IM Subspecialty Fellowship FAQ

[AJM]

Here is the long-overdue subspecialty FAQ. Feel free to PM me with anything you might want to add, correct, or clarify.


What are the internal medicine subspecialties?

There are presently 15 subspecialties that are certifiable by the American Board of Medical Specialists. Internists can begin fellowships after completing their 3 year internal medicine residency. Most residents apply for fellowship programs during the beginning of their second year of residency. Fellowships include:

Specialty: Overall Length of Fellowship Training

3 years of internal medicine training +:

Allergy and Immunology: 2 years
Cardiology: 3 years
Cardiology/Cardiac Electrophysiology: 4 years
Cardiology/Interventional Cardiology: 4 years
Critical Care Medicine: 2 years
Endocrinology: 2 years
Geriatric Medicine: 2 years
Gastroenterology: 3 years
Gastroenterology/Hepatology: 4 years
Hematology: 2 years
Hematology/Oncology: 3 years
Infectious Diseases: 2 years
Medical Genetics: 2-4 years
Nephrology: 2 years
Oncology: 2 years
Pulmonary: 2 years
Pulmonary/Critical Care: 3 years
Rheumatology: 2 years
Sports Medicine: 1 year

ABIM recognized subspecialties/Length of Training

As a somewhat different way to list the above info, the following are ABIM recognized subspecialties where you may be certified as a specialist: http://www.abim.org/cert/policiesssaq.shtm The first number in the parentheses is the total overall months of fellowship required, and the second number is the minimum required time doing clinical rotations during fellowship, as dictated by the American Board of Internal Medicine (ABIM). For example, a fellowship with (24/12) would be a 2 year fellowship with a minimum of 1 year of clinical rotations during the fellowship. The rest of the time is spent at the program's discretion: some fellows will do more clinical rotations as electives, while others will spend that time doing research in their subspecialty field.

(minimum months/clinical months required)
Cardiovascular Disease (36/24)
Endocrinology, Diabetes, and Metabolism (24/12)
Gastroenterology (36/18)
Hematology (24/12)
Infectious Disease (24/12)
Medical Oncology (24/12)
Nephrology (24/12)
Pulmonary Disease (24/12)
Rheumatology (24/12)

There are three dual certification programs:
Hematology & Medical Oncology (36/18)
Pulmonary Disease & Critical Care Medicine (36/18)
Rheumatology & Allergy and Immunology (36/12 rhem & 18 allergy/immu)

There are added qualification programs:
Adolescent Medicine (24/)
Clinical Cardiac Electrophysiology (12/12, requires cardiovascular disease certification)
Critical Care (3 pathways, see http://www.abim.org/cert/policies_aqccm.shtm)
Geriatric Medicine (12/12)
Interventional Cardiology (12/12, requires cardivascular disease certification)
Sports Medicine (12/)
Transplant Hepatology (12/12, requires gastroenterology certification)


Which subspecialties are more competitive to get into then others?

Right now, most people agree with the following order of competitiveness:

Most Competitive:
Cardiology
Gastroenterology
Allergy and Immunology

Moderately Competitive:
Pulmonary
Nephrology
Hematology/Oncology

Mildly Competitive:
Infectious Diseases
Endocrinology
Rheumatology
Geriatric Medicine

Do you think that those fields will always be competitive?

It’s important to realize that levels of competitiveness can rapidly change and what may be competitive now may not be in 5 years due to changes in medical technology, changes in the management of patients, reimbursement, or changes in the patient population. As you can see, with so many different variables, predicting which specialists will be needed and which specialty is in surplus is an inexact science at best. A classic example of this is gastroenterology. During the mid-1990s, it was widely believed that there was a major surplus of all internal medicine subspecialists and there was a drive to train more primary care physicians. Gastroenterology was particularly affected as many of the “experts” foresaw a large surplus of gastroenterologists and they believed that there were many more gastroenterology doctors then gastroenterology procedures that needed to be done. As a result, gastroenterology fellowships became very non-competitive. By the year 2000, the managed care revolution was on the back-swing, and new recommendations were being put out for things like screening colonoscopies, it was recognized that there was not an oversupply of gastroenterologists but rather a shortage of them. As a result, their reimbursement rates rose, and the field became more competitive as many more US graduates realized that their procedures were enjoyable to do, their patients were not all that sick, and they would be compensated well for their work. I point to that story because many medical students choose their specialties based on salaries, when in fact, by the time that they complete their training, the salary of their chosen specialty today may be drastically different then the salary of the specialist of the future. An example of a specialty in flux today in hematology oncology, with the decision of the government to stop reimbursing oncologists as much as they have been for chemotherapeutic agents that by some estimates have been accounting for one half to two thirds of many oncologists salaries. I am certain that this will have the effect of dissuading many people from pursuing oncology, but I would just remind those people of what happened to gastroenterology and just state that it simply is not possible to predict the future. The take home message is to find a specialty that you enjoy and go for it, irrespective of whether it’s very competitive, or reimbursed very well today. If you truly enjoy what you do and the patients that you interact with, none of it will matter.

