The Value of Electives (Both Internal and External) During Pathology Residency

It’s been a while since my last blog. I haven’t had as much time and energy as I would like this past year. For now, I’ll just say…appreciate all that your chief residents do because much more time and effort lies beneath the surface than everyone is able to see.

But the topic for this blog is the value of electives during pathology residency. Our programs vary with respect to electives in terms of number and ability to take them externally or not. My previous program had five electives that could be taken internally or externally. However, external electives did not receive salary support and I didn’t take any electives although I could’ve during my two years in Chicago. Since we had a decent number of electives, many residents scheduled them internally during fourth year to have lighter months to study for boards although a handful did utilize them during earlier years for external electives.

My current program has two and we do receive salary support with external electives. For my first, I had an extra month of hematopathology internally because I wanted to see another perspective on one of my chosen subspecialties. Internal electives are good to spend more focused time in an area of subspecialty interest that you may have for fellowship. It also allows for the opportunity to develop deeper relationships with the faculty who will most likely be writing your letters of recommendation for that fellowship. They may also provide you with the opportunity to become more involved in research and/or publications (eg – book chapters, case reports, research articles) with a mentor and these are all helpful in enhancing your fellowship and future job applications and build up your CV.

Currently, I’m on an external elective at the institution where I’ll do both my hematopathology and molecular genetic fellowships. I’m laying the groundwork for molecular hematopathology research now that hopefully results in data analysis over the ensuing months to culminate in an abstract submission for the American Society of Hematology (ASH) which has a deadline only a month after I start fellowship. I also want to use this time away to get to know people at my future program better, prepare for my eventual move here, and study for boards. Hopefully, I’ll also get a sense of the daily work flow as I am also attending signouts and intra- and interdepartmental conferences so that I can manage my time as efficiently as I can from day 1 of fellowship. I really like the culture and people here, but that’s subject matter for a future blog. I also am enjoying the benefits of attending inter-program activities as TMC is the largest medical center in the world with active interaction and collaboration between member hospitals. Not so much in my case since I obtained both my consecutive fellowships last year as a PGY-3, but for many, the value of an early external elective is that it can be seen it as an “audition” rotation to obtain a desired fellowship. You may even be able to ask for an interview before you finish (which saves you time and money). I also have some friends who were offered fellowship spots at the end of their elective rotation because they impressed the fellowship director. Obtaining fellowship positions is pretty competitive and there tends to be fewer spots than there are for residency. And in many cases, positions are not even available if an internal candidate is chosen early (even during their PGY-1) so anything to augment your fellowship application is a plus.

Now that I’ve mentioned external electives, I’d like to give some advice on setting up an external elective. First, start as EARLY as possible! Even a year or more before isn’t too early to ask about getting the ball rolling. Start preparing and updating your CV from your PGY-1 as you’ll need this for both external elective and fellowship applications. Scan and keep a PDF of all your vaccinations and work-related health requirements (eg – PPD/Quantiferon results, flu vaccine, hepatitis B testing, MMR and hepatitis B antibody titers, and N-95 fit testing) as well because its likely you’ll also have to include this in your external elective application.

I initiated the elective rotation request about a half year prior to the actual rotation. And even then, that was not early enough and everything came down to the wire. It’s far more complicated than when we applied for elective rotations as a medical student and takes much more time. Since we are now physicians, you are more than likely required to have at least a medical permit in that state to rotate and this process can take a while. Also the back-and-forth between program coordinators and the respective GME departments can appear glacial at times, and in my case, was the main cause of delay. I hit several delays at obtaining paperwork (especially between Christmas and New Year’s when many staff were off at both programs, my medical school, and the Texas Medical Board where I needed paperwork from). It can be time-consuming to have to make multiple phone calls, and often, the process cannot be completed until its antecedent step has been approved. I know residents who have had to postpone external rotations because paperwork between GME departments (eg – PLAs or malpractice agreements) were not in place in time. Maintaining constant and open communication between all parties involved is a must and sometimes easier said than done the more people that are involved.

