For most residency applicants, the arrival of November marks the beginning of the interview season. This often brings back memories of the medical school admission interview, with the ubiquitous “Why do you want to be a doctor?” question.

Four years later, you find yourself in a similar situation – this time, hoping to land a position in the specialty and residency program of your choice. “Why do you want to be a doctor?” is now replaced with “Why do you want to go into [this specialty]?” and “Why are you interested in our residency program?” While the questions will differ to some extent, you may be experiencing the same gamut of emotions – uncertainty, nervousness, and perhaps even fear.

Given the highly evaluative nature of the interview process and its importance in the residency selection process, this anxiety is well-placed. Over the years, many surveys of program directors have inquired about the importance of the interview. Recently, the National Resident Match Program surveyed 1,840 program directors representing the nineteen largest specialties to determine the factors used for ranking applicants.¹ Ranked number one, even higher than clerkship grades and USMLE scores, was the residency interview. A number of previous studies substantiate this finding. In one study done at the Children’s Hospital of Pennsylvania, interview scores were found to be the most important tool for the ranking of applicants.² In a survey of family medicine and obstetrics/gynecology residency program directors, the residency interview was found to be most valuable in the ranking of applicants.³ Program directors of internal medicine residency programs have also rated the interview as most useful for ranking decisions, with 96% of respondents reporting the interview to be highly or moderately useful.⁴

While receiving an interview invitation is an honor, simply being interviewed does not guarantee a place on a program’s rank list. In a study of emergency medicine residency programs, with data obtained from 3,800 individual interviews, a total of 14% of interviews resulted in unranked applicants.⁵ In another study, one third of applicants were actually ranked less favorably following the interview.⁶ Dr. Reilly, former program director of the University of Texas medical school at Houston psychiatry residency program, states that a “good interview can save someone with the less than perfect application. A bad interview cannot always be salvaged by a paper record.”⁷ The conclusion here is that the interview is critical to your chances of a successful outcome.

Recognizing the importance of the interview, we have devoted four chapters and nearly fifty rules to the interview process in our book, The Successful Match: 200 Rules to Succeed in the Residency Match. In this column, we discuss three of the most important rules for interview success.

Dig deep

The primary goal of an interview is to impress upon the decision-makers that your unique qualifications are exactly what they seek.  Many decision-makers refer to this as “fit.” Will your strengths and aspirations help the program achieve its own goals? Are your proven qualities the type necessary to achieve success as a resident in their program? In order to convey this message, you need to know yourself, and you need to know the program, and you need to be able to convey this knowledge during the interview.

Conveying this message starts with demonstrating a strong and sincere interest in this particular residency program. One of the easiest ways to impress an interviewer is to arrive well prepared, having thoroughly researched the residency program. Start with the program’s website. What is the program’s philosophy? Is the program known to produce academicians? Is it recognized for its contributions to community service? Is research an area of key emphasis in the department? What is the program looking for in a resident?  With this knowledge in hand, you will be better prepared to demonstrate to the program that you are precisely the type of individual they seek. Equally important, the information that you gain will help you decide if this is a program where you would like to train.

While most applicants will review the program’s website, too often the research begins and ends there. We recommend that you dig deeper. Perform an internet search to learn more about the program, its faculty, the hospital, and the city. Well before your interview, contact graduates of your medical school who are residents or faculty at the program. Locate physicians in your area who trained at that program. These individuals can provide valuable information about the program, which you, in turn, can refer to during the interview. For example, “Dr. Ran, the chairman at my medical school, was recently a visiting professor in your department. In speaking with him, I learned about how your program really pioneered human simulation training as a teaching tool. I’ve been looking forward to learning more about that during this interview.” Candidates who make the effort to take these steps can convincingly demonstrate that they are truly interested in the program.

Many applicants do an excellent job in researching a program in advance. Unfortunately, many don’t know how to, or don’t feel comfortable, demonstrating this knowledge. They may end up making no reference to the specific information that they have read or learned about the program, or they may ask the type of basic questions that could have been asked by any other applicant.  The end result is a generic interview, and a lost opportunity to demonstrate your strong interest in the program.

First impressions can make or break you

Multiple studies have shown that creating a favorable first impression is critical to interview success.  In one study done by Thomas Dougherty, chair of business and economics at the University of Missouri, a favorable first impression led to an easier and more successful interview. Interviewers who are more favorably impressed by interviewees during the first few minutes went on to treat those applicants more positively. They spoke with a more positive vocal style, engaged in more active recruiting of the applicant, and asked less questions.⁸ Although this study was in another field, medical faculty interviewers are not unlike those in other fields. The impressions they form of you through your first interactions will play a pivotal role in your interview success, or lack thereof.

The obvious measures in managing first impressions remain critical. One should arrive early and be well-dressed and impeccably groomed. The ability to maintain appropriate eye contact and shake hands properly are little discussed in medicine, yet are no less important. One article in the Lancet found a strong correlation “between a firm handshake – as evidenced by strength, vigor, duration, completeness of grip, and eye contact – and a good first impression.”⁹ It is important to be able to walk into a room and project self-confidence through your body language, facial expressions, and tone. In addition, the ability to engage in small talk is more important than many applicants realize. Dr. Jamie Collings, program director of the emergency residency program at Northwestern University, states that “whether the topic is the weather, current events, or sports, you’re expected to participate.”¹⁰ She encourages applicants to get “up to date on current events, see a movie, read a non-medical book, and read the paper regularly.”

Dr. Ziegelstein, associate program director of the internal medicine residency at Johns Hopkins Bayview Medical Center, states that “individuals who interview and judge others for a living (e.g., program directors) often form very strong first impressions. Typically, those individuals are flexible and those impressions are changeable, but those first impressions are nevertheless important.”¹¹ In our experience helping applicants prepare for interviews, we know that applicants spend considerable time preparing for anticipated questions. Unfortunately, most applicants then give little or no thought to the factors involved in a favorable first impression. Preparing for the subjective factors involved in first impressions is just as important as preparing for the typical interview questions. If you’re uncomfortable with small talk, practice with others. Mock interviews with friends, colleagues, and mentors may highlight weaknesses, and are an important tool in interview preparation. Make sure you’ve received honest feedback on your interview performance.

Stand out from the rest of the crowd

You are competing with, perhaps, hundreds of other applicants. It is critical that you ask yourself “What is it that sets me apart from the other candidates?” Through our own experiences interviewing applicants, and through discussions we have had with other faculty interviewers, we know that few applicants make a concerted effort to stand out from the rest of the pack. We agree with Dr. Krogh, former faculty member of the department of family practice and community medicine at the University of Minnesota, who reminds applicants that “programs interview hundreds of applicants, many of whom are compatible with the program. Make yourself noticeable enough. How you do it is up to you but many unfortunately do not even try to do it.”¹²

We understand that you may not consider yourself unique. In fact, parts of your background and qualifications are likely to be similar to other applicants – good grades, solid USMLE score, and good medical school. Is there anything truly unique about this package? Not on the face of it. But there can be. Many applicants have remarkable accomplishments, but fail to recognize or discuss them. Others have unique strengths or particularly strong qualities that they fail to emphasize in their application materials and interview.

Did you have a fantastic overseas international health experience during medical school? Were you involved in cutting edge research? Do you have a special or unusual talent? Have you gone out of your way on clinical rotations to emphasize patient education and the provision of patient educational materials? Do you have an aptitude for teaching, and have you demonstrated that through your activities in medical school? Were you the founder of your medical school’s pathology club or the president of AMSA? If so, the interview represents a wonderful opportunity to highlight these accomplishments.

We’ve spoken to applicants who brainstorm, and don’t feel as though they can discuss anything remarkable or unique about themselves. While that’s hardly ever the case, you can still utilize additional ways to stand out. Impress your interviewers with your level of preparation. Showcase your strong communication skills. Answer each question by taking it one step further than most applicants. For example, applicants often answer the question “What are your strengths?” with a short list of qualities. “My strengths include my attention to detail, interpersonal skills, and ability to persevere.” Most applicants stop there. The few that continue with an example that highlights their strengths succeed in leaving a memorable impression. “My ability to persevere has been central to my success. The pathology interest club that I wanted to set up at my medical school was initially applauded, but my cofounder and I hit many obstacles. Even though I started during first year, the club didn’t come into existence until my third year, and it was my perseverance that kept me going and dealing with all the roadblocks.”

Asking insightful questions is yet another way to distinguish yourself. These can highlight your individual qualities, as well as your interest in the individual program. Dr. Ksiazek, program director of the Pritzker School of Medicine ophthalmology program at the University of Chicago, states that “You do not want to blend into a sea of other applicants by asking the same old questions.”¹³ As interviewers, we’ve all heard the typical “What do you consider to be the weaknesses of the program?” Contrast that with: “In medical school, I have had several international health experiences which I have found very fulfilling. That’s why I was particularly excited to learn about the global health track your residency offers in Kenya. What kind of impact has the global health track had on residents in your program?”

And finally…

As you approach your interviews, focus on how far you’ve come.  By offering you an interview, the program has essentially informed you that you are a competitive candidate. Given that programs routinely receive hundreds or even thousands of applications, an interview invitation is a real honor. Programs only extend these invitations to candidates who are being seriously considered for a residency position. Having come so far, it is essential now that you devote the effort, time, and preparation necessary to sell yourself effectively and convincingly to programs.

References

¹Results of the 2008 NRMP Program Director Survey. Available at http://www.nrmp.org/data/programresultsbyspecialty.pdf.  Accessed on October 26, 2009.

²SwansonWS, Harris MC, Master C, Gallagher PR, Maruo AE, Ludwig S. The impact of the interview in pediatric residency selection. Amb Pediatr 2005; 5 (4): 216-220.

³Taylor CA, Weinstein L, Mayhew HE. The process of resident selection: a view from the residency director’s desk. Obstet Gynecol 1995; 85 (2): 299-303.

⁴Adams LJ, Brandenburg S, Blake M. Factors influencing internal medicine program directors decisions about applicants. Acad Med 2000; 75: 542-543.

⁵Martin-Lee L, Park H, Overton DT. Does interview date affect match list position in the emergency medicine national residency matching program match? Acad Emerg Med 2000; 7 (9): 1022-1026.

⁶Gong H, Parker NH, Agar FA, Shank C. Influence of the interview on ranking in the residency selection process. Med Educ 1984; 18 (5): 366-369.

⁷Reilly E. Career counseling: psychiatry. Available at www.uth.tmc.edu/med/administration/student/ms4/2003CCC.htm.  Accessed October 22, 2008.

