Applying For Hematology/Oncology Fellowships as an International Medical Graduate: An Interview With Hematology Educators

Matching into a hematology/oncology fellowship can be extremely competitive for international medical graduates (IMGs). According to the National Resident Matching Program (NRMP), there were 909 applicants for 638 positions offered at more than 160 U.S. hematology/oncology (HO) fellowships in 2021. All 638 positions were filled, and while more than half of applicants were IMGs, only 28 percent of those who matched were non–U.S. citizen IMGs.¹

Apart from feeling the need to achieve higher academic accolades than other applicants, IMGs may also face challenges related to immigration visa considerations as well as varying rules from institutions regarding visa sponsorships. Matching as a married couple when both applicants are physicians is particularly challenging for IMGs and it is not uncommon for couples to be separated during fellowship training, which may add additional stress to family and professional life. In the hopes of strengthening their candidacies for fellowship positions and in attempting to overcome hurdles related to immigration, applicants often resort to nontraditional paths such as practicing internal medicine for a period or engaging in research for many years prior to applying for fellowship.

With the 2022 HO fellowship match approaching, we interviewed hematology educators who directly participate in HO fellowship candidate recruitment.

Dr. Ariela Marshall is the newly appointed director of the Women’s Thrombosis and Hemostasis Clinic at Penn Medicine and will serve as associate program director for their hematology fellowship. Dr. Vijayalakshmi Donthireddy is the Hematology/Oncology fellowship program director at Henry Ford Hospital. Dr. Srikanth Nagalla is the chief of benign hematology at the Miami Cancer Institute and former hematology/oncology fellowship director at UT Southwestern Medical Center.

Q: Please describe your philosophy in inviting HO fellowship candidates for an interview.

Dr. Ariela Marshall: I think this really depends on the individual fellowship program and what they are looking for. Some are looking for trainees who will primarily become physician-scientists, some are looking for trainees who will go on to practice clinically, and many are looking for some balance between the two. Different programs also use different metrics to select candidates and place different priorities/values on things like USMLE [United States Medical Licensing Examination] scores, letters of recommendation, prestige of the institution where an individual attended medical school and/or residency, etc. Personally, I advocate for a holistic view of fellowship applicants where we do not “pre-screen” or set specific cutoffs to select interviewees (e.g., minimum USMLE score, training at only top-tier programs, etc.) but instead consider each applicant individually based on their background, struggles they have faced versus advantages they have had, and the success someone has achieved with what they had to work with at the start. For example, someone who comes from a disadvantaged background may not have the opportunity to attend a good college and thus may not be accepted to a top-tier medical school, and therefore not get into a “best” residency and have the advantage of doing research with well-known scientists. But if they did the best they could with what they had to work with and demonstrate an incredible work ethic and drive, I would consider them a qualified applicant.

Dr. Vijayalakshmi Donthireddy: Candidates who are considering a career in HO must have a certain curiosity for the challenge of this science, the vigor towards a sustained clinical or academic professional life, and the grit and compassion to endure emotions with a personality to succeed at teamwork. The institutional milieu and priorities have to match with the candidates’ personalities and priorities for a successful training period to serve as a strong foundation for their careers. The various domains of the ERAS [Electronic Residency Application Service] application give a glimpse into the candidates’ professional and humanistic attributes, which are weighed in for the selection of interview candidates.

Q: Do you have a different approach for foreign medical graduates?

AM: We know that IMGs face huge barriers when applying to U.S. fellowship programs. IMGs are often unlikely to match at top-tier U.S. residency programs, so any fellowship program that relies heavily on the prestige of the medical school or residency an applicant attended is going to screen out a lot of IMGs that could be incredibly smart, productive, and dedicated. This is a big reason why I advocate for holistic applicant review. Additionally, while USMLE examinations are stressful and we hope that making Step 1 pass/fail will offload some of that stress on medical students, high USMLE scores were actually one of the few advantages IMGs had in the past, as it could set someone apart even if they did not attend a prestigious training institution. I worry that when scores become pass/fail, IMGs may lose this advantage, and it may become even more difficult to get into a good fellowship.

