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.

Dr. Rajani Katta and Dr. Samir Desai, who provide “The Successful Match” column to the Student Doctor Network, have written a book called The Successful Match to aid students in their applications.  The book provides 200 rules and over 130 tips on how to prepare for all phases of the match process.

Katta and Desai have combed the research on medical education to provide evidence-based strategies for improving the odds.  Detailed and easy to understand steps teach students how to influence the content of letters of recommendation and the Dean’s Letter, draft better personal statements, and highlight their strengths during the interview and audition elective.

The Student Doctor Network spoke with Dr. Katta and Dr. Desai, who serve on the faculty of the Baylor College of Medicine, about The Successful Match.

Why did you want to write this book?

If the 2009 match is similar to previous matches, over 40% of U.S. senior medical students will fail to match with the program of their choice. In competitive specialties such as dermatology and plastic surgery, over 30% of U.S. senior students will fail to match at all. The numbers are significantly worse for international medical graduates.

A successful match – matching with the program and specialty of your choice – requires a well-thought-out strategy. Strategizing always begins with full knowledge of the process, followed by informed decisions. Our goal was to help applicants make informed decisions by offering highly specific, evidence-based advice and recommendations.

We wanted to highlight the wealth of impressive research that’s been done in the field of medical education, and in the field of the residency match in particular. Many researchers have asked questions about the factors that lead to match success, and have approached the study of these questions in a scientific manner. The results of these published studies provide the basis of our evidence-based recommendations. Studies such as these are continuously being added to the medical literature. In the last two months, two impressive and highly useful studies were published:

• One study, performed by the NRMP, surveyed directors of all programs in the 19 largest specialties that participated in the 2008 NRMP Match. The goal was to determine applicant factors which are important in the residency selection process.(1)
• In another survey of program directors in 21 specialties, Dr. Green and colleagues at the Feinberg School of Medicine (Northwestern University) sought to ascertain the relative importance of criteria used in the selection process.(2)

The results were published too recently to be utilized in our book, but we will be able to utilize these results to help those students whom we advise.

Which residency selection factors were found to be most important to orthopedic surgery residency program directors? How important is published medical school research to pathology residency programs? What degree of importance do plastic surgery residency program directors attach to the quality of questions asked by an applicant during the interview?

This is precisely the type of information necessary for a well-thought-out application strategy – one that will lead to a successful match.

What aspect or aspects of an application that are important to administrators are most often discounted or overlooked by students?

When it comes time to make interview and ranking decisions, residency programs will use all the available information. Therefore, applicants should use every component of the application – the common application form, letters of recommendation, personal statement, and interview – to capture the attention of program directors.

Program directors are understandably overwhelmed by the deluge of applications they receive. To stand out from the rest of the field, every component of your application has to demonstrate your unique strengths. What is that sets you apart from other candidates? It’s that message that needs to be consistently communicated throughout your application.

Far too often, candidates end up sounding the same. We devoted a chapter in our book to guide applicants on how to distinguish themselves from others in the most compelling manner possible.

What are the most common misconceptions that students have about the match? Which of these misconceptions is most dangerous or damaging to a student’s chances of successfully matching?

While applicants recognize the importance of recommendation letters, they often assume that letter writers know how to write the most compelling letter possible. However, that’s a dangerous assumption. In one analysis of recommendation letters, reviewers noted that 35% of letters had no information about an applicant’s clinical judgment, while 32% lacked information about interpersonal skills.(3) In our chapter on letters of recommendation, we describe the type of evidence that applicants can provide to the writer to increase their chances of having the most helpful letter written – one that includes information most useful to programs. Your letter writers want to write the best letter possible, and you can do much more than you realize to make this a reality.

Another common misconception has to do with minimizing the importance of the personal statement. It is true that individual specialties, residency programs, and application reviewers attach varying degrees of importance to the personal statement. However, you won’t know how the statement is used or viewed at each program. Therefore, you must create a well-written, high-quality statement that makes the application reviewer say, “This is definitely someone I want to meet face-to-face.” We believe that statements written by many candidates have a neutral effect, and that this represents a lost opportunity.

What are some of the key steps students should take to improve their chances of a successful match?

First, obtain detailed and specific information from your medical school. The right advisor can be invaluable, yet many applicants don’t have one.  In one study of third and fourth-year medical students, only 36% reported having a mentor or advisor.(4) Your specialty-specific advisor can share with you detailed information about how your school’s previous students fared in the residency selection process with respect to specific programs. How do their credentials stack up against your own? This type of information can help you more accurately assess the strengths and weaknesses of your application and target programs where you have the best chances.

