By Aakash Desai, MBBS, MPH

As we approach June, thousands of internal medicine residents will get ready to apply for specialty fellowship positions. In 2019, 5,969 applicants applied for a total of 4,932 specialty positions, according to the data released by the National Resident Matching Program (NRMP). In hematology and oncology alone, 758 applicants applied for 573 positions offered. Since 1993 the NRMP has shown a constant increase in the number of specialty fellowship applicants, disproportionate to the increase in the number of programs or positions. This is why the middle of the year brings forth anxious times for internal medicine residents.

It is not uncommon to see these statistics being cited over lunch in the resident lounge leading up to the fellowship season. While learning the vast spectrum of medicine in the intensive care unit, I remember citing these statistics more often than the mortality reduction numbers demonstrated by the Surviving Sepsis Campaign. Agonizing over the number of published manuscripts and pending protocols while struggling with feelings of imposter syndrome are all widely prevalent prior to the application season. Lastly, juggling between duty hours, adjusting to a senior resident role, finishing up pending projects, and talking to seniors who have matched into fellowships is a common checklist among residents.

If you have gone through the fellowship application process, this likely sounds familiar to you—and if you have not, I do not say this to scare you. Instead, I want to tell you that (believe it or not) all of this is normal! Based on my personal experience going through a hematology/oncology fellowship match season in 2019, I wish to offer some advice for a good fellowship application season. Some of this will be more relatable for a hematology/oncology applicant, but it is broadly applicable to other specialties as well.

Know What Matters—and What Doesn’t

Before you even start working on a fellowship application, take a moment for self-reflection. Stay focused on what is truly important: making the right choice for yourself and your family, and becoming the best doctor you can be.

Family comes first. Three additional years of fellowship training is a commitment (which may not be for everyone). Certain family circumstances, like the need for financial stability, visa restrictions, childcare, or caring for an ailing parent, may affect your plan of joining a fellowship. It is important to consider whether adequate financial, emotional, and family support is available for you to go through fellowship training. Also, adequate funding support for the cost of applications, interview travel, and accommodation can occasionally be a deterrent. Make your family your first priority, since their support will be vital to set yourself up for success.

Take a step back and look at the bigger picture. In life, as in medicine, we can get caught up in the numbers. With respect to fellowship programs, it might be an institution’s ranking on the U.S News Best Hospitals for Cancer, the number of open positions, or the salary offered. Although these things are important, it is most vital to consider whether a program matches your goals, values, and beliefs. Understand that the education, training, and experience will largely be consistent in any American Council of Graduate Medical Education accredited program. When you find yourself anxious about perception and prestige, remind yourself that your ultimate goal is to practice as a hematologist and/or oncologist and care for patients.

Application Tips

Get ready to make myERAS your homepage! All your application materials will be prepared, monitored, and submitted through the Electronic Residency Application Service (ERAS) website. Some good news: You can pull in data from your residency application season.

1. Application: ERAS generates a curriculum vitae (CV) from the details you enter. So, make sure you enter everything you want the program leadership to know—your grand rounds talk on myeloma, an ongoing study in lung cancer, an online publication of abstracts you presented at the ASCO Annual Meeting, CHEST, and other professional conferences, or your in-press review article.
2. Personal Statement: This is the major rate limiting step to completion of your application materials, so start early and revise often! This is where most of us experience writer’s block. Although cliché, this is really your medical version of an elevator pitch. You are trying to impress the program leadership with your story—yes, your story. You do not want to regurgitate the information in your CV but paint a picture of why you are passionate about this specialty and how this move will enable you to reach your career goals. Personal statements are generally not make-or-break (so don’t agonize), but they tell an interviewer who you are and can provide a starting point for interview conversations (so do put in appropriate time and effort).  
3. Letters of Recommendation (LORs): ERAS allows you to upload a total of four LORs (three faculty recommendation letters plus one from your program director). A common misconception is that the academic stature of the letter writer is more important than the content of the letter. In fact, the most important thing is what the letters of recommendation say about you. Ask people who know you the best and will be able to support your candidacy for a fellowship position. A letter from a junior attending who knows you well and is willing to support you will supersede one from a senior attending writing a generic letter. While it can be good to obtain letters from specialty physicians given their ability to assess your readiness for the particular specialty, it is not necessary. Finally, make sure you inform your letter writers well in advance, preferably 3 to 4 months, in order to ensure timely preparation of all your application materials.

Balance Your Program Selections

The type, number, geographic region, and funding limitations should enable you to filter the programs that you will apply to. A general rule of thumb is to apply to a mix of highly competitive programs and less competitive programs.

For visa applicants, it is generally a good idea to apply broadly and find out whether the programs you are applying to sponsor visas. After all, you would not want to waste that hard-earned residency cash! 

