formidable and competitive every year for IMG’s, one can still get into a program of one’s choice. It is imperative that you apply early and thoroughly plan the application and interview process.

All the best!