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[AJM]

How do I make myself competitive for fellowships?

Besides doing very well and impressing your attendings during medical school and residency, there are other things that you can do to help you obtain your fellowship of choice. For the most competitive fellowships, research in the respective field is almost considered a pre-requisite by many attending physicians. Besides the summer in between their first and second year of medical school, many medical students take off years during medical school to pursue research. It is also possible to do research electives during your fourth year of medical school, as well as during your internship year and during your residency in general. Some internal medicine residency programs have a research requirement. It is generally considered a requirement that internists train at University programs in order to be considered competitive for fellowships as well. Generally, it is better to train at a main University hospital rather then a private affiliated University hospital as well as the training is often regarded as superior (oftentimes rightfully so). Becoming a chief resident in internal medicine can help your application if a program has not already accepted you yet as well. It is not necessary to do your residency at a place different then your medical school in order to be competitive for fellowships.

What is “fast-tracking?”
Fast tracking, or short tracking, is an option that some residents do who are interested in pursuing academic medicine in a certain subspecialty. People who fast track complete their IM residency in 2 years, instead of 3 years, and then start their fellowship after their second year. The catch to it is that they have an extra year of research added on to their fellowship, so it does not save them any overall time. Advantages of fast tracking include: the ability to pursue a more in-depth research project as a fellow in order to jump-start one’s academic career; and less overall clinical training time (some may view this as a disadvantage). A major disadvantage is that in order to fast track, the resident must pretty much know which subspecialty they want to pursue before they even start residency, because they will have to apply for fellowships early in their intern year, and they will not have enough time to adequately explore most subspecialties. Most people who fast-track have MD/PhD’s or have already done extensive research in their intended subspecialty. In order to short track, you must get permission from your residency program, then apply and get accepted to a fellowship program as a short-tracker. You do not have to stay at the same institution as your residency in order to short track, although that is the most common way to do it.

When and how do I apply for subspecialty fellowships?
If you are looking to start your fellowship immediately after residency, and are not planning on fast tracking, you will need to apply during your second year of residency to secure a spot for after your third year. Many people, however, do not know which specialty they want to pursue by then, so it is becoming increasingly more common for people to apply during their 3rd year of residency or even later. By applying later, IM graduates will have to take 1 or more years off between residency and fellowship. Many IM grads will take that time and work as hospitalists in order to line their pocketbooks with a little more cash. Applying while working as a hospitalist is fairly easy to do: because the hospitalist schedule is so flexible, applicants find it very easy to attend multiple interviews. In my own fellowship interview process, about half of the applicants I was interviewing with had already finished their residencies and were working as hospitalists.

Each subspecialty has its own application process and deadlines, so it is best to check with the individual programs you are interested in. In general, some fellowship programs operate through the NRMP match, and some operate more like normal job interviews, where they offer or deny positions after each interview. The specialties that participate in the Match are: Cardiology, Pulmonary/Critical Care, Infectious Disease, and Rheumatology. See the NRMP fellowship match website http://www.nrmp.org/fellow/index.html for more information. Generally for the programs that participate in the Match, applicants submit their applications in November/December, interview in March/April, submit their rank lists in May, and match at the end of June. Keep in mind that you match to a program more than a year before your start date, so you must plan ahead. The rest of the specialties do not participate in the Match, and use their own timeline. Out of these, GI has the earliest timeline. Typically, applicants submit their application in August-September, interview September-November, and hear about their acceptances/rejections while they are interviewing. So most people accepted into GI know where they will be more than 18 months before the start of their fellowship. The timeline of the other subspecialties is generally: submit application October/November; interview and hear about offers December-February.

