In the increasingly competitive world of medicine, and more specifically radiology, one must consciously create a plan to achieve desired goals. The days of "things just working out" are long gone. For current and future radiology residents, obtaining a great fellowship is a frequent goal. Unfortunately, fellowships are afterthoughts in too many cases, and are left for the fall of the third year of residency. The road to a great fellowship starts much earlier. Let there be no misunderstanding; average fellowships, even some great fellowships, can be snagged last minute. Why rely on luck when planning ahead can tremendously increase the odds of landing a distinguished position? After all, in Hollywood, you’re only as good as your last movie — and in medicine, you’re only as good as the last place you trained.

What is the role of fellowships in radiology today? Many people don’t enter fellowships and do well throughout their career. These days, the job market for radiologists seems so healthy, that it may be unnecessary to do a fellowship. Stories spread throughout the radiology community all year about people leaving in the middle of fellowships to accept positions as attendings. In the end, the decision may be geographic, as expectations regarding training vary in different regions of the United States. In any region, however, if you desire a position in an academic institution, completing a fellowship is practically essential. If post-residency training is the chosen road, then what is the best tack to take to find a prestigious spot?

The best advice is often the most basic. Be a hard worker. From the day you arrive at your residency to the day you leave, be an honest, dependable, strong link in the chain of health care. It may seem like a simple concept, but it is very important. Though hard work may feel unappreciated at times, it never is. Always keep your patients’ and your attendings’ best interests in mind. It may surprise you how effectively a reputation for reliability translates into outstanding letters of recommendation.

Letters of recommendation can make or break an applicant. The great majority of letters are glowing, and look exactly like all the other letters. Rarely, letters are derogatory. Also rare is the sizzling-hot masterpiece that practically grants the applicant an interview on its qualities alone. This is the one we are all after. Ask the older residents in your program. They’ve all gotten letters before, and they will know who writes generically and who has a gift for literary composition.

Radiology is a relatively small world, and the people you work with every day may be well-known and/or may be acquainted with the Fellowship Directors whose attention you seek. Ask these attendings for advice, and see if they know people at the programs you are applying to. If they have connections, a letter and a phone call can often set the stage for an interview.

A letter from a friend of the Fellowship Director is certainly one way to set an applicant apart from the pack. Unfortunately, this approach doesn’t always pan out, and it should never be relied upon as a replacement for being a strong candidate. Separation from the pool of applicants is an important concept, however, and if a letter won’t do it, then other strategies, such as the ones discussed below, should be attempted.

There’s safety in numbers. It’s best to score high on your USMLE’s. It’s a great way to set yourself apart as an intelligent, educable individual. As much as we would like to think that we are evaluated on our merits as doctors and people, the truth of the matter is, in programs with many applicants, the first cut is sometimes made on the basis of numbers alone. That isn’t a hard and fast rule, and exceptions are most certainly made, but why give programs a reason to place your application in the circular file? Even if your exams are behind you, it is important to understand their impact, and if an applicant is lacking in this area, extra effort should be made in other areas to offset below-average boards scores.

Some people don’t have perfect board scores and they still get choice fellowships. Rest assured that the space labeled "Publications & Presentations" was not left blank on their application! This space must be occupied, whether it is with research done in medical school, or a poster presentation done in residency. Almost all fellowships are anchored in academia, and directors like to see active participation in research, if for no other reason than to have someone they can rely on to help with their projects.

Activities or interests related to radiology, but outside the realm of research, can also be helpful in catching the eye of an otherwise unimpressed Fellowship Director. Membership in Radiological Societies may not be enough, but a leadership position in a society could be just the thing.

Interests outside of radiology can be helpful as well. Not only do they convey the fact that the applicant is a normal, well-rounded person with a life other than radiology, but certain skills can come in handy. An interest in computers, for example, may be attractive to a Fellowship Director whose hospital is currently installing a PACS system. A great golf handicap may allow the radiology golf team to finally grab a win at the annual charity tournament. Directors desire a program full of real people—not a bunch of radiology robots who only know how to spit out never-ending differentials.

A great way to let Program Directors know that you’re a "real" person is to meet and work with them before they ever get your application in their hands. If possible, arrange an elective during the second year of residency at your most sought after fellowship program. When your application does cross their desk, the question of your intelligence, personality, and work ethic should already be answered—for better or for worse! Try to do a rotation in that subspecialty at your own hospital before you visit elsewhere, otherwise that month will be focused on learning the ropes, rather than impressing the director. The optimal situation would include knowing your stuff, working your butt off for a month, and getting along with the personnel in the department. When the time comes to decide who gets a spot, you would like the boss to say, "I remember that applicant—smart, hard working, and fit right in. Let’s extend an invitation for an interview!"

Selecting which fellowships to apply to can be a daunting task in itself. The first factor to be considered is geography. Pick institutions that are in the area where you would like to settle. Local practicioners often have relationships with nearby Program Directors and ask, "Who’s good this year?" when they are looking for someone to hire. Getting to know a geographic area for a year or two will allow you to purchase real estate in a good location, if you decide to stay after fellowship.