⁸Dougherty TW, Turban DB, Callender JC. Confirming first impressions in the employment interview: A field study of interviewer behavior. Journal of Applied Psychology 1994; 79: 659-665.

⁹Larkin M. Getting a grip on handshakes. Lancet 2000; 356: 227.

¹⁰Available at www.saem.org/…/0/…/MSS_CollingsTheInterview2009SAEM.doc.  Accessed on October 22, 2009.

¹¹Ziegelstein RC. “Rocking the match”: applying and getting into residency. J Natl Med Assoc. 2007; 99: 994-999.

¹²Krogh C, Vorheis C, Abbott G. The residency interview: advice from the interviewer. The New Physician 1984; 8.

¹³Ksiazek S, Taylor TL. Pritzker residency process guide: ophthalmology. Available at http://pritzker.uchicago.edu/current/students/ResidencyProcessGuide.pdf.  Accessed on October 22, 2009.

Dr. William James

By Samir P. Desai, M.D., and Rajani Katta, M.D.
Authors of The Successful Match: 200 Rules to Succeed in the Residency Match and
250 Biggest Mistakes 3rd Year Medical Students Make And How To Avoid Them

As the Paul Gross Professor and Vice Chair of the Department of Dermatology at the University of Pennsylvania, Dr. William James directs the dermatology residency program at the University of Pennsylvania, which recently was found to be the highest ranked academic dermatology department in the United States.¹

He is widely regarded as an outstanding clinician, teacher, and researcher, having received numerous honors and awards. He has published over 200 peer-reviewed publications, served as the editor-in-chief emeritus of the emedicine dermatology section, and been on a variety of national committees.  We recently had the opportunity to speak with him about the dermatology residency selection process.

In a recent survey of dermatology residency program directors, 87% of programs cited a letter of recommendation from the department chair as an important factor in selecting applicants to interview.²  How can students interact and work with the chair in such a way that the chair is able to write a productive and meaningful letter?

First of all, the Chair is certainly a great person to be able to work with and get a letter from. In many circumstances, though, that’s not going to be the person who is most involved with students, especially depending on the size of the program. Your letter doesn’t necessarily need to be from the Chair. It could be from one of the academic dermatologists in the program, either the Program Director or one of the faculty members.

It should be from someone with whom you’ve worked and who knows you in some meaningful way. That would usually mean at least working in a clinic with the letter-writer. Specifically, not just observing in clinic but actually interacting with patients and discussing diseases. It may involve rounding with the inpatient team and presenting patients in follow-up. It could be writing or participating in a project, such as a clinical project or a case report. There should be some meaningful interaction. There needs to be information about how the applicant works, what kind of ideas they have, and how they interact with patients and the team. That really is the key: being able to get to know your letter-writer long enough so that they can take examples and then detail how an applicant would be a good person to have in the residency program. For the people reading the letters, they’re going to be looking for some meaningful pieces of information that is based on personal observation.

Audition electives have been found to be very important in the dermatology residency selection process.³ What sets apart students who shine during these rotations from those that are average?

First of all, enthusiasm. There are students, believe it or not, who show up and look a little bored. I think enthusiasm for the work and the subject is very important. The way students interact with others is certainly a key. You can have all the brains in the world, but if you can’t get along with people, that doesn’t say much for your ability to work on a team or work with patients. Sometimes students can be a little too aggressive in their interactions, probably because they’re trying to either come across as enthusiastic or they’re trying to show off their smarts. There is a fine line regarding what is appropriate for the level of training. At the same time, I think faculty members do take into account that students are trying to make a good impression, so I think there is some leeway there.

Hopefully, there will be opportunities to demonstrate their knowledge base or get involved with a project. If you find that the dermatologists are getting excited about a case and saying “I haven’t seen this before” or “I don’t really know what is a good treatment for this condition; let’s go look it up”, this would a great opportunity for the student to follow up by reporting ”This is a case that I learned something from; I looked it up, I thought about it, and I’d like to pursue it a little further.”  

Dr. Miller, who is Vice Chair of Clinical and Educational Affairs in the department of dermatology at Penn State College of Medicine, has encouraged applicants to make their personal statement unique.⁴ Too often, he has read statements where an applicant writes about “being a visual person” or is drawn to the specialty because of the “ability to do procedures.” Having read thousands of statements, what advice can you offer for the dermatology applicant seeking to create a unique statement?

I think the main point is that this can’t be a recitation of what’s already in other parts of the application. I’ll get to the positive side, but one of the main things that bothers me with personal statements is reading about that first I did this, and then I did that, and I wrote this paper, and I did this research, and I published it in this journal, and I did this volunteer work. It’s all in the CV already and the whole statement becomes “I, I, I.”

But while the personal statement is just that – personal – if it’s all going to be about delineating accomplishments that are covered in other places, then that simply isn’t helpful. What is helpful is to draw a picture of yourself that can’t be obtained from anywhere else in the application. It should be personal – this is who you are, this is what makes you excited, these are your special interests. Sometimes it may be outside of medicine, sometimes it may be a volunteer experience that is expanded upon, or it could be a personal connection that stimulated the applicant to want to do something more, such as a specific part of Dermatology down the line. You might express your future goal, as that is something that wouldn’t be revealed in other parts of the application.  

It certainly has to be sincere. If everyone just says at the end of their statement “I want to be an academic dermatologist” and there’s nothing else in the application that tells a reason for this, it’s not believable. It would help if you can describe your personal background and bring in information about your life that isn’t available in other places, and then transfer that into a future plan.

Overall, your statement has got to be personal, sincere, and bring out information not available in other places.

Students recognize the importance of research in the dermatology residency selection process and hope to participate and, perhaps, become published in the field.  Although there are over 100 dermatology residency programs in the United States, some programs are more prolific than others in terms of scholarly activity. For example, between 2001 and 2004, your program produced 318 publications, placing it among the top dermatology programs in the country.¹ What recommendations do you have for students who wish to do research but are either at schools lacking a dermatology residency program or for those whose dermatology department focus is largely clinical?

I would expand the idea of research. If a student doesn’t have any background in laboratory-based basic science research, then they could work in a lab to see what it’s like. However, most of the time people that don’t have that type of background, and don’t have advanced degrees, are not going to end up in that situation.

Most of the time, students are going to be looking for more of a clinical-based project. Protocol-based projects and clinical research do require a fair amount of time in order to get things off the ground and move through the process. For the person that you’re describing, they could get involved with a review article, a case report, or a small case series. Other possibilities could be a review of charts or a review of pathologic specimens. With that type of background, these are the types of projects that such a student would be both capable of and interested in, and would make the most sense for their background.

There is a growing shortage of academic dermatologists with fewer residents pursuing a career in academics.⁵ Years ago, your program developed the unique Dermatology Fellowship for Academic Clinician-Teachers, with the goal being “to develop future leaders in dermatology who will attain positions such as residency program directors, professors in clinician-educator tracts, and departmental chairman.”⁶ As a lifelong academician, what are some misconceptions that students have about academic dermatology?

Students are, of course, being taught in an academic setting, and depending upon the people they’re exposed to, some may tend to see the bright side of things, while others will focus on a less attractive side. There are pluses for academic Dermatology and pluses for private practice, but there are also negatives for both. If someone is more negative they may assume that “since this is what academic medicine is about, private practice must be better.” However, they don’t have the knowledge base about what actually goes on in private practice, and they don’t know the negative aspects.  In other words, they think it’s greener on the other side of the fence, but they don’t really look on that other side to see what’s there.

I think that some of the misconceptions are that academicians don’t make such a good living – but I don’t really know any academic dermatologists that are living out of their car.  I think we make a better living than 99% of the citizenship in the United States, so I think that that’s underappreciated. 

I sometimes hear things like “there’s too much politics in academics” and I can’t say I don’t understand, but personally I think it’s an overstatement. In my opinion, it’s all about interactions with others, and if you have good interaction skills, then you’ll do fine.

Certainly there are concerns about independence and the size of organizations, or what some people might call bureaucracy. I think that you have to be able to operate in a larger setting. If you are someone who is an entrepreneur and wants to be in charge all the time, then you probably aren’t built to go into academics.  But if you are more able to accept some bureaucracy, then certainly in exchange for that you get a lot of infrastructure. You have a lot of the business side of medicine that you don’t have to deal with, and in return you can concentrate on patients.  In private practice, you’re responsible for hiring and firing, balancing the books, and complying with the regulatory requirements. Private practitioners are small business operators and good business sense is necessary.

You have to be self-aware of what kind of arena your personality would best operate in, and in the end that’s something you are going to have to figure out for yourself.

Dermatology residency programs routinely receive hundreds of applications for just a few positions. As the years have passed, the academic credentials of applicants have become more impressive. In the 2007 Match, 47% of U.S. seniors who matched were members of AOA and the mean USMLE Step 1 score was 238.⁷ While strong credentials are certainly important to secure interviews, it is the interview that ultimately makes the difference. What advice can you offer students as they prepare for interviews? 

One of the things I find is that people tend to want to downplay what they have done. If it’s done out of modesty, that’s fine, but I think there are people that have a pretty darn good record, and unfortunately they say things like “Well, my boards could have been better, but you know I had this happen in my personal life.” Basically, they’re apologizing. They may have gotten 80% honors grades and yet they’re apologizing for this one rotation that they didn’t honor, and trying to come up with a reason or excuse. That’s just not a good way to approach an interview.

The way to approach an interview is to be self-confident and to accentuate the positives. They’re clearly there, because if you’re interviewing for a program, you must have a lot of positives. We don’t just interview anybody. You’ve got a good record, so you want to go in and be self-confident about that. You want to look good, and you want to come in sharp and enthusiastic. 

You should also treat everybody well. Some applicants will bow down before the Chair and then are rude to the residency program coordinator. That’s just not a good practice. I also think there’s something to be said for a practice interview if you’re nervous.

Ultimately, you want to be honest and open during your interview.

In 2007, out of 407 U.S. seniors applying to dermatology, 158 failed to match (39% of U.S. senior applicants).⁷ Applicants who fail to match often wish to reapply the following year. What can these applicants do to strengthen their application?

There are certainly a number of dermatology fellowships out there. It’s been documented that applicants who complete these fellowships have a higher match rate the second time around. I think that’s probably because you get to know the director well, and since they know how you work and how you produce results, they can write you a better letter of recommendation. I’ve also seen some individuals plan to do degree-producing programs, such as a Masters of Public Health, or a program with a focus in biostatistics or epidemiology.

