By Michael LaPelusa, MD
The 2022-2023 National Resident Matching Program Medicine and Pediatric Specialties Match was the largest ever. A total of 9,387 applicants rode the tortuous rollercoaster known as the Fellowship Match. A lucky 7,648 fellowship applicants matched to a fellowship position. This figure included 3,892 graduates of MD medical schools, 1,093 graduates of DO medical schools, 935 U.S. citizen international medical graduates, and 1,715 non-U.S. citizen international medical graduates. With regard to hematology and oncology, 703 applicants matched out of a pool of 923, or 76.2%. This proportion of matched applicants was relatively similar to other internal medicine subspecialties like cardiology (1,150 of 1,659, or 69.3%), gastroenterology (656 of 1,039, or 63.1%), and pulmonary/critical care (713 of 930, or 76.7%). 185 certified hematology and oncology programs offered a combined 708 positions, and all but two positions were filled.
These applicants bravely asked their mentors for letters of recommendation. They put pen to paper and dug deep within themselves to formulate a personal statement about how their experiences in medicine led them to pursue a particular subspecialty. They painstakingly filled out their Electronic Residency Application Service (ERAS) applications and triple-checked each word to ensure there were no grammatical errors. They carved out time in their impossibly busy schedules to interview remotely. They DIYed impressive personal studios and put their best self on camera in front of interviewers who would decide their future. They consulted their friends, family, and colleagues to get perspective on their favorite programs and cities. And ultimately, they certified their rank order list.
Sound stressful? It certainly is. Professional aspirations aside, the Fellowship Match takes place in the context of a number of extremely personal circumstances. Moving closer to (or further from) family and friends, the latter of which were sometimes relationships forged by experiences not easily compared to or understood by those outside of medicine, weighs on the mind of nearly all fellowship applicants. Those with significant others, whether it be a budding relationship, a long-term partner, or something in between, must consider the impact of the Match on their combined future. The challenges associated with the Couples Match, which I participated in, add another layer of complexity whose text could easily occupy an entirely separate written column. Applicants with children are tasked with identifying a program and city’s ability to provide a nurturing environment for their little (or not so little) ones. Lastly, the fact many graduating fellows take their first job at the same institution or in the same geographic area where they complete their fellowship training makes the outcome of the Fellowship Match arguably more consequential than any other transition in the long, arduous path toward attending-hood.
The Role of Mentors and Advocates
The ideal time to begin preparing a fellowship application is a personal decision. I’d argue that the rate-limiting step in the process is the time it takes to decide to pursue a subspecialty. As soon as a trainee develops an interest in a subspecialty, whether it be as a fresh new intern or a graduating third-year resident, identifying potential mentors and advocates is crucial.
To me, mentors are individuals in a trainee’s intended subspecialty who can provide support for, and guidance through, clinical and scholarly activities. Mentors also write letters of recommendation supporting a trainee’s fellowship application. Working with mentors in their clinic gives trainees a more realistic sense of many subspecialties, especially hematology and oncology, given that most trainees’ exposure to subspecialties is skewed heavily towards the inpatient setting. Working hard in clinic and making a good impression on a mentor, their colleagues who share a workroom, their support staff, and their patients is essential. This entails, most importantly, being kind. It also requires preparation. Before my first time in my primary mentor’s clinic, I asked one of the clinical fellows what to expect. They patiently talked me through where to show up, how to obtain access to the clinic schedule, what note template to use, and what the clinic’s workflow was like. Over the year that I worked with my primary mentor in clinic (which occurred nearly one-half day every month), I got in the habit of preparing the evening before by reading prior clinic notes for each patient I intended on seeing to learn more about their medical history. I also perused the National Comprehensive Cancer Network guidelines to make an educated assessment of what I believed should be the next step in a patient’s treatment course. Performing this exercise was challenging, especially the first few times, but it allowed for a more fruitful learning experience. It also allowed me to ask insightful questions—which served as a springboard for research projects.
In my mind, advocates (or sponsors) function in a slightly different capacity than mentors; they are individuals who may or may not be in a trainee’s intended subspecialty and elevate their work, promote applicant’s assets to future prospective employers (e.g., fellowship program leadership) using their reach because they care about a trainee’s fulfillment and success. They also may write letters of recommendation for a trainee’s fellowship application. An example of someone who was an advocate of mine, and a fierce one at that, was my internal medicine residency program director. Other examples of advocates can be fellows a trainee has developed a friendly and professional relationship with or an attending that a trainee impressed on an inpatient service, committee, or research project.
