EMRA Fellowship Guide, 3rd Edition

Women's Health

Author

Tanesha Beckford, MD
Chair, EMRA D&I Committee
Boston Medical Center

Special thanks to our 1^st and 2^nd edition writing teams

1^st edition
Krystle Shafer, MD
Jenelle Holst Badulak, MD
2^nd edition
Marian Sackey, MS4
Linelle Campbell, MD, MS

Special thanks to our 2^nd edition faculty editor

Krystle Shafer, MD

INTRODUCTION

Description of the specialty
This fellowship is known as Women’s Health Fellowship, Global Women's Health Fellowship, and/or Sex and Gender Fellowship.

Some of these fellowships focus more on the research of domestic and global women’s health issues. These programs create physician leaders in education and research in gender-specific medicine, with translation of these concepts to real-life emergency medicine practice. Additionally, fellows learn how to promote high-quality and culturally competent care for women, both locally and globally.

Other women’s health fellowships focus primarily on clinical training in the clinic, urgent care, and emergency department settings. These programs allow for additional female and reproductive health training, beyond the usual training in emergency medicine residencies.

History of the specialty/fellowship pathway
Originally, women's health was essentially synonymous with reproductive and gynecologic care. As such, initial fellowships were geared toward OB-GYN physicians. Because internal medicine physicians and family physicians are also involved in gynecologic care, it was a natural fit for these fellowships to offer training to these physicians as well. Over time, interest arose into developing a better understanding of how certain disease states affect women throughout their lives. Women’s health has subsequently expanded beyond reproductive and gynecologic care to include the interactions of biological, societal, behavioral, political, psychological, and environmental issues on the overall health of women. With this expanded vision of the women’s health fellowship, it comes as no surprise that psychiatry and EM physicians are now completing women’s health fellowships.

Why residents choose to follow this career path
This career path is for residents interested in the development of academic research, educational initiatives, and leadership skills specific to women's health, or for residents interested in additional clinical training in gynecology and obstetrics. Fellows obtain a foundation of knowledge of women’s health issues in the setting of social, cultural, and political environments. This foundation helps physicians achieve successful careers post-fellowship that are dedicated to the health and well-being of women.

How do I know if this path is right for me?
Are you interested in cardiovascular disease and how it affects women? Are you interested in learning more about female genital mutilation: why it exists, how it impacts a woman (both in the gynecological capacity and psychological perspective), and how to stop it? Would you like to help women with family planning in a war-torn country or in a country devastated by Zika virus? Do you want to be a leader and expert among emergency physicians in regard to the health of women? Do you have a specific research interest in the health issues of women displaced due to disaster? Do you want more advanced procedural training in the fields of gynecology and obstetrics? Are you interested in rural or critical access emergency medicine and want focused clinical OB-GYN training? If so, this may be the career path for you.

Career options after fellowship
Physicians who have completed this fellowship have gone on to achieve:

- Board member for the Sex and Gender Women's Health Collaborative

- Leadership positions in the American Medical Women's Association

- Funded researchers specializing in gender differences in medicine

- International employment with focus on (but not limited to) gender based violence, human trafficking, mental health, sexually transmitted diseases, health services to rural communities, etc.

- Leadership in humanitarian response in war-torn countries

- Appointments with Ministry of Women's Rights

- Appointments with Partners in Health

- Appointments with the Department of Health and Human Services

- Rural or critical access emergency medicine attending positions with higher likelihood of managing complications of second- and third-trimester pregnancy and labor and delivery

Academic vs. community positions
When choosing between academic, community, or global positions after fellowship, this is typically determined by the applicant's personal career aspirations. For example, those with strong research interests gravitate toward academia, whereas others may seek appointments working in underserved areas.

