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Are residents applying too early for fellowship slots?

Some changes already streamline the application process—but housestaff want to wait longer to apply

From the March ACP Observer, copyright 2005 by the American College of Physicians.

By Yasmine Iqbal

In the midst of working 80-hour weeks as an intern at Boston University School of Medicine, Harmony Allison, MD, took on what amounted to a grueling part-time job: applying for a gastroenterology fellowship.

When she started researching fellowship programs in January 2004, she hadn't even completed her gastroenterology elective—but with fellowship slots in short supply, she knew she had to get an early start. She began applying last August to dozens of different programs, asking gastroenterologists she'd known for only a few weeks for a recommendation.


By waiting until her third year to apply for an endocrinology fellowship, Bismruta Misra, ACP Associate, says she 'felt like I was making an informed decision.'



By September 2004—just into her second year—she was interviewing around the country and had started receiving offers. But many programs required her to accept or decline a position before she'd had a chance to complete her interviews, a demand that made it impossible to consider all her options.

In the end, Dr. Allison secured a slot at one of her top choices: Seattle's University of Washington, where she will begin in 2006. Although she's excited about the opportunity and is certain gastroenterology is the right field for her, she wishes she could have applied after she had attained more clinical and research experience in her chosen field.

"In your internship year, you're just learning how to be a doctor," she said. "It's tough enough to manage your time, let alone think about what you want to do two-and-a-half years into the future."

George B. McDonald, MD, director of University of Washington's gastroenterology fellowship program, fully understands Dr. Allison's dilemma. "We're putting enormous pressure on residents to make early career decisions," he said. Nevertheless, he feels compelled to compete within the system to snap up the best and the brightest.

"Last year, we started interviewing in October, and we lost our top two candidates because other programs beat us to the punch," he said. "This year, we're going to start in September."

While gastroenterology is perhaps the most notorious for early recruitment, other subspecialties, such as hematology/oncology and endocrinology, are "only slightly less chaotic," said Donald W. Brady, ACP Member, co-director of the internal medicine residency program at Atlanta's Emory University Medical School.

Several years ago, the Alliance for Academic Internal Medicine (AAIM), the nation's largest academically focused specialty organization, set out to streamline and reform the fellowship application process.

The AAIM's efforts already have borne fruit with a Web-based application system that most internal medicine fellowship programs will use come July 2006. But many residents want more fundamental reform: They'd rather postpone applying for fellowships, ideally until late in their second year, with offers going out to prospective candidates in October of their third year.

At stake, reform advocates say, is the ability to rationalize an increasingly unsettled process and encourage residents to get a more rounded education. But fellowship directors, like Dr. McDonald, point out that delaying the process will work only if programs collectively agree to stop trying to get an early lock on the best candidates. And to impose even more order on recruitment, some fellowship directors are calling for reviving a tool that, for many subspecialties, fell by the wayside: the subspecialty Match.

A moving target

The current problems began in the 1990s, when health care pundits forecast a glut of subspecialists. A study in the Sept. 4, 1996, Journal of the American Medical Association, for instance, predicted a surplus of gastroenterologists and recommended reducing the number of gastroenterology fellowships.

At the same time, the Balanced Budget Act of 1997 cut funding for some fellowship positions, and some subspecialties began requiring fellows to complete more years of training. With fewer residents applying for fellowships, programs started competing aggressively for candidates.

But the predicted surplus never materialized, and by the late 1990s, a growing demand for subspecialists—along with rising starting salaries—pushed more residents to apply. With the applicant pool outstripping available slots, associates were obliged to start applying earlier in residency, sometimes well before they'd been exposed to the full range of internal medicine subspecialties.

The first move for change came in 1999, when the AAIM established a task force to look at problems with the fellowship application process. In the July 1, 2004, American Journal of Medicine, task force members described the current process as "premature, antiquated, and unwieldy."

But according to task force chair David L. Battinelli, ACP Member, who is also vice chair for education at Boston University School of Medicine, some subspecialty programs were satisfied with the status quo.

"It was clear that the interests of the programs were being placed before the interests of trainees," he said, "but the programs weren't convinced that there was a problem, and they weren't interested in finding a solution."

To make the case for change, the AAIM in 2001 surveyed more than 16,000 internal medicine residents. They found that the vast majority of residents wanted a more uniform application system, a need the AAIM has moved to address.

In 2001, it began working with the Association of American Medical Colleges to institute a synchronized, Web-based application system for all internal medicine subspecialties based on the electronic residency application service (ERAS). The system, which has long been used to process residency applications, will be adopted by most internal medicine subspecialties within the next two years. (For more information, see "Shifting fellowship applications online.")

The AAIM survey also found that 70% of respondents believed the fellowship recruitment process took place too early in residency. How to fix that problem, however, is a lot less clear.

Pros and cons

While many residents support the idea of delaying fellowship applications, members of the academic community say there are pros and cons.

On the plus side: "Fellowship programs are often looking for clinical exposure and research experience in the subspecialty, and if they wait longer, they get applicants that are academically more well rounded," said Emory's Dr. Brady.

University of Washington's Dr. McDonald agreed, saying he's always been biased toward candidates who apply later in their second year because they're more experienced and mature. He also noted that he's had several residents who've applied as interns, only to drop out a few months before their fellowship began, perhaps because they weren't really committed to the field.

But delaying the application process could also create problems. According to Charles Clayton, AAIM's vice president for policy, one potential pitfall is how to synchronize an application for an out-of-state fellowship with a state's licensing requirements.

