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 1st 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 1st 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.
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.