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- Kevin Shah, MD∗ ()
- ↵∗Reprint requests and correspondence:
Dr. Kevin Shah, PGY-4, UCLA Division of Cardiology, 650 Charles E. Young Drive South, A2-237 CHS, MC: 167917, Los Angeles, California 90095.
“So, where do you really want to go for fellowship?” my mentor asked me more than 1 year ago. It seemed like a very straightforward question with a presumably uncomplicated answer. I hesitated, which was apparent. He responded, “This isn’t an easy decision. There are a lot of factors to consider.”
All fellows of cardiovascular disease have undergone the process of matching in to their ideal training program. It took me time to realize the many considerations in selecting the “best” fellowship. There are many aspects of each program, including prestige, location, outcomes, mentorship, and quality of training; these are not easily quantifiable or comparable. This selection process demonstrated the value of professional mentorship and, more importantly, how ranking my priorities helped me better understand my value system.
The Accreditation Council for Graduate Medical Education website lists 187 fellowship programs specializing in cardiovascular disease that are enrolled in the National Resident Matching Program (1). Most Accreditation Council for Graduate Medical Education programs will require the following for application: current curriculum vitae, personal statement, letters of recommendation, United States Medical Licensing Examination transcripts, and Educational Commission for Foreign Medical Graduates certificate for foreign medical graduates. Gathering and optimizing these aspects of application is similar to the previous process of applying for internship and residency.
Questions and Advice
“The programs are very similar in a lot of ways,” another attending told me. “We’re all guided by COCATS [Core Cardiology Training Symposium]” (2). Given the similarities in core training principles, I began my organization of programs by geography, being cognizant of the fact that many fellowship graduates practice in the area in which they train (3). This is not only because professional relationships are built and fostered locally, but also because personal lives including marriages and families tend to converge during fellowship. I was told, “Keep in mind what a real geographic restriction is. We don’t love to hear that your love for surfing is a reason to be restricted to the coast.” With this in mind, I began my process of ranking.
“What do you want to do after fellowship? What do you want your career to look like?” another mentor asked me. I have always had an idea about what kind of practice I want (academic versus private practice) and even if I wanted to subspecialize. The types of careers that graduates from the program have pursued are not clandestine information. In fact, programs are likely to find the ideal match when having candid conversation with applicants about their goals after finishing training. The type of practice after graduation is 1 of the top 2 factors in searching for a graduate’s first post-training position (3). Although many applicants are not absolute on their desires to pursue a subspecialty, it is best to examine which subspecialty fellowships recent graduates have sought out with the understanding that previous graduates can help open doors to these programs. The decision between academic and private practice careers after training is multifactorial and complex (4,5). I was told, “Expect your goals to change in training, but it’s good to have a plan.” Therefore, I began rearranging my list on the basis of programs with a higher likelihood of helping me achieve my current goals.
One adviser told me, “You want to train at the best program possible.” Although this advice is sound, I learned that the quality of training is very difficult to measure. It could be considered a fusion of the tangible and intangible: procedural volume, patient pathology, hospital staff, conference quality, teaching from seniors, and the balance between autonomy and guidance are just some of the components that comprise the quality of a program. Often, senior faculty will cite programs as being of high quality on the basis of track records and positive interactions with program graduates. Prestige is also difficult to measure. Trainees will often look to ranking systems, such as the lists published by U.S. News & World Report, which have complex algorithms to grade hospital systems. These algorithms include factors such as readmissions, patient volume, nurse staffing, and Society of Thoracic Surgeons ratings (6,7). Applicants should be cautious to treat these ratings for what they are: a media company’s attempt to rank hospitals for public consumption and discussion. The factors in consideration for these rankings do not necessarily prioritize the factors that will optimize the training environment for the fellow. I surveyed mentors close to me and had a rough idea of which programs had a stronger reputation for training well-rounded cardiologists. My list continued to evolve.
After my interviews for fellowship were completed, I approached the most challenging part of the process: formulation of the final rank list. Another attending told me, “When you have to make a difficult decision, rank each factor’s importance to you and then assign a numerical value to each factor based on the program. When you add up scores for each decision, the decision with the highest value is the best for you.” This seemed like a very objective way to go about the process. Spreadsheets to help organize this decision-making process, called an “Idea Sandbox,” are available. I began creating my sandbox, but soon realized there was not a place for “gut instinct.” Here, I began to understand the difficulty in this process. There are parts of decision making that are very personal, and no one may fully be able to relate to your beliefs. I was able to narrow my list down to my top 3 programs, and I asked a senior faculty member how to finalize my decision. He reminded me, “If you work hard, you’ll excel at any of these programs you’re considering. The biggest decision you have to make at this stage is who you want to marry and how much balance you want to have with your career.” These were wise words from a universally well-respected veteran of cardiology, serving as a poignant reminder to not overthink the process and to not neglect life outside of training.
I finalized my list keeping all advice in mind. My top-ranked program reflected what I felt was the best fit for me, which may or may not have been what others saw as the “right” or most strategic choice. Ultimately, I made my decision on the basis of both logic and instinct, knowing that even if I could not be 100% sure I played my cards right, I felt comfortable with my hand. There can be a lot of pressure to divulge your number 1 pick to both colleagues and various program staff. It should be cautioned that if this strategy is pursued, only 1 program should be identified as your top choice. Academic cardiology is a close-knit community, and a misunderstanding or miscommunication can blemish a reputation early in a fellow’s career.