In addition to obtaining the state medical permit (which generally requires an application fee; in my case, $135), there may be other requirements that are also time-consuming and financially expensive. You may be required to do pre-employment-type health screening (in my case, a $36 urine drug screen) at your own cost as you are not a true employee. I also had to become ACLS certified (at $120, despite being BLS certified and a former American Red Cross CPR instructor). But since I’m going to be a fellow here, I can get it reimbursed through my GME funds and would have to do it later anyways so I might as well do it now. But if you are not doing an elective at your future fellowship institution, it’s good to find out what items may incur cost in your application for your elective since you are not likely to get reimbursed and so you can decide whether those expenses are acceptable. One way to defray costs is to apply for grants such as the ASCP subspecialty grant which is administered to six residents twice a year (Jan/Aug). In fact, the next deadline is this Friday, Jan 15th! You can find more information on how to apply at



-Betty Chung, DO, MPH, MA is a fourth year resident physician at Rutgers – Robert Wood Johnson University Hospital in New Brunswick, NJ.

Final Thoughts from the Fellowship Application Process

And with the dawning of a new year, I’m another year closer to becoming a full-fledged pathologist. Exciting and yet daunting at the same time as I have only 1.5 years and my AP/CP boards left before I start my fellowships! So, I thought I’d leave some final words on what I learned during the fellowship application process for those who have yet to go through it.

The earlier you decide on your choice of fellowship(s), the better you can prepare by presenting and publishing research in your area of interest, spending extra rotation time and study in areas related to your interest, and networking within your academic subspecialty organizations. I would say for the first half of first year, concentrate on your rotations especially surgical pathology and grossing technique. But at the latest by the second half of your first year, start honing in on what you think you’d eventually like to do and working toward that goal. Most residency programs are amenable if you ask them to adjust your schedule so you can rotate early through subspecialties of possible interest during your second or early third year. Don’t forget to ask for lighter rotation months and less/no call duties during peak interview season (Oct-Jan).

If you can, do an elective during your second or early third year in your subspecialty of interest at your dream program(s) before fellowship decisions are made and fund it through grants such as the one offered by ASCP (1/16/14 deadline; application here). I found that often, positions were already promised or eventually went to internal candidates or external candidates who had done an elective prior to their interview. Scheduling for elective rotations takes foresight, time and effort (eg – state medical license can take months), and an available rotation spot during your desired month, so start the process early!

Research early to create your application list. Only you will know the number you feel comfortable applying to which depends on your personal situation (eg – subspecialty competitiveness). I found that attending conferences and listening to speakers in my content area of interest helped me to decide which programs I may like. I’m also very active in CAP and ASCP and the physicians I work with in these roles, pointed me toward programs where the culture might be a good fit for me as they were role models of the type of people that I would like to work with. Of course, I also applied to top programs that I knew or that my attendings advised me were good.

Then check with programs about the opening date for application submissions if it is not posted on their website. I found that frequently, these were not hard deadlines. Since we don’t have a match, decisions are rolling (eg – I got promised an offer during my interview day and have friends who also had similar experiences). Once again, the early bird may catch the worm, and not because they are necessarily the best bird, but the first bird that a program likes. While some programs have a schedule for decisions, I found that just as many made offers as soon as they found someone they liked.

Make sure that personal statements are no longer than one page, shorter is better. You can follow this format: 1) how and why you fell in love with that subspecialty, 2) what you bring to the table especially for the program, and 3) what you want out of your fellowship and why that program is the best to accomplish those goals. Ask multiple people in your subspecialty or more senior residents to give you feedback on your personal statement/CV and for letters of recommendations very early – give a deadline earlier than you need so that you can have them ready by the time you want to submit.

I applied mostly to programs that had both hematopathology and molecular pathology fellowships and stated in my cover letter that I wanted to do both consecutively at the same place (but that it wasn’t a deal breaker). I received invites at almost all but decided to interview at a select number. For the ones where I interviewed for both fellowships (ARUP, Hopkins, MD Anderson, UPMC, Houston Methodist), it was usually the program looking for the fellow first who made the arrangements with the other fellowship. ARUP had interviews over 2 days (paid expenses except airfare) but the others all worked it out so that half a day was interviewing for hematopathology and the other MGP. Receiving an offer from one did not necessarily mean that I would automatically get one from the other. Scheduling both on the same day, also made things a little more difficult.

Respond to invitations quickly because this process is truly rolling. I was often given a limited choice of date(s). One place gave me only one date for an interview that I couldn’t make. Rescheduling can result in losing an interview because programs interview less people over fewer dates than they did for residency and will schedule someone else if you can’t make it. Some programs told me they were interviewing 2-3 per position while others said 5-10.

