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Getting Into Residency: Part 2

 
As the current residency application cycle is winding down, the next wave of applicants is getting ready to apply for the 2009/2010 season.  As you begin thinking about your residency application, you should consider who will be writing your letters of recommendation (LORs), how you will talk about your path to residency at your interview, and how you should contact programs and follow up with them (and if this really makes a difference in outcome).
This article serves as a follow-up to the article, “Getting Into Residency: Part 1,” which was published on the Student Doctor Network in October 2008.
Letters of Recommendation
I encourage medical students to treat every attending as though he or she will one day write them a letter. Why? I believe this helps the student perform well and also creates a safety net of sorts. Since you don’t know whom you will meet in the future, it may well be that a good LOR could come from the internal medicine attending from your third year rotation or a preceptor from an introduction to medicine course during your first year.
If you have identified someone with whom you have rapport and who thinks highly of you anytime during your medical education, don’t wait to ask that person if he or she would be willing to write you a strong letter of reference in the future. Then be sure to keep in touch with the attending from time to time. Keep the attending updated on your progress and achievements so, when it comes time to write your letter, the attending won’t have to play catch up, which will make the letter more sincere.
While writing a letter of reference is extra “work” for an attending, it is also flattering since it indicates that you respect and think well of that individual. Writing excellent letters for my stellar students that I knew would help them get to the next level of their education and training was one of my greatest joys in academic medicine.
Which letters have the most impact when it comes to residency? It depends. If you are applying for orthopaedic surgery, for example, you don’t want to have three letters from non-orthopaedic faculty. ERAS allows you to select four letters to be sent to each program so, for a very competitive specialty, you want at least two of these letters to be from attendings within the specialty to which you are applying. When applying to residency, titles matter; a letter from a community doctor will carry less weight than a letter from the chair at a major academic center.
A survey sent to directors of all programs participating in the 2008 match by the National Residency Matching Program (NRMP) addressed this issue. Most important, the survey showed, are letters from clerkship directors, colleagues and chairs within the specialty. Letters from “other faculty,” while still important, have the least weight.
Writing a good LOR takes skill and experience. Sometimes junior faculty don’t know what constitutes a good letter, another reason why it is sometimes “safer” to have letters written by more senior faculty. A more experienced faculty member, who has read and written hundreds of letters of reference, understands the essential elements and “buzz words” that make a great LOR.
Keep in mind that the smaller the specialty, the more likely everyone is to know each other. When I reviewed residency applications, it was comforting to read a letter from someone whom I knew and trusted. At the same time, letter writers get “reputations.” I remember a clerkship director who wrote outstanding letters for every single applicant who rotated in her department. As a result, I questioned whether I could trust this individual’s evaluation. As an applicant, you have no way of knowing who writes good letters and who doesn’t, but it is important to understand that some attendings are talented in this area while others aren’t.
How do you go about asking someone to write a letter? To some degree this depends on your relationship with the individual.  If an attending offers to write a letter on your behalf and you have had an open dialogue about this, then simply ask him if he would like any supporting documentation.
Otherwise, it is best to schedule an appointment to meet with the attending.  It is fair to ask this person openly if she would be willing to write a strong letter on your behalf. You must hope that you will get an honest reply.
Your job is to make the letter writer’s job as easy as possible. Arrive at the meeting with a folder in hand that has a copy of your CV, your personal statement (if you have already written it) and any information she may need, such as your AAMC number and where the letters should be sent. ERAS has downloadable cover letters that you can fill out for your letter writers for both US students and IMGs. Remember to give your letter writers plenty of time to write your letter (at least one month), and understand that you may need to “nudge” or remind them more than once.
The Interview
Your most recent interview probably was for medical school. The emphasis for residency interviews is different, so don’t think that you will be telling the same story all over again. It is important to think about the path you have taken since you started medical school. What has motivated you, who has inspired you and what determined the choices you have made?  Applicants are judged most on the following during the interview:

