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Research Fellowship

Author

Erik R. Hofmann, MD, MS
Emergency Medicine, PGY4
Administration Chief
LAC+USC Medical Center

Special thanks to our 1st edition writing team

Erik R. Hofmann, MD, MS

INTRODUCTION

Description of the specialty
Emergency medicine research fellowships provide a non-ACGME-accredited post-graduate training opportunity for emergency medicine (EM) residency graduates interested in pursuing a career in basic and clinical research. The Society for Academic Emergency Medicine (SAEM) has approved a subset of eligible research fellowships that have met a number of milestones based on predetermined guidelines. Fellows who complete a research fellowship at a SAEM-approved site receive a certificate of approval upon completion. Emergency medicine is a dynamic specialty that relies heavily on evidence-based medicine to guide everyday practice. EM is an ideal specialty for studying acute emergencies with a broad mix of patients and conditions. The proportion of academic faculty involved in research and the proportion of studies published in emergency medicine journals that have research funding has been climbing. Emergency medicine research is growing quickly, and fellowship training has been one successful pathway to increase EM research success.

History of the specialty/fellowship pathway
The Josiah Macy Jr. Foundation sponsored a conference in 1994 titled “The Role of Emergency Medicine in the Future of American Medical Care,” which recommended that medical schools develop and enhance academic departments of emergency medicine. The conference also recommended that the American College of Emergency Physicians (ACEP) and SAEM should convene a conference to develop an agenda for research in EM and to define strategic options for implementing that agenda. The Research Directions Conference in 1995 presented 5 recommendations of their own in response to the Macy conference in order to develop and enhance research support both outside and within departments of EM. These recommendations included: support for basic, clinical, and health services research pertinent to EM practice; promoting collaborative and interdisciplinary research within and across traditional institutional boundaries; development of new systems to manage clinical information; development of new methods to assess the outcomes of emergency care; and to seek and develop increased funding sources for EM research. The Future of Emergency Medicine Research Conference in 1997 issued a call for more EM physicians to pursue fellowship training within and outside the traditional EM settings, to seek advanced degrees, and to develop focused research mentorships. The conference also recommended that academic institutions draft a strategic plan to develop or improve research capabilities for EM, protect time for productive researchers, support promising interdisciplinary collaborations, and provide statistical and study design support within their departments. The Emergency Medicine Foundation, SAEM, and ACEP have been tasked with advancing these various goals and to act as a clearing house of advanced research training opportunities pertinent to EM and to facilitate the advancement of promising individuals into research fellowship training.

Why residents choose to follow this career path
Residents who desire to incorporate the conduct of research into their career while working at an academic institution choose to follow this career path. Several studies have demonstrated that residency and fellowship training with a focus on research is associated with increased career satisfaction, as well as success in obtaining increased grant funding, academic promotion, and an increased number of publications.

How do I know if this path is right for me?
If your goal is to become a leader in the field of emergency medicine research, then this is the right path for you. Individuals who pursue a research fellowship have a passion for discovery in health services and clinical research, research methodology, and/or biostatistics. A career in research also includes a fair amount of writing in the form of manuscripts and grant proposals. Consequently, an aptitude for writing, while not a necessity, is definitely an advantage. Individuals who go into academic emergency medicine in general are enthusiastic about teaching and enjoy collaborating with an interdisciplinary team.

Career options after fellowship
Most research fellows remain in academic medicine after fellowship. Some fellows accept an attending position at the institution where they completed their fellowship, giving them the opportunity to continue their research. Others accept faculty positions at other academic institutions as members of a research division. There are also positions available in health policy if you opt to do a health services research fellowship. Where you end up really depends on what your research focus was during fellowship. It is important to find a program that will allow you to develop your clinical skills as a faculty member at an institution that has the resources available to fund your research.

