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The Successful Match: Getting into Radiology

Created October 10, 2010 by Samir P. Desai, MD, and Rajani Katta, MD
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Of the 4,455 total residents training in 188 ACGME-accredited radiology residency programs, 88.3% are graduates of U.S. allopathic medical schools, 7.6% are international medical graduates, and 3.9% are osteopathic graduates.1 Dr. Vicki Marx is the director of the radiology program at the University of Southern California Keck School of Medicine, and we asked for her insights into the radiology residency selection process.

After graduating from the Ohio State University College of Medicine, Dr. Marx remained there to complete her residency in diagnostic radiology. She then completed fellowships in abdominal imaging and interventional radiology at the Washington University Mallinckrodt Institute of Radiology in St. Louis, Missouri. Prior to joining the Department of Radiology at USC, she held faculty appointments at both Washington University and the University of Michigan. At USC, she also serves as the Vice Chair for Education.

At many U.S. medical schools, students are unable to take a radiology rotation until the beginning of their fourth year. How can medical students who have an early interest in radiology explore the field?

This is a difficult issue.  Currently, many medical students become captivated by the puzzle-solving aspects and clinical importance of medical imaging as they progress through their core clinical clerkships.  Based on this somewhat aesthetic perspective, some decide to go into Diagnostic Radiology without having a clue about what the residency training process and work life are like.   Two approaches can help provide this missing information.

First, join a Radiology Student Interest group.  This is an excellent way to get information about the field.  Such groups are active in most medical schools.  If your school doesn’t have one, start one!  This not only will provide useful information for you, it is a citable activity to add to residency applications.   Make sure at least one session addresses what the professional work life is like after residency; many practice models exist and should be explored.

Second, shadow a radiologist – often.  Shadowing practitioners through a clinical day as often as possible is the best way to investigate the field.  An interested student should observe radiologists in multiple subspecialties to get a well rounded view.  Although this activity might be difficult to schedule while on clerkships that are time-intensive, it is worth the effort.   In addition, radiologists work evenings and weekends, so shadowing can be done outside the standard work week.  Off-hours work in Emergency Radiology is a particularly effective way to get an overview of the field.

A good way to begin the process of shadowing is to introduce yourself to the Radiology clerkship director and/or program coordinator.  Schedule some days to shadow.  Show up on the scheduled clinical service and explain to the resident/fellow/faculty why you are there and what you hope to learn.  Pay attention.  Stay until the work is done.  Participate.  When you get home, think about the experience and write down your impressions of the specialty.  Use the reflection as a resource for further career planning.

Securing a position in a radiology residency program requires that an applicant have the numbers. In 2009, the mean USMLE Step 1 score among matched U.S. seniors was 238.2 Many programs have established cut-off points for USMLE scores. According to a recent survey of radiology program directors, 79% of respondents reported having a target USMLE score.3 What can lower-scoring applicants do to improve their chances?

I’d like to step back a bit first.  Current medical school culture is Pass/Fail.  Medical students learn early in their educational process that “P = MD”.  What medical students may not realize in their pre-clinical years is that “P ≠ Residency”.  Competition for residencies is fierce, particularly in some fields, including radiology.  Competition is rising according to NRMP data (NRMP Results & Data, 2010 Main Residency Match, April 2010, www.nrmp.org).  In the foreseeable future, it is possible that there will be qualified graduates of US medical schools who can’t get a residency position at all.  So, why mention this?  The time to begin preparing your medical school record for the match is on the first day of medical school!  Sustained effort over time to achieve a consistently excellent academic record is the best way to keep all career options open.

Back to the USMLE Step 1 score:  The reason this score is so important is that Step 1 is an easily accessible metric of pre-clinical performance and knowledge base.  The rest of the preclinical transcript is typically hard to read and is nearly identical for all students.  All medical students pass everything.  With that background, the importance of a low USMLE Step 1 score is magnified, implying lack of knowledge, lack of intrinsic ability to learn, or lack of effort.  In general, medical students are not “poor test takers”.  This is especially true now because medical schools teach to the test, and a large industry exists to produce study aids for USMLE test preparation.   An exception to this pattern is the USMLE performance of the nontraditional student.  Students entering medical school after a previous career, or educational path, may do less well in the preclinical years and on the USMLE Step 1 than students coming to medical school directly from college.   Other aspects of the application will make apparent the nontraditional student’s strengths.