There are certain objective measures that can’t be changed. You can’t change the Dean’s letter, you can’t change your board scores, and you can’t be AOA the second time around. However, you can publish and get new letters of recommendation. These are ways to strengthen your application.

Some applicants who fail to match pursue a pre-residency dermatology fellowship. In a recent survey of fellowship directors, it was learned that 92% of past fellows (176/190) were able to match successfully following completion of the fellowship.⁸  How can applicants make the most of these fellowships?

Most of these fellowships are directed by individuals that are fairly well-known in their specialty. A letter of recommendation from a faculty member that spent months, or sometimes a year, with an applicant is a very valuable resource. That’s going to be more information than the prior application, and the letter writer is able to be very rich in their detail about what supports the positive things that they say about the applicant. We look very closely at that.

Many fellowships are directed by some very productive members of our specialty. If the director is known for publishing, putting abstracts in meetings, and making headway in addressing different questions, then it’s expected that the applicant will have participated in those results.

There may be interview questions such as “why do you think you didn’t match?” There are certainly applicants who don’t match who have fantastic records, and for some reason they just didn’t make it. There may be cases where you cannot say that’s the reason I didn’t get in. But if there were an item or items that weren’t so good, then you have to plan to address those. You can’t change those items, but another way to address prior performance is to demonstrate in a more current job that you can do the work, and you can do it well.

References

¹Wu JJ, Ramirez CC, Alonso CA, Berman B, Tyring SK. Ranking the dermatology programs based on measurements of academic achievement. Dermatol Online J 2007; 13(3): 3.

²Results of the 2008 NRMP Program Director Survey. Available at http://www.nrmp.org/data/programresultsbyspecialty.pdf.   Accessed June 12, 2009.

³Clarke JT, Miller JJ, Sceppa J, Goldsmith LA, Long E. Success in the dermatology resident match in 2003: perceptions and importance of home institutions and away rotations. Arch Dermatol 2006; 142(7): 930-2.

⁴Miller J, Miller OF 3^rd, Freedberg I. Dear dermatology applicant. Arch Dermatol 2004; 140(7): 884.

⁵Resneck, J Jr, Kimball AB. The dermatology workforce shortage. J Am Acad Dermatol 2004; 50: 50-4.

⁶Available at the University of Pennsylvania Department of Dermatology website (http://www.uphs.upenn.edu/dermatol/education/clinician-educator.html).  Accessed on June 12, 2009.

⁷Charting outcomes in the match: characteristics of applicants who matched to their preferred specialty in the 2007 National Resident Matching Program main residency match (2^nd edition). Available at http://www.nrmp.org/data/chartingoutcomes2007.pdf.  Accessed June 12, 2009.

⁸Wasong SH, Miller JJ, Zaenglein AL. Does a predermatology fellowship increase the chance to match in dermatology? J Am Acad Dermatol 2008; 59(3): 535-6.

By Jessica Freedman, MD
President, MedEdits : Medical Admissions

With medical students starting to think about the upcoming residency match season, it’s a good time to review what residency applicants can do to improve their chances of matching. Many students think that how they write their residency personal statement is all that matters, but this simply is not true. As September looms, I want to focus on factors that are still (for the most part) within the residency applicant’s control.  This article should also be useful for anyone who may be entering the match in the future.

1. Do away electives
   These “audition electives” can really help your chances of matching at a program. Some applicants with whom I speak are often fearful of doing away electives because they believe a less than perfect performance may actually hurt their chances of matching at the program where they rotate. Indeed, this is often not the case. As the associate director of a program, I often found that applicants who demonstrated a solid (or even mediocre) performance when rotating with us were ranked higher than other applicants with slightly better stats. Most program directors would rather take a student whom they know will be a solid, “no-problem” resident than take a risk on someone with whom they have not worked.
2. Get letters of reference from attendings in the specialty to which you are applying
   It is essential that you ask for letters from faculty within the specialty to which you are applying. I recommend getting at least two letters from faculty within that specialty. In general, the best letters are written by people with whom you worked and, ideally, they should be clerkship directors, program or associate program directors, chairs or other academic faculty. When I reviewed applications for an emergency medicine residency program, while I read all of the letters carefully, I paid special attention to those letters from emergency medicine faculty.
3. Demonstrate interest in your desired specialty
   Your interest in your specialty goes beyond doing well on your rotations. For most residencies, doing research is not essential, but, in general, the more involved you are in your specialty, the more committed to it you appear. Consider joining your specialty’s national organization or becoming a student member on a national committee.
4. Communicate your interest in your specialty through your residency personal statement
   It is most likely that the last personal statement you wrote was for medical school. The approach you should take for your residency personal statement is different; you must convince the reader of your commitment to the chosen specialty. Some creativity will help engage your reader, but, in general, this statement should be a less creative piece than was your medical school personal statement.  A well-written personal statement that piques the reader’s interest will increase the odds that you will be granted an interview. The Electronic Residency Application Service (ERAS) allows you to write more than one personal statement so consider writing different statements for different types of programs. For example, a community based program does not necessarily want an applicant who hopes to make research a major part of his or her residency training.  You can also write a statement targeted to a specific geographic area.
5. Do not skimp when writing about your work/volunteer/research/ experience in your ERAS application
   The written descriptions of your activities in your application are also key.  Make these entries interesting. Be sure your application entries and personal statement complement each other.
6. Practice for your residency interviews
   I find that many students are not comfortable talking about themselves so it is essential to practice interviewing. The interviewer is trying to assess your interest in, understanding of and commitment to the specialty. They want to discover if you have good interpersonal skills and if you will be a good fit for their program; they also want to make sure you do not have any major psychopathology. Most residency interviews are conversational and are conducted by a wide spectrum of people from senior residents to chairs. As a result, the experience and skill of your interviewers may vary tremendously.
7. Plan a strong fourth year curriculum
   Your candidacy does not have to end when you send in your application. I was always impressed when applicants still had some “real” rotations scheduled for the remainder of the fourth year and weren’t wasting a valuable part of their medical education by taking rotations or electives that were obviously fluff.  This told me they were serious, really interested in becoming great doctors and took advantage of their time and opportunities. When I asked interviewees what they had planned for the rest of the fourth year, the least impressive answers went something like this: “Well, I have only one requirement left, so I am going to travel around Europe and take it easy before I start internship.”
8. Be energetic, attentive, and personable and smile on your interview days
   All of your interactions on your interview day are important. Be kind and respectful to everyone you meet, including residents, nurses and staff. If, during an interview day, my residency coordinator had concerns about an applicant, I listened since I knew and trusted her judgment. Remember that everyone has influence in this process. One negative impression can cause your ranking to suffer– or worse, it may bump you off a list.
9. Be courteous throughout this process
   A recent survey of program directors by the National Residency Matching Program indicated that following up with programs and “second looks” were not important factors when ranking applicants. That said, I believe that thanking those who took time out of their day to meet you demonstrates that you are gracious and courteous, which are important qualities for a medical professional.
10. Do not be swayed by letters from programs
    I am amazed by some of the letters applicants receive from program directors to express the program’s interest in the applicant. While some of these letters may be sincere, I have found that many of them are not. While it surely isn’t a bad sign to receive these letters from programs, do not become too confident since often, it seems, these letters are sent to people who are not “sure to match.”
11. Seek out an advocate
    Before you even start interviewing, identify a faculty member whom you think would be a good advocate. Once you decide how you will rank programs, ask this person to call your top choice programs to put in a good word. You should also consider asking for additional letters of reference that can be sent individually to all of the programs where you interview or will rank.
    
12. Do not rank programs in which you are not interested
    It is Murphy’s Law. If you rank a program where you really don’t want to go, you will match there.  If you know, without a doubt, that you do not want to go to a program, then don’t rank it.

Think of all your written materials, such as letters of reference, application and personal statement, as your “ticket” to your interview. If the person reviewing your application is intrigued, they will invite you for an interview. Then, your interview day becomes the key to your success. I know that all of this may be overwhelming as you embark on the path to your residency match, but as you start interviewing, you will become less anxious and more comfortable.  Good luck to everyone and match well.

Jessica Freedman, MD is a former medical admissions officer and president of MedEdits (www.MedEdits.com), a medical school, residency and fellowship admissions consulting firm. She is also the author of the MedEdits blog, a useful resource for applicants. (www.MedEdits.blogspot.com)

Dr. Andrew Lee

Of the 654 applicants who applied to ophthalmology in 2009, 196 (approximately 30%) failed to match. Similar results were noted in the 2007 and 2008 matches, making ophthalmology one of the most competitive specialties.

We recently discussed the ophthalmology residency selection process with Dr. Andrew Lee, chairman of the Department of Ophthalmology at The Methodist Hospital in Houston, Texas and Professor of Ophthalmology at the Weill Cornell Medical College. Prior to becoming chairman, Dr. Lee was professor of ophthalmology, neurology, and neurosurgery at the H. Stanley Thompson Neuro-ophthalmology Clinic at the University of Iowa Carver College of Medicine.  Following residency training at the Cullen Eye Institute at the Baylor College of Medicine, Dr. Lee completed a fellowship in neuro-ophthalmology at the Wilmer Eye Institute.

Dr. Lee is an accomplished author, having written two full textbooks on ophthalmology and over 260 peer reviewed articles. Presently, he is a member of the editorial board of 12 medical journals, including the American Journal of Ophthalmology and Eye. He is also the editor in chief of the Journal of Academic Ophthalmology. For his significant contributions to the specialty, he has received several prestigious awards from the American Academy of Ophthalmology including the Honor Award, Senior Honor Award, and the Secretariat Award.

In a survey of junior and senior US medical students who had chosen to pursue ophthalmology as a career, 13% entered medical school with the intent to become an ophthalmologist.¹ How should students who have an early interest in the specialty proceed?

A junior medical student with an early interest in the specialty should concentrate on insuring that ophthalmology is the right career choice for that particular student. Many medical schools (including the University of Iowa) have an Ophthalmology Student Interest Group (OSIG) that can introduce the student to the field, provide networking opportunities with fellow students and access to busy clinical faculty, and can allow participation in an OSIG service project. The student should consider whether his or her personality matches the “ophthalmology personality type” (e.g., do they enjoy seeing the entire spectrum of ages of patients, taking care of mostly ambulatory healthy patients with focused eye problems, and having a patient mix of both surgical and medical problems). Shadowing both a private practice eye MD or an academic faculty member might allow the student an insider glimpse into the practice of ophthalmology, and can create a mentoring opportunity that could lead to an important and convincing letter of recommendation downstream. The bottom line is that the most important task of the junior medical student interested in ophthalmology is making sure that ophthalmology is the right choice for them.