Academic vs. community positions
Nearly all EM researchers practice at an academic institution. However, there are a limited number research opportunities within the community setting, including the Clinical Research in Emergency Services and Treatments (CREST) network within the Kaiser Permanente health system, and other regional institutions. It is important to determine what funding revenue streams are available and the scope of research being performed at each institution when considering a career in research in either setting after your fellowship.

IN-DEPTH FELLOWSHIP INFORMATION

Number of programs
There are currently 40 non-SAEM approved sites and 13 SAEM approved sites in the United States and Canada. 

Differences between programs
All of the programs will aim to train you to be an excellent researcher in emergency medicine or a multitude of other disciplines. SAEM created a list of fellowships in order to promote standardization of training for fellows, though many excellent programs do not participate in the SAEM review process. There are a number of milestones that institutions must address in curricular elements, faculty support recommendations, and career development opportunities in order to be considered an SAEM-approved site. Fellows will receive a certificate of approval upon completion of a SAEM-approved site. Many programs offer opportunities to obtain an advanced degree including a Master’s of Public Health (MPH) or a Master’s of Science in Clinical Research (MSCR). Research fellowship programs are often dedicated to a specific area of research while others provide research opportunities in a number of different areas specific to emergency medicine. It is important to visit each institution’s web site to determine if there is a specific research focus. 

Length of time required to complete fellowship 
Research fellowships are 2-3 years in length.

Skills acquired during fellowship 
All programs will train fellows to conduct high quality research. In general, research fellowships will include the following components: course work in methodology, biostatistics and content area expertise; direct mentoring from senior research faculty; and practical experience in the form of a fellowship research project. SAEM-approved fellowship programs are required to specifically address instruction in areas including hypothesis generation, research design, data collection methods, data monitoring and interim data analysis, data analysis, presentation of research, project management, ethical aspects of medical research, regulatory requirements, informatics, teaching skills, manuscript submission, and grant submission. Fellows are expected to submit at least one study to the IRB during training. Fellows are also expected to author at least 2 full-length manuscripts and submit a competitive grant application to the NIH or another major national organization for at least $100,000. It is recommended that clinical hours be restricted to 8 hours per week, and it is required that clinical hours be restricted to a maximum of 12 hours per week. All fellows are required to pursue their research training for 40 hours per week, and programs must guarantee that trainees will have at least 75 percent nonclinical time for at least 2 years.

Typical rotations/curriculum during fellowship 
The curriculum is institution-dependent, especially with non-SAEM-approved sites. Generally, the first-year concentrates on didactic coursework working towards a MPH or MSCR, and conducting preliminary work on a research project. The second year focuses on continuing master’s coursework and preparing a grant for submission to a federal agency. Fellows also have clinical duties and teaching during their two years. A minimum amount of protected time is set aside for research related academic activities, which is dependent upon each program. Other activities can include fellow seminars, which involve grant proposal discussions and work-in-progress presentations.

Board certification afterwards? 
There is currently no board certification for research fellowships, although there is an SAEM-approved fellowship certificate of approval. 

Average salary during fellowship 
Salary is variable, ranging from a low range approximately equivalent to that of a PGY-4 to a higher range similar to other clinical instructors. Practically this range is between $55,000 to $95,000 per year. Most of this variation is driven by the clinical work differences between fellowships. Benefits, tuition, and travel funds vary based on institution.

PREPARING TO APPLY

How competitive is the fellowship application process?
Research fellowships are not generally thought of as highly competitive. Most applicants who apply end up finding a position but applicants for research fellowships tend to be very accomplished. Fellowships vary in terms of mentorship and structure. It is important to find a research fellowship with good mentors and one that has a structured plan to gain skills in data analysis, manuscript preparation, and grant writing. 

Requirements to apply
The only requirement is that applicants are board-prepared or board certified in emergency medicine. Since this is a research fellowship, a demonstrated interest in health services or clinical research, and a commitment to a career in academic emergency medicine is a must. There are no set guidelines in terms of how many publications an applicant needs to be considered competitive, however, it is recommended that the applicant complete at least one research project during residency. Ideally the applicant should have at least one publication in a peer-reviewed journal and at least one poster presentation of their research at a national conference. 

