Article In Brief
Neurology subspecialty fellowships can vary from one subspecialty and institution to the next. Five fellowship directors share advice about how to find—and secure—a spot in the right program for you.
For many neurologists, deciding to pursue a subspecialty fellowship may be easy. However, deciding which fellowship programs to pursue can be more challenging because such programs vary dramatically.
Jeffrey Cohen, MD, completed a fellowship in neuroimmunology at the University of Pennsylvania in 1987. His career subsequently has combined patient care and clinical/translational research. Since 1994, he has worked at the Cleveland Clinic Mellen Center for Multiple Sclerosis Treatment and Research, where he directs the Experimental Therapeutics Program and Clinical Neuroimmunology Fellowship.
Tyson Burghardt, MD, was finishing his neurology residency at Wayne State/Detroit Medical Center, when he decided to stay for a fellowship because he was unsure about what kind of practice he wanted. Within a month, he recognized his knack for neurodiagnostics and knew he had found his right place in medicine. Today, he is director of neurophysiology, vice chair of neurology, and program director of the epilepsy fellowship at Sparrow Hospital in Lansing, MI.
“The thing to do is to right-size the fellowship opportunity with your career goals,” said Dr. Burghardt, associate professor and chief of the epilepsy division at Michigan State University College of Osteopathic Medicine.
How to do that? Neurology Today spoke with five fellowship directors to get their advice about how to secure a place in the right fellowship program for you.
Medical training can be brutal, but a person’s career should be fun, so the choice of subspecialty should align with a neurologist’s personal and professional preferences, said Rajesh Pahwa, MD, FAAN, chief of the Parkinson and movement disorder division at the University of Kansas Medical Center (KUMC) and director of its Parkinson Foundation Center of Excellence.
“If someone wants an eight-hour shift job, neurology hospitalists and neurocritical care/stroke doctors can do that,” said Dr. Pahwa, Laverne & Joyce Rider Professor of Neurology at KUMC. “If someone wants few emergencies, they might want to consider movement disorders.”
Those work-related preferences should be considered in tandem with lifestyle choices, such as the size of the city or university setting in which a neurologist hopes to work.
Those preferences should influence fellowship decisions, Dr. Burghardt said. A neurologist who wants to perform advanced epilepsy surgery at a level 4 center needs a fellowship that provides that level of training.
“But not everyone wants to do advanced brain mapping in the OR, and by the same token, not everyone wants to just do a 9-to-5 in the clinic,” he said. “So, matching what a fellowship offers in terms of training and case volume and case complexity with what you want to do in your career is really important.”
‘Unaccredited’ and Matching Explained
In some subspecialties—such as neuro-oncology, headache medicine, and interventional neurology—fellowship programs are accredited by the United Council for Neurologic Specialties or the Accreditation Council for Graduate Medical Education. (An accredited fellowship program meets the standards set by the accrediting body, and fellows take an examination to demonstrate their mastery of the material.)
Many neurology subspecialties have no accreditation program, however, so each institution that offers a fellowship decides the content. In those subspecialties, it’s important to factor into the fellowship decision the reputation of the program and its faculty.
Movement disorder fellowships, for example, are not accredited, and Dr. Pahwa said he would be unlikely to hire a fellow trained in a program with which he is unfamiliar.
“When we in the movement disorders field are looking at other fellows, we pretty much know by reputation which institutions would produce the fellows we would want,” he said. “Even though we (as a subspecialty) are not accredited, we know how well the fellows are trained.”
Some neurologic subspecialties—movement disorders, neurocritical care, headache medicine, vascular neurology, and others—have matching programs administered by SF Match or the National Residency Matching Program. Those programs, like residency matching, allow candidates to file a single application.
Institutions that offer a fellowship in a particular subspecialty are not required to participate in the matching program.
The Competitive Landscape
Some programs have a rigorous application process, while others do not. The New York-Presbyterian neurocritical care fellowship typically receives more than 60 applications annually; this year, about 40 applicants were interviewed. The two-year program offers five positions one year and four positions the next for a total of nine fellows at any given time.