“When should I start a research project?” is a question universally asked by residents intent on applying for fellowship. As with all aspects of the Match, there is no universally correct answer. Time is a finite entity, and the clinical responsibilities of residency are not compatible with becoming a well-funded, independent, internationally recognized investigator at this stage in training. For that reason, trainees should set their expectations accordingly.
My initial approach was to take complete ownership of one project related to a topic I was genuinely interested in rather than getting peripherally involved in several projects that may or may not have been done by the time I finished residency. In the back of my mind, one of the goals I set before undertaking the project was to have a first-author manuscript prior to submitting my fellowship application. I felt showing I could take an idea from conception through IRB submission, data collection, data analysis, writing, and publication would show fellowship program selection committees I was scientifically curious, could think critically, and was a “finisher.” I tried to develop a research question that was interesting to me, which my mentor helped polish. In conjunction with my primary mentor, I chose to wait until halfway through internship before diving into a national database containing data relevant to our research question. With a load of help from my mentor and other co-authors, I presented our findings virtually at the 2021 ASCO Annual Meeting and subsequently published a manuscript.
In retrospect, I would not change much about how I embarked on committing to a research project. Not only did being the point-person provide the opportunity to learn about a particular disease entity, recognize what skills are required to achieve success in research, and expand my network, it helped form the foundation for the “narrative” I told during my fellowship interviews (more on that later). I found joy in this process and felt energized by writing. Subsequently, I worked to answer more questions and took on projects offered to me by mentors who knew I relished this type of work. Hard work and luck beget more hard work and luck!
What Matters to Fellowship Programs?
Knowing what matters to programs is crucial for trainees as they begin preparing a fellowship application. As determined by a 2007 survey of 562 internal medicine subspecialty fellowship program directors, the ten most important selection criteria were (in order of most to least important):
- Fellowship interview
- Letters of recommendation from known specialists
- Letter of recommendation from a trainee’s internal medicine residency program director
- Training at a university-based residency
- Interest in research
- Not requiring an H-1B visa
- Elective completion at the fellowship program’s institution
- USMLE scores
- Graduating from a U.S. medical school
In a subset analysis of cardiology and gastroenterology fellowship program directors, training at a university-based residency, interest in research, publications, and research experience mattered more (relative to fellowship program directors of all internal medicine subspecialties, as a whole). Compared to community-based fellowship program directors, university-based fellowship program directors placed more value on training in a university-based residency program, graduating from a U.S. medical school, and applicants not requiring H-1B visas.
While these data are 15 years old, a few themes are apparent. Perhaps the most striking is the importance of personal interactions and relationships. Interactions with an interviewer and an applicant’s relationships with their professional network (e.g., mentors and advocates who write their letters of recommendation) mattered more than research interest, publications, and USMLE scores. While this generalization certainly does not ring true for every fellowship program, personal interactions and relationships have an immeasurable impact on how an applicant fares in Fellowship Match.
What Matters to You?
Being honest with oneself about personal and professional motivations for training at a program is more important than knowing what programs want from applicants. For some, location trumps all. For others, matching at a program that provides a certain type of training is vital. Fortuitously, in my case, those values intersected at multiple programs, which made the process of choosing programs to apply to relatively straightforward. However, the weight I put on these sometimes-competing interests shifted throughout the interview season. For example, my significant other and I thought some programs that were not in geographic proximity to our families offered an attractive training environment. I say this to emphasize that if a trainee’s circumstances (and financial situation) afford some flexibility that allows them to train somewhere they don’t have ties to, it is worth considering applying to a geographically diverse range of programs. I found many “diamonds in the rough” during the interview season.
Programs are heterogeneous in the types of training they provide. If a trainee is self-motivated to learn, all programs train their fellows to become excellent hematologists and oncologists. Some programs are better suited to producing expert clinicians who can provide a broad range of hematologic and oncologic treatments to patients in the community. In contrast, others focus on equipping fellows with skills to become laboratory-based physician-scientists, clinical investigators, or clinical educators. Within the latter group of programs, a few will prefer to train fellows who intend on becoming board-eligible in only hematology or oncology. Most of this information is available on the program’s website, although the information on some programs’ websites may be out of date. Surprisingly, I did not find a comprehensive resource to inform applicants which programs were motivated to train fellows who intended to practice as expert clinicians in the community versus those keen on training academicians. Broadly, fellowship programs affiliated with a university medical center aim to train fellows to become academic hematologists and oncologists. I relied on my professional network to help provide information on programs I was interested in but didn’t know much about.
