From the Brain Rehabilitation Research Center (D.B.F.), Malcom Randall Veterans Affairs Medical Center, Gainesville, FL; Department of Neurology (D.B.F.), University of Florida, Gainesville; and Department of Neurology (A.L.M.), University of Massachusetts Medical School, Worcester.
Address correspondence and reprint requests to Dr. David B. FitzGerald, Department of Neurology, McKnight Brain Institute, 100 South Newell Drive, L3-100, P.O. Box 100236, Gainesville, FL 32610-0236 dfitzger{at}massmed.org
Electing to continue formal medical education through a fellowshipis an important career decision. Unlike finding a residency,the process of finding fellowships and the accreditation statusof fellowships are not standardized. This article attempts toclarify the advantages and disadvantages of fellowships in neurology,as well as to describe how to learn of subspecialties that offerfellowships, fellowship availability, and accreditation systems.
After residency, fellowship is often the next step in formalgraduate medical education. Approximately 74% of neurology residentspursue fellowships.1 Unlike the process for finding internshipand residency positions, the process and timetable for seekingout, interviewing, evaluating, and, finally, selecting a fellowshipdepend on the type of fellowship and the institution. Thereis no national match for fellowships, no standardization offellowship applications, no centralized list of fellowship positions,and no single accreditation body for all fellowships.
Fellowships offer one a competitive edge when applying for privatepractice positions. In fact, subspecialty fellowship trainingis often a requirement for private practice or academic positions.Fellowships also offer one a chance to delve into a field andto gain clinical and laboratory experience in a subspecialtyarea. Many fellowships offer the opportunity to try writingand teaching, thus providing a chance to experience some aspectsof academic neurology.
Fellowships are quite varied in their focus, with a wide rangeof subspecialty training available (see table). Informationabout fellowship opportunities is available from multiple sources.The American Academy of Neurology (AAN) Web site offers a listingof many fellowships in its Residents & Students section(www.aan.com/education/fellowships). Fellowships can be selectedon the basis of subject matter, state, or keyword. The UnitedCouncil for Neurologic Subspecialties (UCNS) Web site (www.ucns.org/apps/directory)also has options for selecting programs by topic matter andstate. The UCNS was established in 2003 to provide accreditationfor some neurologic subspecialties. The goal of this processis to enhance the quality of training in neurologic specialtiesand the quality of patient care through setting standards forprograms. Listings of types of fellowships accredited by theAccreditation Council for Graduate Medical Education (ACGME)can also be found on the ACGME Web site (www.acgme.org/adspublic/reports/accredited_programs.asp).The ACGME Web site includes some of the information found inthe "green book" published each year by the American MedicalAssociation (AMA). The online version can be found at the AMAWeb site (www.ama-assn.org/ama/pub/category/2997.html). Somefellowships are not listed on the AAN, ACGME, or UCNS Web sitebut only on the individual program’s Web site.
Table Types of fellowships available and accreditation status
In addition to online resources, an efficient venue for face-to-facediscussion with multiple fellowship programs is the fellowshipfair, or career night, usually held on the Monday night of theannual AAN meeting. Fellowship openings are also advertisedin mainline or subspecialty journals, e.g., in the Dendritesection of Neurology Today, as well as on some recruitment Websites.
A more informal means of finding information about the availabilityof fellowships in a particular area is discussing program availabilityand suitability in your area of interest with a faculty memberwho has similar interests. Often, he or she will know of fellowshipsin that area or of specialists who are looking for fellowshipcandidates. Fellowships can also be created on an ad hoc basisusing overlapping areas of interest between a specialist ina field and an interested resident. In this instance, it isup to the resident to contact the specialist to determine whethera fellowship can be created.
Accreditation and certification are two different processes.Accreditation applies to a training program, and certificationapplies to a person. Accreditation of a program signifies thatthe curriculum, environment, and resources present in the programmeet with the requirements of the accrediting body. The term"certified" is used to designate that an individual has metthe requirements of one of the member boards of the AmericanBoard of Medical Specialties [e.g., the American Board of Psychiatryand Neurology (ABPN)] or the requirements of the UCNS. As anexample, a pain medicine fellowship at a particular institutionmay be accredited by the ACGME. Those who complete the fellowshipat that institution and pass the examination offered by theABPN are considered to be "diplomates" or board-certified. Anotherexample is behavioral neurology and neuropsychiatry: fellowshipsin this subspecialty are accredited by the UCNS, which alsocertifies neurologists as being diplomates in behavioral neurologyand neuropsychiatry.
Fellowships are broadly classed into ACGME-accredited programsand non-ACGME-accredited programs. ACGME-accredited programsprovide a mechanism for non-permanent resident aliens to beemployed with a J-1 visa through sponsorship by the EducationalCommission for Foreign Medical Graduates (ECFMG). UCNS accreditationof a fellowship does not result in ACGME accreditation. TheECFMG can also sponsor J-1 visas for non-ACGME-accredited fellowships,but the details of this process are beyond the scope of thisarticle. Additional information can be found on the ECFMG Website (www.ecfmg.org), the U.S. Department of State Web sitefor exchange visitors (http://exchanges.state.gov/education/jexchanges),and the U.S. Department of State Web site for J visas (http://travel.state.gov/visa/temp/types/types_1267.html).Many educational institutions also have sections on their Websites that provide information about the details of the visaprocess.
