Eyes on the prize: How to land an ultra-competitive fellowship

By Naveed Saleh, MD, MS | Fact-checked by Barbara Bekiesz

Published June 23, 2023

Key Takeaways

The competitiveness of any fellowship program will depend on factors like the number of unfilled positions and the number of applications per applicant, along with novel metrics.
Significant competitive advantages include building a brand and networking.
It’s important and advantageous to invest in cultivating strong relationships with mentors when pursuing fellowship.

The competition to get into a selective fellowship can be fierce. There are many subspecialties that will be completely filled after the match, including cardiology and pediatric surgery. To win acceptance to any competitive fellowship requires dedication during residency.

Fortunately, you can increase your chances of being chosen for a competitive fellowship by building a personal brand that conveys engagement, finding good advisors, and networking.

Boosting your odds for selection

Let's reiterate a point that cannot be overstated: It’s crucial to establish connections with a mentor, or several mentors, who can help you reach your goals.

According to the authors of an article in the Journal of Community Hospital Internal Medicine Perspectives, “Understanding how to advise residents to maximize their success in an environment with limited spots and limited fellowship faculty resources to perform holistic review remains one of the primary objectives of most residency mentors.”^[]

The authors also note that while you're still a resident, you can alter the odds in your favor by making connections with local faculty, joining national society mentorship programs, performing research, crafting a strong and positive personal brand, and making sure your personal statement is well-written and high quality.

The most competitive fellowships

Assessing the competition of specific fellowships depends on perspective and what’s being measured.

For instance, in a 2023 fellowship match summary published by the National Resident Matching Program (NRMP), competitiveness can be judged by considering the number of fellowship types that were 100% filled.^[] These include the following:

Medical toxicology (emergency medicine)
Cardiovascular disease (internal medicine)
Interventional pulmonology (internal medicine)
Oncology (internal medicine)
Complex family planning (OB/GYN)
Gynecologic oncology (OB/GYN)
Minimally invasive gynecologic surgery (OB/GYN)
Reproductive endocrinology (OB/GYN)
Pediatric surgery
Vascular surgery

You can also assess fellowship competitiveness by using the average number of applications submitted by each applicant. The most recent published statistics by the AAMC are from the 2022 match.^[]

The top-three most-competitive fellowships for applicants who are US medical graduates (USMGs) are gastroenterology (internal medicine), with 68.7 applications/applicant; cardiovascular disease (internal medicine), with 64.9 applications/applicant; and gynecologic oncology (OB/GYN), with 54.5 applications/applicant.

The following are the numbers for international medical graduates (IMGs): cardiovascular disease, with 115.1 applications/applicant; gastroenterology, with 102.4 applications/applicant; and hematology-oncology, with 87.9 applications/applicant.

Researchers from the California Northstate University College of Medicine developed a metric to estimate entry competitiveness in a single number.^[] Factors considered in the Fellowship Competitiveness Index include fellowship filled percentages, the percentage of applications from USMGs, mean matriculating United States Medical Licensing Examination (USMLE) Step 1 scores, and mean post-fellowship salary.

According to the researcher’s calculations, cardiology was the most competitive procedural fellowship in the field of internal medicine, whereas hematology-oncology was the most competitive nonprocedural fellowship.

"We believe that this metric is a simple, accessible, and valid measure of competitiveness of fellowship entry and with further manipulation can be generalized to residency competitiveness. "

— Authors, Journal of Community Hospital Internal Medicine Perspectives

Building your brand

Certain past factors can’t be changed when applying to fellowships, say the authors writing about gastroenterology fellowships in the journal Digestive Diseases and Sciences.^[]

Such factors include current residency program, USMLE scores, medical school attended, pool of faculty available to write letters of recommendation (LORs), and IMG/visa status. Consequently, it’s important to concentrate on strengths that can be improved and weaknesses that can be addressed.

Through self-reflection, competitive fellowship applicants can help build their reputation/brand, achieve personal growth, and hone interpersonal skills.

A resident should also demonstrate engagement in the subspecialty they choose, according to the authors of the Journal of Community Hospital Internal Medicine Perspectives review.

