In this edition of the American Journal of Obstetrics and Gynecology , Iqbal and colleagues report the results of a cross-sectional survey of applicants to the match in 4 obstetric/gynecologic subspecialties (Maternal-Fetal Medicine, Reproductive Endocrinology and Infertility, Gynecologic Oncology, and Female Pelvic Medicine and Reconstructive Surgery) in 2013. The prematch survey focused on attributes of the applicants, whereas the postmatch survey focused on the match results as well as expense borne by the applicants. The authors main objective was to assess the characteristics of those who were successful in the match, compared with those who were unsuccessful (ie, did not match). The authors sent electronic surveys to over 300 applicants, and had a response rate of just over 60%. The main findings of the paper were several fold. First, applicants spend a relatively large sum of money in applying to fellowship—the mean was 9.5% of their pretax income (or just over $5200.00). Second, factors associated with match success in the unadjusted analysis included: (1) having a letter from a nationally known member of the subspecialty, (2) membership in AOA or Phil Beta Kappa, (3) completing an elective in the subspecialty, and (4) the amount of money spent in the process. Interestingly, only the last variable—amount of money spent—was associated with success after adjustment.

What does these survey results mean to fellowship programs? In my opinion, this confirms what many of us know in terms of successful fellowship applicants. First, that they have a letter of recommendation from someone we know personally and more importantly from someone who has likely been involved in the training of fellows at some point (ie, a nationally recognized member of the specialty). Second, successful match applicants more commonly have prior academic achievement in terms of admission to honor societies. Third, matched applicants have generally engaged in research in the past. Still, I do believe that we must be missing some diamonds who perhaps bloomed late in their education and did not attend a large academic training program that allows them ready access to national leaders and research. I do believe that there are national examples of such people, though I wish I knew how to identify them (not that I would tell anyone if I did!). But as fellowship directors, I do believe that we should be working together to identify the strongest applicants—those who will continue to move the field forward. A first step may be to survey fellowship directors to understand the prematch factors that identify a successful fellow (not a successful applicant). And we may learn more about fellow selection from those who ultimately were disappointments and failures as fellows.

The survey results in this manuscript are extremely valuable to prospective applicants. First, I would advise anyone considering applying to have a frank discussion with a seasoned fellowship director about the chances of success (using some of the data provided in this paper). Although this may be intimidating to prospective applicants, I believe I can speak for all subspecialties in that virtually all of us would be willing to have that honest discussion with those outside of our own institution. Second, for those who come from small residency programs without national leaders or without a stellar academic pedigree, think carefully about whether to apply for fellowship. If one decides early to apply, I think there are hurdles to overcome, but that these are not insurmountable. I would suggest that such individuals need to identify a mentor for research and get something done during residency. Likewise, if there is an opportunity to work with a national expert in the specialty (and one that will support the fellowship application), I would suggest taking advantage of that. For less strong applicants, another reasonable option is to spend 1 year after residency doing research or pursuing an advanced degree—both of these, although expensive, likely increase the chances for success in the match.

The most provocative finding of this article is the relationship between the amount of money an applicant spends and the likelihood of success. I was frankly a bit surprised by this, and perhaps part of it may be selection bias (ie, less competitive applicants get fewer interviews, etc). But still there is an economic reality for applicants to consider—is the monetary investment in applying for fellowship worth the payout? In purely economic terms, and if one is successful in the match, then the answer is clearly yes. The differential in salary for those in general obstetric/gynecology compared with subspecialists is profound. And although changes in health care and payment may diminish these differences somewhat, I believe that substantial pay between specialists and subspecialists will continue into the foreseeable future.