Be courteous and prompt, send your “thank you” email/note early and no later than by the next day. You can have a basic “thank you” email template ready to go that you can personalize so that you can send it even while waiting at the airport to go to your next interview. And be honest. I found that being upfront made it easier for programs to extend me a counteroffer when I mentioned that I had to make a decision soon on another offer. Once you’ve accepted a position, keep in touch with your program to hit fellowship running! I hope to do a PGY4 research elective in order to submit abstracts for conferences that occur soon after I start my fellowship and to familiarize myself with the EMR and clinical workflow in both fellowship areas.

And finally, be true to yourself about your goals, realistic possibilities, and most importantly, the program characteristics that will make you most happy. When I was applying to college, academic prestige and idealism were important, and for medical school, proximity to my aging parents. But now, what I find most important is the fit of the program. I want to be happy and feel like it is my home. I want to be at a place that hires their alumni and goes out of their way to help them find jobs. I want to be around role models working in areas that I want to as an attending: advocacy, medical education, and research…and of course, foremost, clinical diagnostic excellence…and who I feel will continue to support me as colleagues in the future. For me, fellowship isn’t just the time to merely refine my clinical expertise or learn things that I didn’t get to during my residency. It was more like interviewing for a job rather than for school admissions, making decisions with a more immediate goal of what I want to accomplish after and no longer “down the road”, and most importantly, building toward my future.

And I’m happy to say that I did get multiple offers from great programs and accepted at the place I felt the best fit. It was my last interview in mid-December, so you never know. I can say that having served in positions with CAP actually helped me because I already felt at home with 2 of my interviewers with whom I serve on a CAP Council (we just had a meeting 4 days prior) and one of the current fellows who I also met through being involved with CAP. So, networking, even when it isn’t deliberate or conscious as it was in this case, can help. In case you’re wondering, I’ll be completing hematopathology (2016-2018) and molecular genetic pathology (2018-2019) fellowships at Houston Methodist and also hope to participate in research at the Houston Methodist Research Institute.



-Betty Chung, DO, MPH, MA is a third year resident physician at Rutgers – Robert Wood Johnson University Hospital in New Brunswick, NJ.

Resident Concerns, Part 2: Fellowship Applications

So, continuing on with resident concerns I heard about during conversations at the 2014 CAP Residents Forum and Annual Meeting, let’s move on to the fellowship application process.

One nice offering by the Residents Forum for the past two years at the Annual Meeting is a mock fellowship interview. The process was simple in that I only needed to fill out a brief application prior to the meeting with my fellowship interests and I was matched up with a member of the CAP Board of Governors or another CAP national leader who either practiced or had experience in my area of interest (or as close to it as CAP could find out of the available pool of mock interviewers). Once matched, I emailed my personal statement and CV to my mock interviewer (who turned out to be someone I already knew from my work on a CAP Council). I also participated in the mock interviews last year with a pathologist who I didn’t know beforehand. Both times, I received valuable feedback on my submitted materials and advice for the actual interview as well as an open invitation to contact them in the future if I had questions or needed more advice. I highly recommend these mock interviews if you are attending a future CAP Annual Meeting.

Obtaining fellowships can be even more competitive than getting into a residency. There are far fewer spots in that some may only offer one position per year in that subspecialty, programs may have already filled their positions with internal candidates, and the majority of residents (96%) apply for at least one fellowship (85% of third and fourth year residents according to the 2014 ASCP Fellowship and Job Market Survey had already accepted fellowship positions by the time of this survey during the RISE).

The trend these days is to complete at least one fellowship (56% answered yes to this question on the ASCP survey) and many often complete two (39% on the ASCP survey indicated that they would pursue two fellowships). I personally also know individuals who completed three although they are in the minority.

And it’s currently fellowship application season. Even though the suggested deadline is December 1st, we all know that most programs start accepting applications in September. I called some programs in August with questions and they had received applications already! Suffice it to say, from totally anecdotal evidence that I’ve heard, it seems that there are two periods for interviews: Oct/Nov for those accepting applications early and Jan/Feb for those who wait until December 1st to look at their applications. Even from friends in other specialties also going through this process, it seems that the process actually begins the year prior to application.