Although some students enter medical school feeling certain of ophthalmology as a career choice, most do not make their specialty choice decision until after completing an ophthalmology rotation. In the aforementioned survey, 52% did not make their specialty choice decision until late in their third year or early in their fourth year. These students only have a few months to strengthen their application for a particularly competitive specialty. What can students do to make the most of the time that they have?

Once the student is convinced that ophthalmology is for them, then the important task for the student becomes convincing others that they are right for ophthalmology. Ophthalmology is a competitive specialty and an honors level performance on the required ophthalmology rotation and any subsequent eye electives is mandatory. Reading in advance of the rotation and on a day to day basis, coming early and staying late, asking relevant and insightful questions, demonstrating enthusiasm and passion for the job, and connecting with an interested faculty mentor are key differentiating features of the best applicants. Working on a short case report or case series can be an easy way for the student to acquire new knowledge and skills in ophthalmic research, and provides evidence and content for genuine interest and effort in the field at the time of future interviews.

In January 2009, the average USMLE step 1 score for applicants who matched into ophthalmology was 235.² The average score for unmatched applicants was 212. Many applicants are concerned that their application might be screened out because of their score. What recommendations do you have for these applicants?

Ophthalmology programs receive far more applications than available positions. While it is true that most programs use the USMLE step 1 score as a “screening device”, the score alone neither guarantees acceptance nor rejection. This test was not designed for this purpose, but in the real world it is used as a screen. Applicants with a great score should not become overconfident, and applicants with a subpar score should do everything possible to demonstrate their value in other ways. Taking the Step 2 as early as possible to demonstrate a higher alternative score is one tactic. Another tactic is to tackle the problem head on in the personal statement and to highlight other alternative evidence of performance and intelligence in their record (e.g., honors grades, AOA, clinical proficiency). Getting the program to ignore a subpar score is challenging but not impossible. For applicants with scores towards the unmatched level, having a back up application plan is always a good idea. The bottom line is that if you have a good score don’t get cocky, because everyone else has a good score too, and if you have a less optimal score you must demonstrate to the interviewer or the screener that you offer something else in your application that can justify looking away from the score alone.

Medical students often wonder if they should do an audition elective in ophthalmology. In a recent survey of 46 program directors, audition electives were ranked 12^th among a group of sixteen residency selection criteria.³ What are your views on the role of audition (away) electives in the ophthalmology residency selection process?

The official party line is to discourage “audition electives”. The real goal of an away elective is to gain new knowledge and to experience ophthalmology in a different setting. Having said that, however, the away elective offers the applicant the opportunity to shine at a prospective institution and introduces the student to the faculty at that specific institution in a real world setting that can create a relationship that leads to an interview or even a higher ranking for the match. Ranking a “known” quantity with a personal track record and a letter of recommendation from an insider is always a great relief, especially for risk averse programs. In addition, if the choice is between two applicants with similar credentials, the known applicant obviously has the edge. My recommendation for a student doing an away elective is to use the time wisely, read in advance, make a great impression, talk with the residents and the faculty, and make yourself memorable in a good way. The goal is to “stand out,” however, not “stick out”.

In your article, “Re-engineering the resident applicant selection process in ophthalmology,” you wrote about “common but overused themes” in personal statements, including “a personal experience with a vision disorder, having a relative with an eye problem or requiring eye surgery… or some type of dramatic epiphany regarding the intricacies of the anatomy or physiology of the eye.”⁴ How would you advise applicants to approach the personal statement?

Your personal statement is your chance to “talk” to the evaluator in a special way and to make your case for acceptance into the ophthalmology “club”. Thus, the ultimate purpose of the personal statement from an applicant’s perspective is to get an interview. The message should be clear but concise, and should emphasize that information which is not apparent from the credentials and scores in the application. The personal statement would ideally highlight what is unique or novel about a particular applicant and the “storyline” should emphasize a quality or anecdote or credential that is based upon a credible, genuine and personal experience. As a reader, I am looking for evidence of leadership potential, altruism, sincerity, or scholarship potential. The best personal statement to me is one that is memorable, unique, exciting and demonstrates an applicant’s intangible qualities (e.g., passion, humanity, charisma, enthusiasm, motivation, or future academic potential). At the end of reading a great personal statement the reader should want to meet the writer in person (i.e. for an interview).

In a 2006 survey of ophthalmology residency program directors done to determine the prevalence of residents who experience difficulty mastering surgical skills, nearly 10% of residents were found to be surgically challenged.⁵ Types of problems encountered included poor hand-eye coordination and poor intraoperative judgment. In the survey, 20% of participating programs (11 total) were found to use vision testing during applicant screening and 4% used some form of dexterity testing. In the future, do you feel that testing of vision, stereopsis, and hand stability will be a routine part of the selection process?

I believe that validated metrics for determining baseline hand-eye coordination skills in ophthalmic surgery are needed before routine testing can be advocated for resident selection. Testing of vision, stereopsis, and color vision are already required in some professions (e.g, pilots, military) and some jobs require pre-employment testing for dexterity with basic hand-eye coordination instruments. The difficulty lies in correlating performance on such examinations with the actual job description and surgical performance.  I believe that these types of performance evaluations probably should be taking place at the medical school level and not as part of applicant screening, where presumably it would be too late for the applicant to do anything about a failing performance. Many applicants already self direct themselves towards or away from surgical specialties based upon their own self assessment of ability. Unfortunately, one unintended consequence of such screening might be to deter applicants who envision a career as a non-surgical or medical ophthalmic specialist (e.g., neuro-ophthalmology) from pursuing ophthalmology residency.

In your article, you wrote that extracurricular activities “might provide evidence for non-cognitive attributes that may predict resident success.” Which attributes do you feel are important to ophthalmology residency program directors?

The first priority of a residency selection committee is insuring that the applicant does not wash out or cause trouble during their time in the program. This is sometimes referred to generically as “fit”. Everyone wants a team player who is unselfish and working towards a common goal. Leadership skills demonstrated by being an officer in extracurricular activities or being an Eagle scout, or a leader or founder of a new organization or club are all looked upon favorably. The second goal is to look for evidence of noncognitive attributes that might make a superior ophthalmologist (conflict resolution, team work, leadership ability, communication skills, performance under stress, maturity, seriousness of purpose, prior scholarly activity). Finally, programs are looking to graduate (and thus select) residents who will make the program proud.

Many programs encourage applicants to attend a social event (e.g., pre-interview dinner) to learn more about the program. Through these events, programs also learn more about applicants. How do programs use these events to evaluate candidates?

Every part of the application process is important. The applicant needs to present their best face and be on their best behavior throughout the process. Treating every person in the application process with respect, dignity, and courtesy is important. Likewise, the social event is a chance for one to shine, make new friends, network with the other applicants, and most importantly make a good impression. The residents and fellows are looking for someone with whom they can work for three years, and not necessarily the smartest or the most academic applicant. Their vote counts, and while I encourage people to be “themselves” I would caution applicants that being on your best behavior is a good idea. Although these events are a great opportunity to learn more about the program, it is also a chance for the program to get to know you. You should treat the social events as seriously as the rest of the interview process.

What impresses you most about an applicant during an interview?

I am looking for three things in a resident interview. First, eliminate the people who may have looked “great on paper” but are terrible in person (e.g., psychopathic or sociopathic types, hermits or hotdogs, socially inappropriate duds, or selfish, arrogant jerks). Second, elevate the people who look mediocre on paper but are superstars in person (e.g., charismatic, engaging, enthusiastic, well spoken, and passionate). Third, and perhaps less tangible, I am looking for philosophical and personality “fit”. Applicants should understand their own, as well as the prospective program’s, learning environment, institutional culture, and teaching philosophy. Hard work, intelligence, teamwork, leadership, communication and interpersonal skills and professionalism are welcome attributes in most programs, and demonstrating these qualities can be a challenge in a short conversation. I am most impressed by applicants who are comfortable with themselves and with emphasizing their achievements in a credible manner, who can communicate clearly and concisely their career goals, and who can make the interview time “fly by” and who make me want to keep talking with the person beyond the assigned time.

Applicants who fail to match often wonder how they should spend the year before they reapply. What recommendations can you offer to these applicants?

The best chance for a match in ophthalmology is as a first time US senior medical student. The match rate drops off precipitously after this first application. The second application needs to be better than the first application if the second time applicant is to be successful. This means demonstrating perseverance, passion, and persistence through a research year in ophthalmology (e.g., a clinical or bench project), a pre-residency fellowship (e.g., ocular pathology), or an observational fellowship combined with the above. The “brick walls” in the process are meant to keep the other people out (i.e., those who don’t want it as badly or who fail to make a significant improvement in their application).

References

¹Nissman SA, Kudrick NT, Piccone MR. Motivations and perceptions of US medical students pursuing a career in ophthalmology. Ann Ophthalmol 2002; 34(3): 223-229.

²Data from the San Francisco Ophthalmology Matching Program. Available at www.sfmatch.org.

³Green M, Jones P, Thomas JX. Selection criteria for residency: results of a national program directors survey. Acad Med 2009; 84(3): 362-7.

⁴Lee AG, Golnik KC, Oetting TA, Beaver HA, Boldt HC, Olson R, Greenlee E, Abramoff MD, Johnson AT, Carter K. Re-engineering the resident applicant selection process in ophthalmology: a literature review and recommendations for improvement. Surv Ophthalmol 2008; 53(2): 164-76.

⁵Binenbaum G, Volpe NJ. Ophthalmology resident surgical competency: a national survey. Ophthalmology 2006; 113(7): 1237-44.

A key component of the successful match is a full understanding of the residency selection process, and the factors that influence it. Program directors are key decision-makers in this process, and their insights and experience are invaluable. In future columns of The Successful Match, we will present conversations with program directors and other key decision-makers across the different specialties.

We would like to preface these upcoming columns by highlighting the results of an important study done by Dr. Marianne Green. Dr. Green is the Associate Dean for Medical Education at the Northwestern University Feinberg School of Medicine. She is the former associate program director of the internal medicine residency program at Northwestern. Dr. Green is the recipient of multiple teaching awards, and her peers have recognized her as one of the “Best Doctors in America.”