Second, begin working on the application as early as possible. Often, applicants underestimate the time and effort required to produce a high-quality application. A late start leads to the inevitable last-minute rush.

Third, take interviews seriously. Multiple surveys of residency programs have shown the interview to be most important in the residency selection process. In one survey, 66% of applicants had either no change in their ranking or were ranked less favorably following the interview.(5) We believe that most applicants recognize the importance of the interview, but few go to the lengths required to become a good interviewee. In recognition of this fact, we devoted four chapters of the book to the interview process.

As an interviewer, what are the most common mistakes you see students make during the interview process?

One important mistake is inadequate preparation. Begin by thoroughly researching the program. Spend time on the program’s web site, talk with professors and residents at your school who are knowledgeable about the program you will be visiting, and so on.  Don’t stop there.  Take the knowledge that you acquire and use it during your interview visit. In fact, being knowledgeable about the program is one of the easiest ways to demonstrate your interest. It’s also a great way to impress interviewers.

Another common mistake is not offering the interviewer enough information about those qualities that set you apart from other candidates or that make you particularly attractive to a particular specialty. For example, we discuss the importance of leadership qualities. In a survey of emergency medicine residency program directors, having a “distinctive factor” such as being a medical school officer was one of three factors most predictive of residency success.(6) If, however, you leave an interview without discussing this experience, you’ve lost out on a valuable opportunity to highlight this strength. Our general rule of thumb is that if your answer to a question could be easily given by another applicant, your response is probably not as good as it could be. This is such a common mistake that we devoted an entire chapter to interview questions, and provide detailed information on how to answer commonly asked questions.

The end of an interview can be just as important as the beginning. Almost all interviewers will end with the question, “Do you have any questions for me?”  At some programs, and with many interviewers, the quality of questions asked by an applicant is a factor used in evaluating interview performance. In talking with interviewers across the country, most applicants ask basic questions that fail to impress. That’s why we outlined the questions to avoid, and provided multiple examples of thoughtful, insightful questions.

The book has a lot of great details on the competitiveness of different specialties. How can students assess if they are competitive for one of these popular specialties or for a highly sought after program?

Chapter 2, “Specialty-specific Information,” explains what programs in different specialties seek in their applicants. Reading that chapter will give you a reasonable idea of what your own strengths and weaknesses are. Once you recognize where you stand, take this one step further by approaching your specialty-specific advisor. Ask him or her how you compare to previous graduates who did or did not match into your chosen specialty. With this information, you should be aware of what a program director is likely to see as your strengths and weaknesses.

Take this information and together, with your advisor, develop a strategy. How can you make your application stronger in the time that you have remaining? What’s the best way to highlight your strengths? What can you do to turn your weaknesses into strengths? Or if that’s not possible, what can you do minimize them? The book specifically addresses how to add an extra competitive edge to your application.

What steps can students take to proactively address any weaknesses in their application?

First, you must have a clear understanding of the strengths and weaknesses in your application. Again, your specialty-specific advisor can help you.  Individuals are not always the best judges of the strength of their own candidacy.

Once you have identified areas of weakness, take action to overcome or minimize them. Seek out opportunities, responsibilities, or experiences that would enhance your application. Do you need to take the USMLE step 2 CK before you apply? Do you need to have a letter written by a particular faculty member in your school’s department? Should you begin a research project?

Do you need to do an audition elective? Don’t underestimate the power of an audition elective. For applicants with shortcomings in their application, an outstanding performance during an audition elective can lead to a match at that particular program. Personal knowledge of your skills, qualities, and work ethic can provide a huge boost to your application.

Do the matching statistics cited for osteopathic graduates in Chapter 1 take the osteopathic match into account?

The matching statistics that we present in chapter 1 relate to the NRMP Match alone. In recent years, approximately 30% of osteopathic applicants participating in the NRMP match failed to match. Some of these applicants, who failed to match into ACGME-accredited programs through the NRMP Match, then scrambled and were able to find positions in AOA-approved programs.

If you are an osteopathic student or graduate interested in securing a position in the NRMP Match, our book will show you how to strengthen your application and make it more competitive for allopathic residency programs. If you are participating in the osteopathic match, you’ll find that many of our recommendations are applicable to you as well.  Although there are fewer studies and surveys done of the osteopathic residency selection process, we do present this information in our book.

