Fellows

This is the most basic question to be answered, and probably the most difficult. As long as you realize that there is no right answer to this question, even for a single person at different times, you are on the right track. Like all things in life, doing a fellowship brings about some advantages, at a variable price. While the perks can best serve one, the price may be too high for another. The choice remains, ultimately, a personal one.

There are a few hard rules, however, that will serve to trim the decision tree thinner. First and foremost, subspecialty training is now the prerequisite for entering academia. The next rule applies to the intervention enthusiasts.

While a general radiologist can be familiarized with most diagnostic modalities through widely available, year-round seminars and workshops (cardiac CT and CT colonography are popular examples), the nature of intervention with a living and breathing patient as its substrate is prohibitive of such liberty for the inexperienced apprentice. So if you are born to intervene, there is no escape from subspecialty training. For those who remain ambivalent towards academic or non-academic practice until the PGY4 year, fellowship training will bring more time, and leave their options open until the right decision can be made.

It is worth mentioning that there is a strong recent trend towards subspecialization. A quick overview of pros and cons of subspecialization is offered below:

1. Competitiveness versus flexibility: A fellowship trained radiologist will be more competitive in a shrinking market that is putting increasing emphasis on quality patient care. On the other hand it is becoming increasingly difficult to find “sure” subspecialty jobs in private practice:
2. Obligations of the profession: A few subspecialties strongly dictate their type of future practice. Some are more in demand in academic centre, while some others are more popular in non-academic settings.
3. Depth versus breadth: The former belongs to subspecialty training, and the latter to the general radiologist. If you enjoy being the jack of all trades, then subspecialisation may not be for you. But if you take pride in being the master of one, rather than none, subspecialisation shall remain the path to follow.

Finally, bear in mind the one can always change directions, from generalist to subspecialist, or from one subspecialty to another. The choice of joining a fellowship program is not an eternal condemnation, but a step along a career path that may change bearings many times. Eminent radiologists who are living examples of this plasticity are not few. It is only when the residency or fellowship ends, that the ultimate quest for life-long learning begins.

The challenge lying ahead of the resident who is now determined to become a subspecialist remains daunting. How can an early PGY4 resident, only half way through the core training, choose the “right” subspecialty? With so many to choose from, and with some clinical rotations still to come, how can one make an informed decision? A major part of doing things right, is not doing them wrong. Find below a few strategies to avoid for choosing a fellowship:

1. Forget the market: financial comfort is a side benefit everyone enjoys while pursuing the higher calling of their profession. But even for those with major monetary momentum, choosing a fellowship based on current market demands is a far too common mistake. A radiologist is ultimately a small part of the “radiology industry”, which assumes 5-7% of a 3 trillion dollar global healthcare business, with an unpredictable course and trajectory. In addition, the profession is heavily dependent on the rapidly changing landscape of high-tech industrial innovations, as well as exploding biomedical advances. What appears fashionable and in demand today, may not be so even in three years’ time when your fellowship comes to a close.
2. Behold the conditional job offer: In a similar tone, caution should be exercised when choosing a fellowship based on an early, mid residency job offer, usually from the home institution. This is particularly perilous if the promise comes with anything less than an attractive fellowship. Take into consideration that such offers are usually based on immediate or near-future needs of the practice, which may dramatically change by the time your fellowship contract is signed. Nobody wants to start the PGY5 year with an unwanted fellowship contract in hand. Therefore, unless backed up by a strong contract, conditional to a favorite fellowship as the icing on the cake, these offers should only serve the purpose of reminding you of your merits as a resident. If you are a desirable candidate at the beginning of your residency, rest assured that your value will certainly increase by continuing to work hard and further subspecialization in your favorite field.
3. Consider the career obligations/advantages of the fellowship: Keep in mind what is important to you and consider the importance of these elements in your decision-making process.
4. Beware of the lifestyle: the distinction here is between interventional and diagnostic radiology. The diagnosticians usually are less prone to midnight wake-up calls; even when summoned, they can still complete the task at hand in their pajamas from the comfort of their home office, or bedside laptop. This is in sharp contrast to the necessity for on-site presence of the interventionalist.
5. Fellowship certification / recognition: Not all subspecialties are officially recognized by the Royal College of physicians and Surgeons of Canada (RCSPC) or its American counterpart, Accreditation Council for Graduate Medical Education (ACGME). The choices are accordingly limited if recognized certification is an important determinant for the resident.
6. By applying these principles, the menu shortens to a more manageable number of choices. However, the single and final inclusion principle is yet to be revealed: passion. Do what you love, and refuse to do otherwise. Nothing is worse than waking up every morning to a job that does not appeal to you, especially after all these years of hardship and sleeplessness. It feels almost effortless to excel in what you are passionate about, and the power of excellence will open many doors. If you see endless joy and reward in being the lead-armored adrenaline-avid ambidextrous catheter wizard, making patients whole through a hole, then you are born to be an interventionalist. Let what you do be not the means, but the end in and by itself. Your fellowship year will then be a pleasant prelude to a rewarding career for years to come.