Relationships with individuals who are not mentors or advocates play a massive role in the Match. As an intern, I bounced research questions off senior residents and fellows and asked them which faculty had a record of successfully mentoring and advocating for trainees. Occasionally, this led to collaboration on research projects whose findings were presented at national meetings and published in manuscripts. Outside my institution, I engaged with residents and fellows on social media, namely Twitter. Twitter was a thermostat I checked to gauge the various level of research activity in multiple topics relevant to my area of interest within oncology. I found and followed oncologists and institutions involved in said area. Additionally, Twitter is one mechanism to learn about opportunities within oncology for trainees (e.g., to apply for a travel award or position on a committee), create or consume content related to research or clinical medicine, and increase engagement with a trainee’s presentations and manuscripts. When done appropriately, announcing a new publication can let others understand a trainee’s skill sets, such as making unique figures or expertise in data analysis. It can also highlight a trainee’s areas of scholarly interest. Posting on Twitter can get a trainee’s findings in front of people who otherwise may not have come across them, which could lead to feedback, wider impact, and future collaboration. Lastly, multiple independent Twitter accounts (e.g., @HemOncFellows) and fellowship program-run accounts exist to amplify the scholarly work of trainees and provide a forum for current and future fellowship applicants to interact with hematology and oncology fellows kind enough to impart their insight into topics related to research and the Fellowship Match.
For those not inclined to spend time on social media, in-person networking is slowly settling into a new level of normalcy as pandemic restrictions have eased. At the annual ASCO and ASH meetings, as well as other local and national hematology and oncology meetings, specific sessions, and often entire tracks and physical spaces, are devoted to helping trainees socialize and create relationships with potential advocates and mentors in a natural, comfortable environment. For example, I attended the 2022 ASCO Annual Meeting in Chicago and joined several trainee-specific networking events that allowed me to make new friends and mentors and strengthen relationships with people I’d already known. I also learned about trainee-specific opportunities, particularly those not heavily advertised online.
Logistics and Timeline
In 2022, the ERAS fellowship application opened in late June. Programs could start reviewing submitted fellowship applications by late July. Interview invitations were extended to fellowship applicants from the end of July to the end of September, although most were extended in August and early September. Most interviews offered by fellowship programs took place during the last two weeks of September and the first three weeks of October. Occasionally, interviews were offered outside this window. Therefore, if a residency program permits trainees to request rotations for certain times of the year, it is worth asking to be scheduled for rotations with fewer clinical obligations during this period. I requested to be scheduled for as many clinic and elective rotations (rather than rotations on the wards or in the intensive care unit) during these months and was granted this request. It made my life a lot easier, as I did not have to stress about finding coverage for shifts when I scheduled interviews.
I, and most other applicants I spoke to, started asking mentors and advocates for letters of recommendation (LOR) in late March and early April. This is when trainee-mentor and trainee-advocate relationships have ripened but is early enough to allow ample time (approximately three months) for mentors and advocates to write their LOR before the ERAS fellowship application opens. I asked my letter writers for a 15- or 30-minute in-person meeting. In the meeting, I stated how grateful I was to learn from them, referenced a clinical scenario or patient we encountered that was meaningful to me, and explained my rationale for wanting to be an oncologist. Immediately after the meeting, I emailed them to express gratitude for their willingness to support my fellowship application and attached an updated copy of my CV and a rough draft of my personal statement. I also noted the deadline for when I hoped to have their LOR uploaded to ERAS. Having my CV and a rough draft of my personal statement ready before asking my letter writers for a LOR required a bit of extra work, but I felt it would be an example of my ability to be proactive.
Something I did not know about ERAS until I started working on my application was that ERAS certifies all uploaded documents, including LORs, which can take up to ten days. Therefore, uploading documents as soon as possible after ERAS opens is essential so the application is complete before fellowship programs can start to review them.
As I did for the residency application process, I created a new email address for my fellowship application that was separate from my personal and professional email addresses. I wanted instant notifications when I received a new email so I could schedule interviews immediately. As soon as I scheduled an interview, I created an event in my mobile calendar. As I received more invitations to interview, I quickly referenced this calendar to ensure I did not double-book interview dates. I scheduled interviews for fellowship programs that were not my top choices earlier in the interview season to gain experience before interviewing at the programs I thought would be my top choices. It is impossible to be completely prepared for every glitch or hiccup that will undoubtedly occur. However, having a sense of confidence in my interview skills made me more relaxed in the interviews I thought were most important.