The first thing I suggest to a student with a low Step 1 score is a moment of introspection.  Is Radiology in the current competitive climate for you?  Remember, all the rest of the people getting into Radiology residencies have really high Step 1 scores so the learning environment of all training programs is geared to that group.  Next I recommend that a student for whom a low Step I score is an aberration in performance explain their academic strengths very clearly up front in their personal statement.  I recommend that the student work hard over a sustained period of time in the third year of medical school to excel on clinical rotations.  Clinical rotations scores of Honors and High Pass carry significant weight in screening ERAS applications.  So does a high Step 2 score.  Finally, students with a low Step 1 score must apply widely to radiology programs all over the country in order to match in their chosen specialty.  Success in the match is correlated closely with length of the rank list in the first choice specialty (Charting Outcomes in the Match; Characteristics of applicants who matched to their preferred specialty in the 2009 Main Residency Match; NRMP; 3rd Edition; August 2009).

Dr. Scott Pretorius, former radiology residency program director at the University of Pennsylvania, wrote that “in this competitive market for radiology residency slots, medical students with research backgrounds…allow themselves the opportunity to stand out in a field of increasingly highly qualified applicants. As an advisor of medical students, I routinely recommend that students intending to apply for radiology residency seek out a research mentor and undertake some kind of research project.”4 Not all agree that research involvement is required, however. In the 2008 NRMP Program Director Survey, only 64% of programs cited involvement in research as a factor in selecting applicants.5 What are your views on the importance of research involvement in the residency selection process?

I see two types of research on applications for residency:  1) real research experience leading to peer reviewed presentations and/or publications, and 2) simulated research experience that takes place in proximity to the due date for submission of the ERAS application and does not lead to a peer-reviewed work product.  Real research experience has a very positive influence on candidacy for residency – particularly at institutions where faculty research productivity is high and where ongoing scholarly activity is highly valued, or even required of residents.  Research done to pad an application is easily identified.  It has no negative effect on the application because it is ubiquitous in the applicant pool.  It has little positive effect either.

Absence of simulated research may have a negative effect on the ERAS application for students with mediocre academic records.  My own opinion is that these students should put their energy into improving their core clinical skills rather than add another activity that will dilute the focus of their efforts.

Students with excellent academic performance throughout medical school, supported by documentation in ERAS, do not need to pad their applications to succeed in the match.   Will some programs exclude them from an interview on this basis?  Yes, but not many.

In a survey of radiology residency program directors, audition or away electives in the field was ranked 15th in importance out of a total of 16 residency selection criteria.6 While audition electives are not necessary for matching into the field, are there times when you would recommend an audition elective for a student?

The away rotation is a mixed bag because the student is in the position of being interviewed by the program over a period of weeks instead of minutes.  For most people this is great but for a few it isn’t.  The investment and anxiety are most likely to be worthwhile when the student has a well informed opinion that the program is where s/he wants to do residency.  The drive could be geographic or academic.  For instance, an applicant with an interest or background in molecular imaging has an excellent reason to do an away rotation at an institution with a mature molecular imaging program.   More commonly, a student of a culture where living close to extended family is a priority has a valid reason to investigate programs close to his/her family.  The student should explain the reasons for doing the away rotation openly and honestly with the clerkship director and the residency program director early in the rotation.  The rest of the clerkship should be spent in sustained effort to do a good job and to learn more about the program.  The student should meet with the program director a second time near completion of the rotation as a courtesy and to remind the PD about his/her interest.  We are old.  If you don’t remind us (politely and without being pushy) we will forget.

Dr. Sandra Oldham, radiology residency program director at the University of Texas Medical School at Houston, wrote that the personal statement “is perhaps one of the toughest parts of the entire application process…But once you have ‘acceptable grades’ and have an USMLE score above our ‘bar,’ the personal statement is the next item on the agenda for scrutiny. After reading your statement, I should want to meet you, and I should feel that I would actually enjoy working side by side with you at the workstation…Remember, I am reading about 200 personal statements. Make yours stand out.”7 Applicants recognize the importance of the personal statement, but often struggle to find ways to make it stand out. What advice can you offer to applicants?

