How difficult is it get a fellowship after internal medicine residency?

[voxveritatisetlucis]

I have been thinking about possible specialities that I would like to pursue and a few are only possible through fellowships. I am specifically thinking about cardiology and hematology/oncology. How hard are these fellowships to get and what other options are available for an internal medicine resident who wanted these fellowships but didn’t get them? If debating between specialties that require IM residency and ones that do not, should one always go with the option that doesn’t require IM?

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[whataweirdo]

Wow, I was just thinking about this as well. I'm also considering Hem/Onc. From what I have heard, Cardiology/Pulmonology and Critical Care/Gastroenterology are all really competitive. Hem/Onc is also competitive, but not on the level of Cards/Pulm/Gastro apparently. I think the goal should be to match into a really solid IM residency program in order to have the best chance at one of the more competitive subspecialties. The good thing is that the back-up is practicing as an internist, which is still obviously better than not matching at all LOL.

 

[Bonne Nuit]

Cards and heme/onc fellowships are always competitive, but these are not extraordinarily difficult to match into if you're a skilled resident coming from a solid academic IM residency and you apply broadly. It helps if your institution has a home fellowship in your target specialty.

It becomes a lot more challenging to match into competitive IM fellowships (heme/onc, cards, GI) from lesser-known community programs. Additionally, MDs match into competitive IM fellowships at much higher rates than DOs, but DOs can and do match every year.

The NRMP releases annual fellowship match data. If you are curious, you can google "NRMP fellowship match data" and it will come right up.

The bottom line is that, like anything else, connections matter a great deal for fellowship.

 

[voxveritatisetlucis]

Cards and heme/onc fellowships are always competitive, but these are not extraordinarily difficult to match into if you're a skilled resident coming from a solid academic IM residency and you apply broadly. It helps if your institution has a home fellowship in your target specialty.

It becomes a lot more challenging to match into competitive IM fellowships (heme/onc, cards, GI) from lesser-known community programs. Additionally, MDs match into competitive IM fellowships at much higher rates than DOs, but DOs can and do match every year.

The NRMP releases annual fellowship match data. If you are curious, you can google "NRMP fellowship match data" and it will come right up.

The bottom line is that, like anything else, connections matter a great deal for fellowship.

Do you think that cardiology and oncology will be off limits for mid to low tier MD students, considering it will be hard for them to get into strong IM residency now that step I is pass or fail? How does cards/heme-onc compare to derm/plastics/ortho etc.?

 

[KnightDoc]

Do you think that cardiology and oncology will be off limits for mid to low tier MD students, considering it will be hard for them to get into strong IM residency now that step I is pass or fail? How does cards/heme-onc compare to derm/plastics/ortho etc.?

It's like anything else, which means it is not nearly as binary as you are framing it.

Top tier schools give you a leg up. They don't guarantee anything, and everyone at Harvard who wants to be a plastic surgeon doesn't get to do it. The same works in reverse at low tier schools.

You appear to be an extremely talented guy with some heavy duty baggage in your past. I think if you figure out how to get out of your own way, nothing will be off limits to you no matter where you go to school.

 

[voxveritatisetlucis]

It's like anything else, which means it is not nearly as binary as you are framing it.

Top tier schools give you a leg up. They don't guarantee anything, and everyone at Harvard who wants to be a plastic surgeon doesn't get to do it. The same works in reverse at low tier school.

You appear to be an extremely talented guy with some heavy duty baggage in your past. I think if you figure out how to get out of your own way, nothing will be off limits to you no matter where you go to school.

It may not be binary but how would somebody stand out from a mid ranked MD school that does P/F, no rankings, without a step 1 score? I’m sure I could have got a high score considering I’ve always done well on exams (sat, MCAT etc.) but it won’t really make a difference.

I’ll be content being any type of doctor for the most part, but part of me will probably always wonder what could have been. I know this sounds like moving goalposts, but I’m just wondering what options will be available to mid tier md students in a post-step1 world.

Aren’t the high match rates advertised by medical schools due to extreme self-selection?

 

[KnightDoc]

It may not be binary but how would somebody stand out from a mid ranked MD school that does P/F, no rankings, without a step 1 score? I’m sure I could have got a high score considering I’ve always done well on exams (sat, MCAT etc.) but it won’t really make a difference.

I’ll be content being any type of doctor for the most part, but part of me will probably always wonder what could have been. I know this sounds like moving goalposts, but I’m just wondering what options will be available to mid tier md students in a post-step1 world.

