Getting into Residency: Most Important Factors

How do residency program directors decide whom to interview? And what factors influence how they rank those applicants they do interview? The National Residency Matching Program (NRMP) surveyed residency program directors in 2008 and 2010 about what they consider most important when deciding which applicants to interview and what criteria are most valuable when ranking residency applicants. This survey, an underutilized resource, provides valuable insight and information that can help medical students determine how competitive they are for a given specialty. The data can also empower applicants if they use the information to improve their candidacies.
Here is what the survey showed about 1) what factors influence program directors to offer a residency applicant an interview, presented as the percentage of program directors who considered each factor important, and 2) what specific criteria influence their decision to rank a residency applicant after the interview, using a scale from 1 (not at all important) to 5 (very important).

Letters of reference

Across all specialties, program directors surveyed indicated that letters of reference in the specialty were one of the most important factors in deciding whom to interview; on average, the percentage of program directors who considered letters of reference important was 71% and the rating across all specialties for how this factor influenced ranking was 4.2.
Residency applicants participating in the NRMP can submit up to four letters of reference via the electronic residency application service (ERAS) so it is important to select carefully! My general recommendation is that at least two letters be from individuals who are part of the specialty to which the applicant is applying.

USMLE/COMLEX steps scores

Of all program directors surveyed, 73% considered this score important in deciding whom to interview. The average rating of how the Step 1 score influenced applicant ranking was 4.1 and Step 2 results were rated as 4.0.
If you are a first or second year student, your goal should be to obtain a minimum Step 1 score of 209 and, ideally, a score above a 227. Why? Some programs do use “target scores” for Step 1 to decide whom to interview and this average “target score” was 209. Programs surveyed said that almost all applicants with USMLE Step 1 scores above 227 are granted an interview.
Across all specialties, 60% of programs have a “target score” they want applicants to earn on Step 1. Applicants must achieve this “target score” to be considered for an interview at many programs;16% of programs won’t consider applicants who have failed Step 1. The more competitive the specialty, the higher the USMLE “target score” used to screen applicants for interviews. The average Step 1 “target score” for less competitive specialties is lower. Even within less competitive specialties, however,  some prestigious residency programs likely have criteria that are well above the average.
Average USMLE Step 1 “target scores” for some specialties:

• Dermatology: 221
• Orthopedic surgery: 217
• Otolaryngology: 224
• Plastic surgery: 221
• Pediatrics: 200
• Family medicine: 194
• Psychiatry: 197

Regarding Step 2 CK, 44% of programs have a target score and 29% won’t consider an applicant who has failed.

Basic science grades and core clerkship grades

Across all specialties, 60% of program directors consider grades in the desired specialty important when considering whom to interview and this same criterion earned an average rating of 4.2 in deciding how to rank applicants. Also, 62% of program directors considered grades in required clerkships significant, but only 40% cited honors earned in the basic science grades as important in deciding whom to interview. So, while you want to earn the best preclinical grades as possible, the USMLE/COMLEX Step 1 performance, clerkship, and specialty elective rotation performance are more important to most program directors.

Where you attend medical school

Compared with less competitive specialties, those that are more competitive do consider more seriously the prestige of an applicant’s medical school when deciding whom to interview. For example, 54% of dermatology program directors surveyed considered graduating from a highly regarded medical school to be important, an opinion shared by only 35% of family medicine program directors. Interestingly, across all specialties, being a graduate of a highly regarded medical school had a ranking rating score of only 3.6.

The personal statement

Of all program directors surveyed 68% considered the personal statement important in deciding whom to interview. The personal statement became much less important after the interview, however, and earned only an average rating of 3.4 as a factor that influences applicant ranking. Therefore, the personal statement is used mostly as a screening tool in deciding whom to interview.

Extracurricular activities

Across all specialties, 52% of program directors surveyed valued volunteer and extracurricular activities, and 41% valued research when deciding whom to interview. For the more competitive specialties, however, research experience is considered important. For example, 62% of dermatology program directors valued research, as did 61% in orthopedic surgery, 61% in otolaryngology, 62% in psychiatry, 75% in plastic surgery, and 79% in radiation oncology. In the more competitive specialties, research experience was also a factor that influenced rankings. Some residency programs have criteria that may specific to their program. For example, one program may value community involvement while another may not.

Away electives

The more competitive the specialty, the more valuable program directors consider electives in their own departments when deciding whom to interview. About 55% of otolaryngology program directors considered a rotation in their department influential in deciding who received an interview, 64% in radiation oncology, 59% in orthopedic surgery, 57% in psychiatry, and 50% in plastic surgery. Interestingly, electives in the department earned an average rating of 3.7 when deciding whom to rank, but this rating is higher in the more competitive specialties.

Medical school performance evaluation (MSPE)

Only 26% of programs wait for the release of the MSPE to offer interviews, and these programs tend to be in the more competitive specialties that can afford the luxury of waiting to extend interviews since they know applicants will accept interviews regardless of when they are offered. Specifically, 78% of dermatology, 70% of orthopedic surgery, 85% plastic surgery, and 72% of radiation oncology programs did not offer any interviews until after the November 1^st release of the MSPE. This is why an early residency application submission is a must for applicants to less competitive specialties.

Most important factors when ranking applicants

The data indicate that the residency interview is the most important factor when deciding how to rank a residency applicant. The interview received a rating of 4.7 across all specialties, interpersonal skills 4.6, interactions with housestaff during interview day 4.6, feedback from current residents 4.5, evidence of professionalism and ethics 4.5, perceived commitment to the specialty 4.2. Other than a match violation which overwhelmingly influenced rankings (4.8), letters of reference from individuals within the specialty (4.2) and grades in clerkship in desired specialty (4.2), the most important factors that influenced rankings are evaluated on interview day. For competitive specialties, however, research and elective rotations in the department are also important factors.

Thank you notes and “second looks”

Across specialties, “post interview contact” earned a rating of 2.9 as a ranking influence and second looks/visits, were rated at 2.7. Some programs now tell applicants specifically that thank you notes are not encouraged and second looks have no impact on rankings!

Also important

When researching residency programs in which you are interested, pay attention to what each specific program values in applicants. These ideals may also vary from year to year if the program has leadership changes; every program director will have his or her own vision of what he would like to see in applicants. Results of the program director survey should, however, serve as a great starting point when deciding what specialty to pursue, and I suggest that all medical students review this document before they begin the residency application process.
The 19 following specialties are outlined in the NRMP program director survey and participate in the National Residency Matching Program:
Anesthesiology, Dermatology, Diagnostic Radiology, Emergency Medicine, Family Medicine, General Surgery,  Internal Medicine., Internal Medicine/Pediatrics, Neurology, Obstetrics and Gynecology, Orthopaedic Surgery, Otolaryngology, Pathology-Anatomic and Clinical, Pediatrics, Physical Medicine and Rehabilitation, Plastic Surgery, Psychiatry, Radiation Oncology, and Transitional Year.
All medical students, regardless of their year, should read the NRMP Program Director Survey. It is best to be aware of what residency program directors are seeking early in your medical education so you can be better prepared for the residency match.
Dr. Jessica Freedman, a former emergency medicine associate residency director and medical school admissions member at the Mount Sinai School of Medicine, is president of MedEdits Medical Admissions. MedEdits offers advising and professional editing for applicants to medical school, residency, fellowship, and post baccalaureate and special master’s programs. Like MedEdits on Facebook.