What recommendations do you have for international medical graduates?

Over 200,000 physicians in the United States are international medical graduates. These physicians have made valuable contributions to patient care, research, and medical education. If you speak to these physicians, you will hear about the difficulties and challenges they experienced in their efforts to secure a residency position in the U.S.

The process is difficult, and our experience working with international medical graduates has shown us that they frequently overestimate or underestimate certain residency application criteria. These misperceptions may result in a failure to match. In our chapter on international medical graduates, we provide information from those individuals directly involved in the residency selection process – program directors and other members of the residency selection committee. International medical graduates can use this information to develop a strategy for success.

References

(1) 2008 NRMP Program Director Survey. Available at www.nrmp.org.

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

(3) O’Halloran CM, Altmaier EM, Smith WL, Franken EA. Evaluation of resident applicants by letters of recommendation: a comparison of traditional and behavioral-based formats. Invest Radiol 1993; 28: 274-7.

(4) Aagaard EM, Hauer KE. A cross-sectional descriptive study of mentoring relationships formed by medical students. J Gen Intern Med 2003; 18: 298-302.

(5) Gong H, Parker NH, Apgar FA, Shank C. Influence of the interview on ranking in the residency selection process. Med Educ 1984; 18(5): 366-9.

(6) Hayden SR, Hayden M, Gamst A. What characteristics of applicants to emergency medicine residency programs predict future success as an emergency medicine resident. Acad Emerg Med 2005; 12(3): 20

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.

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

In researching our book, we asked applicants what they found most difficult about the residency application process. A number of applicants commented on the same issue. “There’s so much conflicting information out there. How do you know what to believe? Who should you listen to?”

Applicants with mentors have a decided advantage. A joint committee of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine described a mentor as “someone who takes a special interest in helping another person develop into a successful professional.”¹ In defining the term, the committee described a fundamental difference between mentoring and advising. “Mentoring is a personal, as well as, professional relationship. An adviser might or might not be a mentor, depending on the quality of the relationship.” While the two terms are not synonymous, for the purposes of this column, we will use them interchangeably.

Mentoring relationships are invaluable. Students benefit greatly when the wisdom, experience, and perspective of a knowledgeable faculty member are used to help them achieve a successful match. Having a mentor to guide you through the complex residency application process is recognized by students as an important factor in boosting the strength of their application. In a survey of third- and fourth-year medical students at UCSF, 96% of all participants rated mentors as important or very important.² Unfortunately, recognizing the value of a mentoring relationship is a far cry from developing such a relationship. Although 96% of the participants rated mentors as important, only 36% actually reported having a mentor.

The value of mentoring is recognized in all fields. The literature in the fields of business, education, and medicine all support its value. Comments made by medical school faculty emphasize the value of a mentoring relationship:

“I had a difficult time learning the rules of the game.”³

“Without a mentor…I had no idea really what to expect from academic medicine. I have been feeling my way through the tunnels because I don’t know where the roadblocks are. I just kind of deal with them when I get there.”³

These words resonated with us, as they mirror the type of comments we hear from applicants. It’s tough to learn the rules of the game when they’re not actually written down anywhere. “I didn’t know you could customize your personal statements for different programs.” “I didn’t know I should have sent an email thank you immediately after the interview, especially since I was planning to send a note later.” Particularly difficult is when you learn the rules of the game too late to make a difference. “I didn’t know that 93% of matched applicants to radiation oncology in the NRMP data from 2007 had reported one or more abstracts, publications, or presentations. I’m in my fourth year now, and it’s probably too late.”⁴

Medical schools have recognized the importance of mentoring and advising students, and have responded with the development of mentoring programs. As would be expected, these programs have differed widely in structure and scope. At schools such as Johns Hopkins and Columbia, highly organized programs have been developed.

At other schools, the mentoring process is much more informal. Students may be given a list of faculty members willing to serve as advisors, and then encouraged to cultivate relationships. As one student in a survey of UCSF students stated, “I create the relationship, and then I follow it. I sort of take the risk.”⁵ Not all students find it so easy. Some have blamed themselves for not being assertive enough to find a mentor. “I just didn’t know how to go about setting myself up for a good thing to happen.”⁵ Others maintained that the problem lies with the system, citing the short duration of courses and clerkships as impediments to developing relationships with faculty.

