Author + information
- Arun Kanmanthareddy, MD∗ ( and )
- Saurabh Aggarwal, MD
- Creighton University School of Medicine, Omaha, Nebraska; and the CHI Health Creighton University Medical Center, Omaha, Nebraska
- ↵∗Reprint requests and correspondence:
Dr. Arun Kanmanthareddy, Creighton University School of Medicine, 3006 Webster Street, Omaha, Nebraska 68130.
Match day brings mixed emotions for trainee applicants matching into programs outside their own residency program. Although the joy of matching into a cardiology fellowship program is insurmountable, the pressure of having to move to a new place and the nervousness about working with new people creates a challenging atmosphere, which may create friction on professional and personal fronts. In this paper, we explore the challenges often faced by external applicants (EAs) and steps that may facilitate an easier integration.
The Role of the EA
1. Know the program. Applicants match into outside programs for a variety of reasons. Some choose to go to an outside program because of its obvious strengths, whereas for others, it is a geographic preference or for familial reasons. In the latter situations, the applicants are less likely to feel anxious about the transition. However, those applicants matching into outside programs by virtue of the match algorithm may encounter a difficult transition period. The applicants, therefore, should choose their ranking order wisely after thoroughly assessing the strengths and weaknesses of individual programs. Formally, they should apply due diligence during the interview day and informally through other channels to get a true sense of the program. Having advanced knowledge about the program helps model expectations and is likely to lessen anxiety and circumvent confrontation on July 1. After match day, it becomes imperative that the EAs use all of their resources to understand the program, the city, and their new peers.
2. Communication. This is a key element for successful integration into the program. After the match, the onus is on the EA to actively dialogue with program leaders about their goals and expectations during fellowship. Early on, the EA should communicate about the types of board certifications he or she intends to seek, and this may help in designing the curriculum. Graduating residents most often have to take internal medicine board certification during the first year of fellowship, and they should let the program director or the chief fellow know about this, so that education leave could be allocated to them for their board preparation. At the same time, the EA has to be considerate to the needs of their cofellows to work toward achieving a balance between meeting core requirements, subspecialty electives of choice, and providing coverage for other fellows.
3. Flexibility. Although most of the programs are designed similarly, they may differ in practice patterns, the types of procedures and the way procedures are performed, didactics, and call structure. EAs have to understand that the curriculum is designed in a way that works best for the fellows and the faculty, and they need to adapt to the practice patterns of the new program. At the same time, they may bring up issues that they identify as inconsistencies or practice gaps in a nonconfrontational manner. This may lead to further opportunities to improve patient care if the parties are flexible and receptive to new ideas.
4. Planning. It takes a great amount of planning when going to an external program, especially so if the program is in a different city. Moving to a new city, finding housing, and potentially relocating family could all be quite stressful. Planning, therefore, should begin immediately after the match results are announced to alleviate pressure prior to fellowship. Applicants with a working partner may face an even more difficult situation. The partner may face difficulty in finding a job, especially when moving to a smaller city, and so they may face the prospect of living apart temporarily. This may further aggravate the stress of fellowship and may manifest as hostility in the workplace. Again, communication is integral, even personally. EAs should have discussions with their partners prior to the ranking process and make appropriate contingency plans in case they have to face this situation. Those EAs with their partners in residency/fellowship training can contact the program immediately after the match to find about vacancies to facilitate a possible program transfer. The EAs also should seek help from the program leaders and keep them abreast of their personal situation. Arrangements with respect to housing should be sought early, and they can seek the assistance of their peers or program coordinators. Attempts at selling/leasing their existing home should begin early enough so they do not have to deal with these nuances during fellowship.
5. Peer assistance. Peers can be of great assistance to an EA, providing them with a wealth of information. The EA can quickly learn about the expectations and preferences of the faculty. Peers also can guide the EA regarding necessary books and other learning resources. In addition, peers are a quick guide to learning the electronic medical records and the computer systems. Although the majority of peer assistance could be sought after joining fellowship, it is probably a good idea to seek this support prior to joining fellowship.
The Role of the Program
• The program director. The program director is probably the single most important person in the integration process of an EA. Most often, the program directors try to get a sense of background training, interests, and barriers for the applicant to come to their program during the interview. Although this is a welcome practice, the short duration of the interview may be inadequate to provide the program director with all the required information. After the match process, the program director should reinitiate the dialogue process to identify problem areas and try to resolve them. Particular attention should also be paid toward the personal lives of the EA. With his or her wealth of information and experiences, the program director should seek to direct them toward appropriate resources. Once the fellowship training starts, the program director should pay particular attention to the EAs, providing them with constant feedback until he or she feels that the EA has successfully integrated into the program. The program director also should welcome ideas and suggestions from the EAs to identify gaps within the existing training environment and be open to modifying them if appropriate. Additional consultation should be sought with the EA regarding career goals, and the curriculum should be designed to meet the individual needs after having met the obligations of the core requirements of the fellowship training.
• The faculty. They should set the record straight by underlining the objectives, workflow, practice standards, and their expectations to EAs at the beginning of the rotation. Understanding these pre-established expectations and working toward them in each rotation may be a good way for the EA to acclimate to the new environment. Faculty should also make an effort to understand the background training received by the EA and allow some time to adapt to the new systems and practice standards.
