How to Choose a Radiology Fellowship

As you read this, about 855 physicians starting their third year of radiology residency are preparing their fellowship applications for a 2017 start date. Or perhaps their applications are already submitted. A radiology fellowship is rarely seen as optional these days, it’s the expected next step taken by radiologists finishing their four-year residency program, with more than 90% of radiologists delaying that first job for one or (more rarely) two years of subspecialty training. “Over the last 10 years the discussion has changed a bit from whether you’ll do a fellowship to which fellowship you’ll do,” said Jonathan Flug, MD, MBA, assistant professor of radiology at the University of Colorado. Yet even with such high participation, the process is far from standardized. Fellowship programs have similar requirements (transcripts, personal statement, recommendations, interviews), the specifics vary as do dates for applications, interviews, and offers.

Add in the confusion of residents applying for fellowships two years before the training starts, they’re forced to choose a subspecialty without having necessarily rotated through it yet. “It’s a relatively early process. It doesn’t give you much time to cement your interests,” said Joshua C. Ewell, DO, a second-year resident at Norwalk Hospital’s Department of Radiology in Connecticut.

Here’s a primer to help residents get through the process.

When to Apply

Neuroradiology and interventional radiology are the only radiology subspecialties to use the match system. While residents sign up for the match in spring of their third year of residency (matches are made in June, at the end of the third year), the individual programs often begin accepting applications closer to the end of second year or beginning of third year.

While each subspecialty (and even each program within that subspecialty) has its own timeline, there are some basic guidelines to keep in mind. Musculoskeletal (MSK) radiology fellowships, for example, usually accept applications starting June of your second year, said Flug. He said that when he was applying for his 2013-14 MSK fellowship, the application dates kept creeping earlier and earlier into the second year. “Informally, people agreed that July 1st, the beginning of the third year would be the gentleman’s agreement. The earliest I saw (for applications) was April of the second year.” He cautions that it can take a few months to get the paperwork together, so residents should start preparing a few months ahead of the application dates.

When to Start Thinking About It

Most people start thinking about options in the second year, said Flug. “It’s pretty early in my opinion. A lot of people feel that pressure of not fully knowing what they want to do yet but having to think about it.”

Current residents, though, may actually be thinking about it much earlier. “It’s something I’ve been thinking about since the beginning (of residency), said Fan Yang, MD, a third year resident at the Department of Radiology at Norwalk Hospital. He’s been compiling a list of programs to apply to, checking program websites and getting his paperwork together to apply for neuroradiology fellowships. “It seems like a rolling process,” he said, adding that neuroradiology programs start accepting applications as early as June, some as late as September.

Second-year resident Ewell said he started thinking about fellowships while still in medical school, and started looking at programs within six months of starting his residency. “I wanted to see what my options were, what I should pay attention to, who I should get to know, where I might get my letters of recommendation,” he said.  He plans to pursue a pediatric or pediatric interventional fellowship, and has been using LinkedIn to send information requests to pediatric fellowship program directors across the country. “I asked them questions about their experience, their program, what they recommended. I cast a wide net to get a lot of people’s opinions.” Ewell plans to limit his search geographically, and wanted to get the most information possible before he begins applying.

As part of this process, Ewell looked into doing a rotation off site. Since Norwalk Hospital is affiliated with the Columbia University’s pediatric program in New York City and Ewell wants to stay in New York for his fellowship, he applied for this off site rotation. “It helps to do an away rotation at an affiliated site, if your residency affords you the opportunity,” he said. He wants to see if that department would be a good match. “It’s an opportunity to see what sort of cases they have and whether they’re the type of cases I like.”

Application Strategies

Most information about fellowship applications comes from the seniors, said Yang, in terms of the process of what to do and when. “The [program] websites are somewhat helpful, but have generic requirements about the paperwork required.”  

While applications may be accepted over several months, Flug recommends turning them in at the beginning of the application period, so they’ll be on the top of the pile. If you apply late, you’ll have lost the opportunity to get in to many of the programs, he said. Send the application in early, even if it’s not complete, Flug said. Letters of recommendation and undergraduate or medical school transcripts can be sent later. “At least they’ll see that you got your part in early,” Flug said. “It helps to not be at the bottom of the pile.”