I want more information on the specific subspecialties!
The subspecialty fellowships are so different from each other that all of them deserve their own section. Below, each specialty will have a brief overview and links to relevant threads to provide more information.

 

[AJM]

Allergy and Immunology
Generally considered one of the most competitive IM subspecialties because of the very small number of fellowship positions available as well as the nice lifestyle it offers. Allergists tend to focus in, well, allergy, and it is a 2-year fellowship. It is typically an office-based practice, in which they see patients with severe allergies of all varieties: foods, pollens, beestings, and medications. They can do a few “procedures”, including skin testing of allergens (of which the billing rates are quite high), and allergy shots. A growing area in allergy is in the use of desensitization protocols. These are typically done at academic centers where patients need to get a specific chemotherapy regimen or antibiotic, but they have had an anaphylactic reaction to those medications. The allergist will admit these patients to the hospital for short stays to undergo desensitization regimens to the specific medications.

The American Academy of Allergy, Asthma, and Immunology

Some threads for more information:
What about Allergy/Immunology?
The future of Allergy/Immunology?


Cardiology
This is another popular and competitive IM subspecialty. It also is considered one of the three most procedural subspecialties in IM (sharing the honor with GI and Pulmonary/critical care). Cardiology is a 3 year fellowship, with at least 2 years of required clinical training time. The rest of the fellowship can be spent in research or additional clinical time. The clinical practice of cardiology is highly varied, and it allows for a large number of areas of subspecialization. Cardiologists can do angiograms, angioplasties (with interventional training), right heart catheterization, echocardiograms, manage heart failure, coronary artery disease, hypertension, treat arrhythmias, treat pre- and post- heart transplant patients, and manage adult patients with congenital heart disease, just to name a few. Some cardiologists will choose to do further subspecialty training. After cardiology fellowship, graduates can do a 1-year fellowship in interventional cardiology, where they get trained in such things as angioplasties, coronary artery stenting, valvuloplasty, and even things like pulmonary artery stenting. Another certified fellowship that cardiology grads can do is a 1-year fellowship in cardiac electrophysiology, where fellows are trained in pacemaker placement and interrogation, intracardiac defibrillator placements, cardiac resynchronization therapy, and VT/VF and afib/flutter ablation techniques, among other procedures.

The American College of Cardiology


Threads for more information:
Cardiologists
Cardiology vs Interventional Cardiology
Anyone applying to Cards this year 2005


Endocrinology
Endocrine is a 2-year fellowship, with a minimum of 1 year of clinical training during the fellowship. The rest of the time can be spent either doing research or in additional clinical training. Endocrine is one of the least procedural of the IM specialties. Endocrinologists typically spend their time in outpatient clinics and mostly treat patients with diabetes, and hypo- and hyperthyroidism. They also will deal with the more rare endocrine disorders, such as pan-hypopituitarism, Addison’s, and diabetes insipidus.

The American Association of Clinical Endocrinologists

Threads for more information:
Endocrine
Endocrine info


Gastroenterology
Gastroenterology is another of the fellowships considered to be very competitive. GI is also a very procedural specialty. It is a 3 year fellowship, with a minimum of 18 months of clinical training. The remainder of the time can be spent in research or in additional clinical work. Gastroenterologists deal with disorders of the stomach and intestinal tract, as well as diseases of the liver, pancreas, and biliary tree. They do a number of procedures, including colonoscopy, EGD, enteroscopy, ERCP, endoscopic ultrasound, PEG tube placements, and liver biopsies. Some GI graduates will do further subspecialty training in the field. Hepatology, for example, is a 1 year fellowship that graduates can do, where they can further train in the management of liver disease, such as cirrhosis, and in the treatment of patients pre- and post-liver transplant.