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

I encourage applicants to review their written applications before interviews so they can remember what they have written. Anything on your application is “fair game” for discussion so be prepared to discuss everything in detail.  Don’t be afraid to try and guide your interview. The interviewer isn’t the only one in control here and you should try to make segues to topics that you would like to discuss.
The ideal interview is an open conversation – a back and forth dialogue. While everyone has their own interview style, most (skilled) interviewers know they will get the best idea of who you are if you are at ease and comfortable. In my experience, it is the less experienced interviewer who tends to “shoot questions” at you.  And remember, you aren’t going to be tested on your medical knowledge. Non-US citizen IMGs are often asked to discuss an interesting case to make sure they can communicate effectively about medical issues, however.
Also remember that feedback from current residents and support staff (such as the residency coordinator) plays a role in resident selection. Residency is intense and, especially for small residency programs, being a good “fit” for a program is important. This is why your behavior and interactions with the residency staff, during tours of the facilities and during dinners and lunches with the residents, is vitally important.
When I was in residency leadership, if my residency coordinator identified someone as rude or disrespectful, I listened. Residency leadership teams are small and a negative interaction with one member of that team is likely to negatively affect your ranking. Along the same lines, if a resident thought highly of an applicant and believed she would mesh well with our program, I also listened.
A few questions you should be prepared to respond to on residency interviews:

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

Follow up with Programs
I always encourage applicants to contact the program directors where they interviewed early in the season. While some programs rank as the season moves along, others hold a “ranking day” in late January/early February when they rank applicants. From experience, I can tell you that it was very difficult to remember applicants who interviewed early in the season. That said, the research done on this topic indicates that the timing of your interview does not affect your ranking.
Interestingly, the NRMP survey results indicate that program directors do not place much importance on second looks or visits or that postinterview contact affects ranking. Nonetheless, I believe that you should send a thank you note just “to play it safe,” and demonstrate respect and because doing so is just good manners. Also, sending a letter of intent to your first choice program is wise. The worst thing that can happen to a program is not to fill its positions, forcing the program to enter the scramble. It also “looks good” for a program director to boast, “We got our top three applicants!” If a program knows you are ranking it #1 and it doesn’t want to “go too far down on their list,” your letter of intent may influence your ranking.
As match day approaches, good luck to everyone and match well. For 2009/2010 applicants, start thinking about your strategy for next season.
While this article (and Part 1 of this series) addresses some of the concerns related to the residency match, keep in mind that many nuances affect the process and this varies from applicant to applicant.
Jessica Freedman, MD, a former medical admissions officer, is president of MedEdits (www.MedEdits.com), a medical school, residency and fellowship admissions consulting firm. She is also the author of the MedEdits blog, a useful resource for applicants: (www.MedEdits.blogspot.com).
Meet Dr. Freedman at the American Medical Student’s Association Meeting in March in Arlington, Virginia.

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    Peter Kolbeck
  • February 24, 2009
Thanks for providing a valuable service for medical students. I am a practicing physician who is being asked by my daughter who is applying to medical school an important question: does the medical school you attend have a major impact on getting accepted to a particular residency? I graduated from medical school in 1982. At that time, I would have answered my daughter in the affirmative but added that other factors such as medical school grades, contacts/references and research were probably more important. What say you on this topic?
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    Dear Peter,
    Thank you for your comment.
    The medical school you attend does have some impact on residency acceptance but, that said, your USMLE scores, evaluations, electives rotation performance, research, other involvements and interview also play key roles.
    Someone who attends a top notch medical school may not get into a competitive residency if their application is weak in other areas whereas someone who attends a less prestigious medical school may get into that competitive residency if they have bolstered their application in other areas.
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    Peter Kolbeck
  • February 24, 2009
Thank you so much for your thoughtful reply. It rings true.
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    Steve
  • February 28, 2009
As always, Dr. Freedman's advice is right on target for anyone applying to residency. I can tell SDN readers that finding such sound guidance is not easy. I only wish that I had such a valuable resource when I was going through the application process which would have made my life much easier. I would love to recruit Dr. Freedman to become a faculty member with me (for our students) at my medical school!
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    Marcy Cage
  • March 5, 2009
I have to do an interview report for my class can i send you some questions to answer
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    AndrewR
  • February 23, 2010
Great article. I'm currently a med student and am wondering about the time frame for asking attendings about LOC. I understand that it's best to to at least pitch it too them while on rotation. But when would I actually have the meeting to formally request a letter?
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    4th year med student '11
  • November 6, 2010
From someone going through this very process right now (starting my first interview next Tuesday), I concur that this these two articles are getting into residency are spot-on and excellent advice for future residency applicants. I am thoroughly grateful for this provided service.

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