VD: Not really. The application does provide a sense of the candidate’s goals and their journey toward the goal. Since the immediate qualifier for the fellowship program is the residency training period, which is a relatively even playing field for trainees from all training backgrounds, there is more weight placed on what the applicant has achieved during their residency and in the years following their graduation if they were in the workforce before applying to the fellowship.

Q: Please describe a typical sequence of events after applications are uploaded in ERAS. What are some of the filters that program directors use?

AM: After applications open, program directors can filter based on any number of conditions, including minimum USMLE score (Step 1 and/or Step 2 Content Knowledge), visa status, etc. Personally, I do not believe in the use of filters as there could be incredibly talented applicants who are filtered out based on only one factor. For example, if you set a filter to “USMLE Step 1, 220 or above,” there could be an amazing applicant who had a bad test-taking experience and got a score of 219 and is otherwise a fantastic candidate. Therefore, I personally think program directors and associate program directors should review all applicants without filters. The only exceptions for me where an automatic filter is reasonable is filtering out those who have been convicted of a serious crime, or possibly filtering based on visa status, but only if a program cannot physically support a certain visa type because of institutional rules. Does this make it more work for us? Yes. Do I review hundreds of applications? Yes. But do I believe this is the right thing to do? Absolutely.

VD: Applications for training programs open in mid-July. The few weeks following this date are busy, with many hours and days spent reviewing all the applicants. Applications that are complete by the opening date probably get the most attention as they may have a chance of being reviewed multiple times in that period. ERAS does provide multiple filtering options, which helps with capturing exceptional candidates. Each application is also reviewed without any use of filters. Ultimately, the entire list of applications is reviewed one by one, sliced and diced multiple ways with the use of filters, and the process is repeated periodically to shortlist the candidates for interview.

Dr. Srikanth Nagalla: There is a minimum USMLE score cutoff that is used by some program directors as one of the criteria. Once the minimum score criteria are met, the actual score does not play a huge role in the eventual selection process. Some programs do use medical school graduation and visa status as filters. Each program is different depending on the vision of the program leadership and the institution.

Q: In order of importance, please rank the following: USMLE/Comprehensive Osteopathic Medical Licensing Examination (COMLEX) scores, letters of recommendation, research experience, program director letter, personal statement, other (please list).

AM: The importance of different applicant components differs by program and by individual. Personally, I find that the letters of recommendation are very helpful since they (ideally) comment on the applicant’s specific talents and skills both clinically and research-wise. In some cases, the letter from the internal medicine program director can be helpful as well, but in some cases, letters from program directors put applicants into vague tiers, such as “outstanding,” “excellent,” etc., without a clear guide as to what this means, such as “outstanding = top 10 percent.” These terms are difficult to interpret. USMLE scores are helpful if very high or low, but otherwise they don’t matter to me personally. Research experience is important, as is publication experience. This is not to say someone needs a large number of publications, but I want to see follow-through on the research experience: Did it lead to a publication? I would rather see someone with one or two research experiences and one or two abstracts, and at least one full-length manuscript than someone who has 10 case reports and no true research experience, or someone who has done research with five mentors but never followed through and published anything. Finally, while many folks agonize over the personal statement, I generally find it best to keep it bland. All I am personally looking for is, does this person communicate well and have a good command of grammar and language, and are they able to articulate why they want to pursue fellowship in this specialty? The touching personal stories are nice, and many of my colleagues put more stock in the personal statement, but for me, it is not one of the more important components to an application. Everyone is different!

VD: All these factors are weighed during the application review process. While the USMLE and COMLEX scores are considered, the academic achievements, work experience, and overall personality as reflected by the personal statement and the letters of recommendation carry equal, if not more, weight. While there is no rank attributable to each domain of the application, the strength and trajectory of the achievements before the fellowship application timeline is used as a surrogate indicator for future success in the program.

SN: While all components come into play when selecting a candidate, letters of recommendation, followed by the letter from the program director are most important to me personally. I then evaluate research experience/scholarly activity and the candidate’s residency program reputation. USMLE scores are of the least importance to me.

Q: Does being a chief resident help?