The next step in the selection process is identifying what fellowships are out there. Almost all residency programs have paper versions of fellowship directories, but they are often outdated and in demand by multiple people at the same time. On the web you can get updated directories, often with links to home pages and email addresses. ACR's Resident Section is a great place to start. They offer the ability to search for programs by State, Institution, Subspecialty, or by Faculty. Some people have trouble logging on to the site, but a quick visit to the ACR's section for password help should put an end to that. Other sites that should be surfed include The AMA's FREIDA (Fellowship and Residency Electronic Interactive Directory). This site doesn’t separate residencies from fellowships, however a handy list of check boxes can limit a search to only programs of interest. The RSNA's Residency and Fellowship Resources page is a similar list of Radiology Departments throughout the country, and the programs they offer.

The initial list of fellowships can be intimidating, but applying a few selection criteria makes the task more manageable. Once the list is narrowed, the next part of the journey starts. The number of applications to fill out is a personal decision determined largely by one’s assessment of their own stature as a candidate. The better the candidate, the fewer applications need be completed. An interesting and important trend to be noted is the move by the ACR to universalize the applications for fellowships. A copy of the Universal Application from the ACR’s website can be viewed using Adobe Acrobat (most people have this program, but if not, one can download Acrobat reader from Adobe for free). This application can be used for fellowships beginning in July of 2002. Just like the universal application for residencies, all programs may not accept the universal application, so confirm participation in the program before you apply.

Don’t allow the ease of the universal application to lull you into a false sense of security. Starting early is still a must, as many programs require documents from medical and undergraduate schools. This process can consume a surprising amount of time. Letters of recommendation also may take time after the initial request is made. Attending radiologists are often very busy people and asking them for letters in advance is only courteous. Keep your applications well organized, and try to keep track of what tasks still need completion for each application. All of the necessary hoops must be jumped through in order to project the appearance of an organized, mature individual. Bummer, huh?

As with all advice; read the above, take it in, think about it, and decide for yourself which of the suggestions are worth heeding. If you have recommendations of your own, please feel free to contact RadiologyWeb (editor@radiologyweb). Perhaps we will collect a few and publish them on the site. Best of luck to you in getting a Great Radiology Fellowship!

As a receiver and annual judge of fellowship applications, I must applaud Dr. Lustberg's article.  It is full of sound advice, good sense, and practical tips, and should be taken to heart by all applicants.  There's not much I can think of to add, but there are a few notions which might be useful.

• First of all, remember that the application process is not the same from institution to institution. The process is much less formalized than the residency match with the exception of the few specialties which have, admirably, started a match for fellowships.

Fellowship offices require different things to be included in the application, and it takes some effort to keep track of them all.  The effort is very much worth making, however, as nothing can derail your plans quite like an incomplete application.  So even though you are certain you remember sending everything, and your letter-writers insist they've mailed your recommendations, it's a good idea to call each office a couple of weeks after you think everything should have arrived to be sure it's all there.  The call will not only catch missing pieces, but indicate to the program that you're really interested and that you're meticulous.

• Next, during your interview, try to find out how the program deals with the fact that most fellowships have unique schedules for offering positions and individualized policies regarding acceptance.  Some may insist that you accept immediately upon receiving an offer; others may give you some time to decide.  The situation is an awkward one: fellowships which allow candidates a long time to choose risk waiting too late in the game to get candidates they like, whereas those that insist that you sign or resign immediately may require you to choose before the rest of your choices are known to you.  Discuss each program's policy candidly with the Program Director.  The more you find out, the better prepared you will be to manage the timing of your choice.

This issue will also give you a feel for how important your fate is to the faculty in the fellowship (which has a lot to do with how pleasant the year will be!).  You should be able to expect them to live up to their promises, but you should live up to yours, too. Accepting a position from which you later withdraw is a serious breach of trust, and while the jilted Program Director may not be able to hold you responsible in any painful way, your behavior may seriously diminish the attractiveness of subsequent candidates from your residency, and destroy the credibility of the faculty who have sung your praises in their recommendations.

• Finally (or perhaps firstly), think flexibly about the scope of experience you want your fellowship to include.  Certain career plans absolutely dictate the sort of fellowships that are needed. It would be hard to get a job in women's imaging in a highly-subspecialized university department immediately after completing a fellowship in neuroradiology, and vice versa.  But most radiologists take jobs after their fellowships that only partly match the clinical activities of their fellowships; inevitably you'll be doing some things that you haven't even thought about since your residency.  Since that is typically the case, don't worry if a cross-sectional imaging year doesn't include much MRI, or if your abdominal radiology fellowship gives you no special additional experience in musculoskeletal  imaging. You are not likely to fare poorly in the job market just because your fellowship didn't include some topic or other.

Give greater relative importance to other aspects of the fellowship, such as whether you get along well with the faculty, or whether the academic-clinical balance suits you.  The place that you are happiest is certain to be the place where you will do the best job, which will then generate the strongest letters of recommendation, and so forth.  As Bobby McFerrin nearly said, "Don't worry (too much); be happy!"

Links

• ACR’s Resident section:
  • http://www.acr.org/frames/f-residents.shtml
    
    
• By state:
  • http://www.acr.org/departments/operations/
    by_state/index.shtml
    
    
• By institution:
  • http://www.acr.org/departments/operations/
    by_institution/index.shtml
    
    
• By subspecialty:
  • http://www.acr.org/departments/operations/
    by_subspecialty/index.shtml
    
    
• By faculty:
  • http://www.acr.org/departments/operations/
    by_faculty/index.shtml
    
    
• ACR password help:
  • http://www.acr.org/main/computer_help/
    text.shtml#passwd
    
    
• AMA’s FREIDA:
  • http://www.ama-assn.org/cgi-bin/freida/freida.cgi