Internal Medicine Residency: Is Subspecialty Fellowship Right for Me?

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Congratulations! You’ve made it to internal medicine residency and are settling into the swing of things. As you hunker down for the rest of the 3-year adventure, another big decision looms on the horizon: should you pursue an internal medicine fellowship after residency?

According to recent data from the National Resident Matching Program (NRMP), the number of applicants applying to the Medical Specialties Matching Program in 2021 was the largest in history, with over 7,400 active applicants. Nearly 80% of these applicants matched into a fellowship, and filled over 90% of participating medical subspecialty fellowships.

With so many options available, your next steps can be overwhelming to think about while also adjusting to residency. Here are a few ways to decide if a subspecialty fellowship is right for you and take early steps towards applying.

Explore your career options

After internal medicine residency, most graduates choose to either enter general practice or pursue an internal medicine fellowship for focused training in a subspecialty.

General internists can work in a variety of clinical settings. In the outpatient arena, they can practice primary care medicine and deliver acute, chronic, and preventive care to a panel of patients over time. General internists can also work in the inpatient setting as hospitalists. Some general internists practice both primary care and hospital medicine or work in other clinical settings, such as urgent care clinics. There are opportunities to engage in research in a specific area, get involved in medical education, or complete a 2-year fellowship in general internal medicine. Over time, some general internists focus their practices on a particular area of interest, such as perioperative or complementary medicine. Others may concentrate on the care of specific patient populations, such as university students or nursing home residents.

There are many subspecialties within internal medicine, such as cardiovascular disease, pulmonary/critical care, gastroenterology, allergy and immunology, and hospice and palliative medicine. Subspecialty training is either exclusively certified by the American Board of Internal Medicine (ABIM) or by the ABIM in combination with other specialty boards. Physicians typically enter subspecialty fellowship after completing internal medicine residency. Fellowships can vary between 1 to 3 years. Within each subspecialty, there are opportunities to practice in inpatient or outpatient settings and get involved in focused research and medical education.

Consider what you enjoy about medicine

Ask yourself whether you enjoy interacting with patients across a broad range of conditions (big-picture view) or treating patients for a limited number of conditions at an in-depth level. Having an interest in a certain disease or working with a specific patient population can also impact this decision.

If you’re interested in researching particular areas or performing specialized procedures, you might consider a fellowship in that area. For example, gastroenterologists may commonly perform upper endoscopies and colonoscopies, and interventional cardiologists may perform cardiac catheterizations. Additionally, consider the typical income and lifestyle (such as typical work hours and call responsibilities) related to your subspecialty of interest.

Inform your decision

Many residents make the decision to pursue a subspecialty fellowship in their first or second year of residency, although there are still opportunities to enter a fellowship later. You may be wondering how to gain the insights and experience needed to determine if a subspecialty is right for you. Having varied clinical experiences during residency in both general internal medicine and in subspecialties will help you get a sense of what practice is like in each field.

You can also take steps during day-to-day encounters in early residency to expose yourself to the subspecialty you’re considering. Perhaps you’re on the general wards as an intern interested in exploring hematology and oncology. You learn that a patient with newly diagnosed acute leukemia has just been admitted to your team. Being proactive in caring for this patient can help you learn about the condition, provide valuable care, and also get to know current fellows and attending physicians in the field.

Make connections and get involved during residency

Finding a mentor in the field and connecting with people who work in a variety of clinical settings within the subspecialty is also important. Interacting with mentors builds an understanding of what life is truly like as a specialist both at work and outside of work. Mentors can also help you find opportunities for scholarly work and research in the field.

While finding the time for academic pursuits as a resident can seem overwhelming, you can get involved in scholarly work by publishing a case report on an interesting patient encounter or developing educational material for other trainees. Other ways to engage in research include performing a quality improvement project or dedicating an elective month to work on a focused research project. Maybe you’d like to attend subspecialty conferences to learn about the broader scope of the field and meet people at different institutions, which may include places you’re interested in pursuing a fellowship.

You may also consider having a discussion with your residency program director early on about your interest in a subspecialty fellowship. Program directors may offer insights and guidance into the process and recommend mentors or related experiences in that subspecialty. They can also help plan your residency schedule to facilitate rotations in the subspecialty and accommodate fellowship interviews.

Understand the fellowship application process

Internal medicine fellowships generally start in July after the third year of residency finishes in June. You can apply to most subspecialty fellowships within internal medicine through the Electronic Residency Application Service (ERAS), a centralized online application service. You can find a list of fellowships participating in ERAS on their website and contact nonparticipating programs directly for information on how to apply. ERAS applications for fellowship typically open in June of each year, so it’s common to begin working on applications around the time the third year of residency starts. This is around the same time you may begin studying for your ABIM certification exam as well, so it’s a good idea to give yourself plenty of time.

Internal medicine fellowship applications require supporting documents such as a personal statement and letters of recommendation, so it may be helpful to begin preparing these during the second year of residency. Fellowship programs can start viewing applications in late July, and individual programs set their own deadlines for applications. Fellowship interviews are often during the fall of the third year of residency.

The NRMP is a separate organization that handles the process for applicants and programs to enter their preferred rank order lists to match candidates to fellowship programs. As with ERAS, some fellowship programs don’t participate in the NRMP match. Applicants participating in the NRMP typically find out which fellowship they’ve matched to on Match Day, typically during November or December of the third year of residency. On Match Day, applicants who participated in NRMP but didn’t match can view a list of unfilled fellowship programs so they can contact the programs to determine whether a spot is available.

Write your personal statement

The approach to writing your personal statement for an internal medicine fellowship may differ somewhat from essays you wrote for medical school or residency. Since fellowship applicants have already had multiple years of experience as a physician, the personal statement should demonstrate a maturity level and focus. Unlike earlier applications, you don’t need to extensively detail how you decided to become a physician or how you chose your residency specialty, although you may discuss these topics briefly as they pertain to explaining your subspecialty choice.

The essay should generally begin with an introduction that clearly indicates your chosen subspecialty and area of interest. It’s important to describe your prior experiences in the subspecialty, such as focused clinical interactions or research activities, to establish a solid record of your knowledge and accomplishments in the field. Explaining which aspects of the fellowship program are particularly attractive to you can be beneficial. Describing your future career path within the subspecialty can also be helpful.

The length of the fellowship personal statement should typically be brief, roughly 650 words, but this is not a hard-and-fast rule. Begin drafting your personal statement early so you have ample time to refine it and seek and incorporate feedback from those you know personally and professionally, such as friends, family members, mentors, and residency program directors.

Commit to a lifetime of learning

Pursuing a career in medicine is a continual journey of lifelong learning and fine-tuning your path along the way. Deciding whether to pursue a subspecialty fellowship is an important step along this journey. Although the road may appear daunting at first, by taking small and achievable steps early in your residency, you’ll be able to gather the insights and experiences needed to determine the right career path for you.

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By Melinda Chen, MD

Melinda Chen, MD is a general internal medicine physician, medical educator, and health services researcher. She enjoys working with the Internal Medicine team at Blueprint/Rosh Review to help learners achieve their goals.