Postgraduate Medical Education

After completing four years of medical school and several years of residency, many physicians consider seeking a fellowship for training in a subspecialty. While still in medical school, additional training beyond the residency is considered remote but this attitude is reversed in the course of time. By gaining an awareness of the advantages of subspecialization, trends in various medical disciplines, and the challenge involved in securing a suitable fellowship, one can more easily decide if this is an appropriate course to follow.

Motivating factors influencing residents to pursue fellowship training vary. For some, the issue is to enhance the marketability of their own specialty. Others are concerned with the issue of variety of work experience, while some seek the special challenge that certain subspecialties present, such as critical care, neonatology, etc.

Financial remuneration is also significant when considering subspecialization. While primary care physicians are now in increasing demand, specialty practices are financially more rewarding, as specialists perform more billable procedures. In addition, their patients are more likely to have medical insurance.

Subspecialization is also attractive to some because of its implied higher status within the medical community. Being interested in a limited area makes it easier to keep abreast of new information and technological advances in a particular field. A subspecialist also usually has a more routine work schedule. Thus, all the aforementioned features have resulted in the increased attractiveness of subspecialization in recent years. While the number of medical school graduates choosing an internal medicine residency has declined somewhat, the number of those electing to subspecialize in this field has remained high. Some subspecialties are attracting more candidates than others. There has been some decline in interest in hematology, rheumatology, endocrinology, geriatrics, and infectious diseases. On the other hand, the fastest growing subspecialty within internal medicine is critical care, due to the fact that it is an action-oriented area. The demand for this type of subspecialty will continue to grow as more hospitals offer high tech procedures such as open heart surgery and organ transplants.

Another very popular field is pediatric emergency medicine, with a substantial increase in the number of fellowships available. Orthopedic surgery is still another area where subspecialization is very common. Areas of special interest include orthopedic oncology, knee reconstruction, and hand and spine surgery. Subspecialization is also increasingly common among radiology residents.

During medical school and residency, the individual has to focus on the clinical side of medicine. After the residency, research becomes important. This includes developing a suitable project, collecting data, and analyzing and reporting the results. Potential fellows should determine in advance where research funding will come from or if they must secure it on their own. Candidates should determine the extent of interest of the fellowship program in generating publications, especially if the program is academically oriented. This can be ascertained by inquiring about the program's publication record and if it supports fellows in presenting abstracts of their research at academic meetings. Fellowship candidates should try to determine the strength of the director's commitment to the program, so as to judge the extent of support they can anticipate.

It is useful to determine in advance the role of the fellow in the program to find out if the staff position, while an important one, does not place an excessive burden on the individual. Knowing the number of attendings and residents available to assist can help determine if the fellowship will merely serve to fill a resident gap, or if it will be a genuine advanced training position. Obtaining a current copy of the conference and call schedule can provide a good insight into the nature of the position. The number of fellows in a program is also important, because the environment is more stimulating when a group that is on a similar educational level is working together.

Accreditation of fellowship programs varies. It usually takes place after being established at a large hospital that has an adequate number of fellowships. When a program is not accredited, it is important that the program director have a strong enough reputation to compensate for this liability. This is especially relevant in less traditional subspecialties, such as fertility.

Currently, there is increasing pressure to standardize subspecialty educational programs and create a matching process in this area, as for residencies. This effort is geared to enhance the overall quality control of fellowship offerings. It already exists in some of the internal medicine subspecialties and is now impacting on other areas, such as radiology and pediatrics. Gradually, the number of free-standing programs will be reduced as accreditation of fellowship programs increases.

Obtaining a Fellowship

To obtain an attractive fellowship requires careful strategic planning. Standards for fellowship applicants vary. Program directors are quite selective and competition for an appointment is keen. Completing a residency at an institution where the fellowship is offered can usually give the applicant an edge. The disadvantage in continuing at the same institution is that the fellow receives rather narrow training, since the fellow is in contact with the same attending as in the residency, and the opportunity to expand contacts is limited. If one anticipates ultimately seeking a fellowship, the residency training should at least be at an institution that has a good track record of its residents securing fellowships. Thus, the site of one's residency training is one major critical factor in the process of finding suitable subspecialty training.

A second strategic consideration is selecting appropriate faculty to provide letters of recommendation. The goal is to receive these from the people you worked with and who are prepared to write as strongly as possible in your behalf. The impact of a favorable letter is significantly influenced by the stature of the author of the letter. Obviously, a department chair's letter has greater credibility than one from a junior faculty member. Similarly, a positive impact can be made by a letter from a prominent person in the specialty or a known acquaintance of the fellowship program director. Completing an elective in the prospective area of subspecialization can facilitate obtaining helpful letters of recommendation.

Of special importance is the interview and interpersonal and communication skills that the candidate demonstrates. Showing that you are open-minded, flexible, and enthusiastic, and that you are amenable to open discussion of issues will enhance your chances to secure a fellowship.