Suggested elective rotations to take during residency
The research fellowship is unique because there are no specific rotations to take during residency. It important to start looking for a research project early in your training, especially if you are coming from a three-year residency. Starting a project on your own and finding a mentor that will work with you may not be time effective given the time it takes to plan, execute, and publish a research project. The best way to mitigate the time constraint of residency is by joining an active project that is already underway within your department. One way to get involved early is by attending research meetings within your department’s research division and finding out what projects are currently active or in the planning process. Another way to get involved is by contacting a mentor within your department that is involved in a research project that may interest you. Joining an ongoing project may have a number of advantages. It enables you to contribute to a project early on in your residency with the potential for your name on a publication and provides an opportunity for you to present your research at a national conference. Working on an existing project can also lead to your involvement in other group projects or allow you to develop a project of your own with a member of your team. Most residencies allow time for research electives in 2-4-week blocks as long you demonstrate that your time off will be spent on a meaningful research project with a mentor.

Suggestions on how to excel during these elective rotations
The research elective is unique compared to other rotations because most of your time is spent alone working on your research project with a mentor. It is important not to fall into the trap of using this time as a second vacation. You should have a clear plan of what you would like to accomplish during your elective and an agenda for each day. Make sure that the faculty member that you will be working with has the time to work with you during your elective and that they understand the goals of your elective as well. This is the time during residency when you can dedicate all of your energy to your research project. However, don’t expect to finish your project during this limited time period. Rather, you should use this time on aspects of your project that might require more of your attention. You could also use this time on reporting your research, including writing an article, preparing a poster for an upcoming conference, or completing a manuscript. 

Should I complete an away rotation?
Rather than an away rotation, consider a remote collaboration with an experienced researcher involved in an area of emergency medicine research that does not exist at your institution. This is a viable option, particularly if the research does not involve direct patient interaction. Working with a faculty member from another institution can also provide opportunities for future collaborations. 

What can I do to stand out from the crowd?
Your application should reflect meaningful involvement in a research project. Performing meaningful research on one or two related projects during your residency rather than on multiple unrelated projects at a cursory level will have more of an impact on your fellowship application and your professional development as a researcher. Meaningful research includes working on the design and implementation of the project, assisting with the Institutional Review Board (IRB) and grant application, presenting a poster at a national conference, and primary or secondary authorship on a peer-reviewed manuscript. Involvement in educational and administrative activities at your institution in addition to your research activities would demonstrate your commitment to a career in academics. Taking on a leadership role within your institution’s research track or on the national level with a research committee can reflect positively on your application and show reviewers your potential as a leader in the emergency medicine community. Being a chief resident is not a requirement.

The other thing you may consider is applying for an Emergency Medicine Foundation (EMF) resident research grant to fund your project during residency. Although the funding is modest, this level of commitment and organization demonstrates a skill set that is valuable for future trainees in a research fellowship.

Should I join a hospital committee?
Consider joining a hospital committee if it relates to your research in some capacity. Being on a committee may expose you to faculty members from other specialties that may have similar research interests and provide for future collaborations. 

Publications other than research 
There are a number of opportunities in emergency medicine to publish including blog posts, book chapters, magazine articles, and podcasts. Contact faculty members in your department who are active in Free Open Access Medical Education (FOAM) to see if there are any opportunities for you to publish articles pertaining to your area of interest. Publishing a case report in a journal or blogpost that relates to your research is also a quick and easy way to add to your resume. 

How many recommendations should I get? Who should write these recommendations? 
All programs require a letter from either your program director or chair of the emergency department. You should also submit a letter of recommendation from the faculty member with whom you worked the most closely on your research project. 