If residents don't get appointed to an out-of-state fellowship until late October of their third year, for example, there's a chance their state license won't come through by the time the fellowship begins. (For instance, California has one of the lengthiest licensing processes, taking up to nine months to process a new one.) Because of this and other considerations, Mr. Clayton said, the AAIM has yet to formally broach the issue of pushing back the application process.

Some experts also see a potential disadvantage for residents in waiting. Joyce P. Doyle, ACP Member, Emory's internal medicine residency program director and vice chair for education, said residents who have their fellowships in hand by their second year may feel more free to pursue a variety of electives, getting a more well rounded education during the remainder of their residency.

By contrast, residents who delay applying may instead spend all their elective time in their subspecialty of choice to strengthen their application. "Residents can really bias their training if they wait until their third year to apply," she said.

But some residents refuse to let the system rush them, electing instead to apply for a fellowship in their third year and then waiting a year before starting. A case in point is Bismruta Misra, ACP Associate, who began looking for an endocrinology fellowship last October as a third-year resident at Brown University Medical School in Providence, R.I.

"I had an idea that I wanted to go into endocrinology early on, but I wasn't 100% sure," she said. "When I did apply, I felt like I was making an informed decision." Still interviewing through January of this year, Dr. Misra has since accepted a fellowship at New York's Columbia University that wil begin in July 2006. She is looking forward to the one-year gap, and plans to spend it studying for her boards and perhaps working as a hospitalist.

Lawrence M. Phillips, ACP Associate, a chief resident at North Shore University Hospital in Manhasset, N.Y., took a similar route. After being offered the chief residency in the fall of his second year, he waited until his third year to apply for a cardiology fellowship. He received a position at North Shore in June 2004 and will start in 2005.

"By the time I applied, I had already done several electives in coronary care, and the experience cemented my desire to go into cardiology," Dr. Phillips said. "I saw many people who were doing a subspecialty elective just as they were interviewing for a fellowship in that subspecialty, and many of them ended up questioning whether they were making the right choice."

The debate over the Match

Some experts say the best way to make the application process saner in subspecialties like gastroenterology might be to restore a subspecialty Match.

Three internal medicine subspecialties—cardiovascular diseases, pulmonary and critical care, and infectious diseases—already participate in the Medical Specialties Matching Program, with rheumatology planning to institute a Match this year. But so far, other internal medicine subspecialties are opting instead for an unstructured application process.

Gastroenterology programs did participate in the specialty Match from 1986 throughout the 1990s, but it was officially defunct by 2000, after participation rates fell sharply. An article in the August 2004 Gastroenterology pointed out that since it collapsed, fellows have been recruited increasingly early in their residency. (The article also pointed out that, with the Match's demise, more associates began accepting a fellowship from the same institution where they completed their residency, leading to less diversity in fellowship programs.)

Many gastroenterology fellowship directors want to see the Match restored—which

automatically would push the application process back later in residents' second year. But a Match would work only if programs agree to abide by the rules, said Deborah Proctor, MD, chair of an American Gastroenterological Association ad-hoc committee that studied a possible Match restoration. At least 75% of programs with available positions would have to register in the Match—and use it to fill at least 75% of the open slots.

According to Dr. McDonald, fellowship programs will fall in line only if they're subject to stiff penalties for jumping the gun and forming too many agreements outside the Match. One way to ensure that programs stay honest, he said, is to give the Accreditation Council for Graduate Medical Education (ACGME) the option of withdrawing accreditation from fellowship programs that don't abide by Match rules. "The ACGME is the only organization that has any clout and can put some teeth into the Match rules," he said.

Getting fellowship programs to play by the rules may not be easy, but Dr. Proctor believes the specialty is moving in that direction.

"We all realize that chaos reigns now, and it's not going to get any better," she said. "The timing may finally be right to bring back the GI Match."

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Shifting fellowship applications online

When it comes to changing the way residents apply for fellowship, the Alliance for Academic Internal Medicine (AAIM) has moved to create a streamlined application process across internal medicine subspecialties. That effort has been a clear success story.

In 2001, the AAIM began working with the Association of American Medical Colleges (AAMC) to adapt the AAMC's synchronized, Web-based application system. The system had been used for years to process residency applications.

By July 2003, the AAMC had adapted its Electronic Residency Application Service (ERAS) for fellowship applications. In November of that year, fellowship programs in pulmonary and critical care medicine (both separately and combined) piloted the service for positions starting in July 2005. In July 2004, infectious diseases and rheumatology programs signed on for positions starting in July 2006. And many other internal medicine subspecialties are following suit in 2006 for positions beginning in 2008.

The new service has many advantages. It allows residents to submit a common application to multiple programs; eliminates paperwork; and makes comparing, tracking and communicating with applicants much easier. It also creates a common timeline for programs and applicants. They can start applying in July of their second year but programs can't download those applications until December 1.

But while many academic leaders applaud the new system, Joyce Doyle, MD, internal medicine residency program director and vice chair for education at Emory University Medical School in Atlanta, warns residents that they still need to do their homework. "It's important to be selective and research each fellowship position, and not just apply to every program because it's easy," she said.

Residents still need to decide, for instance, whether they want to pursue a career in academics or in private practice.

"If they are interested in a career in academics, they should train at a university-based academic program with opportunities for research, appropriate mentorship and a strong clinical training base," said Dr. Doyle, adding that physicians headed for private practice have more latitude in choosing where they train. "They can be more flexible and don't need that strong focus on research—as long as they get strong clinical training."

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