Finding a potential mentor and developing an effective relationship can be very difficult. Understandably, students often hesitate to burden faculty members who are already clearly very busy. However, while faculty members have many demands placed on their time, there are faculty at every medical school who find mentoring and advising students enjoyable and rewarding. While these individuals are sometimes recognized publicly for their work, it is more typical that they go about their work diligently but quietly. You should make every effort to identify these types of motivated, dedicated individuals. In one study, 28% of students met their mentors during inpatient clerkships, 19% through research activities, and 9% during outpatient clerkships.²

Some students won’t find a mentor through their randomly assigned clerkships and courses. Persistence, courage, and some degree of assertiveness may be necessary. The process may be very informal. You may hear from the residents or your colleagues that Drs. A, B, and C have helped advise many students applying to your field in past years. You may then request that faculty member for a clerkship assignment or research elective. Some may be open to meeting with you. On the other hand, you may be advised to start the process by setting up a meeting with the clerkship director, program director or chairman of the department. The intent of this meeting would be to state that you’re planning to apply to the field of …. From there, the meeting can go in several directions. You can ask for recommendations on potential advisors. You can ask for recommendations on the application process, given the strength of your credentials. You can seek opportunities to work on a case report, to work on a research project, or to arrange a research elective.

Some schools lack residency programs in certain specialties. That poses obvious difficulties for students applying to that specialty. One option would be to seek advisors elsewhere, such as during an audition elective. In addition, local or national organizations may provide assistance. The Society of Academic Emergency Medicine (SAEM) has a medical student virtual advisor program open to students at all institutions. Through this program, students can query experienced individuals about a variety of issues, including the EM residency application process. Recognizing the importance of mentorship, SDN has launched an innovative mentorship program as well.

Finding the right mentor can be difficult. Even when a formal system for assigning mentors exists, this doesn’t necessarily mean that the mentor will be the right fit for the student. Should this happen, you should seek guidance from other faculty members. Few mentors have the answers to every question, and it is often to your advantage to have several opinions on certain issues.

As you consider possible mentors, you should be aware of problems that can occur in the advisor-advisee relationship. Chief among these is the potential conflict of interest that can occur with a mentor who advises a student and also serves on the residency selection committee at a program affiliated with the student’s medical school. In a survey of 740 graduating medical students from 10 U.S. medical schools, Miller found that nearly half met with their advisors during or following the interview season.6 The results indicated that:

· 31.8% were encouraged to rank the advisor’s program highly.
· 10.3% were asked which programs they planned to rank highly.
· 4% were asked how they planned to rank the advisor’s program.

Not surprisingly, students reported varying degrees of discomfort from these queries. One respondent stated that “it felt very uncomfortable to talk to him about my own strengths and weaknesses and about which programs I preferred knowing that he would later be evaluating me in comparison with many other applicants and deciding whether or not to advocate for me to be accepted.” Faced with such dilemmas, some students felt pressured to make misleading statements. Miller went on to raise some important questions. “What is safe for applicants to tell their advisors? Can applicants be sure that their advisors will put their interests first in these situations?” You need to consider how you would respond to these types of queries, since you may be placed in a similar situation.

Studies on medical students, mentoring, and the match are sparse. However, our experience has clearly demonstrated that having an effective advisor is invaluable. Mentors can help students with career decisions, evaluate potential residency programs, review curriculum vitas and personal statements, write letters of recommendation, and conduct mock interviews. Since faculty members often sit on residency selection committees, many can offer the type of insight into the selection process that is not available elsewhere. By analyzing and comparing your credentials with previous years’ students who have matched, specialty-specific advisors can identify specific ways in which you can strengthen your application. They can work with you to develop an overall strategy for success. Applicants should work hard to identify potential mentors, since these relationships can be invaluable in ensuring a successful match.

References

¹Adviser, teacher, role model, friend. (http://stills.nap.edu/readingroom/books/mentor). Accessed 3/13/08. Washington, DC: National Academy Press; 1997.

²Aagaard EM, Hauer KE. A cross-sectional descriptive study of mentoring relationships formed by medical students. J Gen Intern Med 2003; 18: 298-302.

³Jackson VA, Palepu A, Szalacha L, Caswell C, Carr PL, Inui, T. “Having the right chemistry”: a qualitative study of mentoring in academic medicine. Acad Med 2003; 78(3): 328-334.