Tip: If there is a specific program you are interested in, it is helpful to do an away elective (if allowed by your residency program) to get an idea of the program as well as introduce yourself to the program leadership.

What to Expect at the Interview

The interview is the fun part! Yes, despite all the travel fatigue—if time permits, enjoy the travel and be a tourist. The fellowship interview process can be a bit more challenging than residency due to the need to find coverage for your clinical duties (since you will be on service some of these interview months), clashing interview dates, and clinical paybacks.

Interacting with co-interviewees is probably the best part of the interview trail. Some of them you might know from residency application season or through mutual friends, work, or a shared disease interest. You will meet the same people many times over and may even match into the same program. (In that case, you already have friends at your new program!)

The interview season provides you an opportunity to meet people whose work you have followed, people you admire, or people you want to work with. You might meet a member of the National Comprehensive Cancer Network (NCCN) lymphoma guideline panel, the lung cancer trialist whose work you saw presented in a Plenary Session, a Journal of Clinical Oncology (JCO) editorial board member, or other prominent people in your field of interest. This is a beautiful feeling, so enjoy and make the most of it.

The format and number of interviews varies by program, from a series of one-on-one meetings to panel interviews conducted by three to seven faculty members. The interviewers are generally faculty from the hematology/oncology department, but this can differ among programs as well—don’t be surprised if statisticians or research lab attendings are part of your interview.

The interview itself is geared towards understanding your future goals, previous and current research interests, and other topics of professional interest. As an interviewee, you should be able to talk articulately about the things you have stated on your CV. For example, if you have participated in the publication of a phase III trial, you should be able to explain the methods, rationale, and findings of the study; this serves as the surrogate for your involvement with the project. None of the interviewers will be testing your medical knowledge in hematology and oncology or in general internal medicine—the point of the interview is to determine how your interests and aims align with those of the program.

Finally, be comfortable talking about your disease-specific interests, research interests, and future career goals (and it is okay if you do not have all the answers just yet!).

Ranking Your Options

Ranking is probably the hardest step of the entire process. You’ve interviewed at some of the places you applied, given your best at these interviews, and now it is time to decide where you want to go for fellowship.

Like residency, there is only one mantra that really helps here: Trust your gut. I know this is cliché and vague, but let me explain. Everyone’s top priority is different. Some want to move to a warm climate, while others want to train at the most prestigious institution. Some want to stay close to family, while others prefer a certain curriculum. While we weigh all these pros and cons in our carefully formatted spreadsheets, the most important thing remains how you feel about the program.

How did you feel when you were there for your interview? Do you see yourself working with the fellows and attendings you met on interview day? Do you see yourself working on a research project with the lab faculty here? Do you see yourself living in this city? What compromises are you making? The answers to these questions will provide you an idea of your quality of life at this institute as a fellow and how fulfilling the experience will be for you, which is much more important than the salary, the number of calls, and the institution’s ranking.

Also consider the broader perspective. What do you want to do post fellowship: academics, industry, or private practice? Do you think the program in question will prepare you for that future goal? Should you rank the clinical programs higher if you want to do private practice in the future, rather than focus on laboratory or clinical research? These should be the questions to ask yourself while ranking.

Last tip: Do not rank a program you don’t want to match in, period. Including it as a just-in-case option is ultimately a disservice to yourself and to the program.

After agonizing over your final top three choices—which now look completely different from your original favorites—and locking in your rankings, now is the time to relax. The wait between the submission of your rank order list and match day feels much longer than it actually is.

Match Day: Celebrate!

Matching is a humbling experience. It is the process where your attendings and program directors attest to your ability to provide specialized care to patients. The interviewers and fellowship program leadership bestow their faith in your abilities. As residents, it is a time for gratitude. Be grateful that you have crossed a major hurdle to fulfill your dream of becoming a hematologist/oncologist.

As you celebrate the success of your fellowship match, it is best to remind yourself of what lies ahead: the American Board of Internal Medicine (ABIM)  exam! As you train to become a specialty physician, internal medicine becomes even more important—not only is this the last chance for you to review the concepts of medicine, it is the time to lay your foundation as a well-rounded physician.

Finally, as you train and learn, be grateful for the help you received and strive to pay it forward by helping another on their journey. There is no greater service to the profession than to bestow it with another skilled professional.

Dr. Desai is currently an Internal medicine resident in the Department of Medicine at the University of Connecticut Health Center. He will be pursuing his hematology/oncology fellowship at Mayo Clinic Rochester starting in July 2020. He holds a master’s degree in public health from the University of Texas Health Science Center in Houston and a certification in Health Professions Education. He also serves as a vice chair of the Connecticut State Medical Society Resident and Fellow Section. Follow him on Twitter @ADesaiMD.