Charna Albert
July 2026—When Neha Gupta, MD, attended a fellowship fair early in her second year of residency, she was caught off guard by the number of programs already accepting applications from her peers. It was only March, and she had been told she could apply for her fellowship in late summer.
Dr. Gupta adjusted her plans, applying in June rather than August. “Honestly, I was scared,” she recalls. She went on to complete fellowships in hematopathology and molecular genetic pathology, but even now, as assistant professor in the Department of Pathology, Microbiology, and Immunology at the University of Nebraska Medical Center, the nail-biting moments of the application process have stuck with her.
Pathology subspecialty fellowship programs in recent years have been soliciting and accepting applications increasingly early in residents’ careers, and applicants have been pressured to accept offers on short deadlines or risk losing them. At the same time, more programs have reported applicants withdrawing from positions long after accepting, leaving them scrambling to fill unexpected openings. More than one attempt over the years to standardize application dates and processes has failed, but since 2023, an increasing number of subspecialties have joined the National Resident Matching Program Fellowship Match, to positive reviews.
Dr. Gupta, program director of the hematopathology fellowship program at UNMC, is supportive of hematopathology’s recent move to the NRMP Fellowship Match. “Candidates know they have until December to apply, because programs are not going to start interviewing before that. I think that’s the biggest advantage,” she says.
How the Match works: Interviewing does not begin before Jan. 1, roughly a year and a half before the fellowship is slated to begin. In April, programs and applicants submit their rank lists, or their list of preferred applicants and programs. Match Day—when a mathematical algorithm places applicants into their fellowship positions—is at the end of April, and fellowships begin July 1 of the following year.
Those in pathology education have been working toward this for a long time.
Some of the difficulty is in getting fellowship program directors on the same page. The Association of Pathology Chairs (now Association for Academic Pathology) and the Association of Directors of Anatomic and Surgical Pathology (now Association of Directors of Anatomic and Subspecialty Pathology) in 2013 formed a Fellowship Directors Committee as a venue for the leaders of the subspecialty fellowship programs to explore common issues and to better communicate. Paul Staats, MD, professor and chair of the Department of Pathology at the University of Maryland School of Medicine, is its current chair.
Pathology is virtually the only medical specialty that hasn’t adopted an organized approach to fellowship recruitment, Dr. Staats says. “And most have moved to a match under the National Resident Matching Program,” he says. “Pathology is definitely an outlier in that regard.”
A significant number of subspecialties in the early 2020s agreed to a common timeline, rather than a formal match, but abandoned it after program directors expressed dissatisfaction with “the chaotic nature of the week of the offer date,” among other things, Dr. Staats says. The CAP and other organizations weighed in last year with a statement in support of subspecialty-based coordination for fellowship recruitment. The goal of the statement was not to be prescriptive about what a subspecialty should do, Dr. Staats says, but to encourage program directors who might be on the fence about an organized approach “to side with the majority of their fellow program directors in giving it a try.”
Now, he’s hopeful the NRMP Fellowship Match will catch on—and stick.
There seems to be momentum. Forensic pathology was the first subspecialty to join, participating in the 2023 Match for the 2024 appointment year. Hematopathology, bone and soft tissue pathology, and molecular genetic pathology followed in 2025 for the 2026 appointment year. And for the 2028 appointment year, gynecologic and breast pathology, dermatopathology, and cytopathology will join.
For Dr. Staats, the entire effort comes back to what’s best for residents. “In surveys across multiple decades, residents consistently indicate by wide margins that they desire a later timeline and a more consistent timeline for fellowship recruitment,” he says.
Before hematopathology joined the Match, Alexa Siddon, MD, director of Yale’s hematopathology fellowship program, saw how the status quo affected residents.
“It forced fellows to make quick decisions,” says Dr. Siddon, professor of laboratory medicine and pathology at Yale School of Medicine. “Maybe some place would offer them a fellowship spot, but the place they were really interested in hadn’t even interviewed yet. And they had to make the decision of whether to take the position that was offered versus wait.”
Michael Linden, MD, PhD, who directs the hematopathology fellowship program at the University of Minnesota, wouldn’t interview applicants until after July 1 of third year. “But by that time, a third of our applicants had already accepted other positions. So we just did the best we could,” says Dr. Linden, who is the Richard D. Brunning professor of hematopathology at UMN.
“That was the arms race that was going on,” says Geoffrey Talmon, MD, senior associate dean of medical education at the University of Nebraska College of Medicine. Programs were attempting to “one-up” each other, he says, in terms of being the first to interview and get offers out. Why the programs do it is understandable, he says. “But the people who get put in the middle are the trainees.”