Aren’t the high match rates advertised by medical schools due to extreme self-selection?

You're going to pursue your passion, whatever that turns out to be. You'll do research. You'll make connections. You'll do away rotations.

And, if you distinguish yourself, you'll be recognized and rewarded. Like people do every year, coming out of mid tier and below programs, who beat out people coming from the top schools in the country for some of the most competitive residency slots. Of course, they are the exception rather than the rule. But you are perfectly situated to be one of those exceptions, given the reason you will not be at a top school, if that turns out to be the case.

You are still you. Sure, top programs have great resources and connections, but the lack of those advantages are overcome by talented people every year.

The biggest reason top schools have amazing match lists is because they disproportionately have amazing students. It's worth keeping in mind, though, that every school has at least some amazing students, and they tend to excel wherever they go.

Don't you ever wonder how some people at HYPSM end up DO, reapplying, or having to find something else to do with their lives, while some people from Podunk U end up at HMS, Stanford, etc. each cycle? This is how, and it continues with residencies, fellowships, etc. It gets harder and harder as you move along in life, but the cream always tends to rise to the top.

At least you are holding true to form, continually moving the goalposts. First you just wanted a few IIs. Then a few more. Then a few more. Then you just wanted an A. Anywhere. Now all you want is "cardiology and hematology/oncology."

Maybe just do your best, be thrilled that you are not going to be stuck doing whatever it is that you are doing now, and take it from there? A little armchair analysis from someone who has never met you -- try to chill out and realize that, whatever you achieve, you are going to be dissatisfied because there is going to be something "better" that you won't be able to do. Better school, residency, fellowship, specialty, whatever.

I bet on you when you started posting, and I won. I'm going to keep betting on you. Unless, of course, this is all an elaborate troll, because you are honestly doing way too well, given all you have been through, to seriously be worrying about this. Maybe try to relax a little and have faith in yourself.

 

[Med Ed]

Do you think that cardiology and oncology will be off limits for mid to low tier MD students, considering it will be hard for them to get into strong IM residency now that step I is pass or fail? How does cards/heme-onc compare to derm/plastics/ortho etc.?

2021 NRMP Numbers for Internal Medicine (categorical positions):

• 9,024 positions offered in the match
• 4,124 MD senior applicants

In other words, every MD senior could match and over half of the positions would still be unfilled.

Matching into the most selective programs is obviously very difficult, but decent MD students from low or mid tier schools have no problem matching into solid university IM programs with fellowship options aplenty.

 

[allseasons]

I have a few friends that recently entered fellowships in competitive fields (GI and Cards) who said school rank matters more than they thought and they ended up in programs they didn't prefer. But, they still matched. Or whatever you call a fellowship.

Also, you might want to check your curriculum a little more closely. IDK any mid tier that doesn't do clerkship grades, or at least post-clerkship grades.

 

[Bonne Nuit]

Do you think that cardiology and oncology will be off limits for mid to low tier MD students, considering it will be hard for them to get into strong IM residency now that step I is pass or fail? How does cards/heme-onc compare to derm/plastics/ortho etc.?

Not at all. A ton of program directors and other people involved in the resident selection process have openly told me and my classmates that Step 2 is the new Step 1. They were literally like "We are replacing the Step 1 filter with the Step 2 filter because this is the easiest solution." It's pretty openly stated at this point, so I think that's what you should expect.

There are academic IM residencies that routinely place people into IM fellowships virtually everywhere. You can verify this yourself by looking up cardiologists or whatever specialty you like and then checking out their CVs or the blurbs on their website. Every random University of Whatever can place their IM residents into cardiology fellowships.

The only thing that is realistically going to change about the residency/fellowship process after P/F step 1 is that people will be pivoting from their plastics/ortho dreams after M3 instead of M2.

 

[cander67]

Cards and heme/onc fellowships are always competitive, but these are not extraordinarily difficult to match into if you're a skilled resident coming from a solid academic IM residency and you apply broadly. It helps if your institution has a home fellowship in your target specialty.

It becomes a lot more challenging to match into competitive IM fellowships (heme/onc, cards, GI) from lesser-known community programs. Additionally, MDs match into competitive IM fellowships at much higher rates than DOs, but DOs can and do match every year.

The NRMP releases annual fellowship match data. If you are curious, you can google "NRMP fellowship match data" and it will come right up.

The bottom line is that, like anything else, connections matter a great deal for fellowship.