In March 2009, her article ”Selection Criteria for Residency: Results of a National Program Directors Survey” was published in Academic Medicine.¹ The study findings were based on questionnaires submitted to 2,528 program directors across 21 medical specialties in 2006. Dr. Green and her colleagues sought to determine the relative importance of various residency selection criteria. Recently, we had the opportunity to talk with Dr. Green about the study’s results.

Before your study was published in March, deans, residency advisors, and applicants relied primarily on the results of a similar survey published in 1999 by Dr. Norma Wagoner, former dean of students at the University of Chicago Pritzker School of Medicine. What were the factors that led you to revisit this area now?

As I became increasingly involved in residency advising for our students, I felt uncomfortable relying on older data, and realized it needed updating. My colleagues and I approached Dr. Wagoner and she graciously let us modify her survey for this updated study. In addition, several specialties were not represented in the 99 study, the competiveness of specialties had changed, and new data (CSE, MSPE etc) were now available.  Charting Outcomes in the Match has a lot of detailed information that is very valuable, but several domains (e.g. clinical grades, preclinical grades) are not included and this information becomes important when advising students.²

What are the key findings that residency advisors and students should take away from your study?

Clinical performance as measured by clerkship grades is the most important thing that program directors look for across all specialties.  Letters of recommendation are extremely important in most specialties with the exception of Internal Medicine, Family Medicine and Radiology.  USMLE step 1 scores remain very important, but USMLE step 2 scores may even be more important in the primary care specialties.

In the article, you wrote that you hope to “highlight possible misperceptions that may affect student advising for residency application.” What do you believe are the more common misperceptions?

Many medical students believe that research is an essential part of their application to residency. With the exception of Radiation Oncology and Plastic Surgery, program directors in other specialties ranked published research among the lowest of the available selection criteria.  (see below for more on this)

Many students believe that their grades in the preclinical years are very important.  With the exception of a course failure, preclinical grades are not important.

Students should consider taking USMLE step 2 in time for residency application especially if they are looking at the primary care specialties like Pediatrics, Internal Medicine or Family Medicine; many of the less competitive specialties are putting increasing emphasis on Step 2 scores.

In Dr. Wagoner’s study, grades in required clerkships received top ranking from both competitive and less competitive specialties. In your study, grades in required clerkships were once again found to be the most important academic selection criteria. Students are often surprised to learn that grades in required clerkships are so important, ranked ahead of other criteria such as USMLE step 1 score and grades in senior electives in the chosen specialty. Why do program directors place so much emphasis on core clerkship grades?

Our study did not address the question of “why” for any of the selection criteria. I can only answer this as a practicing internist responsible for supervising residents and former associate program director.  Program directors and selection committees are looking for people who are going to become excellent physicians with the primary emphasis on patient care and teamwork.  A student’s performance on a clinical team in the direct care of patients is perceived to be the best assessment of these skills.  It is the job of the medical schools and faculty to insure that clerkship assessments are an actual representation of the achievement of competence.

You found that the USMLE step 1 score was the second most important criteria. Many students who seek residency positions in competitive specialties are concerned that their USMLE step 1 score is too low. What advice would you offer to these applicants?

The NRMP’s Charting Outcomes in the Match provides excellent data for the percentage of students with certain USMLE Step 1 scores matching in a given specialty.  I would certainly refer students to this source.  This can provide some realistic information for students.  I would never discourage a student from applying to a specialty that he/she is passionate about.  I would however, be sure that the student understands his/ her chances with whatever data is available.  Often schools track the success of their own students, and that data can be a very valuable tool for an individual student.  If a student’s chances of receiving an interview are low, he/she needs a “back up plan” and this often includes application to a less competitive specialty as well.

Overall, published medical school research and research experience were ranked next to last and last, respectively, in importance among academic selection criteria. However, you did note that some specialties highly value research, particularly competitive specialties. Students are often told that research experience and being published can strengthen their residency application. In light of your study’s findings, how should we advise students in this area?

Only Radiation Oncology and Plastic Surgery program directors ranked research highly; however even among some of the less competitive specialties, research may be an important part of the student’s application.  In my experience advising students, those that are looking at the top 5 programs in a certain specialty are competing with other highly qualified students across the country. Scores and grades are all outstanding, so something else may be needed to highlight the student as a competitive candidate.  Personally I believe that depth in any area (not necessarily research) can make a student stand out.  Extensive international experience or experience in patient safety & quality outcomes are two examples from our own institutions.  Certain residency programs are looking to train research scientists. Clearly a background in research will be a necessary qualification for these programs.

The medical school performance evaluation (MSPE), previously known as the Dean’s letter, is a standard component of the residency application. Critics of the MSPE maintain that these letters are often lacking in key information that programs need to assess and compare applicants. In an effort to make the MSPE more effective and useful, the AAMC has made efforts to standardize and improve the quality of these letters. In your study, program directors ranked the MSPE lowest of all criteria. Did you find that surprising given the AAMC’s efforts in recent years?

There are a few possible explanations for this finding.  The November 1^st deadline may be too late for program directors to use the MSPE extensively in decision making regarding the granting of interviews.  Students can begin applying on September 1^st and many interview offers start going out as soon as applications are received.

More importantly, most of the information contained in the MSPE is available elsewhere.  The grades and narratives for courses and clerkships may be on the transcript.  USMLE Scores are available directly. The ERAS application contains a lot of the “extracurricular information” about a student and so the MSPE is not necessary to view this information.

Probably the most important piece of the MSPE is the students “rank” in comparison to his/her classmates.  Although the AAMC has attempted more standardization in the reporting of class rank, many medical schools do not comply with this request and residency selection committees are faced with interpreting a student’s rank using vague terminology.

Your study did not address the importance of the interview in the residency selection process. As someone who has interviewed many residency applicants, what recommendations can you offer students preparing for interviews?

Relax and be yourself!  Most interviews are not high stress situations. Faculty are looking to see if you can interact effectively with others and would “fit in”. Certain specialties and programs may have some unique interview questions, but these are not common.  Departmental advisors can shed some light on the idiosyncrasies of certain specialties. (One year, some of the ENT programs were asking students to carve a bar of soap while they answered questions!) If you are someone who gets very nervous in an interview, I would recommend practicing a mock interview with a faculty member, advisor or dean.  Be prepared to talk about your interest in the field and why you would be a good addition to the program.  Know something about the program you are applying to.

References

¹Green M, Jones P, Thomas JX Jr. Selection criteria for residency: results of a national program directors survey. Acad Med 2009; 84(3): 362-367.

²Charting outcomes in the match: characteristics of applicants who matched to their preferred specialty in the 2007 NRMP Main Residency Match. Available at www.nrmp.org.

As the current residency application cycle is winding down, the next wave of applicants is getting ready to apply for the 2009/2010 season.  As you begin thinking about your residency application, you should consider who will be writing your letters of recommendation (LORs), how you will talk about your path to residency at your interview, and how you should contact programs and follow up with them (and if this really makes a difference in outcome).

This article serves as a follow-up to the article, “Getting Into Residency: Part 1,” which was published on the Student Doctor Network in October 2008.

Letters of Recommendation

I encourage medical students to treat every attending as though he or she will one day write them a letter. Why? I believe this helps the student perform well and also creates a safety net of sorts. Since you don’t know whom you will meet in the future, it may well be that a good LOR could come from the internal medicine attending from your third year rotation or a preceptor from an introduction to medicine course during your first year.

If you have identified someone with whom you have rapport and who thinks highly of you anytime during your medical education, don’t wait to ask that person if he or she would be willing to write you a strong letter of reference in the future. Then be sure to keep in touch with the attending from time to time. Keep the attending updated on your progress and achievements so, when it comes time to write your letter, the attending won’t have to play catch up, which will make the letter more sincere.

While writing a letter of reference is extra “work” for an attending, it is also flattering since it indicates that you respect and think well of that individual. Writing excellent letters for my stellar students that I knew would help them get to the next level of their education and training was one of my greatest joys in academic medicine.

Which letters have the most impact when it comes to residency? It depends. If you are applying for orthopaedic surgery, for example, you don’t want to have three letters from non-orthopaedic faculty. ERAS allows you to select four letters to be sent to each program so, for a very competitive specialty, you want at least two of these letters to be from attendings within the specialty to which you are applying. When applying to residency, titles matter; a letter from a community doctor will carry less weight than a letter from the chair at a major academic center.

A survey sent to directors of all programs participating in the 2008 match by the National Residency Matching Program (NRMP) addressed this issue. Most important, the survey showed, are letters from clerkship directors, colleagues and chairs within the specialty. Letters from “other faculty,” while still important, have the least weight.

Writing a good LOR takes skill and experience. Sometimes junior faculty don’t know what constitutes a good letter, another reason why it is sometimes “safer” to have letters written by more senior faculty. A more experienced faculty member, who has read and written hundreds of letters of reference, understands the essential elements and “buzz words” that make a great LOR.

Keep in mind that the smaller the specialty, the more likely everyone is to know each other. When I reviewed residency applications, it was comforting to read a letter from someone whom I knew and trusted. At the same time, letter writers get “reputations.” I remember a clerkship director who wrote outstanding letters for every single applicant who rotated in her department. As a result, I questioned whether I could trust this individual’s evaluation. As an applicant, you have no way of knowing who writes good letters and who doesn’t, but it is important to understand that some attendings are talented in this area while others aren’t.

How do you go about asking someone to write a letter? To some degree this depends on your relationship with the individual.  If an attending offers to write a letter on your behalf and you have had an open dialogue about this, then simply ask him if he would like any supporting documentation.

Otherwise, it is best to schedule an appointment to meet with the attending.  It is fair to ask this person openly if she would be willing to write a strong letter on your behalf. You must hope that you will get an honest reply.

Your job is to make the letter writer’s job as easy as possible. Arrive at the meeting with a folder in hand that has a copy of your CV, your personal statement (if you have already written it) and any information she may need, such as your AAMC number and where the letters should be sent. ERAS has downloadable cover letters that you can fill out for your letter writers for both US students and IMGs. Remember to give your letter writers plenty of time to write your letter (at least one month), and understand that you may need to “nudge” or remind them more than once.