⁴Charting outcomes in the match: characteristics of applicants who matched to their preferred specialty in the 2007 NRMP main residency match. (www.nrmp.org/data/chartingoutcomes2007.pdf ). Accessed 3/20/08. Washington, DC: National Resident Matching Program; 2007.

⁵Hauer KE, Teherani A, Dechet A, Aagaard EM. Medical students’ perceptions of mentoring: a focus-group analysis. Med Teach 2005; 27(8): 732-734.

⁶Miller JB, Schaad DC, Crittenden RA, Oriol NE. The departmental advisor’s effect on medical students’ confidence when the advisor evaluates or recruits for their own program during the match. Teach Learn Med 2004; 16(3): 290-295.

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

Every aspiring physician knows the importance of memorization, especially in the basic science years. As you advance in your career, however, communication skills come to the forefront. Physicians with poor communication skills are more likely to be sued. (Virshup) They are more likely to be disciplined by the medical board. They may not receive as many professional referrals from colleagues or word-of-mouth referrals from patients.

Successful communication requires establishing a connection and imparting a message. Successful patient care does not end with gathering data from your patient. It revolves around imparting that information to the entire team that is involved in patient care: your team members, the consulting physicians, the nurses, the patient and family members, and even the cafeteria, among others. (“The patient’s allergies include a history of anaphylaxis to shrimp.”)

Third year students, in the midst of early clinical rotations, quickly recognize the importance of communication. Memorization may be a crucial skill for those taking exams and receiving grades based on an objective test score. However, when receiving a subjective grade based on your ability to take care of patients, one’s ability to communicate with patients, to establish rapport with colleagues, and to impart medical information, become important indicators of communication skills.

How exactly do medical schools determine a student’s ability to provide excellent patient care? A student’s grade in core clinical rotations is determined by several factors, including subjective ratings and objective test scores. One study examined the evaluation techniques of 97 US medical schools. (Kassebaum) Faculty and resident ratings accounted for 50-70% of a student’s grade in core clinical rotations.

How do faculty and residents arrive at their subjective rating of a student’s abilities? Clerkship evaluation forms ask faculty to rate students on specific skills, such as a student’s ability to take a history and perform a physical examination. However, attending physicians rarely or infrequently observe students in these areas. In fact, in a survey of 322 University of Virginia medical students at the end of their third year, 51% reported never having a faculty member observe them while taking a history; 81% had never been observed performing a complete physical exam. (Howley) Therefore, many faculty draw conclusions about a student’s ability in these areas from the quality of the oral case presentation.

In a study of surgical faculty, Pulito found that it was rare for faculty members to directly observe a student taking a history or doing a physical examination. (Pulito) In fact, only one of nine faculty members surveyed had done so. Despite this, five of the nine faculty participants rated students in this area. They inferred the rating of this characteristic from other factors, particularly the oral case presentation. Pulito wrote that “in the clinic setting, for example, if a student presents a patient to an attending and is verbally facile, succinctly describing a focused history and physical examination, the inference may be drawn that the student expeditiously obtained the relevant history and performed an appropriate examination.”

In one study focusing on communication apprehension among medical students starting a surgery rotation, Lang wrote that “much of a student or resident’s evaluation is based on oral presentations.” (Lang) In another study assessing student performance on a pediatrics clerkship, Greenberg found “a highly significant relationship between students receiving a final grade of honors and an ‘A’ on their case grade.” (Greenberg)

In oral case presentations, students aim to effectively transfer important clinical information between team members. When done well, these presentations facilitate patient care, improve team efficiency, and become a valuable learning experience. Since they also serve an evaluative function, students hope to deliver high-quality presentations to prove their competence. While some students are inherently gifted in the area of making presentations, all would benefit from practice and the following suggestions:

• Expectations for the oral case presentation vary from clerkship to clerkship, attending to attending, and resident to resident. For this reason, always meet with your attending and resident on the first day or two of the clerkship to ascertain their expectations.

• Your goal is to leave this discussion knowing the attending or resident’s personal preferences (preferably before your first presentation). Ask specific questions about time limits, the order in which to present information, and so on. “Do you want me to report the entire physical exam or just pertinent positives?” “Which labs would you like to hear, or would you prefer to hear all of them?”

• What worked well with one attending or resident may not work well with another. You may have internalized a certain set of “presentation rules.” With the start of a new clerkship or arrival of a new attending, recognize that these rules may not meet their needs.

