The evolution of fellowship: New tech, more competition, and the quest for inclusivity

By Joe Hannan | Fact-checked by Barbara Bekiesz
Published June 20, 2023

Key Takeaways

  • The practice of medicine is changing, and medical education—including fellowship—is changing along with it.

  • Central to how fellowship is evolving are changing demands in the medical profession, technological transformation, and efforts to make fellowship a more diverse and inclusive experience.

  • Residents who are considering fellowship can familiarize themselves with the prevailing trends to help determine whether fellowship is a good fit for them.

The sheer quantity of medical knowledge is rapidly increasing. According to an article published in the Transactions of the American Clinical and Climatological Association, medical knowledge doubled every 50 years, back in 1950. By 2020, the same article projected a doubling of medical knowledge every 73 days.[]

According to James Stoller, MD, medical education had to evolve as a result. Dr. Stoller, chairman of the Education Institute at the Cleveland Clinic, told MDLinx that fellowships will continue to remain a vital component of clinical education as medicine continues to follow specific trends.

Changing demands

One of those trends is increasing competition for fellowship spots. According to the National Resident Matching Program (NRMP), there were a record number of applicants (nearly 14,000) seeking 13,365 open positions.[] And over the last 5 years, the number of MD graduates in the US applying for fellowships increased by 990; the number of DO graduates increased by 809. 

Related: Eyes on the prize: How to land an ultra-competitive fellowship

Some fellowship positions are more competitive than others, added Dr. Stoller. According to the 2023 NRMP data, of 73 total specialties, 33 filled at least 90% of their positions.

Specialties such as medical genetics, geriatrics, pediatric infectious disease, and nephrology are less competitive, according to Dr. Stoller.

He also said that emergency medicine fellowships experienced a dip in interest, likely stemming from the COVID-19 pandemic.

“This portends a concern about the pipeline of doctors looking downstream,” Dr. Stoller said. “If people don’t want to go into infectious disease, and you need an infectious disease doctor, unless you go to a big place that attracts these people, you may not be able to avail yourself of the services of those individuals.” 

Advancements in technology

Just as COVID-19 affected fellowship demand, it also reshaped the technological landscape of medical fellowship. Dr. Stoller noted that the fellowship interview process shifted to video conferencing during the pandemic—something that might have seemed improbable a decade ago. This, perhaps, has also created certain advantages for fellowship applicants, who face fewer travel requirements during the application process.

Related: Acing the real test: Your interview into fellowship

Technological transformation has permeated other aspects of fellowship as well, Dr. Stoller explained, with simulation-based training chief among them.

"Medicine has followed suit from commercial aviation and expects that doctors, like airline pilots, will go to simulation equipment and practice procedures before they perhaps do their first procedure on a patient."

James Stoller, MD

Technology is also changing actual care delivery, Dr. Stoller said, and the fellowship process is evolving to better equip fellows with technological skills. “There are more and more ways in which high-technology instruments are embedded in the practice of medicine,” he said. 

Dr. Stoller, a pulmonologist, cited quantitative CT scans for lung imaging as one example, noting enhanced breast screening and pathological studies as well.

“This is sort of mainstream now, but it’s clearly evolving, and so doctors as a matter of their practice will need to be more comfortable using technology,” he said.


The diversity of medical education is also evolving along with medicine, Dr. Stoller said, but the work is far from complete.

"I think there are still unmet needs to be completely inclusive. "

James Stoller, MD

“But I think when you simply look at the numbers, people that are underrepresented in medicine are still underrepresented in fellowship, and there’s a drop-off between residency and fellowship that continues in underrepresented groups.” 

Among the ongoing efforts to make fellowship more diverse and inclusive are holistic interviewing strategies that regard candidates in more multifaceted ways beyond test scores.

“We’re working hard on this and deeply committed to it, but there’s still work to do,” Dr. Stoller said.

Work hours and wellness initiatives

Along with diversity, the health and well-being of fellows has received more attention in recent years. 

“The work-hour restrictions that were imposed about 15 years ago apply to fellowship training,” Dr. Stoller said. “We monitor this and keep track of it as a compliance requirement.”

Related: Expert perspective: Maintaining mental health during the rigors of fellowship

Dr. Stoller added that there’s an increasing focus on ensuring work-life balance for fellows, owing to the demanding nature of their work and training. 

This goes beyond work-hour restrictions and includes addressing feelings of imposter syndrome, communicating and engaging with house staff regularly, and creating recreational and social activities.

What hasn’t changed

Amid these and other changes to fellowship, Dr. Stoller said that one thing remains consistent: the importance of individual passion and commitment when selecting a subspecialty. While fellowship may add a few more years onto the medical training process, with the right intention, those extra years will be well-spent.

“The decision about what discipline to engage in in medicine, for the sake of longevity in a career, is really around, ‘What contribution do I want to make?’ And, ‘What do I find exciting in that contribution?’” Dr. Stoller said. 

"If you spend another year or two in preparation for what you really love over the long run, I wouldn’t shy away from that opportunity. "

James Stoller, MD

What this means for you

As the evolution of medicine accelerates, fellowship can be expected to follow suit. Looking ahead, technology is poised to be a major driving force of the evolution. However, overall, fellowship appears to be taking a more holistic, human-centered approach with the advent of new wellness initiatives. As fellowship evolves, one thing likely will remain constant: the passion that drives most physicians to seek additional training in fellowship.

Read Next: Debunking 4 common fellowship myths

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