For those who want to be ahead of the game, at least start getting your CV and personal statements together. Since I’ve been updating my CV whenever something new came up since college, the CV was no problem. But I can tell you that I wished that I had started on the personal statement as a second year. I thought that I was being a semi-early bird to write my initial draft in August. But it took about a month of back-and-forth feedback from people who I asked to read it for me to whittle it down to less than one page. Turns out that most programs want something short and sweet (one page or <500 words). One program even wanted <250 words so I gave them a super abridged version of what I submitted to other programs. So, second years, start now so that you can submit everything in complete form on September 1st. The other part of applications are letters of recommendation. I’ve only heard residents from one program tell me that their letter writers will give them a letter within a day after being asked. If you’re like me, you’ll probably need to ask your letter writers way in advance and sometimes, give quiet reminders. So start early if you want letters ready by the time you submit.

The controversial issue that I always hear whispers about at the three Residents Forums I have attended is that of a standardized fellowship match like we had when we applied for residency. There are pros and cons for and against a standardized match. I was speaking with someone from the Association of Pathology Chairs (APC) and he supported a match. I would agree that it would deter residents from being subjected to undue pressure from programs to decide quickly once an offer is made (most 4th year residents who I spoke with said that they had up to 1 week at most to decide). It would also eliminate the situation that many of them found themselves in where they had accepted a position but later interviewing programs encouraged them to still interview and disregard their previous acceptances (which I think is unethical and I’d politely decline to interview at that program). But I can understand the conundrum that the later interviewing programs that follow the suggested CAP deadlines are subject to when many of their desirable candidates have already signed by the time they interview.

Unlike when the NRMP decided to go a match system for residencies, and later on, to bar pre-matching from participating institutions, the incentives and ability to leverage are very different when it comes to fellowships. Most fellowship programs offer a small number of single digit positions which they can usually easily fill without a centralized application service. And fellowships are a quasi-limbo state between school and our first “real” job. The job market does not cater to regulation and it is hoped that free competition is enough to ensure that everyone ends up where they are meant to be (although we know that connections and word of mouth still matter, especially in the small world of pathology). Programs (supposedly 51% from one study) will also often fill their spots with internal candidates and residents often feel the need to apply earlier and undertake audition rotations for the most competitive fellowships (eg – 2nd year for dermatopathology). While a standardized match may alleviate some of the aforementioned pressures, it does provide some of its own. Residents often have to spend more money to interview at a larger number of programs to feel secure that they will match somewhere and they also need to wait until later in the year to learn their fate. They also would likely have difficulty if they are trying to match for two successive fellowships which is not that unheard of, especially when those fellowships are related.

So, in terms of a standardized match, even though I usually have an opinion on most topics, I’m not sure which is better and the jury is still out. But I do know that the ability to incentivize programs into such a match process is much more difficult than it was for residency programs. It does seem though that residents do prefer a standardized application timeline according to multiple ASCP surveys even if they don’t support a match process. APC and PRODS (program directors section) tend to support a pan-pathology fellowship match while other organized groups within pathology and most residents remain skeptical that one would solve all the issues on both the resident and institution sides of the equation.

Well, for my compadres who are wading in these murky waters this interview season as I will also be, it’s a moot point. So I leave you with this: CAP had a great webinar last year by two pathologists-in-training who had survived this process as well as a program director. The webinar can be accessed here as well as a Q&A FAQ PDF from that webinar.


  1. KD Bernacki, BJ McKenna, and JL Myers. Challenges and Opportunities in the Application Process for Fellowship Training in Pathology. AJCP, 2012; 137: 543-552. Accessed at
  2. WS Black-Schaffer and JM Crawford. The Evolving Landscape for Pathology Subspecialty Fellowship Applications. AJCP, 2012; 137: 513-515. Accessed at
  3. JM Crawford, RD Hoffman, WS Black-Schaffer.Pathology Subspecialty Fellowship Application Reform, 2007-2010. AJCP, 2011; 135: 338-356. Accessed at
  4. RE Domen and A Brehm Wehler. An examination of professional and ethical issues in the fellowship application process in pathology. Hum Path, Apr 2008; 39(4): 484-488.
  5. N Lagwinski and JL Hunt. Fellowship Trends of Pathology Residents. Arch Path Lab Med, Sept 2009; 133(9): 1431-1436. Accessed at
  6. JL Myers, SA Yousem, BR DeYoung, ML Cibull (on behalf of ADASP). Matching Residents to Pathology Fellowships: The Road Less Traveled? AJCP, 2011; 135: 335-337. Accessed at


-Betty Chung, DO, MPH, MA is a third year resident physician at Rutgers – Robert Wood Johnson University Hospital in New Brunswick, NJ.