If you choose to do a fellowship in Canada, the choices for different locations are not many. If one looks south of the border for subspecialty training, the options will rapidly expand. Depending on the fellowship, choices vary from a few to a hundred locations. Some newer fellowships such as interventional oncology are quite limited in number.

Geographical considerations are the biggest limiting factor for choosing where to apply. It is difficult to spend the fellowship year away from one’s spouse, who sometimes has to stay behind due to professional obligations. Single applicants enjoy more mobility accordingly. Living standards may be prohibitive for a family-bound resident to join a fellowship in an undesirable area. In addition, fellows have a higher chance to be absorbed by the local practices, and a desirable location facilitates such integration when the opportunity arises. On the same note, the weather can be a factor. A word of caution, however, is in order: It is ill-advised to compromise the quality of training for favorable geographical parameters alone. Choosing that seductive, easily available, not so academically recognized fellowship at seaside may seem an attractive choice initially, but will certainly not springboard your career too far down the road. The expression “you are as good as the last place you trained at” may be surprisingly true in today’s competitive job market. Ultimately, such compromise in quality may fail to land you the dream job that you later seek in these prime locations. Consider the fellowship year as one last investment in a secure professional future, well worthy of some degree of personal compromise and hardship. Outstanding fellowships in vacation spots are not many and remain extremely competitive; if you desire the best of both worlds, you have a greater challenge ahead than just choosing a fellowship.

Another decision is whether or not to apply for a fellowship in the home institution. Unless limited by geographical factors and family obligations, residents are usually advised to “leave the nest” for their fellowships. In most cases, after four years of training at an institution, graduating residents become as familiar as the fellows with the local practice and spectrum of pathology.
Interventional radiology (IR) fellowships can be a notable exception to this generalization; IR fellows enjoy far greater hands-on involvement than residents, and a resident’s interventional skills usually lag far behind those of a mid-year fellow. So if an institution holds a competitive IR fellowship, interested residents may as well benefit from their home-court advantage in securing this attractive position.

This is a complicated and unfamiliar issue for many residents who seek a US based fellowship. It is vital that these residents are well aware of related licensing and immigration limitations and requirements, which is far beyond the scope of this article. As a general rule, Canadian residents require either a work visa (H-1B) or an exchange visitor program visa (J-1) to be able to practice medicine in the USA. The H-1B allows you to practice medicine once the state licensure requirements are fulfilled. Therefore, this is an attractive option for those who desire (or have the option) to stay in the US after their studies. However, due to administrative considerations, some institutions do not offer an H-1B option. A valid state license is a prerequisite for an H-1B visa; the former needs passing the USMLE Step3 examination, which has both Step1 (basic sciences) and Step2 (Clinical Knowledge and Clinical Skills) exams as its own requirement. Therefore, exam planning for this path needs to begin a long time before the fellowship application season.

The J-1 visa requires the resident to return to the country of residence for at least 2 years after the completion of training. It prohibits the fellows from working and getting paid outside the boundaries of their fellowship, but does not require completing the USMLE exams, which is a serious practical advantage to many. Under limited and very specific conditions, the “return to country of origin” requirement can be waived; residents are advised to visit the U.S. Citizenship and Immigration Services website (http://www.uscis.gov) or seek legal counsel for further information.

Once you choose the subspecialty and the location(s), finalize the list of your desirable fellowships by talking to your program director or mentor, seeking advice from your peers and seniors, and exhausting the online posts and reviews in discussion forums. A reasonable list would not include more than a dozen of potential fellowships. Know your merits as a candidate.

The application process is usually straight forward, but not instantaneous. Preparing medical school and undergrad documents can take a long time. The most variable part is the personal statement which can make or break a candidate, so devote due diligence and time to it. The other time consuming and unpredictable step involves the recommendation letters. Unless you are willing to settle for a generic letter, which will not take you far no matter the author, you need to give your support staff room to write. The most effective letters come from your highest profile staff, and these academicians are already on a tight schedule.