The Interview

Your most recent interview probably was for medical school. The emphasis for residency interviews is different, so don’t think that you will be telling the same story all over again. It is important to think about the path you have taken since you started medical school. What has motivated you, who has inspired you and what determined the choices you have made?  Applicants are judged most on the following during the interview:

• Commitment to the specialty to which you applying
• Understanding of what it means to practice this specialty
• Interpersonal skills
• Interactions with faculty, residents and staff
• Professionalism
• Maturity
• Leadership ability
• Overall “fit” with the program
• Red flags, explanation for gaps in time, psychopathology

I encourage applicants to review their written applications before interviews so they can remember what they have written. Anything on your application is “fair game” for discussion so be prepared to discuss everything in detail.  Don’t be afraid to try and guide your interview. The interviewer isn’t the only one in control here and you should try to make segues to topics that you would like to discuss.

The ideal interview is an open conversation – a back and forth dialogue. While everyone has their own interview style, most (skilled) interviewers know they will get the best idea of who you are if you are at ease and comfortable. In my experience, it is the less experienced interviewer who tends to “shoot questions” at you.  And remember, you aren’t going to be tested on your medical knowledge. Non-US citizen IMGs are often asked to discuss an interesting case to make sure they can communicate effectively about medical issues, however.

Also remember that feedback from current residents and support staff (such as the residency coordinator) plays a role in resident selection. Residency is intense and, especially for small residency programs, being a good “fit” for a program is important. This is why your behavior and interactions with the residency staff, during tours of the facilities and during dinners and lunches with the residents, is vitally important.

When I was in residency leadership, if my residency coordinator identified someone as rude or disrespectful, I listened. Residency leadership teams are small and a negative interaction with one member of that team is likely to negatively affect your ranking. Along the same lines, if a resident thought highly of an applicant and believed she would mesh well with our program, I also listened.

A few questions you should be prepared to respond to on residency interviews:

• Tell me about yourself
• Why do you want to go into XXX?
• When did your interest in XXX begin?
• What strengths would you bring to the program?
• Tell me about your research
• Tell me about (any flaw in your application).
• How do you feel about moving to our city/town?
• Where do you see yourself in 10 years?
• Why do you want to attend our program?
• Do you have any questions for me?

Follow up with Programs

I always encourage applicants to contact the program directors where they interviewed early in the season. While some programs rank as the season moves along, others hold a “ranking day” in late January/early February when they rank applicants. From experience, I can tell you that it was very difficult to remember applicants who interviewed early in the season. That said, the research done on this topic indicates that the timing of your interview does not affect your ranking.

Interestingly, the NRMP survey results indicate that program directors do not place much importance on second looks or visits or that postinterview contact affects ranking. Nonetheless, I believe that you should send a thank you note just “to play it safe,” and demonstrate respect and because doing so is just good manners. Also, sending a letter of intent to your first choice program is wise. The worst thing that can happen to a program is not to fill its positions, forcing the program to enter the scramble. It also “looks good” for a program director to boast, “We got our top three applicants!” If a program knows you are ranking it #1 and it doesn’t want to “go too far down on their list,” your letter of intent may influence your ranking.

As match day approaches, good luck to everyone and match well. For 2009/2010 applicants, start thinking about your strategy for next season.

While this article (and Part 1 of this series) addresses some of the concerns related to the residency match, keep in mind that many nuances affect the process and this varies from applicant to applicant.

Jessica Freedman, MD, a former medical admissions officer, is president of MedEdits (www.MedEdits.com), a medical school, residency and fellowship admissions consulting firm. She is also the author of the MedEdits blog, a useful resource for applicants: (www.MedEdits.blogspot.com).

Meet Dr. Freedman at the American Medical Student’s Association Meeting in March in Arlington, Virginia.

What are the latest trends in medical admissions? At the annual meeting of the Association of American Medical Colleges (AAMC), 3,800 medical education professionals from around the country addressed changes in the MCAT, criteria for evaluating applicants, predictors of success in medical school, what elements of the residency application are most important, and a wide variety of other subjects that may interest premedical and medical students and residents. Here are some of the meeting’s highlights.

MCAT Update

Quick facts:

• In 2009, there will be 28 test administrations and 18 score release dates.
• A March date for the MCAT was added to assist students who are on quarter systems with scheduling.
• Scores are delivered 30-35 days after the test is taken.
• A change for this year: since applicants can be registered for only one test date at a single time, they will be allowed to cancel their test after the deadline (and forfeit the fee), enabling them to register for a future test date.
• The MCAT administration plans to review and modify policies regarding testing accommodations in the near future.
• A new publication, The Official Guide to the MCAT Exam, which will include testing tips and strategies, is to be released shortly.

In preparation for the fifth comprehensive review of the MCAT, surveys were sent to 142 US medical schools to find out what factors are important for evaluating applicants. The response rate was 90%. Survey results showed that the undergraduate GPA and MCAT scores are used to determine academic capability and success in the basic sciences. The MCAT score is also used to predict the USMLE Step 1 performance

Personal characteristics and qualities that were identified as important for success in medical school and beyond are:

• Integrity
• Critical thinking skills
• Professionalism
• Motivation for medicine
• Reliability
• Ability to integrate information
• Logical reasoning
• Maturity
• Work ethic
• Team work
• Compassion
• Self discipline
• Oral communication skills
• Intellectual curiosity
• Scientific and verbal reasoning
• Resilience
• Altruism

The MCAT staff discussed how standardized tests do not assess these qualities and that the tools and testing modalities to evaluate them need to be developed. This is why written documents (personal statement, application, and letters of reference) and interviews are so vitally important because they offer admissions members an opportunity to evaluate personal attributes.

The Holistic Review of Medical School Applicants

The AAMC is trying to ensure that applicants “are evaluated by criteria that are institution specific, broad-based, mission driven, and that are applied equitably across the entire applicant pool.” In an effort to increase the overall diversity of physicians (without considering race and ethnicity), the definition of diversity must be multidimensional and to more accurately assess applicants, the entire record must be considered as a whole (the so-called holistic approach). The definition of diversity may also differ from institution to institution so applicants must consider the mission statement of each school. It is also important to understand that with a looming doctor shortage (especially of primary care physicians), the need to increase access to primary care for everyone, including underserved populations, needs to be addressed at the level of the medical school application. There is also evidence that the care provided to racially and ethnically diverse patients is often affected by provider bias and stereotyping, which is why today’s physicians must be culturally competent.  Medical school admissions committees must select not only the most capable students but also those who will make a valuable contribution to our society as a whole.

Predictors of Success in Medical School

There are few accurate predictors of future performance as a physician, though past academic performance and MCAT score predict future academic success and USMLE performance.  Because past behaviors are usually predictive of future behaviors, and this is all admission committees have to go on, it is best to give admission committees enough material to provide a clear and multifaceted view of who you are.  Interviews are important not only because they give the school a chance to really know you, but they give you an opportunity to show your warmth and provide a sense of how you will interact and communicate with patients. Remember, admissions officers aren’t out to get you. They are kind people who carry a tremendous responsibility and have a very important mission.

National Residency Matching Program (NRMP) Update

Quick facts for 2008:

• 25,066 residency positions were offered
• 23,674 positions were filled
• 883 US allopathic seniors didn’t match
• The number of IMG applicants has increased during the past 10 years

Many IMGs register for the NRMP just to get the list of unfilled programs for the scramble. About 13,000 people compete in the scramble to gain an unfilled position. With only 1,390 positions remaining unfilled on scramble day, many of which are preliminary programs, the odds of getting a spot through the scramble are not good. As the scramble now stands, schools and students find out if they didn’t match on Monday. On Tuesday at 11:30 AM, programs find out if they didn’t fill. The list of unmatched programs is released at noon on Tuesday and unmatched applicants begin contacting programs. In 2008, by 4 PM on Tuesday, 50% of the unfilled positions were filled. By Wednesday, 147 positions remained open. Clearly, the scramble is stressful and you should do everything in your power to avoid it. The NRMP website gets more than 5 million hits on the Tuesday of match week.  Because of many “for profit” companies that fax materials to programs for clients, faxes and phone lines are often jammed at programs that have unfilled positions.

The NRMP is proposing a possible change for the scramble but this likely will not be put into effect until 2011. The goal of this change would be to allow applicants and programs more time to interview applicants (by phone), create more time to make decisions, and decrease stress for everyone involved.  A scramble work group has been formed to address these issues and the pros and cons of the current system and to make suggestions for improvement.

Electronic Residency Application Service (ERAS) Update

While growth of allopathic medical school enrollments is projected, the greatest increase of applicants using ERAS is of osteopathic students and international medical graduates (IMGs). The number of IMG applicants to ACGME accredited programs has increased by 14% since 2001, and the number of US ECFMG certified applicants, most of whom are Caribbean students, recently has increased significantly as well.

US allopathic students increasingly are choosing specialties with “controllable lifestyles,” such as anesthesiology, emergency medicine, dermatology, radiology, and pathology. Fewer and fewer medical students are choosing family medicine and internal medicine (primary care). Fifty five percent of those who match in internal medicine choose to subspecialize. IMGs continue to fill the void for specialties that US graduates are not choosing. Interestingly, a survey done by the NRMP of physicians over 50 found that 47% of primary care physicians versus 44% of “controllable lifestyle” physicians felt that they had control of their lives. So, perhaps medical students should start to reevaluate what specialties offer the best work/life balance – primary care might be the answer.

Specialty Choice

What are the factors guiding medical students’ specialty choice?

• Whether the specialty “personality” matches the applicant’s personality
• Mentors and exposure to the field
• Lifestyle
• Income/job market/debt
• Length of training

Getting Into Residency

What are the most important factors for getting into residency? The answer to this question depends on the specific program and the specific specialty. All programs consider the following factors important but not necessarily in the order presented:

• USMLE Step 1 score
• Grades (if not pass/fail), AOA, class rank
• Subinternship performance
• Letters of reference
• Personal statement
• Interview
• Medical School Performance Evaluation or MSPE (formerly known as the Dean’s letter). The usefulness of the MSPE and the timing of release is being evaluated. More to come on this.

Changes Ahead

With the election of Senator Barack Obama as our next president, the country is expected to undergo health care reform, making this a truly exciting time for the future generation of physicians to be a part of medical education.  While it is important to understand what it takes to “get in” to medical school and residency, you should also keep bigger issues in mind. For example, how will we improve the access to and quality of medical care for everyone? How will we decrease the income disparities among specialties so students will pursue the specialties where the need is greatest?

Dr. Freedman’s Bio:

Jessica Freedman, MD, is a former medical admissions officer and president of MedEdits (www.MedEdits.com), a medical school, residency, and fellowship admissions consulting firm. She is the author of the MedEdits blog (www.mededits.blogspot.com). Dr. Freedman is also a practicing emergency physician.