The American College of Gastroenterology

Threads for more information:
Gastroenterology
GI vs Cardiology

 

[AJM]

Hematology/Oncology
Heme/onc is a combined fellowship program that is 3 years long, with a minimum of 18 months of clinical training time during the fellowship. At the end of the fellowship, graduates can be double-boarded in hematology and oncology. A less common path for fellows to pursue is to do a separate heme or onc fellowship. The separate heme and onc fellowships are 2 years each, with 1 year minimum of clinical training time during the fellowship. Heme/onc physicians mostly manage patients with cancer, and will decide on treatment options and chemotherapy regimens for their patients. They will also manage any complications that arise from the chemotherapy and the cancer itself, and pretty much become the oncology patient’s primary care doctor while they are undergoing active treatment. In addition, oncologists do bone marrow biopsies, and bone marrow transplants. They also treat benign hematologic conditions, such as sickle cell anemia, the thalassemias, and TTP. The setting that they practice in is mostly outpatient, although physicians who specialize in hematologic malignancies or BMT often spend a significant amount of time in the inpatient setting.

American Society of Clinical Oncology
American Society of Hematology

Threads for Information
Heme/Onc


Infectious Diseases
ID is another non-procedural IM subspecialty. It is a 2-year fellowship, where fellows must do a minimum of 1 year of clinical training. ID is primarily an inpatient consultation specialty, and typically see consults involving confusing infectious issues, rare contagious diseases, highly resistant bacteria, fever of unknown origin. They are often considered some of the best diagnosticians in internal medicine. With the development and growth of HIV antiretroviral therapy, many ID specialists have decided to focus on HIV treatment, and have moved from the inpatient setting to outpatient clinics. Even with the prevalence of HIV, most ID physicians choose not to specialize in that area, and so have stayed in the inpatient arena.

Infectious Diseases Society of America

Threads for Information
Infectious Diseases


Nephrology
Nephrology, or renal medicine, is a 2-year fellowship, where fellows are required to do at least one year of clinical training during the fellowship. The rest of the time is spent either doing research or additional clinical work. Nephrologists treat diseases of the kidney. A large part of their practice is spent managing patients on hemodialysis and peritoneal dialysis. They also work up patients with new onset renal failure, electrolyte abnormalities, and will do some procedures, including renal biopsies and hemodialysis catheter placements. Nephrologists also manage pre- and post-renal transplant patients.

American Society of Nephrology

Threads for Information
Nephrology
Nephrology competitiveness, general information


Pulmonary/Critical Care
Pulmonary/Critical care is a 3-year combined fellowship, where fellows are required to do a minimum of 18 months of clinical training (1 year in pulmonary and 6 months in critical care). At the end of the training, graduates can be double-boarded in pulmonary medicine and critical care medicine. As an alternative, fellows can do straight pulmonary medicine without the critical care portion. This fellowship is 2 years long, with a minimum of 1 year of clinical time. Straight critical care without the pulmonary portion can be done as a 2 year fellowship, with a minimum of 1 year of clinical time. I am discussing the two specialties together because the combined program is the most common route that IM graduates take to pursue both pulmonary and critical care medicine. Pulmonary/critical care is a very procedural field, although not as procedure-heavy as GI. Pulmonologists have a wide variety of clinical practice. Many focus primarily on the inpatient setting, others work mostly in the clinic, while others will focus on the ICU.
Pulmonologists treat patients with lung diseases such as asthma/COPD, interstitial lung disease, TB, MAC, pleural effusions, diaphragmatic dysfunction, pulmonary hypertension, and pre- and post- lung and heart-lung transplant patients. They also do a large amount of diagnostic work, and will see patients with new lung masses, pulmonary infiltrates, and endobronchial lesions. The main procedures pulmonologists do are bronchoscopy with transbronchial biopsy, endobronchial stenting, thoracenteses/chest tubes, and trach placements. A growing field in pulmonary is sleep medicine, which is a one-year fellowship that can be done after completion of a pulmonary fellowship. Sleep is an outpatient practice, and sleep physicians are involved in the diagnosis and management of various sleep disorders such as sleep apnea, PLM, narcolepsy, and sleepwalking.
With training in critical care medicine, pulmologists will often run both medical and surgical ICUs, and do all the procedures needed in the ICU, including intubations, central lines, arterial lines, and Swan-Ganz catheters. Critical care can also be done as a separate fellowship, or can be added onto another IM subspecialty fellowship for one additional year of training. For information on the different tracks to certification in critical care, check out http://www.abim.org/cert/policies_aqccm.shtm

American Thoracic Society
Society of Critical Care Medicine
American College of Chest Physicians

Threads for Information
Pulmonary Medicine
Thoughts on Pulmonary/Critical Care
Hospitalist vs. Intensivist vs. Critical Care


Rheumatology
Rheumatology is a 2-year fellowship, with a required minimum of 1 year of clinical training, and is another of the less-procedural medical specialties. Rheumatologists deal mostly with autoimmune diseases such as lupus, rheumatoid arthritis, dermatomyositis, and ankylosing spondylitis. They also treat other medical diseases of the joints, such as gout and pseudogout. The main procedure that they do is tapping joints – they will tap pretty much any joint in the body. Rheumatology, while not as competitive as the other medical specialties, is an attractive field for many because of the easier hours. It is primarily an outpatient specialty, and there are very few rheumatologic emergencies.