Why would DO’s have less success matching into those fellowships? Once you match into an academic IM residency as a DO isn’t the playing field leveled with MD’s?

 

[Doctoscope]

Why would DO’s have less success matching into those fellowships? Once you match into an academic IM fellowship as a DO isn’t the playing field leveled with MD’s?

Unfortunately, I've read that the bias persists into residency and fellowships as well.

It's sad how the medical school/residency system is essentially a caste system.

 

[Bonne Nuit]

Why would DO’s have less success matching into those fellowships? Once you match into an academic IM fellowship as a DO isn’t the playing field leveled with MD’s?

My best explanation is that the types of residencies which send their graduates onto IM fellowship (academic IM) are mostly MD to begin with. DO/IMG/FMG tend to make up a larger proportion of the residents at community programs, and graduates of these programs typically aren’t as competitive for fellowship.

In other words, I think it’s a lot of self-selection.

 

[Med Ed]

Why would DO’s have less success matching into those fellowships? Once you match into an academic IM residency as a DO isn’t the playing field leveled with MD’s?

Things get more level, sure, but humans are still involved in the process.

Not all fellowships participate in the NRMP, but the number has been growing steadily each year. The overall match rate of MD grads is about 10 points higher than DO grads (high 80s vs. high 70s). Of the successful matches this past cycle, 12.8% were DO grads. If you go line by line DOs are somewhat overrepresented in some fields (pain med, rheum, sports med, etc.) and relatively underrepresented in others. They break out the denominator for MD grads only, which is annoying.

The saying goes that you are as good as the last place you trained. Which is mostly true.

 

[DOVinciRobot]

Why would DO’s have less success matching into those fellowships? Once you match into an academic IM residency as a DO isn’t the playing field leveled with MD’s?

No. The bias persists, albeit much less than applying to residency. All one can do is make themselves as competitive as possible, meet as many people as they can, and see what happens. Good residents get good fellowships, regardless of what their degree is.

 

[voxveritatisetlucis]

When should I aim to take step 2 if I think I can get a high score? Ie when should I take it so I can list it on residency applications?

 

[Bonne Nuit]

When should I aim to take step 2 if I think I can get a high score? Ie when should I take it so I can list it on residency applications?

I am planning on taking mine within about 6 weeks of finishing M3. Your school may have specific requirements/regulations about when you're allowed to take the exam, and they will likely explain their most current policies to you sometime in M2. If you don't hear anything by your Step 1 dedicated study period, that would be an appropriate time to ask.

 

[voxveritatisetlucis]

I am planning on taking mine within about 6 weeks of finishing M3. Your school may have specific requirements/regulations about when you're allowed to take the exam, and they will likely explain their most current policies to you sometime in M2. If you don't hear anything by your Step 1 dedicated study period, that would be an appropriate time to ask.

Thank you for the info.

Wouldn’t residency apps be due before you get your score though? Unfamiliar with the timeline specifics.

 

[Bonne Nuit]

Thank you for the info.

Wouldn’t residency apps be due before you get your score though? Unfamiliar with the timeline specifics.

My score will be back 2-3 months before I submit my residency application, so it’s going to be fine for my timeline. You’ll just have to look at what the ERAS dates are in the 2025-2026 academic year and plan accordingly.

 

[Med Ed]

When should I aim to take step 2 if I think I can get a high score? Ie when should I take it so I can list it on residency applications?

Within 2 weeks of finishing M3.

 

[voxveritatisetlucis]

What should the number one priority of a student at mid/low tier med school. Research, academics to study for step 2, connections with faculty in home residency depts?

I keep comparing the match list of the school that I will most likely be attending to Pitt’s match list (one of the better schools that I got into last time) and the gap is much larger than expected.

 

[DOVinciRobot]

Research, academics to study for step 2, connections with faculty in home residency depts?

Yes.

 

[voxveritatisetlucis]

Yes.

In what order though? I will try balancing all of them but there must be one to prioritize. I’m guessing it would be finding research in an area that lends itself to a high degree of prolificity (eg. data science, high volume clinical, case reports) but I’m not sure if it would be better to put more effort into academics (in hopes of setting the stage for better LORs, Step II scores etc.)

Clearly step 2 can’t be that important for some specialities, considering the graph below

. How is the unmatched average higher than the matched average for NS, radiation oncology?

 

[DOVinciRobot]

In what order though? I will try balancing all of them but there must be one to prioritize. I’m guessing it would be finding research in an area that lends itself to a high degree of prolificity (eg. data science, high volume clinical, case reports) but I’m not sure if it would be better to put more effort into academics (in hopes of setting the stage for better LORs, Step II scores etc.)