Authors of The Successful Match: 200 Rules to Succeed in the Residency Match and 250 Biggest Mistakes 3rd Year Medical Students Make And How To Avoid Them

“I saw his drunk photos on MySpace, and he just strikes me as immature. Do you think that matters?” “I don’t know, but we have 30 other great applicants here to choose from.”

“She’s a member of the Facebook group, ‘Medical Students Behaving Badly.’  I don’t think that’s someone we should bring in as a resident.”

Applying for residency, as every applicant knows, is a long, complex process, and understandably so. Residency selection committees use every tool at their disposal to compare applicants. Would programs use internet search engines and social networking sites, such as Facebook and MySpace, to screen applicants?

No studies examining this issue as it pertains to the residency application process have been published. However, there is data available from other fields. In the business world, employers are increasingly using social networking sites to learn more about potential hires:

• In a recent CareerBuilder.com survey of 3,169 hiring managers, 22% used social networking profiles to screen potential hires.¹
• Α Vault.com survey found that 44% of employers reported looking up potential hires on social networking sites.²
• According to the executive search firm ExecuNet, 77% of recruiters surveyed used the Web to screen applicants.³

How did the information discovered affect hiring decisions?  In the CareerBuilder.com survey, 34% of managers who used these sites in the screening process reported dropping candidates from consideration based on the content found.  Most concerning for these hiring managers were candidates posting information about alcohol or drug use, followed closely by posting of inappropriate photographs or information.  Less commonly cited, but still areas of concern, were poor communication skills and discriminatory comments related to race, religion, or gender.  Even an unprofessional screen name, while seemingly much more innocuous, raised concern for some managers.

In a recent study published in the Journal of General Internal Medicine, researchers at a major medical school in the Southeastern U.S. evaluated the Facebook profiles of all students at their institution.⁴ Of the 501 medical student participants in the study, 64.3% had Facebook accounts.  In an analysis of these profiles, the authors found the following:

•    Forty percent joined online groups.  While most groups were benign in nature, some groups raised concern, including those with the names “Party of important male physicians,” “Keep your f***ing hand down in lecture and shut the f*** up,” and “I should have gone to a blacker college.”
•    When a random subset of students was examined more closely, 70% were found to have photographs with alcohol, with a substantial number showing excessive drinking.
•    Some profiles contained unprofessional comments, involving foul language, overt sexuality, and patient privacy violations.

While students maintain that their personal profiles were never meant to be viewed by anyone other than their friends, the reality is that anything placed in a publicly available profile may be viewed by programs and used in the selection process.  As stated by the Student Affairs Office at the Drexel University College of Medicine, “programs/employers are increasingly gaining access to social networking sites such as Facebook and MySpace to see what they can learn about candidates…”⁵

Social networking sites often allow users to restrict access to their profiles.  While students often realize this, many users fail to activate these privacy features.  In the aforementioned study of medical students, 62.7% kept their Facebook account public.  Even when a profile is restricted, however, there are ways around privacy guards.  For example, a member of the residency selection committee who is a graduate of your college or medical school, can create a profile using an alumni email address.  In doing so, he can acquire access to current students at that institution.  In this way, he can circumvent the privacy guards in place at social networking sites such as Facebook.

Some students argue that their online personality is different from their professional personality.  Therefore, no conclusions or assumptions should be drawn from the content posted.  It is currently true that research examining the predictive value of posted content on social networking sites as it relates to on-the-job behavior or performance is not available. However, that’s not likely to stop a program director from making judgments about you based on your personal profile.

In selecting candidates, programs are searching for those who will succeed as residents and, later, as practicing physicians.  They also seek to avoid problem residents, defined as “trainees who demonstrate a significant enough problem that requires intervention by someone of authority, usually the program director or chief resident.”⁶ When Yao looked at reasons why certain residents were considered “problem residents,” among the deficiencies reported were inappropriate interaction with colleagues or staff, unsatisfactory humanistic behavior with patients, and unacceptable moral or unethical behaviors.⁷

Studies have shown that behavioral and noncognitive traits and skills have significant value in predicting resident performance.  However, programs are limited in how they can assess these skills.  The use of social networking sites may provide additional information about potential residents not found in traditional application components (i.e., curriculum vitae, letters of recommendation, MSPE, personal statement, transcript, interview).

In justifying their actions for use of this information, programs may maintain that unprofessionalism displayed at social networking sites may be a harbinger of future unprofessionalism during or after residency.  In a retrospective study done by Dr. Papadakis, associate dean of student affairs at the UCSF School of Medicine, researchers searched for warning signs during medical school associated with an increased risk for disciplinary action later as a physician.⁸ They found that “disciplinary action by a medical board was strongly associated with prior unprofessional behavior in medical school.”

Since programs are free to use whatever tools are at their disposal for the evaluation of residency applicants, we recommend that you view social networking sites as yet another tool.  Even with privacy guards in place, there are ways to circumvent restrictions.  Therefore, we recommend a preemptive stance or approach to keep your online persona clean.  We recommend the following:

•    Google yourself regularly to ensure that troublesome or offensive material does not appear online.
•    Employ whatever privacy guards or blocking tools are offered by your social networking site.
•    Closely review your posted materials (i.e., comments, photos, membership in groups) to ensure you are displaying the professionalism expected in a future resident and doctor.
•    As you examine your online persona, consider your audience.  You and your friends may feel that the content is relatively normal or harmless, but faculty members and program directors may have a completely different viewpoint.
•    Remove any material, including photographs and text, that may be considered inappropriate.
•    If you cannot remove the information, politely contact the company or person who owns the site and request its removal.
•    If the information cannot be removed, be prepared to discuss it should the issue be raised during an interview.
•    Consider creating profiles at professional networking sites such as LinkedIn.  Such sites tend to be ranked highly by internet search engines and profiles placed at these sites may be displayed first on an internet search of your name.

Finally, we agree with the recommendations of Brittany Warwick, in her SDN article “Keep Your Online Persona Clean.”⁹ She recommends using “your online presence to advertise your good qualities.  You can post information about your leadership, maturity, growth, and potential.”  An online persona conveying a professional image may solidify a program’s decision to interview or even rank you favorably.

References

1. Available at www.CareerBuilder.com
2. Available at www.Vault.com
3. Available at www.ExecuNet.com
4. Thompson, LA, Dawson K, Ferdig R, Black EW, Boyer J, CouttsJ, Black NP.  The intersection of online social networking with medical professionalism.  J Gen Intern Med 2008; 23 (7): 954 – 957.
5. http://webcampus.drexelmed.edu/osa/careeradvising/interview.asp
6. American Board of Internal Medicine.  In:  Materials from Association of Program Directors in Internal Medicine (APDIM)’s Chief Residents’ Workshop on Problem Residents; April 19, 1999; New Orleans, LA.
7. Yao DC, Wright SM.  National survey of internal medicine residency program directors regarding problem residents.  JAMA 2000; 284 (9): 1099 – 1104.
8. Papadakis MA, Hodgson CS, Teherani A, Kohatsu ND.  Unprofessional behavior in medical school is associated with subsequent disciplinary action by a state medical board.  Teach Learn Med 2007; 79 (3): 244 – 249.
9. Warwick, B.  Keep your online persona clean.  Available at www.studentdoctor.net.

This two part series discusses the essential ingredients for success, including rotations, written documents, letters of reference, interviews and follow up.

While this article focuses on residency admissions, portions of this piece might also be useful for medical school and fellowship applicants.

Away Rotations and Structuring Your Fourth Year of Medical School

As soon as you have chosen your specialty, you should schedule your away rotations since these slots fill up quickly, especially at top residencies. For programs in which you are especially interested, try to schedule rotations in the summer and early fall of your fourth year to make a good impression before interview season begins.

Your objective for an away rotation is twofold: to impress the faculty and residents of the program where you are rotating and to be a desirable applicant so the program will recruit you. While an outstanding performance during an away rotation is optimal, it isn’t always imperative to secure a decent ranking.

When I was a residency admissions officer, a rotating student whose performance was merely average often was ranked to match.  I would much rather take an applicant who had a predictable performance (and no psychopathology) than take a gamble on someone with whom I had not worked.

Also ideal is to try and secure an additional letter of reference during your away rotation. This demonstrates that you are able to adapt and perform well away from your “home environment.”

While there are specific recommendations for every specialty, here are a few general guidelines for performing well on your away electives:

• Be independent and try not to appear needy. If your resident or attending asks you to do something, get it done as efficiently as possible.
• Be pleasant, be personable and smile.
• Be kind and compassionate to your patients.
• Recognize when you don’t know something or have made an error.
• Arrive early and stay late.
• Work hard.
• Follow up on all labs and diagnostic tests that you have ordered.
• Always offer a helping hand and ask what you can do to make your residents’ and attendings’ lives easier.
• Be respectful to everyone.
• Participate in conferences and morning report.
• Read about your patients’ diseases and study topics that are likely to come up on rounds or in the operating room (depending on the specialty).
• Don’t compare your away institution to your home institution.
• Never speak negatively about anything or anyone.

Structure your fourth year so you have some substantive rotations later in the year. While filling the remainder of your fourth year with fluff is tempting, spending your fourth year doing rotations that demonstrate your interest in the specialty to which you are applying will impress the program.  I also encourage applicants who are applying to competitive specialties and may not match to schedule spring electives or participate in research if they plan on reapplying the following year.

The Application

When writing your documents, consider this scenario: A very tired physician, who has just spent four hours working clinically and then two hours at resident conference, sits down in front of a computer with a large cup of coffee to review the 200 new applications that are waiting for review.  What may catch his or her eye?  Also consider how most people review applications. Typically, reviewers first look at your demographics and, after that, some may review your board scores while others may move straight to the personal statement. All of the different elements of your application are “tabbed” so reviewers can look at documents in whatever order they please. You therefore must write each piece of your application as though it is the “make or break” element.

Your ERAS entries must be distinct from your personal statement and must explain your accomplishments in detail. Describe what you have done with each work, volunteer, teaching and research experience. What have you learned? How has this experience helped shape you, your outlook or your interests? Use simple language and do not be too technical. Reviewers always have the option to skim entries, but they won’t pick up the phone to ask for more information if they want it. I find that many people leave out activities and experiences that should be included in their application. Not every experience should be medically related. In fact, significant accomplishments outside of medicine illustrate that you pursue diverse activities and are interesting. Though you generally don’t want to write about college and high school accomplishments, you can include those that were especially outstanding: Were you an All-American athlete? Were you valedictorian of your high school class? Were you an accomplished musician? You can also mix up the presentation of your entries. One entry might be straightforward, while another one relies on a vignette.