Candidates interview with at least 10 people over at least eight hours.
“Part of the reason that we have this long day of interviews is because the days are long for the neurocritical fellow and we want to make sure that you’re able to withstand the test of time,” said associate fellowship director Alexander Merkler, MD, MS, assistant professor of neurology in the division of neurocritical care at Weill Cornell Medicine.
“You need to go strong—bring some snacks with you—and continue to give your best effort throughout the entire day,” said Dr. Merkler, who is also an assistant professor of neuroscience at the Brain and Mind Research Institute and director of the NewYork-Presbyterian Tele-NeuroICU Service.
By contrast, a joint fellowship offered by the National Institute of Neurologic Disorders and Stroke (NINDS) and the Food & Drug Administration’s (FDA) Center for Drug Evaluation and Research accepts fellowship applications on a rolling basis, said Lauren Reoma, MD, FAAN, a staff clinician at NINDS in neurovirology and neuroimmunology and director of its clinical trials unit.
The fellowship is appropriate for neurologists who want careers outside of pure clinical practice, such as those who aspire to work in academia, the pharmaceutical industry, or in government. Dr. Reoma directs the fellowships intramural site, which focuses on clinical trials methodology. The extramural site focuses on the grants review process and the FDA site focuses on the regulatory science of packages that come to the agency.
The fellowship typically has one fellow a year. Neurologists who express interest in the program submit a CV and statement of interest, which circulates among the three sites. “If the subspecialty area and applicants prior work matches up for all the sites, and the interview goes well, then those are our most competitive applicants,” Dr. Reoma, said.
Similarly, KUMC’s movement disorders fellowship does not participate in the matching program the SF Match offers. Dr. Pahwa mentors the institution’s own residents who show an interest in movement disorders and want a career that combines patient care and clinical research, hoping they might consider staying on for a fellowship.
The program accepts only one fellow at a time, and fellowships can last one or two years. Dr. Pahwa is open to considering candidates outside the KUMC system, but “we don’t go out and look for applicants—we let them find us.”
Ask the Right Questions
When evaluating fellowship opportunities, particularly in subspecialties for which accreditation does not apply, candidates should ask detailed questions about the training program, said Dr. Cohen, who is also the Hazel Prior Hostetler Endowed Chair and professor of neurology at the Cleveland Clinic Lerner College of Medicine. For example, they might ask about whether financial support is available to attend conferences, or if a formal curriculum exists, including lectures or a journal club. They should also ask whether they will “be exposed to a variety of different perspectives, such as clinicians who have different approaches,” Dr. Cohen said.
“And, conversely, does the program have a coherent therapeutic philosophy? Or is it a group of individual clinicians who work in the same program but don’t do anything in common?” he added.
Candidates should seek detailed information about the clinical training aspect of the fellowship. Those pursuing a neuroimmunology fellowship should ask about their opportunities for longitudinal patient care since patients with MS and related disorders need to be managed over time.
By contrast, those pursuing a movement disorders fellowship should ask whether they will get experience with specific therapies, such as deep-brain stimulation, pump-delivered therapy, and botulinum toxin therapy, Dr. Pahwa said.
Other questions to ask: ‘“Will I be getting an opportunity to use the newer Parkinson’s medicines?” he said. “And will I be allowed to go to the meetings and learn what is happening elsewhere?”;’
At NINDS, Dr. Reoma wants to hear candidates ask about opportunities for their subspecialty interest.
“You would certainly need to find a clinical research niche—neuromuscular, epilepsy, or a particular disease focus—to make sure that you can find a focus in our program that fits you,” she said.
Candidates for the NINDS/FDA fellowship also should ask about the patient care responsibilities, which differ markedly from those in standard academic medical centers. Fellows see relatively few patients but spend a great deal of time with them as research participants.
“If you’re looking for a heavy degree of clinical volume, this is not the place,” Dr. Reoma said. “This fellowship focuses less on the individual disease and more on a sound foundation for a future clinical research career. We want to train the leaders in experimental neurotherapeutics of the future.”
