Applying for a Fellowship in Colon and Rectal Surgery

Abstract

Colon and Rectal Surgery is a challenging and fulfilling field with interesting and widely variable tasks, making it the preferred career for an increasing number of residents who are in the final path of their general surgery training. Due to the steadily rising interest in the field, it has become increasingly difficult to match into a fellowship in Colon and Rectal Surgery. For those who have decided to pursue a career in Colon and Rectal Surgery, this overview may be of some use during the quite cumbersome and costly process of applying for a fellowship.

There are many reasons to choose a career in Colon and Rectal Surgery, including the range of complexity from anorectal cases to complex open and laparoscopic abdominal cases. Colon and rectal surgeons overall, appear happy and enjoy what they do. The specialty is growing and unlike vascular or cardiothoracic surgery, other specialties are not trying to encroach on their spectrum of practice.

Colorectal training (fellowship) is currently one year in length; however, there has been discussion of increasing the training to 2 years in the future, especially if general surgery alters their training program. Colon and Rectal Surgery has in the last few years seen a surge in popularity. In 2010, 49 programs in the United States and Canada offered 82 positions. One hundred twenty-three applicants started the process. Thirteen applicants either withdrew their application or did not submit a rank-order list, leaving 110 applicants competing for the 82 positions. Three positions were unfilled and 79 were filled with a match ratio of 72%.

Several programs (including Ochsner) offer a one-year research position, either before, after, or independent of the clinical training year. This additional training could be a fruitful and educational time to delve into specific areas of the field, add research and publications to your curriculum vitae, and participate in regional and national meetings.

THE APPLICATION PROCESS

The application process itself should start during your fourth year of residency. It is a costly process, both financially and in time. The application process is electronic, through ERAS (the Electronic Residency Application Service) or EFDO (ERAS Fellowships Documents Office), which is a part of ERAS but specifically aimed at the fellowship application process. The EFDO is the “designated dean's office” for both U.S. and foreign medical graduates. Through EFDO, the applicant uploads or creates all the necessary documents; the application, letters of recommendation, Medical Student Performance Evaluation (MSPE), transcripts, photographs, and ABSITE transcripts. ERAS then sends your documentation to the program directors of the programs you have listed.

The colorectal training programs have different deadlines for applications. Deadlines and other information about the programs need to be acquired directly from each individual program (some have online information). Important information can also be obtained from FREIDA Online. Registration opens through myERAS in July. It is very important to start the application process early. Be ready with your personal statement and letters of recommendation when the registration opens. Good letters of recommendation are very important. A letter from someone who knows you well and can speak from personal experience will likely weigh more than a generic letter or recommendation (LOR) from a prominent writer. A letter from a colon and rectal surgeon familiar to the program you are applying to will weigh heavily. Also, letters from your chairman, program director, and mentors are important. Keep in mind that you can send different LORs to different programs, thereby tailoring them to specific programs. Foreign medical graduates should pay particular attention to obtaining early medical school transcripts, birth certificates, and such. It is very important to keep a close eye on the process on the receiving end. Call, call, and call again, to confirm that your documents have arrived and that everything is in order. Invest time in managing your paperwork, tedious as it may be. It is important to apply early as interview spots are limited, on average 20 per program. Early scheduling also allows for planning coverage for you while you are away, and lumping geographically proximal interviews together (saving travel time and money).

PROGRAM SELECTION

A challenging part of the application process is deciding which programs to apply to. I had invaluable help from my mentor, a colon and rectal surgeon, who was also my program director. His insight into the field was crucial and without him I might not have been as successful. Having done my general surgery residency in the Northeast, I don't expect I would have applied to residencies in the South without his advice. Aside from personal insight, other important aspects to consider in your selection are the number of fellows, number of cases, hospital size, experience of the staff, and reputation. This information can largely be obtained on the Internet, through various sites, most notably ASCRS, FREIDA Online, and the institutions' home pages. Most applicants already have an idea whether they will pursue a private or an academic career, and this could help steer one to academic versus community-based programs.