The Personal Statement

Everyone thinks the personal statement is the pivotal part of the application. For some reviewers it may indeed be primary, but I know some who save the personal statement for review last and, even then, skim it unless it is really “worth reading.” This is why it is essential to make your essay stand out so even the skeptics– who think they have seen it all before–will read on. This piece must be flawless. Make your personal statement intriguing and make sure it tells your story.

Here are a few guidelines for writing a personal statement:

• Start with something catchy to engage your reader. The first one or two sentences are pivotal. If the opening of your essay bores your reader, he or she may stop reading.
• End with a strong conclusion to leave a lasting impression.
• Do not use cliché phrases such as “I like internal medicine because I enjoy working with patients.”
• In general, it is better to “show” through example or anecdote rather than “tell.” Instead of writing “I am empathetic and hard working,” illustrate with examples how you have demonstrated these qualities.
• With every paragraph, ask yourself if someone else could have written it and, if the answer is yes, go back and make the paragraph more distinctive.
• Do not regurgitate your CV or write about something that can be read elsewhere in your application.
• Do not repeat yourself. With each sentence, ask yourself, “Have I already said that?” If the answer is yes, hit delete.
• Use an active rather than a passive voice.
• Your essay should be authentic. No matter what advice you receive, your essay must be a reflection of you and must be, as the title suggests, personal.

It is essential to illustrate your interest in the specialty to which you are applying. This is also the place to explain any red flags in your application, such as gaps in time, institutional actions, a board failure, etc. Also explain any obstacles you have overcome: Were you the first in your family to graduate from college? Were you an immigrant? Did you have limited financial resources and work through college? Many applicants tend to shy away from the very things that make them impressive because they are afraid of appearing to be looking for sympathy. As long as you explain how you have overcome adversity in a positive or creative way, your experience will be viewed as the tremendous accomplishment that it is.

ERAS allows you to write multiple personal statements. I encourage applicants to write individual essays to express interest in a specific geographic area or for a specific type of program, such as a community versus an academic setting.

The Picture

Many people ask what kind of picture to submit. You do not need to have a photographer take your pictures. Look professional, look neat and smile. No one wants to work with someone who looks grouchy. The picture also serves as reminder of who you are after you have interviewed, so make sure it is current. If you just colored your hair blonde, don’t submit a picture of yourself as a brunette

The Bottom Line

Use every space in your application to your advantage. Tell your story and explain what makes you unique. The key is to engage and keep your reader’s attention, pique their interest and motivate them to click the “interview” check box in ERAS.

Jessica Freedman, MD is a former residency admissions officer and president of MedEdits (www.MedEdits.com), a medical school, residency and fellowship admissions consulting firm. She is the author of the MedEdits blog (www.mededits.blogspot.com). Dr. Freedman is also a practicing emergency physician

This is part one of a two part article, read the continuation of the article here.

Reprinted with Permission

Any transition, be it from college to the work world, or the common transitioning between jobs, can be difficult. But most transitions happen fairly quickly, in a matter of a couple months, compared to that of the medical transition. Transitioning in the medical profession is a way of life, whether it be from student to internship, internship to residency, or residency into a fellowship, specialty or private practice. The family of medicine is always there to support their physicians in training and make the transitions as smooth as possible.

Planning—The Key to Success

The first step in any transition is planning. How much time depends on each person and his or her priorities. For example, for Gary and Ashlie Schooler, physician and spouse started planning at different times. Gary Schooler, a fourth-year medical student at the University of Oklahoma, began planning on the first day of medical school. “I knew doing my best throughout my pre-clinical and clinical years would afford me the best opportunity to be successful in gaining access to the specialty that was best fit for me,” he said. But for his wife Ashlie, planning began in his second year of medical school. “This was the time to start budgeting…so we could afford for me to travel to most of the cities [we were considering for his new job and our relocation] with him,” said Ashlie. “I also saved my vacation through the year at my job to allow me to be gone. With this plan we were able to visit neat places together.”

For others, the planning process was approached in steps. For Dr. William and Gretchen Dupps, the first step was related to the program or job that was the best match for the physician. The second step was researching the areas that were being considered, including the school systems and culture of the region. “After we painstakingly went through lots of research and visits, we would make a list of pros and cons,” said Gretchen, whose husband Dr. William Dupps is two years out of fellowship. “Ultimately the most heavily weighted part of that list would be the job opportunity.”

With this transition process being one of the most challenging decisions of a physician’s life, research is very important. No one knows better about this transition than those who have gone through it. “I asked many questions of the residents who just recently were in my shoes,” said Adam Ostendorf, a fourth-year medical student at the University of Iowa starting his transition to a residency in pediatric neurology in St. Louis. “In addition, certain staff physicians have been extremely generous with advice regarding both transition to residency and the transition to a new city.”

And while some physicians are very open to the idea of moving to a different city, others want to stay close to their roots. “Getting back ‘home’ is most important to us,” said Darla McVay, spouse of Dr. Bryan McVay, a surgical resident in Pennsylvania.

Matchmaking

The “match” process can be stressful for the student and his or her family.

For some, the result can create an easier transition than for others. For the Hogrefe family, their transition takes them no farther than into a new home. Christopher Hogrefe, a fourth-year medical student at the University of Iowa, will be working in a residency in the same city he went to school in, and he will start working with his spouse, Amy Hogrefe, who is a nurse at the University of Iowa Hospitals and Clinics. “However, we laugh frequently because of all of our life changes that are occuring this spring and summer,” said Christopher. “To briefly recap, we [experienced] Match Day, bought a house, will graduate from our respective graduate programs at the University of Iowa, I am starting a new job and Amy is having a baby in July!”

The matching process can take longer for some than others. Gary Schooler was always under the impression after talking with other specialists that when the best specialty for him presented itself, he would just know it was meant to be right away, like a light bulb coming on. But his process was a drawn-out system of weighing likes and dislikes before coming to his conclusion.

Sometimes the conclusion isn’t thought of in great depth because the outcome is already assumed, as in the case of Brent Owen, a fourth-year medical student at the University of Iowa starting his residency at the Via Christi Family Medicine Residency in Kansas. “Originally we planned on [a] residency closer to home but really enjoyed the Via Christi program when we interviewed.” And while a lot of planning can be put into the transition, it can still be overwhelming. According to Adam Ostendorf, “Our lives are about to change in almost every aspect.”

Transitions happen to many people across the country on a daily basis, but most people only make major transitions couple times in their lives. The profession of medicine can make the lives of physicians and their families seem like a constant state of flux. “There are so many transitions throughout training that I felt we were in transition for our entire course of training,” said Gretchen Dupps. “I think we are just now feeling like we are getting settled. This is the first time in our 15 years of marriage that we have been in a location for an [extended] amount of time.”

Along with the continuous state of transition that is unique to the medical field, there are many other factors that only seem to affect those in medicine. “There is certainly nothing like ‘the match’ in the regular working world,” said Adam Ostendorf. “What a stressful process! Then it is complicated by such a short amount of time to tie up loose ends in medical school and then move to your new home.”

Christopher Hogrefe points to another challenge, “Try getting your first job at 26!” Dr. Edward Hill, faculty at the North Mississippi Medical Center and former AMA President, concurs. “Perhaps there is some delay in the development of social skills outside of medicine as well as a lack of opportunity for a balanced lifestyle since being immersed in focused medical studies for seven to 12 years post-college. The physician completing training has non-medical college classmates that have been in the real world already for those seven to 12 years.”

A Life-Long Family Commitment

One other aspect of medical life is the need to continue to learn. Medical advancements are made every day, and physicians are expected to stay up-to-date on the latest and greatest ways of helping patients. “I believe the biggest difference [between medical student graduates and college graduates] is that after medical school a doctor’s education is just really starting to become fine-tuned toward their future career,” said Gary Schooler.

The transition not only affects the future career of the physician, but also that of their spouse in most cases. With moves being made to different cities and states, spouses often find themselves having to leave careers, family and friends behind. “After completion of my intern year, we will be moving to a new area of the country to begin my [residency] in radiology,” said Gary Schooler. “My wife will have to quit her current job and find a new one in our new location.”

Some families with children find this transition period the perfect opportunity to spend more time with them. With one parent being obligated so much outside of the home, the spouse decides to make sure that the children continue to get all the attention they are accustomed to, as is the case with Hilah Owen, wife of Brent Owen. “We are planning on Hilah staying home to take care of our son and future children since I plan on being busy, especially for my first year of residency,” said Brent. Still others find a way to continue their careers while always remembering to support their physician spouse. “Fortunately Amy will be able to keep her current job, while making a few adjustments,” said Adam Ostendorf. “It is certainly challenging to have to help me out so much while having her own career and I respect her immensely for it.”

Children can make the life changes even more difficult. Moving away from friends and family that can help with childcare, and taking children away from friends they have made can complicate matters greatly. “My children’s education, and our support system will be determined, in large part, by the nature of the community in which we find employment,” said Dr. Bryan McVay. Meeting fellow medical families with children is what helped Gretchen Dupps get through the difficult residency years. “One of my best friends from residency became a ‘co-parent’ with me,” she said. “She and I would trade off taking care of each other’s children and spent many afternoons and evenings together letting the kids play and enjoying some adult conversation.”

Support System

Friendship can help overcome the difficult times, but it is most important that all family members appreciate each other for their continued support. “My husband and I work as a team, and he has done an excellent job of giving me credit for all I do and for acknowledging the sacrifices we have made as a family throughout his training,” said Darla McVay. And struggling through these complicated times together can make the bond that much closer if it is handled correctly. “Amy and I have become intimately aware of the importance of confiding in one another,” said Christopher Hogrefe. “Such an approach aided us in gaining perspective and understanding how each of us independently views a situation, which is not always identical.”

The process of moving from one life stage to another can draw extended family closer. “We have been fortunate to live within 10 miles of both our parents while attending medical school,” said Brent Owen. “It has been nice to have them so close for support, baby-sitting and advice. The transition of us moving has been equally hard on them as [it has] for us.”

Dr. Hill repeats a quote he shares with the students he advises, “If you fail to plan, you are planning to fail.” He also instructs them to include the family completely in the planning if the transition is to be successful, stressing that a lot of support is vital. Support can come from many places. Young physicians and spouses should not fear asking for help and guidance.

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