What if I decide to work as an attending before applying? Can I still be competitive when I apply for fellowship?
Yes, it is possible to return to academics after working as an attending for a couple of years, but it is not easy. Most research fellowships are offered informally, which is easier to obtain when you are in residency when you have daily contact with academicians in the field. Also, it may be hard to go back to a trainee salary once you start making a faculty or community physician salary. If you do opt to work as an attending for a couple of years prior to fellowship, make sure that you stay up-to-date on the latest literature in your field of interest, maintain contact with academicians, and continue to be involved in research to be prepared for returning to academic research and practice.

What if I’m a DO applicant?
There are no restrictions for applicants from a DO residency to apply to a research fellowship in an allopathic program. Ensure that you take all 3 USMLE Step exams before applying. 

What if I am an international applicant?
International residents are welcome to apply to research fellowships as long as all program requirements are met and you have passed all 3 USMLE exams. Make sure the programs that you are applying to support your visa prior to applying. 

APPLICATION PROCESS

How many applications should I submit?
Only apply to institutions that you are serious about attending. You should start contacting research faculty toward the end of your residency to find out if they are accepting fellows for the coming year. Some programs have a specific research focus that may or may not interest you while others allow for a broad range of potential research topics. It is important to find out what the research focus is at your institution of interest prior to applying and to see if it matches your research interests. There is no specific number of programs to apply to, but having multiple offers to choose from is better than none at all. 

How do I pick the right program for me?
You need to find a research fellowship that has a robust research program that matches your interests and goals. Some programs have a specific research focus while others allow for a diverse range of research topics. It is up to you to find out which program represents your research interest and to make sure that they have the money available to fund your research for the next 2 years. Find out who has graduated from that program in the past, and find out if they are still actively involved in research to get an idea of what you can expect after graduating from the program. This is probably the single most important variable to consider – are past graduates of this program in academic positions? Are they continuing to conduct scientific research? Have they been promoted? Are they funded? Try and get a feel for the faculty, nursing staff, and other fellows in the program during your interview to see if your personality and goals are in-line with theirs. Geography also plays a role in your education, especially if you are planning on relocating your family for the next two years. Make sure you visit the area with your family, if applicable, before committing to any program.

Common mistakes during the application process
Reach out to faculty members who you are interested in working with early in the application process. Make sure you are continuously updating your CV during the course of your residency, and make sure that your CV is complete and accurate. Be honest about your level of involvement on each project that you list on your CV. Make sure to send your CV, letter of interest, and letters of recommendation well before the November 1 deadline. Give faculty writing letters of recommendation on your behalf plenty of time to complete your letters of recommendation. 

Application deadlines
The deadline for most programs is November 1 of each year. 

Tips for writing your personal statement
Your letter of intent should address why you are interested in a career in research and academic emergency medicine. Use the letter of intent as an opportunity to describe your research in more detail and how you hope to contribute to the practice of emergency medicine on a larger scale. Don’t make the mistake of just reciting what is on your CV. Describe how your research has impacted patient care in the emergency department by providing an anecdote that ties your research and patient care together. Your letter should be a mature reflection of what it means to you to work in academic emergency medicine. Do not forget that research is just one aspect of your fellowship training in addition to resident mentoring, which you should acknowledge in your letter as well. Make sure you send your letter to multiple people in addition to your research mentor prior to submission. Consider sending your letter to people outside of medicine as well (Let’s face it: Doctors don’t always make the best editors). 

Is this a match process?
No. 

What happens if I don’t obtain a fellowship position?
Contact your mentor to review your application to find any deficiencies that might have compromised your admission to a research fellowship the first time around. Talk to your program about staying on for another year in a less competitive fellowship. One year is not enough time to start a new research project, but you might be able to join an existing project with the potential to publish. Use this time to enhance your application and to strengthen your contacts in the research field. This would also be a good time to pursue other interests in EM that you were hesitant to pursue before. 