Respect your supporters by giving them ample time and information. Take time in discussing your goals with them, and provide them with an up-to-date CV. Take into account that they may be away on lecturing circuits or on vacation. The letter from the program director, a mandatory part of application, also takes time.

Try to complete your documentation well before the application season begins, usually the September of PGY4. There are advantages in applying early. You will have ample time to submit additional required documents. Some integral parts of the applications, such as ABR exam results, are announced in late September, and updating your submitted application provides an opportunity to follow-up on your status, and to express ongoing interest. Some programs have a roll-in acceptance policy: they offer their positions as desirable candidates are interviewed, so earlier applications give the more qualified candidates a better chance at securing these competitive slots.

Not unexpectedly, there are also downsides to applying on September first! Some programs do not review applications until a much later date, as late as mid-November: A more difficult situation arises when an early interview is followed by an early offer. Offers often come with a finite grace-period, by the end of which the program expects a decline or a commitment. If the early offer comes from a program that does not rank too high, the candidate will face a difficult situation: the temptation of accepting the offer, playing it safe and “getting it over with”, versus the decision to take a chance and wait for the “first choice” interview to come by.

Under these circumstances, it is fair game to contact the fellowship director of your top-ranked program and discuss your peculiar situation: that despite a decent offer at hand you would like to be interviewed and accepted at their institution. This is a delicate situation and requires a respectful and tactful approach in order to convey interest without being perceived as intrusive; it is, nevertheless, daring and unusual to “ask” for an interview. It is of utmost importance, however, that any commitment is honored by the candidate even if a much better opportunity presents itself later. Do not forget that academia is a small world, and a breach of trust can damage a candidate’s reputation, reflect unfavorably on his home institution and sponsors, and even jeopardize future career opportunities.

It is vital to follow-up on your application: it is prudent to call the application coordinator about a week after submitting your documents, electronically or in paper, to make sure that your package is complete. Electronic applications may end-up in junk mail or get accidentally erased. This is especially important if you receive an automated “vacation reply”. Some attachments may not open and require repeat transmission. Paper applications are slightly more secure, but are no longer the norm. However, there are still programs that require recommendation letters to be mailed in sealed envelopes. In summary, do not assume your application package is complete, until you verify it with the fellowship coordinator at least once.

As already mentioned, an early interview and the offer they bring can be troubling to certain candidates. Try to courteously delay the early interviews in order to cluster a few together; this is generally more time efficient. Especially, make sure your top programs are aware of your early interview plans, and you preferences. You may be surprised to see how accommodating and supportive program directors are.

There is a fundamental difference between the fellowship interview and any other interviews you have so far been invited to. To make sure that your subspecialty training year is well worth the investment, you have to implement a strategy different than “blind acceptance”: you need to “interview back”!

Once you get the interview invitation, start your research: Ask the program about the administrative details of the fellowship such as: salary, vacation time, insurance (professional liability, medical and dental), dedicated academic time, conference time, travel and book stipend and visa and licensure requirements for US fellowships. Find out how many fellows will be accepted. Look into housing and living conditions around the hospital and in the city, and make sure they conform to your standard of living, especially if you are planning to take your family with you to a new city. Talk to your seniors and staff about potential contacts in the programs. If you know a resident or a staff in the program, even if they are not involved with the fellowship program, obtain some general information about the institution and local practice. Check the program’s website for contact information of current or previous fellows.

Next, prepare a comprehensive list of as many variables as you can think of. Put special emphasis on factors that matter the most to you. These differ from program to program, and from person to person. The same fellowship may suit the needs of one applicant perfectly, and yet be completely in discord with the interests of another.  A few generalities should nevertheless apply to most programs:

1. Fellowship-specific information: Most fellowships are broken down to multiple blocks. While it is hard to find the perfect fellowship that fits your needs, your goal should be to maximize the blocks of your interest. If your rotation of interest is not offered by the programs, arrangements may be negotiated for off-site electives. If you are highly interested in academics, ask about teachings on research methodology, manuscript preparation and grant writing. Inquire about the frequency and breadth of multidisciplinary rounds. This information is usually supplied by your interviewing staff, and is best discussed in more detail with the program director directly.
2. Fellow-specific information: there are questions that are best reserved for current or past fellows. By the time of your interview, current fellows have spent enough time to know almost all practical aspects of the training. Try to get face time with at least one or two current fellows to expand on these matters. Start with their subjective assessment of the program and the “feel good” factor, as well as pros and cons. This is an appropriate open-ended question that usually provides ample information, especially regarding the negative aspects of the program. Later, try to fill in the gaps by asking about work hours, day case load, case variety, call frequency and call case load. If there are eminent radiologists in the program, ask whether they are available to fellows or otherwise too involved with administrative duties or on lecture circuits. Ask where they did their residency training, what other programs they considered and interviewed at, and why they chose this specific program over the others.
   Ask specifically whether the positions are usually or predominantly filled internally, again to better estimate you chances. In non-accredited programs, it is vital to inquire about the amount of time that fellows spend in their dedicated section, versus the time they are required to “help out” in other sections due to staffing shortage. While the occasional “helping-out” is a professional courtesy if not an ethical duty, it should not be too frequent to be perceived as detrimental to the core fellowship training. Finally, exchange contact information with the fellows for future questions, advice or simply professional networking.
3. Job-specific information: Try to find out, mainly from the program director, what awaits you at the end of your training based on previous fellows’ career choices. Inquire about career counseling or recruitment channels within the program. Ask about the “retention” factor, the number of fellows who are incorporated to the practice after their training. A high retention factor is usually a good sign, as people will not choose to stay in an undesirable environment. A low retention factor, however, may not necessarily be a red flag as there may be no staffing shortage or needs in the section. Also ask the fellows what their career plans are, whether they have already secured a position, and how the program has influenced their choices and chances.

Finally, make sure you are ready to write down all the information you get. I suggest taking a printed list of your questions and interests to each program, as the amount of information can easily become overwhelming after the first few interviews.

Overall, the fellowship interviews are less formal and stressful than residency interviews. Demands for fellows are still high, and cut-throat competition only applies to a few high-profile programs. Be prepared, relaxed, passionate and most importantly honest. Be prepared for an offer and to courteously buy some time to adequately evaluate your options. Consult your support circle one last time before accepting or rejecting an offer, and respect any deadlines or verbal agreements with the program.

While the application documentation preparation may take a week or two, the building blocks of a strong applicant are laid down much earlier in the residency training. It is a great achievement to join a radiology residency, but this should not lull you into a false sense of security. The key is professionalism, in all aspects and forms. Publications and presentations and academic achievements add considerable weight to one’s CV. Still, it is the non-measurable determinant of professionalism that will bring about that stellar letter of recommendation, and that critical phone call that will secure the future against all odds.

Work hard. Be diligent, punctual, disciplined and dedicated to patient care and departmental mission. Contribute to the well-being and progress of the program. Great knowledge and technical skills are dwarfed by lack of reliability, which may be the single most important attribute of a great radiology resident. Demonstrate initiative and motivation, and go the extra mile rather than stopping at what is expected of you. Involve yourself in teaching, research or administrative endeavors. Choose a mentor early in your training, and seek the company and good habits of the senior residents. If you manage to stand out and become an asset to your program, you will definitely be a sought-after asset to any subspecialty program you choose to train in.

Do not underestimate the power of good grades. There is safety in numbers, and when the competition gets tight, stellar scores on standard examinations maybe the only discriminating factor between two strong applicants. Having passing scores may not do harm, but a trend of outstanding exam performance is definitely a discriminator, especially to a program director who meets you first on paper. Similarly, do not assume that you will be staying in Canada since your subspecialty may require you to travel across the border. Incorporate your USMLE exams somewhere between the LMCC step 2 and ABR physics and written exams; you will never know what the future brings.

Then comes the unpredictable: the outcome. The final product of an application depends of many factors, in addition to the applicant’s strength. Internal applicants can completely fill fellowship spots and leave none to the outsiders. The program director may change, and you may lose some of the leverage afforded by your letter writers. Do not let the outcome of your fellowship application put a dent in your image as a deserving resident. As long as you have worked hard and planned ahead, you will certainly be able to secure a prestigious position.

Just like your final board examinations, the fellowship application process takes more than a few months to prepare for. Recognize the challenge early in your training, and plan ahead. Prepare by persevering in professionalism, every day and in every task. Make the extra effort to stand out, imitate the great. And while you are busy being an excellent radiology resident, you will effortlessly stumble upon the great fellowship you have come to deserve.