IN-DEPTH FELLOWSHIP INFORMATION

Number of programs
Programs with options for primary research focus:

- Brigham and Women's Global Women's Health Fellowship

- Warren Alpert Medical School of Brown University (Rhode Island Hospital): Sex and Gender in Emergency Medicine

- UNC Chapel Hill Global Women's Health Fellowship

- UCSF, GloCal Health Fellowship (must be affiliated with University of California to apply)

- Cedars Sinai Women’s Heart Disease and Health Fellowship

Programs focused on clinical education and varying levels of research emphasis:

- Cleveland Clinic Women’s Health Fellowship

- University of Michigan Women’s Health Fellowship

- VA Advanced Fellowship in Women’s Health (8 sites: Boston, Los Angeles, Madison, Milwaukee, Pittsburgh, San Diego, San Francisco, and West Haven). Please contact each site individually for eligibility requirements.

Additional fellowships (unclear if they accept EM resident applications):

- East Carolina University, Maternity and Women’s Health Fellowship

- Case Western Women’s Health Fellowship

- Columbia Faculty and Fellowship Development in Women’s Health

- OHSU Women’s Health Fellowship

- UMDNJ Reproductive Health Fellowship in Family Medicine

Differences between programs
Some programs focus more on research, with opportunities to obtain advanced degrees such as a master’s degree in public health, science, and/or clinical research. These programs often have access to research funding and can propel a young researcher into a future niche in women’s health. Some programs are focused on clinical training and expanding a women-specific clinical skillset. These programs provide the opportunity to gain specialized skills in areas including labor and delivery, cesarean sections, management of low-risk prenatal care, preventative health, mental health, office-based gynecologic procedures, and breast health. Most clinical fellowship programs also offer opportunities for research with varying levels of emphasis on publication. Finally, some programs have a focus on international opportunities and on public health education.

Length of time required to complete fellowship
Varies by program: 1-3 years.

Skills acquired during fellowship

• Research experience
• Formal public health education
• Global health experience/exposure for those who are interested
• Leadership and administrative skills
• Education and curriculum development
• Education and training on the following topics, including but not limited to:
• Obstetrics: low-risk prenatal care, labor and delivery, cesarean section, breastfeeding, ultrasound
• Gynecology: pelvic pain, office-based gynecologic procedures, family planning, hysterectomy alternatives
• Preventative care: breast health, pap smears
• Eating disorders
• Women and heart disease
• Endocrinology and bone health

Typical rotations/curriculum
Fellows typically divide their time between research, education, and clinical services. The percentage spent in each varies based on the program.

Board certification afterwards?
No. However, many fellowships offer the opportunity to obtain an MPH or advanced degree/certificate in research.

Average salary during fellowship
Varies based on program. Some programs pay a PGY-4, 5, or 6 level salary and others offer a more competitive salary. Moonlighting opportunities, if offered/allowed by a program, will also influence yearly salary.

PREPARING TO APPLY

How competitive is the fellowship application process?
This is a hard question to answer, as this field is one of the newest in fellowship offerings for emergency physicians. Additionally, the interest among emergency physicians in these fellowships is low, especially as compared to other fellowship opportunities. Most women's health fellowships were originally designed for residents from family practice, psychiatry, OB-GYN, surgery, and internal medicine. Many of these programs are open to receiving applications from EM applicants, even if they have not had an EM-trained fellow yet. An applicant must be prepared to “sell” to such programs the advantages of an emergency medicine trained physician and in how choosing such a physician would benefit their program. The list of eligible programs is always changing for the EM resident; thus we recommend contacting all programs to ask if they will accept an EM resident. Because there are limited fellowship opportunities available for the emergency physician, this inherently makes it a competitive fellowship. But, there are also a small number of applicants per year.

Requirements to apply
You must be graduating or have graduated from an accredited emergency medicine residency. You must contact each of these programs individually to formally apply.

Research requirements
Research is highly encouraged (but not required).

Suggested rotations to take during residency
Here are some rotations to consider when planning your elective time: international rotations, women's health clinics, community health clinics, public health administration, addiction clinics, preventive counseling, family planning clinics, domestic violence clinics, etc.

