Megan D. Henley, M.D.
Vanderbilt University Medical Center
Adult Cardiothoracic Anesthesiology Fellow 2018-2019
Critical Care Anesthesiology Fellow 2019-2020
Why these fellowships?
Entering anesthesiology residency, I had an idea that cardiac anesthesia was the subspecialty for me, but found that I also truly missed the ICU. Beyond the challenge and complexity of a perioperative surgical patient and the desire to become a true expert consultant of anesthesiology, I also enjoyed being identified as my patients’ “doctor,” as I fulfilled the role of not only a talented clinician but also a compassionate caretaker and teacher to our patients, families, students, and colleagues. Having enjoyed the role of educator throughout my premedical and medical education, I knew that academic practice would likely follow the completion of my training, and decided to pursue fellowship training in order to hone and develop skills toward this end.
Thanks to these insights, I decided to pursue dual fellowships in adult cardiothoracic and critical care anesthesiology. While this is an increasingly common venture, it remains logistically complex and a predominantly anecdotally guided application process; the only resource we have, especially for those at institutions without either fellowship, is speaking with those who pioneered this dual training before there were even national Matches.
How does the application, interview, and match process work?
Applying for both fellowships is unfortunately not as easy as applying to a “dual” or “combined” two-year program. While a few two-year integrated positions exist, the majority are simply two sequential years of adult cardiac anesthesia and critical care anesthesiology fellowships. It is a two-year process that can involve a match exemption in many situations.
You must first decide whether you would like to complete your training at two different programs, potentially necessitating a move in between. Like many, I chose to complete both fellowships in the same location in order to have reinforcement of knowledge between fellowships as well as continuity of the hospital system, ORs and ICUs, faculty, and model of care. Of course, this may mean that you don’t attend the reputed “best” for both fellowships, but there are many program options that offer equally strong and excellent training in both. Your choice will determine your approach to applications.
Among six criteria (https://socca.org/fellowships-overview/), those completing residency at their desired fellowship institution and those intending to complete more than one year of training at a single institution are eligible for a match exemption, allowing a program to make an offer for both positions simultaneously “outside of the Match.” However, this is somewhat of a misnomer, as exemptions still require completion of a rank list and a formal Match in two sequential years.
To apply for both fellowships in the same location, you will actually apply to both the Cardiac and Critical Care matches in November of your CA-2 year through the San Francisco Match. The Cardiac match usually opens on November 1st and Critical Care opens about 2 weeks later. Unlike ERAS, you can complete and submit your application to programs on this opening day, necessitating significant forethought in having your CV, personal statement, letters of recommendation, professional picture, and multiple other documents (transcripts, MSPE Dean’s Letter, and board and ITE scores) ready to submit. Due to the time frame, CA-1 ITE scores are the only ones submitted with applications. Once the SF Match documentation is complete, you will need to contact each program to express your interest in dual fellowships. Many programs also require copies of some or all of the above documents to be submitted by mail or email, which can be a tedious, time-consuming process. It takes approximately 2 weeks for the SF Match to distribute materials, after which programs review applications and make interview offers. For the most part, programs will coordinate internally to offer integrated visits for interviews with both programs. This is often done in one, longer interview day, but is occasionally done in two back-to- back days, increasing the need for time off from residency for travel and interviews.
Interview stake place predominantly between January and May with a rank lists due in late May or early June and a mid- June Match. Those receiving an “out of match” dual offer will formally accept their fellowship positions in writing, withdraw from the second fellowship’s match, rank their program alone as #1 in the single Match, complete exemption documentation, and undergo the Match for only their first fellowship that year. The next year, a second Match application and additional exemption documentation will be submitted, with the second program ranked alone as #1 to complete the Match for the second fellowship.
For example, since my experience was that of an “outside of match” dual offer at a single institution, I qualified for a match exemption and received and accepted offers in Spring 2017 before formally matching for Cardiac Anesthesia in June 2017 for a 2018-2019 position and Critical Care Anesthesia in June 2018 for a 2019-2020 position. You will note that both applications and matches occurred prior to completion of residency.
Those opting to only apply for fellowship positions at two different institutions will not qualify for the match exemption discussed above (though may qualify for others), and thus will individually apply to respective programs in the CA-2 and CA-3 year and will rank multiple programs in the Match as with residency.
During the application and interview process, one ultimately must also decide the order in which to do the fellowships. There are arguments for cardiac first (continue the clinical momentum of residency, have a strong foundation before critical care fellowship for CT ICU-heavy fellowships or aspirations) or critical care first (have a strong critical care foundation before managing the complex cardiac patients, spend the year out of the OR first so that your cardiac year prepares you for attendingship). For some, programs may guide this decision as they traditionally only offer one order or attempt to balance multiple dual fellows between two years.
What things should I look for during interviews?
As discussed in the Winter 2018 Fellowship Spotlight on Cardiothoracic Anesthesiology Fellowship, there is wide variability in cardiac programs. Differences are largely in annual case volume, case “sitting” versus supervision or a balance of both, and distribution of clinical case types (transplant, pump cases, aortic cases, structural heart, robotic and minimally invasive procedures, etc.) Critical care fellowships have similar variability with differences primarily in the “home” ICU (most are surgical ICU based with a CTICU base in a few), the exposure to different ICUs (burn, neuro, trauma, transplant, medical, VA, etc.), the amount of echo experience (TTE and TEE), and degree of fellow autonomy. Didactic structure and call schedules/responsibilities also vary significantly. Asking about these things in interviews are key to guiding your decision, but it’s also important to get a feel of the program overall and decide if it’s a place you would like to train, with people you like and approachable, involved faculty. Having frank conversations with current fellows was very helpful in understanding the responsibilities fellows have in the day-to-day. Most of my experiences were very collegial and laid back in trying to determine the best fit for both parties.
Ultimately, the application and interview process for “combined” fellowships is complex and challenging for dual applicants, but incredibly rewarding to have comprehensive and specialized training as an anesthesiology consultant. There is no doubt that you will receive excellent training at nearly any institution, and the correct fit exists for most.