Article In Brief
Neurology residency program directors, residents, and fellows are advocating for a more uniform and later start to the fellowship application process.
A movement is abound among residency program directors, residents, and fellow to change the timeline for when trainees can apply for fellowships. And the AAN is supportive of the move. Earlier this year, the AAN called on the United Council of Neurologic Subspecialties (UCNS) to endorse a new universal timeline for neurology fellowship applications. In a January letter to the UCNS, then AAN President Ralph L. Sacco, MD, FAAN, FAHA, laid out a position statement and proposed schedule under which the application process (communications between programs and candidates, interviews, etc.) would begin no later than March 1 of the PGY-3 year for adult neurology residents, and March 1 of the PGY-4 year for pediatric neurology residents.
Under the proposed timeline, no offers could be made prior to August of PGY-4 for adult neurology and PGY-5 for child neurology.
What's the problem with the current timeline? Over the past several years, the fellowship application process in neurology has moved relentlessly forward, various residency program directors told Neurology Today in interviews. Programs that once began accepting applications in March or April of the PGY-3 year now expect to receive them six to eight months earlier.
“I've been program director for our neurology residency program for six years, and associate program director for six years before that, and each year, fellowship timelines have moved earlier and earlier by six weeks to a month,” said Raymond Price, MD, FAAN, associate professor of clinical neurology and director of the neurology residency program at the University of Pennsylvania, and a member of the AAN's Graduate Education Subcommittee (GES), which drafted the position statement.
“Our residents are reaching out to programs as early as August or September of the PGY-3 year, and often sending in applications in October or November, when they've only been in their neurology residency for 13-15 months and have not even been exposed to many areas yet.”
Abhimanyu Mahajan, MD, a movement disorders fellow at the University of Cincinnati Gardner Neuroscience Institute, is also a member of the GES and past chair of the Consortium of Neurology Residents and Fellows. He said the difficulty with the current timing was underscored by a conversation he had recently with a friend who is a current PGY-3 neurology resident.
“He told me that certain headache fellowship programs were accepting applications beginning in August of the PGY-3 year, which is ridiculous,” he said. “A resident has just begun their second year of neurology residency, and they're supposed to have had enough experience with headache to know that they want to pursue a fellowship, and also to know their headache neurology faculty well enough to ask for recommendations and have a strong enough CV to apply? And then what happens if you apply to the program and get in, and by the end of PGY-3 or beginning of PGY-4 you realize that you've committed to a specialty or a program that's not the right fit for you?”
“It's a buyer's market,” said Zachary London, MD, FAAN, James W. Albers Collegiate professor of neurology at the University of Michigan, past chair of the Consortium of Neurology Program Directors, and a member of the GES. “There are more fellowship positions than applicants, and if there's no requirement about when you can offer your fellowships, you are incentivized to do it earlier and earlier. It spirals out of control.”
This inexorable push for earlier and earlier applications and decisions can either force residents to jump into a specialty they're not sure about or paralyze them with indecision, Dr. Price said. “I've had very talented residents apply and accept positions and a year later realize that's not what they wanted to do, and withdraw, which causes negative feelings both for the fellowship program and for the resident,” he said. “On the other hand, one resident found the pace so stressful that he procrastinated and then had to scramble for a fellowship much later than everyone else in the class, because he was having trouble picking a particular neurology subspecialty.”
Because neurology fellowship programs do not have an overarching match system (although a few, like movement disorders, do have their own match), the schedule for interviews and applications is random. Residents must reach out to each program separately to find out their timeline for interviews and applications.
“Even within a subspecialty, programs are acting on different timelines, and so it's very possible that you will interview at one place and they will offer you a position, and you have to tell them yes or no before you can even interview at a second or third place,” said Dr. Price. “Because of this tremendous variability, prospective fellows end up making decisions in an uninformed manner.”
Complicating matters further is the fact that the first year of most neurology residency programs (PGY-2) focuses largely on inpatient neurology, so if a resident is making fellowship decisions early on in PGY-3, he or she has had little to no exposure to subspecialties that are primarily outpatient. “By early PGY-3, my clinical neurology experience was almost all in stroke,” said Dr. Mahajan.