The personal statement is hard to write because no one gets taught how to write well about themselves.  How can you write about yourself without seeming narcissistic or arrogant when your goal is to sell yourself to an audience you don’t know?  Egads, put that way, writing a personal statement should be impossible.  So you have to view the task from a different perspective.  The perspective that seems most useful to me is that of a newspaper article.  In journalism class, I remember being told that a good article answers multiple questions about the topic:  who, what, where, when, and why.   The objective ERAS application components (transcript, MSPE, etc) do a pretty good job of explaining each applicant’s who, what, where, and when.  The personal statement gives you the opportunity to talk about your “why”, to explain your past, your stumbles, your dreams for the future, your motivations for living the life you live, and your reasons for working towards the goals you have set for yourself.  A successful personal statement answers “why” in a way that is sincere and succinct.  You don’t need quotes from obscure literature.  You don’t need references to “Where’s Waldo?”.  You do need honest reflection, clear communication, and ruthless editing.

Dr. Gunderman, Vice Chair of the Department of Radiology at the University of Indiana, wrote that “many residency programs tend to interview students located in geographical proximity, justified in part by a positive correlation between resident performance and connection to the region. Therefore, if an applicant has a particular interest in a program where they have been wait-listed, a telephone call or letter may be helpful to clarify that strong interest.”8 When and how should an applicant with a strong interest in a particular program express their interest?

The applicant’s primary goal is make sure the program director (or designee) knows that the student has a sincere and focused interest in this particular program.  The secondary goal is to avoid being annoying during this effort!  Two points in the application process create natural opportunities for such interest to be brought to application screener’s attention.  The first is a focused personal statement where the interest in a particular program is clearly articulated for the reader.   This strategy requires careful attention to detail – don’t send a tailored personal statement intended for one program to all the programs!  The second is an email to the program director and program coordinator after being rejected or waitlisted for an interview.  The email serves the same purpose as the focused personal statement:  to articulate clearly the reasons the applicant has for being interested in the program and the willingness to interview on short notice should an opportunity become available.    If no response comes to the email, a phone call to the program coordinator is a reasonable step – to make sure the email was received.  Then you wait.  You may get an interview and you may not.   There are no guarantees in this difficult process.

Speaking from my own experience as a program director, I do have a bit of advice about actions to avoid if you want to increase your interview opportunities.  First, do not make multiple phone calls to the department.  Listen carefully to what is said in the first phone call and live with it.  Second, do not trash the program in question on a public internet forum.  Your username may be less anonymous than you think!  Finally, do not let one of your parents, or one of their friends who has connections with the institution, call the department on your behalf.   Those phone calls are uncomfortable for all involved and do nothing to change the content of your application.

The transition from residency to practice is challenging.  Dr. John Cronan, chairman of the Department of Diagnostic Imaging at Brown University, cites  the frenetic pace of work, high volume, and stress associated with having to render the “final read” as particularly difficult for most graduates.9 In evaluating prospective radiology residency programs, how can applicants assess a program’s ability to prepare graduates for practice?

This can be tough.  The most reliable source of this information is a recent graduate of the residency who currently has a real job. This person is unlikely to be present at the interview.   Interestingly, this information is becoming more available to programs though the ACGME requirement to assess residency outcomes by using tools such as surveys of graduates.  It is fair to ask about the results of such surveys but not all programs have a mature survey process in place yet.

Residency training programs that prepare physicians for the frenetic pace, high volume and stress of real life radiology practice are those that provide these opportunities during residency.  Programs with high case volume and high expectations for resident performance under appropriate faculty supervision are preparing residents for the real world.  Programs described by current residents as “totally chill” may be providing less optimal preparation.  Applicants need to ask about case volume, system for providing residents with feedback on performance, and level of on-call responsibilities to get a sense of the training opportunities available.  On-call experience is particularly valuable.  During the standard work day, residents typically work alongside supervising faculty.  At night, residents have faculty back-up but it may be a phone call away.  This is where the resident learns to become independent in interpreting images.  A resident who has never had to render a preliminary opinion on a CT study at 3am while alone in the Emergency Department (with a faculty backup a phone call away) is really not ready to do that without faculty backup.