Clearly step 2 can’t be that important for some specialities, considering the graph belowView attachment 349276. How is the unmatched average higher than the matched average for NS, radiation oncology?

View attachment 349276

The competitive applicants have all 3. Don't underestimate just how impressive some students can be.

Unfortunately that data is outdated now that Step 1 is P/F. Step 2 used to be less important because Step 1 was king, that is going to change rather rapidly. Applicants to specialties like NS used to apply with just a strong Step 1 and take Step 2 late in the season so they would have a score before rank lists were submitted, but programs wouldn't weigh it heavily so those averages would be lower than expected.

 

[voxveritatisetlucis]

Thank you.

Do you know what it means to match preliminary medicine | X speciality vs matching X speciality.

Some match lists have candidates with Preliminary medicine | anesthesiology whereas others on same list just have anesthesiology

 

[DOVinciRobot]

Thank you.

Do you know what it means to match preliminary medicine | X speciality vs matching X speciality.

Some match lists have candidates with Preliminary medicine | anesthesiology whereas others on same list just have anesthesiology

Not all anesthesia residencies start pgy-1. Some of them have you do a prelim medicine or surgery intern year first and then you start the anesthesia residency pgy-2. Some programs are integrated, which means that intern year is just built into the program.

Radiology and dermatology are similar

 

[hfiso]

Not all anesthesia residencies start pgy-1. Some of them have you do a prelim medicine or surgery intern year first and then you start the anesthesia residency pgy-2. Some programs are integrated, which means that intern year is just built into the program.

Radiology and dermatology are similar

How does it typically work - you apply to the intern year / prelim year at the same time you apply anesthesia or rads? or they place you somewhere once accepted?

 

[DOVinciRobot]

How does it typically work - you apply to the intern year / prelim year at the same time you apply anesthesia or rads? or they place you somewhere once accepted?

You apply at the same time. If you match an advanced position (ie pgy2) but don’t match an intern year and don’t get one in SOAP you can actually lose your advanced spot.

 

[Med Ed]

How does it typically work - you apply to the intern year / prelim year at the same time you apply anesthesia or rads? or they place you somewhere once accepted?

I'll add a small bit of detail to what @DOVinciRobot posted: you effectively have two match lists, one for the prelim positions and one for advanced or integrated positions. The system is smart enough such that if you match into an integrated position, your prelim list is ignored.

 

[voxveritatisetlucis]

I'll add a small bit of detail to what @DOVinciRobot posted: you effectively have two match lists, one for the prelim positions and one for advanced or integrated positions. The system is smart enough such that if you match into an integrated position, your prelim list is ignored.

Do most people only apply to one speciality? If not, do they need different prelim programs for each? Thanks in advance!

 

[voxveritatisetlucis]

Should hospital ranking factor in decisions about where to attend school? I’m now deciding between two, one of which is higher ranked but has lower ranked hospitals (with fewer home residencies). The other (lower ranking) has top ranked hospital in region, plus national rankings in some specialties that I may be interested in pursuing?

 

[NegativeMargin]

I have a few friends that recently entered fellowships in competitive fields (GI and Cards) who said school rank matters more than they thought and they ended up in programs they didn't prefer. But, they still matched. Or whatever you call a fellowship.

Also, you might want to check your curriculum a little more closely. IDK any mid tier that doesn't do clerkship grades, or at least post-clerkship grades.

See that brings up a question because in talking with people who have the Charting Outcomes in the Match statistics engrained in their memory they'll often say something to the effect of: " All ortho people from T50 MD schools that ranked >20 places have matched in the last 5 years except for one guy who scored <200 on STEP 1, so you shouldn't have a problem with specialty xxxxx if you approach it properly."

And I wonder how that relates to fellowships? I don't expect you to have every answer, but any opinion or input would be appreciated.

And more broadly, is it really as bad as people make it seem to go unmatched at first, especially with a competitive residency application with no red-flags? With so many medical students openly stating they still don't know exactly what they want to do, from my discussions with them, why isn't the mean number of distinct specialties ranked higher? Is it really best explained by saying "People only match 1.2 distinct specialties because most people know what they want to do."? I know that's almost more of a philosophical question than anything else, but there seem to be a lot of mysteries in how the matching processes and fellowship processes overlap in a way that might benefit people to know beforehand.