What the Surveys Say
Establishing a clear and reasonable schedule for the fellowship application process enjoys wide support among neurology residents and program directors alike. In the 2017 AAN Graduating Resident Survey, 45.6 percent of the residents felt that they did not have enough outpatient exposure to make an informed decision about possible fellowships, and 88 percent felt that the fellowship application cycle should start no sooner than the second half of the PGY-3 year. And in the 2017 AAN Adult Neurology Program Director Survey, 78 percent of the 106 participating directors said that they believe the fellowship application process starts too early, with many making comments that a start date in the late PGY-3 or early PGY-4 year would be better.
Neurology wouldn't be the first specialty to make such a move. In 2011, internal medicine fellowships established a standardized timeline, with applications opening in July of the final year of training, and a match occurring in December of the same year. In a 2014 report in the American Journal of Medicine, the move was praised by program directors, who reported that the new timeline benefited all involved—fellowship applicants, fellowship programs, and residency programs—with fellowship applicants benefiting the most.
“We really are a delayed identifier of this issue,” said Dr. Price. Medicine has gotten all of their much more disparate fellowships, like cardiology, pulmonary, and gastroenterology, on the same time frame toward the end of the second year of training. Pediatric neurology also recognized this as an issue five or six years ago and went to a match.”
So if the vast majority of neurology residents and neurology residency program directors agree that the application process should be reformed, what's holding things back? It's a combination of factors, said Dr. London. “In theory, everybody is on board with this. But there are a few practical concerns. First, some subspecialties do already have a match and they don't want to change their timing. Other subspecialties, like neurocritical care, neuro-ophthalmology, and sleep medicine recruit people from other specialties, and they have to align their application cycle with the cycle of those fields.”
But the biggest issue is: who goes first? “People are afraid that if they agree to wait on interviews, the program down the street won't,” Dr. London said. Internal medicine moved to a match system, while we face this, he said: “If you have an official match and sign a contract, you can't make offers or interviews outside that match.”
“The position statement and the AAN's proposed schedule aren't enforceable,” he continued, “so the concern is that if some programs abide by the recommendations and others don't, it will just hurt the ones who do. That's the feedback we got from subspecialty organizations: We love this idea, but if you can't enforce it, it's hard for us to endorse it.”
Support from the Field
Despite that “prisoner's dilemma” roadblock, eight organizations, including some subspecialty organizations, have endorsed the position statement, including:
- American Headache Society
- American Heart Association/ American Stroke Association
- American Neurological Association
- Association of University Professors of Neurology
- Consortium of Neurology Program Directors
- National MS Society
- Neurocritical Care Society
- United Council for Neurologic Subspecialties
“Getting the support of individual fellowship program directors will be important to moving this forward,” said Erica A. Schuyler, MD, associate professor of neurology and neurology residency program director at the University of Connecticut, chair of the Consortium of Neurology Program Directors, and a member of the GES.
“We have now contacted each subspecialty organization and are making a push to get the different subspecialties and programs to agree to moving their application cycles back starting next year. Successes like we have had getting groups like the American Headache Society to support the new timeline are encouraging. It's not a question of if it will happen, it's how are we going to get from the current state to that more reasonable timeline.”
One idea might be a sort of Kickstarter or GoFundMe-type initiative, but one which generates pledges of timeline changes rather than of money. “We could ask programs to sign up on a public website to say that they will adhere to the recommended timeline for interviews, applications and offers,” Dr. London said. “You put your name on a list of programs that are willing to use the recommended timeline, but unless we reach some sort of critical mass in terms of the percentage of programs that agree to do it, we won't hold you to it. If we reach that critical mass and you don't stick to the timeline, your program will be called out on the website as noncompliant. Public shaming can go a long way, and I think over the course of a year or two, that could make a sea change. And once everyone does it, it will be better for programs and residents alike.”
“We all want good fellows for our programs, but the focus has to be on what's best for the residents,” said Dr. Mahajan.