Suggestions on how to excel during these elective rotations
Residents who do well on these rotations are those who are interested, hard-working, and engaged. Your passion for medicine and helping others should be evident. Strive to make connections with your patients, families, and each member of the health care team. Continue to read and learn throughout the duration of your rotation. It also never hurts to arrive early and stay late; being late to your rotation is a sure way to obtain a bad evaluation.

Should I complete an away rotation?
There is no need to attend another institution for an away rotation, unless it is for a desired elective that is not offered by your home institution. If there is a fellowship program that you are highly interested in, it is worth considering arranging an away rotation at this program. This would allow for both you and the program to get to know one another which could be potentially advantageous during the fellowship application process. If you do arrange such an away rotation, make sure that you are on your best behavior and treat every day as an interview day. Creating a bad impression during the rotation would most assuredly negatively affect your chances at becoming their future fellow.

What can I do to stand out from the crowd?
Become involved in projects that are geared toward women’s health. Participating in meaningful leadership and research opportunities is key. By the time you apply for fellowship during your third (or fourth) year of residency, your research project should be near completion. It's better to have one completed research project than three projects still in the data collection phase. Additionally, women's health is a broad field, so it may be wise to narrow your focus to a particular "niche" that interests you.

Should I join a hospital committee?
Absolutely pursue this opportunity. This would be an excellent way to gain leadership skills and make a difference within your institution.

Publications other than research
Publishing book chapters, blog posts, newsletter articles, etc., that discuss a topic within the field of women’s health would certainly help to strengthen your application and show your dedication to the field. More importantly, however, such publications help to expand your knowledge base about the topics and this field of medicine.

How many recommendations should I get? Who should write these recommendations?
In general, three letters of recommendation are required, one of which must be from your program director or chair of the emergency department. If possible, try and obtain a letter of recommendation from a physician whose career is linked to women’s health topics, such as an international emergency physician or a physician who completes research in related topics. Do not fret, however, if you do not have such physicians available as letter writers from your residency program. Focus instead on obtaining three strong and outstanding letters of support.

What if I decide to work as an attending before applying? Can I still be competitive when I apply for fellowship?
Absolutely. The key when applying after residency is to continue to be involved in leadership and/or research activities during your time as an attending physician and to continue to gear your resume toward the desired fellowship.

What if I’m a DO applicant?
Please note some programs do require applicants to submit USMLE scores.

What if I am an international applicant?
International applicants are highly encouraged to contact each individual program and inquire whether or not they are willing to accept your visa.

APPLICATION PROCESS

How many applications should I submit?
Apply to all programs you would seriously consider if offered a position.

How do I pick the right program for me?
The goal is to pick a program that best fits your career goals and is also located in a place where you would feel happy. You want to make sure the program fellows and faculty fit your personality. Trust your gut instinct during and after an interview with a program. Decide if you are interested in this fellowship for furthering your academic research career or more for advancing your clinical skills in women’s health, as each program emphasizes these differently. Also, look for a mentor/faculty who has similar educational and/or research interests and will be able to help you navigate your time, both during fellowship and beyond. Location is always important, as are the needs of your spouse/family.

Common mistakes during the application process
Some mistakes will quickly sink your chances at gaining a fellowship position. Beware of:

• Turning in your application late and/or incomplete
• Letters of recommendation from physicians who do not know you well or who do not endorse you 110%
• Sloppy, overly short or long, grammatically incorrect, and/or overall strange personal statements
• Incomplete research projects
• Too many projects (research, leadership, or otherwise) without any meaningful contribution in any of the projects
• Having a CV that does not demonstrate any interest in the women's health field
• Being late for your interview
• Treating program staff (such as program coordinators) poorly
• Poor interview skills (not making eye contact, rambling or not saying anything at all, etc.)

Application deadlines
Residents should plan to submit applications at the beginning of their last year of residency. Many programs have an August/September application deadline and November-February admission decisions for a July 1 start date. It is recommended to contact each program individually regarding their application timeline.