“Performing well on the in-house rotation is not in and of itself enough to demonstrate engagement,” they wrote, advising residents to attend specialty conferences held by their institution to facilitate networking among faculty. Establishing these relationships will help fellow-hopefuls find much-needed mentors and increase their likelihood of receiving strong LORs.

Keep in mind that subspecialty electives should be scheduled earlier rather than later to help determine which fellowship appeals to the resident.

Connecting with others

LORs are key in communicating engagement and interest in a subspecialty, write the authors of the Journal of Community Hospital Internal Medicine Perspectives review. Between the second half of intern year and first quarter of PGY-2, residents should meet with the local fellowship director and key faculty members to express their interest, request advice, and secure mentorship.

Although the importance of away electives has been questioned—especially in the wake of the pandemic—it’s important to find advocates at other institutions when seeking fellowship.

Subspecialty associations and their national meetings provide excellent opportunities to connect with potential mentors from other institutions.

Mentors are integral to success, state the authors in the Digestive Diseases and Sciences article, and fulfill different roles, such as research mentors, career mentors, inspirational mentors, and peer mentors. Having multiple mentors aiding with different aspects of training is common.

For instance, senior faculty mentors have connections at specialty societies and publications, which can prove valuable when getting your work published and presented. They can also get you in touch with pertinent fellowship faculty at other institutions.

On the flip side, a junior faculty member with a shorter employment history and fewer connections could serve as a research mentor who is more easily accessible and available to the mentee.

When establishing a productive mentor-mentee relationship, it’s important to define your specific needs and goals at the start, which will inform your mentor as to the appropriate game plan. Mentors can also be useful in finding other mentors who can further contribute.

The authors writing in Digestive Diseases and Sciences (who possess insight about the rigors of attaining a place in a GI fellowship) advise applicants to avoid biting off more than they can chew.

"When working with your mentor, the best strategy is to under-promise and over-deliver since this will strengthen the impression that you are dedicated [and] hardworking. "

— Authors, Digestive Diseases and Sciences

Research and scholarly work

There exists no silver bullet as to the number of papers or projects you need to undertake to match in a competitive fellowship. Nevertheless, due to the competitive nature of residency and the number of exemplary candidates with excellent LORs, scholarly work serves as a proxy for a resident’s motivation to pursue an academic career.

“It is usually advisable to have one project of your own serving as your main focus while also continuing to work on case reports, review articles, or even additional research projects with others in which you may make a smaller contribution,” note the Digestive Diseases and Sciences writers.

“For residents who do not have mentors at their own institution, scholarly work such as writing review articles or helping with meta-analyses and systematic reviews are good ways to engage in projects with mentors at outside institutions, since these types of projects do not require that you have access to a particular institution’s resources or medical records.”

Another way to build a foundation of scholarly work is by volunteering for peer-reviewed journals.

Reviewing case reports and the like can improve your chances at landing a competitive residency, while allowing you to learn more about the peer-review process.

A strong personal statement

Personal statements help distinguish applicants and should expand on—and not regurgitate—other components of the application, like the CV. The personal statement should portray self-reflection and the potential for growth.

The authors writing in the Journal of Community Hospital Internal Medicine Perspectives advise that, if you mention research in your personal statement, it’s a good idea to describe the positives and negatives of the experience, as well as how the research aligns with your future career goals.

Similarly, pivotal life events should be presented from the vantage point of how the event shaped interest in the fellowship and your career path.

Surmounting failure can make for another compelling angle in a personal statement, and can demonstrate the applicant’s ability to accept feedback, commit to lifelong learning, and engage in self-reflection.

What this means for you

Despite the competition, you are capable of earning acceptance into the fellowship of your dreams. Success requires careful attention to your brand and your scholarly experiences. Being the recipient of strong LORs from the right faculty can be pivotal. It’s crucial to establish connections with a number of mentors who can help you reach your goals and who will network on your behalf with their colleagues at other fellowship programs. Attending and presenting at national conferences can also serve as valuable introductions to fellowship directors and faculty at other programs. Finally, remember that an engaging and introspective personal statement can help differentiate you from other candidates.