Dr. Talmon, professor in the Department of Pathology, Microbiology, and Immunology at UNMC and a gastrointestinal pathologist, doubts that residents can reasonably decide on a subspecialty so early in residency. At the beginning of second year, he says, “many times you haven’t even done all the electives yet. You haven’t even seen the breadth of specialties you can do.”
The Society for Hematopathology education committee led the process to recruit hematopathology fellowship programs into the Match, surveying program directors to assess interest, creating a listserv for their questions, and maintaining a website with a list of the programs that signed on. Because of the algorithm used to match programs and applicants, the NRMP Specialties Matching Service requires that at least 75 percent of programs in the subspecialty agree to participate for the subspecialty to join, which a sponsoring organization must affirm.
Dr. Siddon helped spearhead these efforts as former chair of the society’s education committee. Each program that agreed to participate, she says, also had to pledge not to make offers to applicants outside of the Match for the 2026–2027 fellowship year (normally those offers would have been extended in July–August 2024). “Because we signed people on two years in advance, we had to have at least that much lead time and more in order to have that first match,” she explains. “Eventually we got the number, but it required a lot of back and forth. People had a lot of questions.”
When they had commitments from 68 of 86 programs, the Society for Hematopathology signed on as the sponsoring organization. Over the next year Dr. Siddon and her co-committee members spread the word, publishing FAQ documents on the society’s fellowship website and hosting information sessions. They reported their experience in Academic Pathology (Courville EL, et al. Acad Pathol. 2025;13[1]:100230).
Some hematopathology program directors had reservations about joining the NRMP Fellowship Match. A recurring concern was how the Match would handle internal candidates. “Programs tend to prefer internal candidates because you’ve had a chance to watch them grow and they have a home field advantage,” Dr. Linden notes.
To be matched with a preferred internal candidate, Dr. Siddon says, all the program director must do is rank that applicant first. If the candidate does the same, “that will be a guaranteed match,” she says. “So we encourage people to still participate in the Match and just rank them first. It keeps the program in the algorithm so that we have the critical mass to make everything work.”
Some were concerned about how the match would affect the smaller programs. Dr. Siddon argues it’s beneficial for them. “I think it lets them have access to a wider array of applicants,” she says.
The same can be said for programs in geographical locations whose draws are typically less strong than others, like the hematopathology fellowship in the cold state of Minnesota. After joining the Match, Dr. Linden says, his program at the University of Minnesota received more applications than in prior years. “On July 1, we’re getting a candidate from New Mexico who’s spent his whole life in New Mexico. We were shocked but thrilled. We never thought he would want to come to Minnesota, but it was his number one choice,” he says.
Like Minnesota, Nebraska can be a tough sell geographically, Dr. Gupta says, and the Match seems to have brought to her fellowship program a broader pool of applicants in the past two years. Still, the program didn’t match in 2025 for 2026. Applicant numbers were good, and the post-interview surveys were positive, she says. “I still don’t know why we didn’t match.”
On the other hand, she says, it isn’t too surprising, given that there are more positions than applicants. For the 2027 appointment year, for example, 99 trainees applied for 138 hematopathology fellowships. “So, of course, there will be always some programs [that do not match],” Dr. Gupta says. For the 2027 appointment year, they did match with a candidate for one of two positions. “He hasn’t been to Nebraska,” she says, “but he was very much interested in our program.”
In the first year of the Match, Dr. Gupta says, the response from UNMC residents was mixed.
They appreciated the additional months to assess their interests and needs and to decide on their subspecialty of choice, she says. Yet there was comfort previously in knowing so far in advance where they would land. “Now they have to wait until April,” she says. “And if you don’t match, or something happens, you don’t have much time.” (After Match Day, the NRMP makes the list of unfilled fellowship positions public; at that point, candidates who did not match can contact those programs directly to apply.)
The later timeline can also be tricky for those who intend to apply to two fellowships—one, like hematopathology, that has adopted the NRMP Fellowship Match and another that hasn’t.
Dr. Staats concedes it’s a problem. “The important thing to remember is that this was very problematic in the unstructured system as well, perhaps even more so,” he says. “The ultimate solution would be for more subspecialties to move in the direction of the Match, which makes matching across multiple subspecialties very easy.”