One of the first steps any applicant can do in choosing which program to apply to is determining the style of program they are interested in. There are a variety of fellowships available. Some programs are large with four to five ACGME fellows and one to two international fellows, while some programs are smaller with only one fellow. There are obvious advantages to both scenarios. Some are major referral centers affording the fellows opportunity in managing rare diseases or complicated cases. In a program with many fellows, work and call coverage can be spread out. One can also have a good one-on-one experience with an attending with many fellows. An obvious disadvantage is obtaining adequate volume and exposure with so many other fellows around. Thus, when reviewing a program with many fellows, really look at the volume of cases. Still, large programs have strong positives such as research opportunities with databases and dedicated research faculty. Larger programs also provide interaction between trainees. Your colleagues can assist in your education and provide emotional support.

The positive aspect of a program with fewer fellows is that volume tends to be good and all of a program's resources are now pooled toward fewer fellows. Smaller programs can offer a more personalized educational experience and can be less hectic than a larger program. Also, there is the potential for being torn between several attendings if the program lacks structure. Programs that are not in a large tertiary care center, or ones that aren't major referral centers, can also give a broad exposure to many colorectal diseases. Sometimes in a large center, you'll see a lot of rare conditions or a large volume of difficult cases, but “bread and butter” colorectal cases can be fewer. Of course, being in a program with few fellows puts more work burden onto fewer individuals. These are just generalizations of course: There are programs that are major referral centers with only two fellows, and there are some programs with many fellows but provide a very personalized experience. An important way to determine the positives and negatives of a program is during the interview.

Deciding on the number of programs to apply to can be difficult. Too few may limit your chances, too many is expensive and may complicate your final decision process, and limit interview opportunities for your colleagues. Although accurate numbers are not available, most applicants apply to 5 to 20 programs., with the expectation of receiving interview offers at five to eight programs.

THE INTERVIEW

Traditionally, interviews take place during August, September, and October. The rank-order list is due in early November and Match Day is usually in the latter half of November.

Once the interview comes around, be yourself. Be on time. I won't repeat the traditional, streamlined codes of conduct, the subject has been beaten to death of how to dress, the color of the suit and tie, the height of your heels, and so on. The interview is an important chance to introduce yourself. It is also the chance to ask important questions about the program.

You want to know that you will get a well-rounded and balanced education. Make sure you find out about possible deficiencies in the six Core Competencies as reviewed by the Residency Review Committee (RRC) or in achieving minimum numbers of cases by category as defined by American Board of Colon and Rectal Surgery (ABCRS). Use the opportunity to question the current fellows about their experience, if they have enjoyed their year, about living conditions, and about learning opportunities (clinical and didactic). Ask about the trainees and staff case-load, both regarding quantity and complexity, laparoscopic versus open cases, exposure to endoscopy, anorectal cases, and physiologic testing and ultrasound. Ask about the role of the trainee in patient management and operations. Do they watch, assist, or perform the procedure? Ask about structure and organization of everyday work, as well as about research and dedicated research staff. Find out about the available equipment such as TEMS, robotic techniques, ERUS (3D vs standard).

Interviewing is a costly process. During the interviews, I kept a detailed list of all my expenses for my 12 interviews. This amounted to over $5,000 for travel, lodging, food, and clothing. This does not include the cost of the applications themselves. An early application will receive an early invitation, thereby enabling you to schedule interviews according to geographical proximity, and save on cost for travel. Also, using FedEx last minute becomes a very expensive and unnecessary expenditure.

Interviewing is overall an enjoyable, but consuming process. As a chief resident you are leaving behind a busy service and then making up for lost time at work. The process was worthwhile as I enjoyed tremendously meeting colleagues in my future field, which also confirmed my decision of pursuing colon and rectal surgery.