• Be aware of the context in which you are presenting. Your presentation to a resident with whom you evaluated the patient should be different than the presentation given to an attending who is hearing about the patient for the first time.

• Make your presentation flow like a story. Your goal, many times, is to make an argument for a particular condition. Put the details of the case together in such a way as to lead the listener to a diagnosis.

• As a novice clinician, your inexperience makes it difficult to decide what to include and what to leave out. The easy way out, and the route that many students take, is to simply read the written H & P word for word. However, the oral case presentation should be a carefully edited version of the written record. The key is to communicate only what’s relevant. For a new clerk, that can be very difficult. Don’t be afraid to ask for help in this area.

• Use residents as a resource. Residents are often familiar with attending preferences and can help polish your presentation before you have to deliver it to the attending.

• Seek feedback after each and every one of your presentations. The best feedback is that which is explicit and timely. Many attendings won’t automatically provide feedback; you may have to specifically ask for it. “Dr. So, do you have any suggestions on how I can improve my presentation?”

• Uncertainty is normal with oral case presentations. Because of the evaluative function of these presentations, it can be tempting to bluff or lie in an effort to look good. As hard as it can be to say “I don’t know,” honesty and accuracy in the transfer of clinical information is vital to patient care. In a survey of Johns Hopkins medical students, 13% to 24% admitted to cheating during the clinical years of medical school. (Dans) Examples included “recording tasks not performed” and “lying about having ordered tests.”

• Projecting confidence is important. Your choice of words, the manner in which you speak, and your body language are all factors that will be used to judge the quality of your presentation.

• It is rare to present a patient without any interruptions. In one study of emergency medicine faculty and students, the mean number of interruptions was 2.49 per oral case presentation. (Yang) Although students often view interruptions as a sign that their presentation is lacking, this is often not the case. Attendings find it difficult to balance the need to teach with the need to care for a service full of sick patients. In addition to interruptions due to time constraints, you may be asked to repeat information or clarify a certain point. Unfortunately, many students let interruptions derail their presentation, and find they can’t recover.

• Many students stop short of offering an assessment and plan, especially novice clinicians who don’t feel qualified to do so. Always offer your own assessment and plan. Attending physicians are impressed with students who take the initiative to do so.

• Read extensively about your patients’ problems using a variety of resources, including handbooks, specialty textbooks, and the recent literature. As you read, make it a habit to ask “why?” Why did we order this test? Why did we choose this particular antibiotic? Such questions further your understanding of the disease – not to mention prepare you for the attending questions that are sure to come during or following your presentation.

Because of the complexity of the oral case presentation and the varied needs and expectations of residents and attendings, delivering high-quality presentations can be difficult. Is it worth the effort? Absolutely. First, presentation quality is a major factor used in the evaluation of students. Second, the development and acquisition of communication skills is important for your future career as a physician. That’s precisely why, in recent years, organizations such as the Association of American Medical Colleges (AAMC), Clerkship Directors of Internal Medicine (CDIM), and the Accreditation Council for Graduate Medical Education (ACGME) have emphasized its importance. In fact, the AAMC considers the development and acquisition of communication skills a core learning objective for medical students.

Communication skills remain important at every stage of your career. For fourth year students, currently in the process of submitting applications and awaiting invitations to interview, communication skills take on renewed importance. A successful interview requires establishing a connection with the interviewer and imparting a message about your strengths and abilities, a topic we will review in our next column.

REFERENCES

Virshup BB, Oppenberg AA, Coleman MM. Strategic risk management: reducing malpractice claims through more effective patient-doctor communication. Am J Med Qual 1999; 14(4): 153-9.

Kassebaum DG, Eaglen RH. Shortcomings in the evaluation of students’ clinical skills and behaviors in medical school. Acad Med 1999; 74(7): 942-9.

Howley LD, Wilson LG. Direct observation of students during clerkship rotations: a multiyear descriptive study. Acad Med 2004; 79 (3): 276-280.

Pulito AR, Donnelly MB, Plymale M, Mentzer RM Jr. What do faculty observe of medical students’ clinical performance. Teach Learn Med 2006; 18(2): 99-104.

Lang NP, Rowland-Morin PA, Coe N. Identification of communication apprehension in medical students starting a surgery rotation. Am J Surg 1998; 176 (1): 41-45.

Greenberg LW, Getson PR. Assessing student performance on a pediatric clerkship. Arch Pediatr Adolesc Med 1996; 150 (11): 1209-1212.