 

[voxveritatisetlucis]

See that brings up a question because in talking with people who have the Charting Outcomes in the Match statistics engrained in their memory they'll often say something to the effect of: " All ortho people from T50 MD schools that ranked >20 places have matched in the last 5 years except for one guy who scored <200 on STEP 1, so you shouldn't have a problem with specialty xxxxx if you approach it properly."

And I wonder how that relates to fellowships? I don't expect you to have every answer, but any opinion or input would be appreciated.

And more broadly, is it really as bad as people make it seem to go unmatched at first, especially with a competitive residency application with no red-flags? With so many medical students openly stating they still don't know exactly what they want to do, from my discussions with them, why isn't the mean number of distinct specialties ranked higher? Is it really best explained by saying "People only match 1.2 distinct specialties because most people know what they want to do."? I know that's almost more of a philosophical question than anything else, but there seem to be a lot of mysteries in how the matching processes and fellowship processes overlap in a way that might benefit people to know beforehand.

Is the ortho stat true?

 

[allseasons]

See that brings up a question because in talking with people who have the Charting Outcomes in the Match statistics engrained in their memory they'll often say something to the effect of: " All ortho people from T50 MD schools that ranked >20 places have matched in the last 5 years except for one guy who scored <200 on STEP 1, so you shouldn't have a problem with specialty xxxxx if you approach it properly."

And I wonder how that relates to fellowships? I don't expect you to have every answer, but any opinion or input would be appreciated.

And more broadly, is it really as bad as people make it seem to go unmatched at first, especially with a competitive residency application with no red-flags? With so many medical students openly stating they still don't know exactly what they want to do, from my discussions with them, why isn't the mean number of distinct specialties ranked higher? Is it really best explained by saying "People only match 1.2 distinct specialties because most people know what they want to do."? I know that's almost more of a philosophical question than anything else, but there seem to be a lot of mysteries in how the matching processes and fellowship processes overlap in a way that might benefit people to know beforehand.

what do you mean by "why isn't the mean number of distinct specalties ranked higher"

 

[Planes2Doc]

It depends what you are trying to do. As you have mentioned, both cardiology and hematology/oncology are quite competitive. For the former, there are way more applicants than seats available. Then there are some that are unable to fill all the available positions, such as nephrology and infectious disease. Though with one year critical care fellowships available to those that previously did such fellowships, I can see them being tempting for some. I have gone back and forth about doing a two year pure critical care fellowship as well.

 

[jstwannagraduaaate!!!]

If you are a usmd and land at a mid-tier IM you can match into any of the fellowship programs provided you network and do research, just might not be at the program you want

 

[deleted1129181]

Things get more level, sure, but humans are still involved in the process.

Not all fellowships participate in the NRMP, but the number has been growing steadily each year. The overall match rate of MD grads is about 10 points higher than DO grads (high 80s vs. high 70s). Of the successful matches this past cycle, 12.8% were DO grads. If you go line by line DOs are somewhat overrepresented in some fields (pain med, rheum, sports med, etc.) and relatively underrepresented in others. They break out the denominator for MD grads only, which is annoying.

The saying goes that you are as good as the last place you trained. Which is mostly true.

Do you think its just a compounding factor of the fact that being a DO plays a part into what kind of IM program you can match in, which in turn affects what kind of fellowship you match in? I think if MDs are matching into strong IM programs, then they have more connections and a strong IM residency program behind their name, which gives them the edge in fellowships. I don’t think fellowships are actively avoiding DOs.

 

[voxveritatisetlucis]

It depends what you are trying to do. As you have mentioned, both cardiology and hematology/oncology are quite competitive. For the former, there are way more applicants than seats available. Then there are some that are unable to fill all the available positions, such as nephrology and infectious disease. Though with one year critical care fellowships available to those that previously did such fellowships, I can see them being tempting for some. I have gone back and forth about doing a two year pure critical care fellowship as well.

Outside the top bracket of schools, is it better to go to a school that does AOA/internal rankings, assuming one believes that he/she can finish highly ranked.

Also I’ve read that away rotations are important but I am unsure why other hospitals would want to bring in students from other schools. In other words, why are they important if the student isn’t really adding much value.

 

[Med Ed]

Also I’ve read that away rotations are important but I am unsure why other hospitals would want to bring in students from other schools. In other words, why are they important if the student isn’t really adding much value.

If you're a program director, the students who choose to do an away rotation in your department are telegraphing their interest in your program (aka preference signaling). It's also a way to "test drive" those students before you rank them.