Take time after each interview to send letters of gratitude and show your interest—if you are interested. Personally, I preferred e-mails over actual letters, handwritten or not. They were easier to keep track of, appeared more matter of fact, and felt more natural to me—less antiquated or made up. I am not sure though if other applicants or, more importantly, the program staff share my opinion on this matter. You need to do what feels best for you.

Systematically keep track of the programs you interview with, write down your impressions—good, bad, red flags. Speaking with other applicants is a good source of information. Their impressions about programs may provide additional insight or confirm your opinions. It is remarkable how frequently your future colleagues will share your identification of the strengths and weakness of individual programs. It is also interesting how different they may value those impressions.

RANKING

The next important and difficult step is ranking the programs. According to the rules of the match, programs are not allowed to ask you how you will rate their program. However, it seems that programs tend to rank applicants higher who seem to be interested in their program. This may be due to the program and applicant having similar interest. Another reason is that many applicants find a way to express their interest in specific programs. This has been done by having your mentor, program director, or chair communicate with a program of interest. The rank process favors the applicants, so rank highest the programs you liked the most, i.e., those where you could see yourself training. If you definitely don't want to go to a program, do not list it.

If you are considering a research year, you should also communicate with the programs offering such training. Some positions are offered prior to the match, sometimes with a commitment to a follow-up clinical year. Others are offered after the match. Each of these options should be discussed with the program you are considering.

MY SMALL, PERSONAL TIPS

I can't but help to include a couple of tips that proved to be extremely helpful for me during the interviews. If you are one of the few people who don't have an iPhone or an equivalent cousin, I warmly recommend that you get one. It saved me many times with various arrangements such as booking a flight or hotel last minute, finding my way in a new city or airport, finding phone numbers, and even looking up last-minute details about the program or city I was interviewing in. The most extreme save by my phone was when I discovered after driving half the distance of my 3-hour drive that my suit still hung neatly at home. I was wearing unsuitable jogging clothes. While driving, I located through the iPhone all Ann Taylor stores between me and the interview, called the store closest to the highway, told my story and gave my size. With the iPhone, I navigated to this store where a suit and blouse hung ready in a fitting room. I was still in the fitting room while my credit card was being processed, after which I ran out to be 10 minutes early for my interview. Create a FedEx account! It was especially helpful after the match. This enabled me to send documents for the medical license, my visa, and such. Keep FedEx envelopes and labels in your car and office. Just remember to keep track of the charges made to your account, as I had four charges made erroneously for other FedEx shipments. This was quickly resolved by FedEx.

AFTER THE MATCH

Start all your paperwork for the fellowship immediately. Time flies in a busy chief year, and you don't want a lacking medical license to hold up your start.

IF YOU DON'T MATCH

Failing to match can be devastating. After the match results come out, there will be applicants who did not match and sometimes programs who failed to fill their slots. The process of matching these two groups is often referred to as the “scramble.” Information on applicants who did not match is available to programs and program information is provided to applicants. The two may contact each other, so it is important to be available. Programs with an unfilled research year will also contact unmatched applicants.

If you fail to match and colorectal surgery remains your goal, you should attempt to make yourself more competitive for next year's match. This may start with a discussion with your mentor or staff at programs you have interviewed at. What were your strengths or weaknesses? Did you have research experience, publications, or presentations? Was your personality not a match? Did you apply to programs that were not a good fit to your long-term goals, e.g. are you interested in private practice, but applied to a program that is interested in producing academic surgeons? You might consider taking a research position that would allow you to improve your competitiveness.

CONCLUSION

Colon and Rectal Surgery is a wonderful field that has seen a surge in popularity, making a more competitive match. Start early with preparation for the match by researching the programs online and asking other colon and rectal surgeons for their insight. Acquaint yourself early with the application process and have letters of recommendation and your personal statement available early. Apply, schedule interviews as they come in. And finally try to enjoy the interview process as much as you can.

DISCLOSURE

The author is a colon and rectal surgery trainee at the Ochsner Clinic Foundation and the opinions are her own. She has no other conflicts to disclose relative to this manuscript.