Matching for general cardiology fellowship occurs in December, and applicants are informed of the final match via e-mail. This news is the exciting result of hard work, determination, interpersonal relationships, and possibly a little bit of luck. For me, I saw this message pop up on my smartphone while on inpatient rounds and could hardly contain my excitement. However, I continued rounding with the team, and I finally excused myself after rounds to learn the news. I reminded myself before opening the e-mail to reflect on this journey as one that provided the opportunity to understand myself better. More importantly, I needed to trust the process and that wherever I matched would be the best fit for me. I opened the message, read the exciting news, and reflected on the people and advice that guided my decision. A process that I thought would be more objective and strategic led to a journey of introspection and a lesson in balancing priorities while never ignoring my gut—a lesson that I will hold on to with gratitude as I continue to make my way.
- Andrew Wang, MD ()
RESPONSE: Look Inward First
“Outward judgment often fails, inward judgment never.”
—Theodore Parker (1)
A resident’s choice of a cardiology fellowship program is filled with months of preparation, thought, discussion, anxiety, cost, travel, and more contemplation. The decision is obviously significant: cardiology fellowship is the final stage of training after >20 years of formal education and training. It is rare that a fellow will be able to transfer to another program for general cardiovascular disease training. Dr. Shah’s perspective as a current fellow-in-training describes very well the multitude of variables that may influence the final, important outcome. Dr. Shah appropriately emphasizes honest self-reflection and introspection as key elements, more so than program-specific factors, for attaining the optimal result. Rather than simply becoming a competent cardiologist as mandated by the Accreditation Council for Graduate Medical Education, the applicant’s goal should be to seek the most fulfilling professional and personal balance well beyond fellowship completion.
There are many ways for residents to gain a trustworthy self-awareness of what they seek in and beyond cardiology fellowship training. Cardiology has many outstanding role models for trainees, and a resident’s identification with and inspiration from a cardiologist role model is a valid starting point. What characteristics of this role model are worth emulating? What aspects of this cardiologist’s job responsibilities—the clinical, research, teaching, and/or administrative skills—are most attractive to the resident? Recognition of these characteristics from the perspective of the resident’s individual talents and aspirations will begin shaping his or her own career goals as clinician, clinician-educator, clinician-researcher, or other combination. Another valuable experience would be attending a national scientific session in cardiology, such as the American College of Cardiology or American Heart Association annual scientific sessions, to view the breadth of the field and its varied opportunities to be involved and contribute.
Many residents are advised to participate and show productivity in research to strengthen their application for fellowship. More valuably, research experience will help residents understand their affinity and potential for productivity in research and better define their career goals (2). As much as research productivity and publications may still be the currency of academic promotion at many institutions, an early start may help the resident determine his or her “love for the game.” Since 2013, the Medical Specialties Matching Program has been moved later to the start of the third year of medicine residency to allow for a greater maturation of residents’ career plans and research experience.
With a strong self-understanding of one’s career goals, the search and match process should become clearer and less stressful. In their personal statements and interviews, applicants will be able to more clearly and confidently describe not only their reason for choosing cardiology as a subspecialty, but more importantly, their plans within the expansive field (3).
In the era of standardized clinical training requirements by the American College of Cardiology Core Cardiovascular Training Statement (4) and Accreditation Council for Graduate Medical Education, how can applicants differentiate fellowship programs that will develop their individual career goals? Choosing a program on the basis of general reputation or prestige may lead to an unfulfilling match. I have known colleagues and fellows who regretted their fellowship choice because their self-chosen (and perhaps unarticulated) career priorities were not compatible with the program’s resources or track record. When planning an interview, a request to meet with fellows or faculty members with career descriptions similar to one’s own is appropriate. Fellows will provide honest impressions of whether their career development has been supported and mentored as well as their challenges and successes. Fellowship program directors should provide specific examples of graduates who have achieved success in similar career paths in addition to a complete list of their graduates and current placements.
Residents and fellows may naturally feel that commitment toward a specific focus in cardiology closes off opportunities in other directions. However, it is this commitment toward a goal that becomes the catalyst for action and building momentum forward. When a decision about career priorities is made, this enables more individualized advice, opportunities, and most critically, mentorship from faculty and program directors, and begins the living storyline of one’s career development.
- ↵BrainyQuote. Theodore Parker quotes. Available at: http://www.brainyquote.com/quotes/quotes/t/theodorepa159777.html. Accessed July 9, 2015.
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- American College of Cardiology Foundation
- ↵National Resident Matching Program. Results and data: specialties matching service. Available at: http://www.nrmp.org/wp-content/uploads/2015/02/Results-and-Data-SMS-2015.pdf. Accessed June 1, 2015.
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- The Society of Thoracic Surgeons. STS public reporting online. Available at: http://www.sts.org/quality-research-patient-safety/sts-public-reporting-online. Accessed June 1, 2015.