Dans P. Self-reported cheating by students at one medical school. Acad Med 1996; 71 (1 Suppl): 70-72.

Yang G, Chin R. Assessment of teacher interruptions on learners during oral case presentations. Acad Emerg Med 2007; 14 (6): 521-525.

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

Which of the following is the most important academic criterion used by program directors to select residents?

A) USMLE step 1 score
B) USMLE step 2 CK score
C) Pre-clinical course grades
D) Third-year clerkship grades
E) Membership in Alpha Omega Alpha (AOA)

In our own surveys, we have found that students almost always answer this question incorrectly. Students generally base their answer on information gathered from classmates, upperclassmen, residents, and discussion forums, among others. These are all useful sources of information. The ideal way to answer this question, though, would be to discuss it with those individuals directly involved in the residency selection process—in particular, program directors in your chosen field. Ideally, this should be done early in your medical school education. With this knowledge in hand, you can make the most of your opportunities, placing yourself in a position to succeed and match with the specialty or program of your choice.

Fortunately, others have done this work and published their findings. A survey of approximately 800 program directors was performed by Dr. Wagoner, the former dean of students at the University of Chicago Pritzker School of Medicine. These program directors represented 14 specialties, and were surveyed about the importance of various academic criteria used in the selection of residents.¹ Dr. Wagoner and her colleagues learned that grades in required clerkships are the most important academic criteria used to select residents.

At most schools, required or core clerkships include internal medicine, pediatrics, psychiatry, surgery, obstetrics/gynecology, and family medicine.Most medical students are surprised to learn that grades in required clerkships are ranked higher in importance than USMLE scores. In our inaugural column, we presented data from a survey showing that 44% of students from three U.S. medical schools perceived required third-year clerkship grades as moderately, mildly, or not at all important in the residency selection process.²

While many reasons exist for this disconnect between the perceived and actual importance of clerkship grades, we know that this can impact students’ efforts and attitudes during rotations.

As this article goes to press, we recognize that thousands of students across the country have begun, or are about to begin, their third year of medical school. Put simply, your performance this academic year can make or break your chances of a successful match.

• Grades in required clerkships are the most important academic criteria used to select residents.
• “Number of honors clerkship grades” was the second most important academic criteria used to select residents in the most competitive specialties.
• Clerkship grades are the major determinant of class rank. The most competitive specialties rate class rank among the three most important selection criteria.
• Clerkship grades are a major factor used by schools in electing students to the Alpha Omega Alpha Honor Medical Society (AOA). Election to AOA is highly valued by many competitive specialties. In some programs, and in some specialties such as dermatology, membership in AOA is used as a screening tool to determine which applicants are even considered for interviews.
• Comments made by attending physicians on the clerkship evaluation form find their way, often verbatim, into the Medical Student Performance Evaluation (MSPE). The MSPE, formerly known as the Dean’s letter, is often scrutinized closely by residency programs.
• Clerkship performance and grades are important in securing strong letters of recommendation. In competitive residencies where many applicants have excelled academically, letters of recommendation take on additional importance.

We present one final question: Which of the following is the most important academic criterion used by ophthalmology program directors to select residents?

A) USMLE step 1 score
B) Alpha Omega Alpha
C) USMLE step 2 CK score
D) Grades in required third-year clerkships
E) Grades in the ophthalmology clerkship

If you selected choice D, congratulations. The correct answer is indeed “grades in required third-year clerkships.” In the Wagoner study, 46 ophthalmology program directors were surveyed. Grades in required clerkships and the number of honors grades were ranked higher in importance than grades from ophthalmology electives.

Is this finding surprising? In our experience, all students recognize the importance of grades in their chosen specialty. However, fewer understand the overall importance of grades in required clerkships. A review of various discussion forums reinforces this finding.

In our next column, we’ll discuss the transition between the basic science and clinical years of medical school: what makes the transition such a challenge, and can be done to excel?

References

1. Wagoner NE, Suriano JR. Program directors’ responses to a survey on variables used to select residents in a time of change. Acad Med 1999; 74(1):51-8.

2. Brandenburg S, Kruzick T, Lin CT, Robinson A, and Adams LJ. Residency selection criteria: what medical students perceive as important. Med Educ Online 2005; 10:17.

The discussion thread for this article may be found here: http://forums.studentdoctor.net/showthread.php?p=5328043