Networking is helpful too. “Reach out to people at national meetings in your second year,” said Flug. Go to those subspecialty sections or courses and talk to people at programs you’re interested in. “I speak to a lot of residents at those meetings. As a resident you should take advantage of that. I remember those names when the applications come through,” he said.

Residents should keep their CV up to date from the moment they start residency, Flug said. “Compiling the CV can be the first roadblock to getting your application out there. It shouldn’t slow you down,” he said. You can include activities, research, and committees that are planned but not yet completed; it provides something to talk about during the interview process. Flug also recommends having faculty members review your CV and applications.

A lot of people stress about the personal statement, said Flug. “We’re not training you to be a creative writer. Just try not to say anything that’s going to give us any real red flags.” It’s fine if you don’t have a compelling story about why you chose that subspecialty, he said, just don’t make one up. “Write something that will make me want to meet you in person.”

As for personal recommendations, you’ll need one from your program director or associate program director, and you should have one from someone in the planned subspecialty if possible. Then get one from an attending who knows you best. “If they know you well and will write a letter highlighting you and talking about your strengths, that’s better than someone from a different specialty who doesn’t know your strengths.” He recommends asking for those letters two months before you’ll need them, to give the physicians enough time.

One of the questions Flug often gets asked is whether it’s better to do a fellowship in a city where the resident wants to eventually live, or go to a “better named” program elsewhere. While there are good reasons for doing the higher ranked program, if you know you want to be in a certain place, Flug said, you should strongly consider doing your fellowship there. You’ll get a feel for what the local groups want, though it’s helpful to find someone before applying who knows that local market to ask if there’s a feeder program.

It’s also tough to know how many programs to apply to. “My advice is that it’s usually better to apply for more. You don’t have to interview at every program,” Flug said, adding that the only cost for applying is postage.

Applying for more than one subspecialty is difficult, as there’s not a lot of overlap in the interview cycles. “What if you got offers for one, but are waiting for others?” Flug said. That can work to a resident’s advantage, though, if they don’t get interviews in the subspecialty they apply for, said Yang. He’s known residents who successfully switched to a different subspecialty during the normal application cycle to get their fellowship.

That’s harder for those in the match, as they don’t find out their fellowship location until June at the end of their third year, long after most other residents know where they’ll be. “It’s a little inconvenient,” Yang said. “My wife has to look for a job; it would nice to have more time rather than less.”

What Are the Fellowship Programs Looking For?

Every program looks for something different, said Flug, but they all rely heavily on their fellows. “You spend more time with your fellows than residents, because residents rotate,” he said. “Is this someone I can work with closely for a year? That’s probably the most important piece of it.” They also look into whether the fellow will do research, whether they seem responsible, and they question why the resident wants to serve in that region. Since Flug is based in Colorado, he considers whether the resident is applying there in order to spend the winter skiing.

Program directors often call colleagues who know the residents, to do an informal reference check. “For the residents, know that that happens,” Flug said.  Anything questionable in your background may come up at some point, so Flug recommends being up front about it.

Are There Enough Fellowship Spots?

Residents should be able to find a fellowship, though it’s not always going to be in your ideal location. “In New York, it seems that there’s usually a shortage of MSK fellowship positions,” Flug said. If you’re willing to move, you can almost always find something, said Flug. For those who are geographically restricted, it can be tougher. He acknowledges that moving around puts a tremendous burden on the residents, who may be relocating their families for a year, which can also be expensive.

The fellowship process is different than residency. “In residency, the rule is you have a 90% chance of matching if you apply to 10 positions, and 100% chance if applying for 20,” said Ewell. Fellowship doesn’t follow those rules, he said. The competitiveness of various subspecialties changes from year to year. “If you’re applying to competitive fellowships, it would behoove you to apply to many, including safety programs,” he said.

How the Fellowship Application Process Could Be Improved

Residents said that the fellowship application process isn’t well coordinated. “If there was a structured organized system where everybody applied at the same time, that would be a benefit to the residents, rather than every program having their individual requirements,” said Ewell. While submitting paperwork individually for five to ten programs isn’t too difficult, “everyone wants something different and they want a significant amount of paperwork.” It would be helpful to have the same forms, and to upload them to a common place, he said.

Yang added that standardizing paperwork requirements would be helpful. Some programs want a copy of the transcript, for example, where others require the official transcript sent from the school.

Check out resources for applying for fellowships here.