American College of Rheumatology

Threads for Information
Rheumatology
The Future of Rheumatology?
Rheumatology questions

 

[AJM]

How many internists pursue fellowship training?

In 2000-2001, approximately 41% of graduating internal medicine residents went on to pursue different fellowships. It appears that in recent years since 2000, the percentage of IM graduates going on to fellowships is increasing, as the number of fellowship positions/1st year fellows are growing at a faster rate than the number of IM residency positions.

How many first year fellows are there in each subspecialty?*

In the year 2003-2004:

Cardiology: 737
Gastroenterology: 498
Pulmonary: 73
Critical Care Medicine: 100
Pulmonary/Critical Care: 394
Nephrology: 420
Endocrinology: 243
Hematology: 17
Oncology: 66
Hematology/Oncology: 439
Infectious Diseases: 329
Rhemuatology: 171
Rhematology/Allergy and Immunology: 7
Geriatrics: 306

Fellowships 2002**:

Cardiology:
No. of programs: 175
Total no. of fellows: 1,999
16.7% female
64.0% USMG
32.9% IMG
0.5% Canadian
2.6% DO

Interventional Cardiology:
No. of programs: 96
Total no. of fellows: 121
6.6% female
52.1% USMG
42.1% IMG
4.1% Canadian
1.7% DO

Cardiac Electrophysiology:
No. of programs: 77
Total no. of fellows: 103
8.7% female
48.5% USMG
41.7% IMG
3.9% DO

Critical Care Medicine:
No. of programs: 32
Total no. of fellows: 140
21.4% female
33.6% USMG
57.9% IMG
2.9% Canadian
5.7% DO

Endocrinology:
No. of programs: 118
Total no. of fellows: 437
52.6% female
57% USMG
40.0% IMG
2.3% DO

Gastroenterology:
No. of programs: 155
Total no. of fellows: 1,058
21.3% female
65.9% USMG
29.6% IMG
3.9% DO

Geriatric medicine:
No. of programs: 100
Total no. of fellows: 327
52.9% female
45.0% USMG
52.3% IMG
2.1% DO

Hematology:
No. of programs: 20
Total no. of fellows: 72
54.2% female
47.2% USMG
50.0% IMG
1.4% Canadian
1.4% DO

Oncology:
No. of programs: 27
Total no. of fellows: 199
35.7% female
58.8% USMG
38.7% IMG
2.5% DO

Hematology and oncology:
No. of programs: 115
Total no. of fellows: 911
39.5% female
47.2% USMG
39.8% IMG
0.7% Canadian
3.2% DO

Infectious diseases:
No. of programs: 139
Total no. of fellows: 625
42.4% female
56.2% USMG
40.0% IMG
1.4% Canadian
2.2% DO

Nephrology
No. of programs: 128
Total no. of fellows: 711
35.7% female
56.4% USMG
38.1% IMG
0.8% Canadian
4.6% DO

Pulmonary disease:
No. of programs: 31
Total no. of fellows: 114
21.9% female
17.5% USMG
78.1% IMG
4.4% DO

Pulmonary disease and critical care:
No. of programs: 121
Total no. of fellows: 995
24.8% female
57.6% USMG
37.8% IMG
0.5% Canadian
3.9% DO

Rheumatology:
No. of programs: 106
Total no. of fellows: 307
51.8% female
59.0% USMG
35.8% IMG
0.7% Canadian
4.6% DO

IM and Peds fellowships:

Allergy and immunology:
No. of programs: 70
Total No. of fellows: 255
49.4% female
77.6% USMG
19.6% IMG
0.4% Canadian
2.4% DO


*Source: American Board of Internal Medicine

**Source: The Journal of the American Medical Association, Volume 290, No. 9. September 3, 2003. pp. 1119-1268