The NRMP Match Code of Conduct lays out rules for applicants and fellowship programs regarding communication during the Fellowship Match interview season. For applicants, the core principles of their Code are maintaining ethical behavior during recruitment, fully disclosing information to pertinent programs, respecting a program’s right to privacy and confidentiality, limiting post-interview communication, and ranking and matching with integrity.
When I did not receive an invitation to interview from a fellowship program I was interested in by the time other applicants did, or by the time my significant other received an invitation to interview with a fellowship program at an institution where we both were interested in training, I reached out directly to the fellowship director and program coordinator to express my interest. In some cases, it resulted in an interview invitation.
Telling Your Story
The most powerful thing a fellowship applicant can do is become a master storyteller. Applicants are routinely asked open-ended questions in fellowship interviews questions like “Tell me about yourself?”, “Why do you want to train here?”, and “What do you want to do in your career?”. Telling an interviewer a memorable story about what led an applicant to pursue oncology, cohesively tying in how their clinical and scholarly experience has contributed towards that realization, and articulating how, as a fellow, they will utilize a program’s resources and contribute to the program’s mission is a powerful tool that applicants can use to demonstrate how training at that program is the next logical and obvious step in their career.
Developing this narrative requires introspection, foresight, and practice. The first dozen times I tried to speak on this topic out loud were utter disasters. However, after practicing with and receiving feedback from my significant other and refining it with the assistance of one of my mentors, I felt I had a compelling, convincing story to tell. Because it was true, I spoke about it passionately and was excited to tell it.
Based on this advice, it may seem like applicants who did not follow a straight path toward hematology and oncology fellowship cannot employ this strategy. I would argue that those applicants are the exact people who should! Bumps along the road only add character to their story and should be taken advantage of to exhibit the lessons they learned and the insight they gained.
Questions to Ask
While I listed a few common interview questions above, the most common question interviewers ask is, “What questions do you have for me?”. This is a key chance to learn about a program, and an institution, from that interviewer’s perspective. I was surprised at the honesty many interviewers displayed and discovered career possibilities I didn’t know existed. Further, asking interviewers about themselves is disarming. Getting an interviewer to open up opens the door for an applicant to connect with the interviewer personally, potentially making the applicant more relatable and the interview more memorable.
Another question that I found yielded valuable answers was, “What are the characteristics of fellows who have succeeded in your program?”. Answers varied dramatically but, sometimes, were relatively similar among interviewers within a fellowship program. At one program, I remember nearly all interviewers noting that fellows who chose a tumor type to specialize in and a path to study that tumor type (e.g., physician-scientist or clinical investigator) early in the first year of fellowship were more successful there. However, interviewers at many fellowship programs (including the one I matched at) gave heterogeneous answers, which, to me, showed that many phenotypes of fellows could succeed there.
If fellows were available for questions, I found it helpful to ask about housing, moonlighting opportunities, the accessibility of mentors, and more concrete topics that I knew would significantly impact my daily life. I also asked for contact information, either during the interview (from the interviewer themselves) or after (from the program coordinator) for every interviewer I interacted with and tried to send a brief follow-up email thanking them for their time and tying in a part of our conversation to jog their memory about our interaction. I do not know if it made a difference, but it scratched an itch I felt after the interview day finished.
I acknowledge that I most likely benefitted from my background as a white male whose first language is English, was born in the U.S., attended an allopathic medical school in the U.S., trained as a resident at a university medical center, and do not currently have responsibilities such as raising children or taking care of sick family members. I also have a significant other, who I participated in the Couples Match with, who is supportive, generous, and inspiring. She imparted honest and accurate assessments of situations I was not sure how to interpret and made the Match easier to process and navigate. For all those reasons, the insight into the Match I provided should be taken with a grain of salt.
A culmination of hard work, a fraction of which was my own, and luck allowed me to match at my top choice—an accomplishment that took a village. Writing about my experience as an applicant is my attempt, in a small way, to pay forward some of the help I received from my personal and professional support network, mentors, and advocates that will hopefully give future applicants insight into the Fellowship Match.
Dr. LaPelusa is an internal medicine resident physician at Vanderbilt University Medical Center and incoming hematology and oncology fellow at MD Anderson Cancer Center. Connect with him on Twitter @MichaelLaPelusa. Disclosure.