Tips for writing your personal statement
The best personal statements are easy and enjoyable to read. They usually tell a story in such a way that the reader understands why you are passionate about the field and what you hope to achieve in your career. Be careful not to simply repeat what is in your CV; instead, strive to make your statement show your personality. Programs are interested to know what sparked your interest in the field; if you have a particular patient or event in your life that’s driving you, use that as the foundation for your personal statement. For some programs who have never graduated an EM physician, it may be beneficial to use your personal statement to demonstrate why emergency medicine training is beneficial for a women’s health fellowship program. Have multiple people that you trust provide you with honest feedback on your statement. Take the extra time to make sure there are no grammatical errors.

Is this a match process?
No.

What happens if I don’t obtain a fellowship position?
Contact the programs where you applied and respectfully ask why you were not accepted. The goal is to gain insight to the weaknesses in your application so you can correct them and apply again next year. It may also be helpful to ask another physician in a leadership role (not necessarily from the women’s health field) to look at your application and identify weaknesses. Practice your interview skills. If all else fails, it is possible to create a niche within this field as an attending. Consider attending conferences, becoming engaged in research, earning an advanced degree, and/or becoming involved in international opportunities.

INTERVIEW PROCESS

How do I stand out from the crowd?
The best way to stand out is simply to be a well-rounded overall candidate. Build a strong CV that ideally includes research but also displays your leadership skills and skills as a clinician and educator. Becoming chief resident would certainly boost your application. Display a clear interest in the field, and write a strong personal statement. Pick strong writers for your letters of recommendation; try to find a writer who is well-known within the field and is a strong advocate for you. When you interview, aim to appear strong and confident, but not arrogant. Research the program itself and ask pertinent questions that display your interest but are not easily answered on their website. Have a vision about where you would like your career to go and how the fellowship can help you achieve that. Meet all the deadlines, respond quickly to interview invites, and send thank-you notes after your interviews.

What types of questions are typically asked?
Why do you want to complete a women's health fellowship?

Why do you want to complete a fellowship at our institution specifically?

What are your 5- and 10-year plans after fellowship?

Tell me more about [fill in the blank] that you listed here on your CV?

What are your goals to accomplish during fellowship?

How many interviews should I go on?
You should attend every offered interview, since this is a small fellowship field with limited spots.

PREPARING FOR FELLOWSHIP

Textbooks to consider reading

• Oertelt-Prigione S, Regitz-Zagrosek V. Sex and Gender Aspects of Clinical Medicine. New York, NY: Springer; 2012
• Legato MJ. Principles of Gender-Specific Medicine. London: Academic Press; 2009
• Oliffe JL, Greaves LJ. Designing and Conducting Gender, Sex and Health Research. Los Angeles, CA: SAGE Publications, INC; 2011

Important skills to practice while in residency to prepare for fellowship
Focus on developing research, leadership, and educator skills. Work on expanding your foundation of knowledge about local and international women's health topics. Find ways to become engaged in this small community of physicians.

Tips on how to succeed as a fellow
Maintain your work-life balance: Make sure you sleep, exercise, eat healthy, and make time for your family and hobbies. Remain dedicated, compassionate, and reliable while on your clinical rotations. Read every day to increase your knowledge base. Decide what your legacy will be: What will you leave behind at your fellowship? Will you create a new curriculum for medical students? Will you develop a program for sex trafficking victims? Find a meaningful project to become engaged in and develop your niche in the field.

CONCLUSION

Additional resources

Websites

www.womenmdresources.com/

http://swhr.org/

http://orwh.od.nih.gov/resources/cme.asp

Journals

Journal of Women’s Health

International Journal of Women’s Health

NEJM Journal Watch Women’s Health

National organizations

American Medical Women's Association

Academy of Women's Health

ACEP American Association of Women Emergency Physicians

Conferences

Academy of Women’s Health

University of New Mexico Annual Women’s Health Conference

UC Davis Health System Women’s Health Conference

How to find a mentor
Unfortunately, there is no central website that we are aware of connecting you to mentors in the field. Our best advice is to reach out and network with physicians in this field via attending conferences, sending emails, and finding leaders in women’s health within your health system.