OBESITY MEDICINE FELLOWSHIP

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1 OBESITY MEDICINE FELLOWSHIP NYU LANGONE COMPREHENSIVE PROGRAM ON OBESITY The NYU Langone Comprehensive Program on Obesity is seeking enthusiastic applicants for its newly formed Clinical Obesity Medicine Fellowship Program, which will host its first fellow in July The Obesity Medicine 12-month fellowship will provide physicians with an in-depth comprehension of the pathophysiologic basis of obesity as a disease state. The fellow will develop expertise in treating obesity through nutritional, behavioral, and pharmacological interventions. Utilizing an interdisciplinary approach, the fellow will practice in diverse clinical settings. Program Summary: The Clinical Obesity Fellowship is designed to train physicians in management of obesity and weight related conditions, via nutrition, behavioral therapy, and pharmacotherapy, and to foster research in the field. The fellow will work under the tutelage of physicians specialized in treating patients with obesity and its comorbidities. During this training, the fellow will learn to diagnose and treat patients in various clinical settings including the outpatient obesity, bariatric surgery, and endocrinology clinics at NYU Langone Health and NYC Health + Hospitals/Bellevue among others. The fellow will also become proficient in managing type 2 diabetes in patients with obesity, managing post-operative nutritional deficiencies and weight regain in bariatric surgery patients, and prescribing specialized diets and medications for weight loss. The fellow will also participate in at least one obesity-related research project overseen by a faculty research mentor. The selected fellow will be well-prepared to become a Diplomate of the American Board of Obesity Medicine at the completion of the fellowship. Prerequisites: Completed residency in ACGME accredited Internal Medicine, Family Practice, or Medicine/ Pediatrics Board Eligible or Board Certified in completed specialty Deadlines: All applications and supporting documents are to be submitted to ObesityMedicineFellowship@nyumc.org by February 15th, 2018 Interviews will be held February-March 2018 Contact information: Dylaney Bouwman, Program Coordinator (ObesityMedicineFellowship@nyumc.org) The NYU Langone Comprehensive Program on Obesity strives to determine unique causal pathways and strategies for treating and preventing obesity. The Program does this by uniting cutting-edge population, clinical, and basic science research, with a fully integrative clinical care model that is based heavily in translating research findings.

2 1 NYU Comprehensive Program on Obesity 2017 Medical Obesity Fellowship Application This application may be printed and mailed in or submitted electronically. All required fields are highlighted in red and marked with asterisks. Personal Information Contact Information First Name* Preferred Phone* Middle Name Mobile Phone Last Name* Alternate Phone Previous Last Fax Name Suffix Pager Preferred Name * Last 4 digits of SSN Address Current Mailing Address Address 1* Address 2 Country* State City* Postal Code If this is not this your permanent address, please indicate your permanent address below. Permanent Address Address 1 Address 2 Country State City* Postal Code

3 2 Citizenship Information Are you a U.S. citizen?* If yes, are you a citizen of a country in addition to the United States? If yes, list your country of dual citizenship (other than the United States): If you are not a U.S. citizen, list citizenship status: If you are a Foreign National currently in the U.S. with a Valid Visa Status, select your current Visa/Employment Authorization status: F-2: Spouse or Child of F-1 H-1: Temporary Worker H-1B: Special occupation, DoD worker, etcetera H-2B: Temporary worker- skilled or unskilled H-4: Spouse or child of H-1, H-2, H-3 J-1: Visa for exchange visitor O-1: Person of Extraordinary Ability in science, arts, education, business or athletics TN: NAFTA Trade for Canadians and Mexicans E-2: Treaty Investor, Spouse, and Child (EAD) Diplomatic Service/ Employment Authorizaion Document (EAD L-2: Dependent of Intra-Company Transferee (EAD) Please note, only J-1 visas will be offered through the ECFMG to candidates in need of sponsorship. Military Information Are you committed to fulfill a U.S. military active duty service obligation/deferments?* If yes, number of year remaining Branch Do you have any other service obligations? (e.g. Military Reserves, Public Health/ State programs, etc.)* If yes, describe (50 words max)

4 3 Biographical Information General Gender Birth Place Date of Birth Self Identification This section allows you to indicate how you self-identify. If you prefer not to self-identify please ignore this section. How do you identify yourself? Please select all that apply. American Indian or Alaskan Native Asian Black or African American Hispanic/Latino Native American/Pacific Islander White/Caucasian Other: Language Fluency What languages do you speak? List all that apply. For each language that you list, including English, please rate your proficiency in that language using the following guidelines: Native/Functionally: I converse easily and accurately in all types of situations. Native speakers, including high educated, may think that I am a native speaker, too. Advanced: I speak very accurately, and I understand other speakers very accurately. Native speakers have no problem understanding me, but they probably perceive that I am not a native speaker. Good: I speak well enough to participate in most conversations. Native speakers notice some errors in my speech or understanding, but my errors rarely cause misunderstanding. I have difficulty communicating about healthcare concepts. Basic: I speak the languages imperfectly and only to a limited degree and in limited situations. I have difficulty in or understanding extended conversations. I am unable to understand or communicate most healthcare concepts

5 Licensure 4 Please add an entry for any of your state medical licenses. ne Entry 1 State*: License type*: Expiration License Number*: Expiration Year*: Month*: Entry 2 State: License type: License Number: Expiration Month* Expiration Year: Additional Information Was your medical education/training extended or interrupted?* If yes, please provide details: Has your medical license ever been suspended/revoked/voluntarily terminated?* If yes, please explain: Have you been named in a malpractice case?* If yes, please explain: Is there anything in your past history that would limit your ability to be licensed or would limit your ability to receive hospital privileges?* If yes, please explain: Have you ever been convicted of a misdemeanor in the United States?* If yes, please explain:

6 Have you ever been convicted of a felony in the United States?* If yes, please explain: 5 Are you able to carry out the responsibilities of a fellow in the specialty and at the NYU Medical Obesity Fellowship Program to which you are applying, including the functional requirements, cognitive requirements, interpersonal and communication requirements with or without reasonable accommodations? If no, please list your limiting aspect(s): Are you Board Certified? If yes, Board Name: DEA Registration Number:

7 Personal Statement 6 Please describe your individual experiences and unique interest in the field of medical obesity, including how you plan to contribute to further advance this field. Please limit your statement to words.

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9 8 I certify that the information contained within this application is complete and accurate to the best of my knowledge. I understand that any false or missing information may disqualify me from consideration for this position; may result in an investigation by the academic institution as well as the AAMC; may also constitute cause for termination from this program. Print First and Last Name Date Signature Date In addition to this application, please submit the following items to ObesityMedicineFellowship@nyumc.org or 423 E 23rd Street, 15th Fl, 15028BN New York, NY ATTN: Dylaney Bouwman Current Curriculum Vitae with accurate publication citations, be sure to include peer-reviewed articles (including articles currently under-review), oral and poster presentations, and any other relevant publications. Contact Information for Three (3) References, one of which must be a current program director or supervisor Valid ECFMG certificate, if medical school is outside the United States Contact Information: Holly Lofton, MD Fellowship Program Director Holly.Lofton@nyumc.org Dylaney Bouwman Fellowship Program Coordinator Dylaney.Bouwman@nyumc.org