Most fellowship programs, by contrast, provide clinical care and clinical research opportunities, and candidates should inquire about the ratio of the components. Dr. Cohen’s program at Cleveland Clinic offers two tracks: About half the fellows do a one-year fellowship in which about 80 percent of their time is spent seeing patients, with the rest devoted to scholarly activities. The others extend the fellowship to two or three years, earning a master’s degree in clinical research while conducting a research project and treating patients.
Dr. Merkler wants candidates to ask questions that show true interest in working with Weill Cornell Medicine specialists, such as ‘“Tell me what sets your program apart from other fellowship programs,”’ or ‘“Can you tell me where some of the graduates have ended up?”’
He appreciates candidates who have done a bit of research on the professors they would be working with. “I like it when someone asks, ‘Why have you stayed here instead of going to other places?’” he said. “That allows me to expound on why I think it’s a great program, and those are good questions that show that the applicant has done a little bit of homework, which shows automatically that there’s an interest.”
Dr. Merkler also likes to hear candidates ask the direct question: What are you looking for in a fellow? “That allows me to say that we want people who are going to be leaders, who are excellent clinicians, who are trustworthy and who are excited to be here,” he said.
Applications and Interviews
The Cleveland Clinic neuroimmunology fellowship program receives about 50 applications a year, and it typically offers four to six positions. It evaluates applicants based on their academic record, where they trained and their accomplishments, such as publications, meeting presentations, and awards. It also gives stock to an applicant’s letters of recommendation.
“We look to see who the letters are from, whether it is convincing that they know the applicant well, and any accolades that they mention,” Dr. Cohen said.
To Dr. Burghardt, a candidate’s CV is less important than personal attributes. He expects anyone who has completed a neurology residency to be smart enough to succeed in a fellowship; he looks for candidates who are easy to work with, dependable, and honest.
“My fellows can be wrong, and they often are in the beginning—they just need to own up to it,” he said. “And if they cause harm, they need to try and make it right as much as possible. Those are the things I cannot compromise on.”
Institutional funding for fellowship programs is not necessarily available, so candidates should ask whether funding is secure and what their responsibilities for obtaining funding entail.
“Fellows should ask explicitly whether the position is contingent on getting funding or not,” Dr. Cohen said.
In his program, fellows often receive grant support from the National Multiple Sclerosis Foundation; if that is not available, the Mellen Center pursues grant funding from other sources.
“When we offer a position, we commit to that fellow, whether they’re successful getting a grant or not,” he said. “Programs that do not do this put the fellow in a very difficult position if, for example, six months before their fellowship is scheduled to start, they are told that because they didn’t get funding, they don’t have a position.”
Meanwhile, at Michigan State’s epilepsy fellowship, fellows help fund the program themselves by working in the clinic. They are considered trainees except for a half-day of clinical practice each week in which they see patients independently. “The billing for those visits goes directly to our department to help defray the cost of the fellowship,” Dr. Burghardt said.
Fellowship directors offered these other tips for selecting the right programs.
- Ask what others think. The best way to learn about a program may be to seek the perspective of current fellows and residents. “They can give you the nitty gritty on actual day-to-day interactions with the attendings you are going to be working with on a daily basis,” Dr. Burghardt said.
- Avoid certain questions. Dr. Merkler and his colleagues go over the schedule with fellowship applicants. “But I don’t like it when applicants ask, ‘How many hours are we going to be there?’ or ‘What time is sign out?’” he said. “I see that as sort of a yellow flag.”
- Stay engaged and connected in your interview. Looking at a cell phone or not making eye contact during an interview, which Dr. Merkler said occurs a surprising amount of time, gets noticed but for all the wrong reasons.
- Be conversational. Dr. Merkler and his colleagues use the interviews to evaluate whether they will be able to get along well with a potential fellow and whether they can trust the individual to handle difficult conversations with patients and their families. “Just being able to have a conversation is actually really important,” he said.