Climbing the mountain to dual fellowship

Attending the American Society of Nephrology (ASN) conference in November 2005 as a second year resident inspired me to pursue nephrology training upon finishing my residency in internal medicine-pediatrics.

Many of the fellowship directors I met breathed a sigh of relief knowing that I was more than two and a half years away from finishing my residency, saying, “We will have to work fast, but we can make it happen.” Perplexed by this common theme, I could not fathom why the application process for a dual fellowship in both pediatric and adult nephrology would be “rushed” in order for this prospective graduate of June 2008 to enter a fellowship program without a gap in time.

Little did I know what an arduous journey lay ahead. Coordinating a dual fellowship in adult and pediatric nephrology would entail 62 applications, more than $1000 in application fees, 15 vacation days to interview at 16 fellowship programs, a few thousand dollars of airfare, and one chief resident year buying extra time to make it logistically possible.

The journey started during my intern year when my chief resident sparked my interest in nephrology. She suggested nephrology because of my interests in procedures and in having varied experiences in outpatient clinics and critical care settings. She also knew my interests in developing long-term relationships with patients, as well as practicing in a field with intricate involvement with many other organ systems.

A pediatric nephrologist told me about the ASN meeting in Philadelphia in November 2005 and said it would be a great way to learn more about the field, network with nephrology fellowship directors, and discover cutting edge research.

In uncharted territory

Prior to attending the ASN meeting, I thought I would have to choose one fork in the road—either adult or pediatric nephrology—upon finishing residency and entering fellowship. My horizons broadened upon meeting one medicine-pediatric nephrology fellow from the University of Michigan who was very encouraging about the field. Three fellowship directors from around the country were equally inspiring about making a career in medicine-pediatric nephrology work.

With adult nephrology fellowships lasting two to three years and pediatric nephrology fellowships lasting three years, I learned that a combined fellowship could be done in four years. Everything has to fall into place though. I spent an extra year (thanks to being chief resident) thinking about this extra lifetime commitment—almost like a marriage with a career field in uncharted territory.

How would I go about applying for two fellowships? There were very few people to ask for help because my residency program had only one pediatric fellow and a small number of internal medicine subspecialty fellows, none of whom were in nephrology. Of course. Fortunately, two of my chief residents in internal medicine had been accepted to nephrology programs on the East Coast. Plus, great mentors in both the pediatric and internal medicine nephrology divisions gave keen advice on where to apply.

One more feature of the 2007–2008 application cycle complicated entering a combined fellowship in July 2009. The adult nephrology fellowship programs were entering a match for the first time. Coordinating pediatric nephrology, which was not on a match, and adult nephrology, which was on a match, made this journey even more difficult.

I sought out all 31 pediatric nephrology fellowship programs that had a corresponding adult nephrology fellowship program at the same university and hoped for the best. Fortunately, they all used the Electronic Residency Application Service (ERAS), allowing me to save some time in applying by having one common application. I did have to line up eight letters of recommendation (four pediatric and four adult) and tell all authors to explain why I would be a good candidate for two fellowships. In order to be granted an interview, my personal statement had to connect with two fellowship directors in different fields. I had to explain that I was not some crazy guy who could not decide between children and adults, but rather a person who wanted to bridge the gap in care for children with chronic kidney disease as they enter adulthood.

Here was the difficult timeline: All fellowship programs could download my applications on December 1, 2007, through ERAS. The peds programs were motivated to fill their spots as soon as possible because this was being done outside the match. Due to its inaugural year as a match program, the adult programs had no idea how many people to interview to fill all of their spots in the match.

They did know, however, that time was on their side, with five months to interview candidates before a June 19, 2008, match. Having a pediatric program hold a spot for me until I could match with the adult counterpart on June 19 seemed like the impossible hurdle I would have to overcome to make this work. I soon learned that there was a much more feasible approach.

Foreshadowing the difficult process yet to come was the timing of interview invitations. Invites would come in from a pediatric division at one university and a medicine division at another. For the longest time, I was considering whether or not I would have to commute between two states, with a selling point if the two programs were at least in the same time zone! Then things started to work out. After endless emails, phone calls, checking of application status, and explaining what I wished to accomplish through two fellowships, the corresponding divisions offered me interviews to match the initial interview invitations. The next hurdle was scheduling interviews.

Trying to line up two consecutive interview dates—one with pediatric, the other with adults—was quite challenging. But, eventually it worked for almost all the programs I applied to. One school, which had previously accepted a combined fellow, actually was able to interview me for both fellowships on the same day—a very good sign that things could work out at this school.

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During residency, I trekked to a 15,000-foot mountaintop to see the lost ruins of Machu Picchu. The trek to my fellowship was a lot longer, more costly, and with many more bumps in the road. —Stephen Darrow

Interviews Galore

Overall, I sat through 80 interviews, 80 times explaining why I was pursuing this career field. Some institutions were more receptive than others. Some became inspired by thinking outside the box. Others expressed concern that funding and logistics might not work out.

These challenges became quite apparent with the two-year adult nephrology fellowships. Who would cover all the second year of the adult fellowship? With my pursuit of only one year of adult clinical nephrology (followed by one year of pediatric clinical then two years of research), a gap in coverage year two would manifest. I realized that I would have a better shot at making this work if I pursued the three-year adult nephrology programs (where fellows do one year of clinical and two research). The two years of research could then overlap naturally between adult and pediatric.

Most programs were very receptive to my joint fellowship idea and were courteous in allowing me to continue my personal timeline for interviews in January through early April. After that, however, it was all waiting and hoping. It was difficult getting a sense of how things were going.

With the match limiting how much feedback an adult nephrology program could give an applicant, it was like playing poker with the best players. I had decided by that point that the only way a combined fellowship might work out would be to accept a pediatric nephrology fellowship for year one then hope that the corresponding adult program would save a spot outside the match for me a year later. Fortunately, offers came that were even more promising. I was accepted into a pediatric nephrology program for the first year with the corresponding adult division agreeing in advance to hold a spot for me outside the match for year two.

During residency, I trekked to a 15,000-foot mountaintop in the Andes Mountains to see the lost ruins of Machu Picchu in Peru. The trek to my fellowship was a lot longer, more costly, and with many more bumps in the road. I heard on the interview trail that there were possibly two other medicine-pediatric grads pursuing this same goal. If you are out there, look me up at the University of Minnesota. We can all share stories about our journeys.