Dr. Gupta has fielded questions from residents about how individual programs accept applications, she says. “We don’t have a uniform application, like we do for residency,” she says—each program has its own. The hematopathology programs may decide to move to a common application on the ERAS platform, which is the centralized online application service that medical students use to apply for residency. It’s under consideration now, Dr. Siddon says, noting, “It’s sort of a version two, or second step, in building up the Match process.”
Ultimately, Dr. Gupta says, “I think applicants will be in favor of the Match.”
As for the programs, Dr. Staats sees resident preference for a more structured approach as reason enough to sign on. For him, it boils down to the purpose of the fellowship program. “If it’s not to train the next generation of pathologists the best we can, I don’t know why we’re doing it,” he says. “And so, something strongly favored by applicants to the program is something we should take very seriously.”
The programs reap benefits too, he says. In surveys, most program directors say they have lost favored applicants, either because the applicant had already accepted a position elsewhere or because when the position was offered early, they weren’t ready to commit. “The reality is the unstructured timeline has negative impacts on fellowship programs as well,” he says.
Another benefit to programs: a potential reduction in the problem of unexpected vacancies—applicants accepting positions and then withdrawing from the fellowship in the intervening two or more years between acceptance and start date. By reducing this gap to 14 months, participating subspecialties hope to alleviate this problem.
The Match, however, still leaves ample time for something to change in an applicant’s career or life circumstances. In particular, the job market is strong now, and some applicants may choose to forgo a fellowship in favor of a job offer. “It is too soon to know how large an impact the shift from 24-plus months in the unstructured recruitment to 14 months in the Match will have on withdrawals. It may be the Match needs to move a little closer to the start of training,” Dr. Staats says. Because jobs often come on the market in the summer, if Match Day were in the fall, applicants would have a better sense of the job landscape before having to submit their rank list. “Therefore, you’d be less likely to have people who are interested in jobs putting themselves in the ranking system at all.”
The job market also affects the number of fellowships early career professionals take on, says Dr. Linden of UMN. “What used to happen is at least 50 percent of residents would do two fellowships after residency. Some would do three,” he says. Now, because the job market is strong, fewer people are doing more than one fellowship. “And there’s been no change at all to the number of fellowships available.”
Adds Dr. Staats, “I do think fellowship programs need to adjust to a new reality—there is a higher likelihood of having a position unfilled in a given year.”
One problem, Dr. Talmon says, is that many institutions view fellowships being filled as a marker of quality. Given the incentives to fill seats, he sees the Match as a safeguard against practices like accelerating application timelines.
He also sees the Match as beneficial for younger learners. “Data shows that younger generations tend to prefer structured processes as opposed to ambiguity. They have less comfort with ambiguity than older generations,” he says. The match process, with its more explicit rules and guardrails, may be more appealing for Gen Z and the younger learners now finishing medical school and residency.
How have some subspecialties managed to move to the NRMP Fellowship Match more quickly than others?
Program uniformity plays a role, Dr. Talmon says. Hematopathology is a relatively uniform subspecialty; nearly all the hematopathology fellowship programs are ACGME accredited, and because there’s a subspecialty board, most programs are structured similarly. But that isn’t the case for the surgical pathology subspecialties, including gastrointestinal pathology, which is trying now to garner enough program participation to join the Match. “Within surgical pathology, GI is one subspecialty, but there’s a host of other subspecialties. Some fellowships are accredited and some are not.” Even within GI, not all programs have the same focus. “We are a GI transplant fellowship,” he says of the program at UNMC. “Some are just straight GI.” That complicates a universal move to the Match. And some applicants combine fellowships, he notes. “That adds another wrinkle to this as well.”
Another factor is hematopathology’s strong specialty society and program director community, says Dr. Siddon of Yale.
“We have a good group of people, and we reach out to each other and ask each other questions,” she says. “It’s a group bond, that we all want to do what’s best for our fellowship and our specialty.”
From Dr. Staats’ vantage point at the Fellowship Directors Committee, within the subspecialties that have put effort into fostering a community of program directors, “there is more trust in each other that allows this process to be more successful,” he says. “I do think there’s value in that.”
How can program directors encourage that kind of community?
“Reach out to each other,” Dr. Staats says. Surgical pathology, for example, doesn’t have the well-defined sponsoring societies some of the other subspecialties do, and because of that, community must be built more organically. “I think we’ve seen that in gynecologic pathology, where a handful of program directors have been very active in trying to push for the Match, but also to push for more of a community.”
For hematopathology, the team effort led to success, Dr. Siddon reiterates. “We all put work in, and we did it as a group.”
Charna Albert is CAP TODAY senior editor.