Turn a Fellowship Into a Career: How to match up with the right program

The opportunity to gain more surgical experience as a facial plastics fellow was enticing to Hussein Samji, MD, MPH, as he finished his residency at Stanford University School of Medicine in Palo Alto, Calif., in 2010. But after exposure to some of the more mundane aspects of the subspecialty during screening interviews, Dr. Samji said he knew it wasn’t the career path for him.

“When I met people who would be my mentors, I thought, ‘I don’t think I could be you for the next 30 years.’ When it came time to talk about the matching and going forward in the process, I actually dropped out and said, ‘I can’t do this.’”

Luckily, one of the dozen or so programs Dr. Samji applied to was a laryngology fellowship, and when it came time to decide whether that was the best option for him, he spent a lot of time talking with his residency directors to determine if he was making the right choice.

“They said, ‘Let’s not talk about the cool stuff. What’s the stuff you hate to do?’ I had to ask myself, ‘If I saw nothing but patients with vertigo or sinus issues or hoarseness, would I be happy?’”

Fortunately, the answer was ‘yes,’ and Dr. Samji went on to complete a laryngology fellowship at Stanford last June before joining Camino Ear, Nose and Throat Clinic in San Jose, Calif. But the danger of choosing the wrong program is prevalent among residents, he said. “It’s easy to get seduced by a powerful mentor who just shows you the ‘sexy’ stuff. If you’re not willing to deal with the other aspects, you’re going to hate your job.”

Determine Career Goals First

It’s that potential danger that makes discussing career goals with appropriate faculty members at your residency institution the first and most important step in the fellowship process, said Edward J. Damrose, MD, FACS, director of the laryngology/bronchoesophagology clinical instructorship at the Stanford School of Medicine. “People interested in head and neck oncology may want to focus on academic or tertiary care institutions for fellowship training, where the case load is likely to be high. Residents interested in facial plastic surgery may have more flexibility, where location, the specialty of the mentor and the type of practice may have greater weight.”

Depending on which path you choose, three criteria are generally important in determining where to pursue a fellowship, said Devyani Lal, MD, assistant professor of otolaryngology at the Mayo Clinic in Arizona. The first consideration is the faculty, particularly the fellowship director. Is he or she an expert in the field in which you wish to subspecialize? How well do you think you could personally get along? What is the director’s past mentorship track, and how well does he or she continue to support former fellows?

The second consideration involves surgical and clinical training opportunities. What kinds of cases are seen, and what cutting-edge surgeries are being performed? Is this a regional or national referral center? What is the patient volume?

The third consideration is the institution’s available resources. What are the academic credentials and opportunities for research collaborations? Is the institution well-endowed; does it have state-of-the-art equipment? “Ask where do you see yourself in five years; where do you want to be in 20?” Dr. Lal said.

Informal interviews with people in the field are another way to help answer those questions, Dr. Lal added. “Go to meetings to see who is giving presentations and what they are talking about, talk to other fellows and recent graduates, go over journal articles and see who is publishing what. There isn’t one single resource that’s best, but if you only go online, you’re doing yourself a disservice.”

The Numbers Game

There’s no single number of fellowships residents should apply to, mostly because competition for available spots varies greatly among specialties. In rhinology, for instance, the 30 or so spots available are usually comparable to the number of applicants, while in head and neck oncology and laryngology, there are generally more spots available than potential fellows. Competition for facial plastics fellowships, on the other hand, is much steeper.

“All of us have perhaps three top choices in the fellowship matching system, but if you are going for a very competitive fellowship, you need to apply widely,” Dr. Lal said. Residents should also look at their own credentials when determining how many programs to go for. “Look at the strength of your own application,” she added. “If you are a very strong candidate, you will probably be fortunate enough to choose where you want to go. If your experience is comparable to other people going through the process, then you need to apply more broadly.”

If you find that you didn’t match with any of your desired programs, it’s important to meet with an advisor and determine why you weren’t selected, Dr. Damrose said. Reasons could include limiting yourself geographically or applying to too few programs. You could also have made yourself a less competitive candidate through poor interviewing skills, lackluster letters of support or a CV too light on publications.

Residents should also talk to their advisors to determine whether fellowship training makes economic sense. “In most cases it does,” Dr. Damrose said. “But some applicants may feel economic pressures to start practice immediately, especially residents with student loans or with young families.” It can be a tough question to answer, Dr. Damrose added, but taking advantage of an opportunity early in one’s training may be easier than trying to do so after becoming established.

Gregory Farwell, MD, FACS, associate professor in the department of otolaryngology-head and neck surgery at the University of California, Davis, said residents should carefully choose the fellowships they apply to. “With every match there is some uncertainty as to whether you will get your top choice,” he said. “I would recommend residents only rank programs they would be comfortable training in.”

While the search process may be hectic, the fellowship experience makes it all worthwhile, Dr. Lal said. “It’s about getting a degree of expertise which allows you to practice in a more in-depth fashion, offer novel treatments and gain advanced technical skills to perform cutting-edge surgery. A fellowship positions you with the unique skill set to be academically successful and is satisfying because you know you are providing an enhanced degree of expertise to patients from the get-go.”