• The chief fellow and other peers. The chief fellow, in consultation with the incoming fellow and the program director, should design a curriculum starting with lighter rotations and thereby facilitating easier integration for the EA. The chief fellow and other peers can help with the basic survival tips. Initial learning about performing procedures, reading echocardiograms, and standing in and reading stress tests may be best learned by spending time with the senior fellows. The EA may be a valuable resource and may possess additional skillsets, and this, in turn, may be a valuable opportunity for other fellows to learn and benefit from the skills of the EA. This symbiotic partnership will not only integrate the EA but also benefit the whole group in terms of uplifting the morale, extending the camaraderie, and improving productivity.
We think that these steps can help smooth the transition of an EA into a fellowship program. Although the onus of integration does not fall on any single individual, the EA has to take the central responsibility and have the other stakeholders communicate with him or her to have the most successful outcome. Ideally, the environment should bring out the best in everyone in a mutually collaborative partnership that ultimately translates into best patient care. An open communication with faculty, peers, and colleagues is the cornerstone for successful EA assimilation to set up a platform for a productive 3 years of training.
RESPONSE: Antiarrhythmic Options for the “External” Cardiology Fellowship Trainee
The first days of cardiology fellowship for all trainees are filled with excitement and the occasional sinus tachycardia. Both “lifers” and fellows trained at other institutions (termed “external applicants” [EA]) worry about the midnight phone call asking for the stat echocardiogram to rule out cardiac tamponade or the call from the emergency room requesting an ST-segment elevation myocardial infarction consultation. In addition to pushing the sonography machine to the emergency room, the EA must also “bypass” the additional stress test of deciphering a map of the medical campus. Drs. Kanmanthareddy and Aggarwal identify several other concerns and offer many interesting and useful suggestions for the matched EA and the program director. As the authors appropriately acknowledge, the variability between programs and trainees require individualized approaches. I agree that an important goal for the program director is to ensure that all trainees are acclimated during the initial weeks of fellowship. The transition can be difficult for both internal and EAs alike.
Drs. Kanmanthareddy and Aggarwal suggest that EAs participate in a “dialogue process” after the match with program leadership. I wholeheartedly agree, although I believe that it is premature to discuss the goals of fellowship and “the board certifications he or she intends to seek” at such an early time point. Although there is pressure to be certified in everything (1), the focus in the first year of fellowship should not be geared toward board certifications and achieving various levels, but rather learning to be a clinical cardiologist. Furthermore, the authors suggest that those interested in advanced subspecialty training need to communicate their intentions to the program leadership early on. My experience has been that at least one-half of the fellows who claimed definite interest in a particular subspecialty or research during interviews and even during early fellowship training switch their area of focus. Exposure to the cardiology subspecialties is limited in most residency programs, and in-depth experiences and interactions with a diverse mix of cardiology faculty mentors are only possible after initiating fellowship training. Both internal applicants and EAs should keep an open mind, at least during the first year of fellowship, and thus, these discussions are premature. Although EAs may hesitate to seek assistance from both peers and program leadership, potentially to avoid a negative first impression, the advice of Drs. Kanmanthareddy and Aggarwal is right on target. Communicate, seek help as often as needed, and listen, especially to peers.
The perspectives of Drs. Kanmanthareddy and Aggarwal regarding the role of the program director are insightful. They recommend that the program director identify resources prior to fellowship, set expectations for the EA at the beginning of each rotation, and assign the EA to “lighter” rotations. I agree, and these recommendations should naturally also apply to the “internal” applicant.
At Columbia-New York Presbyterian Hospital, approximately 50% of our cardiology fellows are EAs. Despite an outstanding medical residency program and a large percentage of the residency class applying for cardiology fellowship each year, the program leadership believes that external trainees add a crucial dimension to the training environment. Many of our external trainees have taught us how other institutions train residents and fellows, which we have incorporated into our training program. We provide an orientation for both internal applicants and EAs before the first day of training, at which time each rotation director presents the learning objectives and the expectations in both oral and written formats. This is followed by a luncheon, at which time the graduating fellows (frequently moving into subspecialty training at Columbia) share insights and make recommendations to the incoming fellows, closing the circle of life as a general cardiology fellow. Our goals during the first 6 weeks of training are to rapidly equalize the knowledge base of all first-year fellows by providing a lecture series (Cardiology 101) and a “boot camp,” at which faculty teach first-year fellows how to use Swan-Ganz catheters and intra-aortic balloon pumps and how to interrogate pacemakers and implantable cardioverter-defibrillators, for instance. At first, we assign first-year fellows to short 2-week rotations in noninvasive cardiology and cardiac catheterization, which are highly supervised settings, to learn the basics of echocardiography, stress testing, and right heart catheterization. These skills will enable them to take their first overnight call, approximately 8 weeks after starting fellowship. By that time, the “external” applicants are no longer “external” but are “internal.” The Department of Medicine offers additional orientation sessions for all first-year fellows, so that the fellows can meet their colleagues in the other Department of Medicine subspecialties and meet the key faculty members in the Department of Medicine.
Transitions are difficult but are also opportunities to grow and learn. The sage advice of Drs. Kanmanthareddy and Aggarwal may not resolve the debate over staying in 1 place for all of one’s training or moving to a different institution for fellowship; however, their wisdom might just reduce the stress and tachycardia associated with the transition of starting training in a new environment. In any event, deep breaths, frequent pulse checks, an open and positive attitude, and communication remain keystones for success.
- American College of Cardiology Foundation