AM: Being a chief resident may give a candidate a slight leg up, but it is not going to be a major deciding factor. If there were two good candidates from the same residency program, and all other components of their application were equal, then the one who was chief resident may get a bit of an edge. Also, if someone did specific work as a chief in quality improvement or education for example, and had a project or publication that resulted from it, this would help.

VD: I must say that not being a chief resident is certainly not a disadvantage. There are many reasons. Being a chief resident is one step along the professional journey, and each candidate’s ultimate goal in their career path may or may not involve being a chief resident. The skills and qualities acquired during the period of chief residency may lead trainees interested in academic pathways to exploit other academic opportunities during the fellowship.

SN: It does help in my opinion. To be chosen as a chief resident, one must possess a certain degree of maturity, and the trust that the program directors put in chief residents when selecting them does speak highly of the candidate.

Q: Some residents choose to work as hospitalist physicians after residency for various reasons and then apply for fellowship. Would this affect fellowship applications positively or negatively?

AM: This could go both ways. If someone has time during their hospitalist year(s) to pursue research and writing in their field of choice, this could help. For example, someone who does a hospitalist year and also uses that time to pursue research in HO and gets two or three publications from it, or someone who does a quality-improvement project related to HO and publishes on this, could have an advantage, or at least the hospitalist time would not hurt. However, if someone takes a year or two as a hospitalist and doesn’t have any HO-related publications or projects to show for their time, this can have a negative impact on the application, as it will be perceived as a gap in the career trajectory that was not productive. If someone has a specific reason for pursuing a hospitalist year such as lining up with a partner for the couples’ match, then this is something to talk about in the personal statement and during interviews.

VD: Being in the capacity of an attending physician does add an additional layer of maturity — the fellow is able to understand the referral reasons because they have been in those shoes. Many hospitalist applicants are quite accomplished in the field of hematology or oncology even before seeking additional fellowship training. The accomplishments and academic trajectory of the post-residency years are the factors that are evaluated in the application.

SN: It is important to stay engaged. As long as the applicant was working on scholarly projects and publishing while working as a hospitalist, then the application is further strengthened, and there is no downside to that.

Q: What can foreign medical graduates do to improve their competitiveness?

AM: Be realistic. I would say that the number one thing an IMG can do is to get into the best U.S. residency program possible, since many fellowship programs do use prestige or ranking of the internal medicine program quite heavily in their decisions. That aside, personally, one of the most important things is to get letters of recommendation that are personalized, highly supportive, and that quantify a resident as “top X percent” (ideally top 5%-10%) or “top X number” (ideally top 3-5) of the residents that the letter-writer has ever worked with. It is also important to both have research experience and publish from it. As above, it is not about the number of publications, but whether someone followed through on the research projects that they started.USMLE scores are no longer going to be as important now that things are moving to pass/fail.

VD: Engaging early during the residency training period in activities that will demonstrate their interests, abilities, and achievements on the applications is key, as is seeking a senior mentor within the training program early, approaching the office of the chief residents, and making them aware of their interests so that they can be connected to projects or other opportunities that arise in their field. Approaching the research and subspecialty faculty and engaging them early in scholarly and clinical work gives enough lead time to get their fellowship applications ready, since the process of getting institutional review boards approvals and manuscript submissions can be time-intensive.

SN: Working hard, connecting with HO physicians, engaging in research, and publications are all key.

I hope you found the candid answers by Drs. Marshall, Donthireddy, and Nagalla helpful for your fellowship journey. As an IMG with a nontraditional background, I know the path to a successful fellowship match can be stressful. In an effort to be academically productive, one’s hard work may often be lost and misguided; therefore, I would add that finding the right mentor or a sponsor who will take you in and give you direction is critically important. Asking for help with personal statement edits by a native English-speaking friend or faculty member can make a huge difference. Most importantly, continuously delivering excellent patient care and genuine personality traits never goes unnoticed and is often reflected in letters of recommendation. I wish you all a successful match!

1. National Resident Matching Program. National Resident Matching Program Results and Data: Specialties Matching Service 2021 Appointment Year. February 2021.