Creating a Uniform Fellowship Application Process: A Challenge Worth the Measure of the Resident Component’s Best Efforts

Christopher R. Cook, D.O., President-Elect
ASA Resident Component Governing Council

n September12, 1962, President Kennedy spoke at Rice University in Houston, Texas, where he said:

“We choose to go to the moon in this decade and do the other things, not because they are easy, but because they are hard, because that goal will serve to organize and measure the best of our energies and skills, because that challenge is one that we are willing to accept, one we are unwilling to postpone, and one which we intend to win, and the others, too.”

“It is for these reasons that I regard the decision last year to shift our efforts in space from low to high gear as among the most important decisions that will be made during my incumbency in the office of the Presidency...”

This quote really strikes home for me for several reasons. First, it was delivered only a stone’s throw away from the Texas Medical Center. Next, the president’s sense of determination and tenacity in the face of a challenge is a characteristic found in every anesthesiologist. One cannot survive to such a level of education without completely measuring the best of his/her effort and talents. In addition, Mr. Kennedy recognized that the mission to space and the moon was going to be one the largest parts of his legacy as president. For the same reasons, the ASA Resident Component is taking on the task of helping to create a uniform fellowship application process.

According to the American Medical Association’s survey of program directors, of the 1,427 residents or fellows graduating in 2006, 83 percent had known career plans after graduation, and 31 percent (or 366 residents) were planning on continuing with further training (or fellowship). With that information in mind, it is not a stretch to say that there are approximately 1,400 residents between the PGY-1 and PGY-4 years who are interested in pursuing a fellowship. It is to this group that we, the ASA Resident Component, look to assist in meaningful change to an unnecessarily time-consuming, heterogeneous and often unfair fellowship application system.

What is the history of creating a uniform anesthesiology fellowship application process?
For the Resident Component, it began at the 2006 ASA Resident Component House of Delegates meeting in Chicago when the past president of the American Society of Regional Anesthesia and Pain Medicine Resident Section, Jan J. Kraemer M.D., introduced a resolution to create a timeline for applying to pain fellowships. It included creating a universal application for programs and setting dates for both interviews and contract offers. Numerous residents at this meeting thought it was a great idea, albeit complicated. The sentiments from the Resident Component floor at that time were that the resolution still needed a large amount of “wordsmithing” and additional information on the process for a majority to agree with the resolution. In 2007, the ASA Resident Component created an 11-question survey with more than 300 resident and medical student respondents [Figure 1]. In addition, on October 13, 2007, the Resident Component House of Delegates voted on a resolution to improve the fellowship application process, which included the following resolved clauses:

RESOLVED, The ASA work with the ASA Resident Component, subspecialty societies and the SAAC/AAPD in creating a uniform fellowship application process for the currently recognized fellowships; and

RESOLVED, The ASA be involved in creating a universal fellowship application form that will be posted on the websites of the subspecialty societies and encourage fellowship programs to adopt and use this application; and

RESOLVED, The ASA work toward standardizing the period of time when interviews for fellowships will be given and when fellowship contracts will be offered.

However, this resolution excluded the creation of a National Resident Match Program (NRMP) match for anesthesiology fellowships. Residents at the House of Delegates were concerned about the expense and potential of unwanted geographic moves that could be created by the Match process.




What are some of the resident concerns about the current fellowship application process?
Specific concerns include the scheduling of interview dates, lack of uniform dates for contract offers and the number of applications that need to be completed. Some residents have reported interviews and contract offers for fellowships in December of the PGY-3/CA-2 year, while other fellowship programs in the same specialty are not even accepting applications for another six months. Other residents report receiving contract offers that expire in 48 hours while they are in the middle of multiple interviews.

Who has been involved in the discussions to create this process for anesthesiology?
In addition to the ASA Resident Component, the leadership of the Society of Academic Anesthesiology Chairs/Association of Anesthesiology Program Directors (SAAC/AAPD) and the ASA Committee on Residents and Medical Students have been involved in this discussion. They recommended using established systems such as the NRMP and Electronic Residency Application Service (ERAS) to assist in creating a more equitable system for both fellowship applicants and programs.

What are the costs for using the NRMP?
In regard to the NRMP, the direct cost for the NRMP billed at the conclusion of the match, per institution, is as follows:

$100/Institution.

$20/Program.

$20/Matched Applicant.

For residents, the direct cost of the NRMP would be $40 per applicant registered (paid online during registration).

What must happen before an anesthesiology Match can occur?
For a specific anesthesiology subspecialty to participate in the NRMP, the following criteria must be met:

1. At least 75 percent of the programs (nationally) with available positions in a given year will be registered.

2. These programs will actively participate by submitting a rank order list, and

3. At least 75 percent of the available positions (nationally) within the specialty will be registered with the NRMP.

4. Be accredited by the ACGME; or

5. Be affiliated with an ACGME-accredited program in the primary discipline; or

6. Lead to certification or endorsement and oversight by a board recognized by the American Board of Medical Specialties.

For more information on the NRMP, see the NRMP Web site at www.nrmp.org.

What are the details with ERAS?
In regard to ERAS, there is currently no charge for programs to use ERAS. The software is provided without charge. ERAS does not support Macintosh systems. Programs with these systems will need to either purchase a Windows-based system or a PC card for Macs. Some programs with Macs have been able to make this work, but ERAS would not be able to provide technical support.

The direct cost of ERAS to fellowship applicants is as follows:

$100: Registration and first 10 applications.

$10 each: Applications 11-20.

$15 each: Applications 21-30.

$25 each: Applications that exceed 30.

Applicants would begin working on their applications beginning on July 1, and programs could begin downloading applications on July 15. There is no flexibility to beginning earlier than July 1 as ERAS uses the month of June to purge the system from the previous season and prepare it for the upcoming season. This application could be followed by an October Match. It generally takes about 18 months to bring on a new specialty into the ERAS system. If you have questions in regard to ERAS, please check the ERAS Web site at www.aamc.org/audienceeras.htm.

This process is far from complete, and we encourage residents to talk with their program directors and chairs about creating a uniform process that would benefit both residents and fellowship programs. The best fellowships would get the best applicants and vice versa. The goal is to create a smooth, predictable process for residents and fellowship programs without pressure on resident applicants to apply to fellowships before rotating through a subspecialty service. We welcome any and all feedback on this topic. To get involved with ASA, please visit the newly remodeled ASA Resident Component Web site at www.asahq.org/asarc/governing.html, where you will find contact information for all of the ASA Resident Component officers.

In conclusion, creating a uniform fellowship application process pales in comparison to the amazing challenge that President Kennedy faced in getting the United States to the moon. But we, as the ASA Resident Component, will continue to face our unique challenges and take on worthwhile causes that are deserving of our best efforts. In doing so, we will aim for the stars and leave our legacy in the sky.

Christopher R. Cook, D.O., is Chief Resident at Baylor College of Medicine, Department of Anesthesiology, Houston, Texas.