INTERVIEW PROCESS

How do I stand out from the crowd?
The most important thing to remember in an interview is to be yourself. Most interviewers have years of experience interviewing candidates and are quite adept at recognizing insincerity. Try to highlight your strengths as a researcher without appearing too arrogant or self-absorbed. It is important to articulate how the program can help you achieve your goal of becoming a successful researcher while also describing what you can bring to the program. Be realistic in your goals for the next 2 years and discuss what you would like to achieve as a fellow in the research division. Find out as much as you can about the program you are applying to by asking other faculty members in emergency medicine and visiting their website prior to your interview. Find out which faculty are active in the research division and read up on a couple of recent publications in addition to any landmark publications the department might have produced in the past. Be clear about your research goals and talk about which faculty you would be interested in working with to achieve those goals. Go on a couple of mock interviews (with faculty members at your institution) prior to your actual interview with faculty members who have had experience with the fellowship interview process.

What types of questions are typically asked?
Be prepared to explain your research in detail from planning to execution depending on your level of involvement. This shouldn’t be problem as long as you were honest in your application about your involvement on a specific research project. You should appear enthusiastic about your projects and the program where you are interviewing. Make sure you read up on recent developments and publications within your specific research field of interest. You should have a good understanding of what will be expected of you as a faculty member in addition to research. Prepare a list of thoughtful questions that you have about the program that cannot be easily found on their website.

How many interviews should I go on?
There is no specific number of interviews that you should attend when applying for a research fellowship. Only attend interviews at programs that you are really serious about. It is waste of your time and disrespectful to the program interviewing you if are not earnestly considering them to begin with. You should really only be interviewing at programs where you could realistically see yourself staying after fellowship as a faculty member.

PREPARING FOR FELLOWSHIP

Literature to consider reading

Important skills to practice while in residency to prepare for fellowship
Planning for designing a research presentation, presenting research, and writing. 

Tips on how to succeed as a fellow
The overall key to a successful research fellow is being able to develop a program that addresses their professional goals in emergency care research, mastering research methodology through didactic study and individual mentorship, becoming proficient in project management, grant writing and submission, and developing an understanding and appreciation for the career track of an academic emergency medicine physician. Start applying for funding as early as possible before your fellowship starts. Applying early will give you time to reapply if you are rejected on your first attempt. Make sure that your research interests align with your mentor. Formulate a clear plan for postdoctoral funding as you transition from research and fellowship (T & F series) grants to career development grants (R & K series). Join a grant committee through one of the national organizations in order to develop contacts with researchers from other institutions. Finally, participate in a faculty development course which is available through a number of organizations.

CONCLUSION

Additional resources

Journals:

This really depends on your specific area of research. We would recommend starting with some of the more common journals in emergency medicine to find out what is “hot” right now in the field of emergency medicine research. General recommendations are:

  • NEJM Journal Watch for Emergency Medicine
  • JAMA
  • Annals of Emergency Medicine
  • Academic Emergency Medicine

Clinical Resources/Websites/Blogs:

National organizations
Consider joining EMRA’s resident and fellow-run research committee. There are many ways to get involved with the committee, and it’s a great way to connect with other residents interested in EM research. SAEM also offers great mentorship and collaboration for emergency medicine researchers, including trainees. 

Conferences
Consider attending the national conferences including ACEP and SAEM. SAEM also has a number of regional conferences that you might consider attending to find out what is going on in your region, present your research, and to make new contacts. 

How to find a mentor
The best way to find a mentor is at your home institution early in your residency. Find out which faculty members are active in research either by word of mouth or on your residency program’s website. Contact them to see if they would be willing to have you join an existing project they are working on or assist you in starting a project of your own. If they don’t have anything going on at the moment they might be able to direct you to a faculty member that does. You can also reach out to mentors at other institutions if they are involved in research that you are really passionate about. Make sure to come prepared with questions for your mentor and schedule regular meetings.