There are no clear-cut guidelines for choosing between accreditedor nonaccredited fellowships within a subspecialty. It may bethat accredited fellowships are more important for those interestedin academic careers than those interested in private practice,but the role of accreditation and uses of accreditation in subspecialtiesis still evolving. It may be that non-ACGME program graduateswill experience problems with hospital privileges and reimbursement.This is best discussed with a mentor and with those in the subspecialty.Both ACGME- and UCNS-accredited fellowships have work-hour requirementsthat may not always be followed in nonaccredited fellowships.
Initiation of the fellowship search is best started in the beginningof the second year of neurology residency, typically the thirdpostgraduate year. It can be helpful to identify a mentor oradvisor who can provide suggestions about programs to applyto and help with timelines for preparation. Preparation of acurriculum vitae (CV) and development of a list of programsof interest should be done in the winter of the same academicyear, with letters going out shortly after that. Interviewsare often scheduled for highly competitive fellowships in theearly spring, with a complete application package having beensubmitted by March. The timing of the application process isvery dependent on the type of fellowship, with highly competitivefellowships often having earlier deadlines than those mentionedabove. Once one has decided on an area to pursue, one shouldcontact programs directly because an institution’s Website may or may not have current information about applicationtimelines.
CVs should be prepared carefully because the letter requestingan interview and the CV are typically the two documents usedto start the application process. The CV and cover letter formthe basis for initial consideration and should be reviewed byseveral people for advice. One’s advisor and a specialistin the selected field of interest within one’s residencydepartment are helpful resources to ensure that there are noerrors of omission or commission, and that the emphasis of theCV is optimal.
After initial consideration of the CV, usually three lettersof recommendation are requested by the program. Preparationof these letters is best done early in the fellowship searchcycle. Creation of letters of recommendation can be a slow process.The process is helped by giving the requested letter-writersa CV to act as a framework, as well as specific accomplishmentsthat one wishes the author to highlight. The more "pre-work"done for the writers of letters of recommendation, typicallythe faster the letters will appear. With the request for a letterof recommendation, one should also submit the names, addresses,phone numbers, and types of programs to which one is applying.Not all fellowship programs require a personal statement, butshould a personal statement be required, it should be givento the letter-writers as well so that the letters of recommendationalign with the goals of the applicant. If the fellowship doesnot require a personal statement, applicants should considerwriting one in order to assist the letter-writers. Fellowshipdirectors want to hear from individuals who know applicantswell.
Letters of recommendation and CVs will only result in an interview,not a job offer. Job offers are driven by the results of theinterview. The interview is a reciprocal process, with the applicantlearning directly about the program and the fellowship directorlearning about the applicant. Preparation through careful readingof the Web site, recent publications from the program, and discussionwith mentors is essential. Having a list of questions aboutthe program prepared in advance is essential to gathering informationto ensure a good experience once in the program. Items for discussionon the day of the interview should include the source of fundingfor the fellowship, the division of time between clinic andresearch, a typical week’s schedule, the call schedule,if applicable, and the timetable for a decision. The timingof a decision is critical given the asynchronous nature of theinterview process. One should ask what the timing for a decisionis on the part of the program as well as ask for time to makea decision should one receive an offer.
One should carry copies of one’s CV and letters of recommendation.Ideally, one should know the names of the interviewers beforearriving at the interview. During the interview, one shouldmeet the current fellow(s), attend conference, and see the overallfacility. At the end of the interview, one should have a goodidea of the program’s expectations, and the program shouldhave a good idea of the interviewee’s expectations. Afterthe interview, one should write a post-interview "thank you"note, listing the specifics of why the position is of interestand what one could bring to the program.
An interviewee should be concerned if there is a requirementfor a full license because this can be driven by the need forthe fellow to bill for services as part of the program’srevenue stream. In such situations, the emphasis may quicklybecome on revenue generation rather than research or training.Disorganized interview logistics or confusion about the componentsof the fellowship should also raise concerns because the interviewis the program’s opportunity to impress the candidate.High-profile fellowship directors may travel extensively, leadingto limited contact and limited educational opportunities.
In addition to face-to-face interviews, discussion with recentgraduates of the fellowship may help provide direct and frankopinions about the program. Fellowship directors should be willingto provide the names of those who have been in the program.
Having completed interviews, and hopefully with multiple offersin hand, one should next consider which fellowship is most consistentwith one’s career goals. Discussion with one’s advisoror other mentors can be helpful in this process.
Receipts collected during the interview process should be savedbecause the job search and relocation process are largely tax-deductible.Finally, one must be on one’s best behavior at all timesbecause the subspecialty community in neurology is quite small.Unless there are extreme extenuating circumstances, it is unprofessionalfor an applicant to accept a position and then renege on thatpromise and take a more desirable position.
The current neurology fellowship search process is differentthan the neurology residency match process. Those wishing topursue a fellowship should engage in intensive information gatheringand consultation, interview early, and be aware of the differencesin accreditation between neurologic subspecialties and withinsubspecialties to maximize the likelihood of getting the fellowshipthey want and to maximize their career opportunities.
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