Especially daunting to applicants is the residency interview. During the interview, interviewers try to assess an applicant’s personal attributes. What personal attributes do you believe are associated with success in radiology residency?

I hesitate to answer this question because I don’t want to encourage residency applicants to pursue acting careers on the interview trail!  However, the attributes most program directors are looking for are hard to fake, even for 30 minutes.

A successful radiology resident first and foremost recognizes the critical role that radiology plays in patient care and enjoys the responsibility of that role. Successful residents behave professionally in all work activities and put the needs of patients above their own, within the constraints imposed by ACGME work hour rules.  Successful residents interpret as many studies as possible and work hard to learn the clinical judgment, decision-making skills, and communication skills (spoken and written) necessary to ensure that their interpretations are meaningful in real time.  A successful resident is a positive contributor to a team that includes the residency class, the residency as a whole, the faculty, the non-physician members of the department, the referring physicians, and the institution.   A successful radiology resident is smart, hard working, honest, and focused.  That focus must be maintained in three spheres:  clinical work, home study, and relaxation time with friends and family away from work.  All of these personal attributes require an underlying positive energy for being a physician and specific enthusiasm for the specialty of Diagnostic Radiology that is easy to communicate to an interviewer.

Fewer female medical students pursue a career in radiology. Over the years, the proportion of female residents has remained relatively static at just under 30%. Recently, Dr. Marilyn Roubidoux, professor of radiology at the University of Michigan, wrote about the potential negative impact that this has had on the workforce, particularly in certain areas, such as breast imaging and pediatric radiology.10 What do you believe are the reasons fewer women enter the specialty?

This demographic reality mystifies me.  Half of medical students are women.  Therefore half of radiology residents should be female.  Whassup?  According to a recent survey of medical students (Fielding JR et al, Choosing a specialty in medicine:  female medical students and radiology; AJR 2007; 188: 897-900) the two most important factors determining specialty choice  for men and women medical students are 1) direct patient contact and 2) intellectual stimulation.  Men and women each cited lack of direct patient contact as a negative aspect of radiology.  Men viewed the physics requirement as a deterrent in greater numbers than did women.  Neither cited radiation exposure as a negative influence.  So why do women apply to radiology in such relatively small numbers?  The only potential reason teased out in this survey is that more women than men cited competitiveness of getting a residency position as a deterrent to choosing radiology as a career path.    I accept the information as true but it makes no sense to me.  A large percentage of medical students applying to dermatology residency are women.  Dermatology is extremely competitive.  I think we haven’t asked medical students all the right questions yet to guide our response to this reality.

In the meantime, I do think that we in the world of Radiology need to critically review how we project ourselves to the world.  Radiologists have a lot of patient contact (particularly in interventional radiology, mammography and pediatric radiology) and a huge impact on patient care.  Maybe if we did a better job of demonstrating that to students during medical school, their perception of the specialty would be closer to reality.

References

1Brotherton S, Etzel S. Graduate medical education, 2008-2009. JAMA 2009; 302 (12): 1357-1372.

2Charting Outcomes in the Match, 2009. Available at www.nrmp.org. Accessed July 26, 2010.

3APDR Program Director Survey on the Match, 2008. Available at www.apdr.org/index.cfm.  Accessed on July 26, 2010.

4Pretorius E. Medical student research: a residency director’s perspective. Acad Radiol 2002; 9(7): 808-809.

5Results of the 2008 NRMP Program Director Survey. Available at  http://www.nrmp.org/data/programresultsbyspecialty.pdf.   Accessed July 26, 2010.

6Green M, Jones P, Thomas JX. Selection criteria for residency: results of a national program directors survey.  Acad Med 2009; 84(3): 362-367.

7Oldham S. Guide to the Radiology Match. Available at www.uth.tmc.edu/radiology/guide_to_radiology_match_2007_2008.htm. Accessed July 26, 2010.

8Ertel N, Gunderman R. Helping medical students to prepare for radiology residency interviews. Acad Radiol 2006; 13(9): 1168-1171.

9Cronan J. My first job: the transition from residency to employment – what the employer and employee should know. J Am Coll Rad 2008; 5(3): 193-196.

10Roubidoux M, Packer M, Applegate K, Aben G. Female medical students’ interest in radiology careers. J Am Coll Rad 2009; 6(4): 246-253.

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