Deconstructing the Match

Though by no means an expert of the residency application process, I can offer a few pearls of wisdom based on my experiences. I managed to survive a four-month long interview season and an extremely complicated Couples Match across both the San Francisco (January) Match and National Residency Match Program (NRMP in March). In the end, my most ideal prospects were centered around two very different Neurology programs, and I managed to match to the program that is more close-knit, has a broader base of inpatient and outpatient experiences, and was cited frequently by the other program directors I interviewed with across the country as being one of the programs they respect the most (e.g. trains great residents and has great faculty, as opposed to the other which many respect but also do so with some degree of fear, intimidation, and resentment). That being said, there was no guarantee at the onset of this process that I was going to match to any program of my choosing, and I think there are truths and uncertainties that are worth knowing about before beginning this process. The following are frequently asked questions and my answers (from my limited experience).

How many residency programs should I apply to?

There is no definite answer to this. There are several factors to consider:
1. The competitiveness of the specialty – In general, more competitive specialties with fewer programs to choose from will require that you apply to more. However, be aware that even less competitive specialties are becoming more competitive as medical school class sizes are increasing but residency positions are not.
2. Your competitiveness as an applicant – If you assess your application honestly as not being very strong, you may need to apply to more programs of varying competitiveness.
3. Your tolerance/endurance for interviewing and traveling – Interviewing and traveling can be very tiring, especially if you do several interviews in the same week or have the season drag out for many months. Many Internal Medicine applicants typically interview at about 8 programs before stopping (they might, however, apply to considerably more and choose to pursue fewer interviews).
4. Your available finances – The application fee is sizable but not as debilitating as medical school application fees (e.g. no secondary fee). However, traveling is expensive. Some programs will defray costs by paying for meals and occasionally hotel costs. If you can schedule interviews in the same city near one another, this can help. However, I often found that Neurology residency programs in the same city had interviews on the same day and were not accommodating of interviewing on other days.

In general, I would suggest applying to more programs. You can always cancel interviews (preferably as soon as possible so other applicants can be offered interviews).

How are applicants evaluated?

Each program has its own scoring rubric, but they typically involve a 5-point scale with 5+ categories that include some combination of the following: Clinical Performance (clerkships), Overall Medical School Performance (including USMLE Step scores, rank or quintile in class), Interview (your performance during the interview), Extracurricular Activities, Research, and Personal Qualities (judging from Letters of Recommendation). Some programs may have additional categories covering unique life experiences and demonstrations of commitment to values important to that field.

Is research important for residency applications?

I get asked this question a lot. I’m pretty open about my interest in academic medicine, so my assumption is that most students who ask me about this are also potentially interested in academic medicine. Most medical schools, being academic centers, automatically have a bias toward training students to think of career development as a function of an academic track. In academics, it’s important to think of how you as an individual contribute to the community: what additional value do you bring to the institution?

There are many medical students who enter medicine in order to practice as clinicians or combine clinical practice with less traditional pathways such as teaching, public health, health policy, and administration; these students are not very interested in doing laboratory research or clinical research. However, students tend to hear that residency programs want them to do research. It is easy to see why: faculty members need fresh recruits to help drive forward research projects and bring new ideas to the table. Nonetheless, residency programs vary considerably with regards to requirements for research and the amount of time alloted to research. One of the most important principles of the matching of residency programs and applicants is that their values must be aligned: if you find a program that doesn’t emphasize research and you are not interested in research, than this program may be a better choice for you. Students less interested in research may need to reconsider their conception of the “best programs,” as the “highly ranked” and respected programs tend to have extensive research agendas (e.g. they actively contribute to new knowledge and changes to clinical practice that affect the entire field). On the other hand, it may be possible to match to these programs if you are able to bring some other “value-added service” to the program. A notable example is my fiancée who is less interested in research than she is in medical education, and yet she matched to what is often considered the best Pediatric Neurology program in the country.

What do I do if an interviewer asks me an “illegal” question or one I’m uncomfortable answering?

There are rules that residency programs and applicants are supposed to follow with regards to questions and communications that are forbidden. These, unfortunately, are frequently broken. Even when not broken, some interviewers will continue to ask questions that are not technically against the rules but may be considered poor form. For example, about half of the interviewers at one of the programs I visited asked me for a rundown of all the programs to which I applied. It is easy to understand why they would ask this: the program wants to have some idea of who it is competing with for me as an applicant (or how seriously it might guess I am about that program). I answered openly whenever I encountered this question: I figured it wouldn’t help me to be coy, and the experiences of other students at this interview corroborated this guess (i.e. one of the interviewers dogged reluctant students until they finally answered). Many of my fellow interviewees were very flustered and upset by this interrogation. For me, though, I was lucky enough to have enough interviews to be able to write off this highly competitive program as being undesirable and one that I would not place on my final rank list. Would I want to train at a program that seems like it’s trying to hustle me or that is reflecting this type of uncertainty in its standing among other programs? There are definitely other questions that are much more invasive, such as asking women whether or not they plan to have children during their residency training. Again, though, I would pose the question: do you really want to train at this program? Does this program share your values? It’s easy to eliminate bad choices when you have many options, which is again further justification for applying to many programs.

Should I go to all of my interviews?

I think it helps to go to as many interviews as you can tolerate and afford if you see any possibility of potentially training at a program (or wanting to live in a particular city or region). Even in a relatively small field like Neurology, I found an incredible amount of variation between programs. Some programs have split services with a separate Stroke Service, others had only a single Neurology primary service. Some programs are very heavily weighted towards inpatient care while others have a somewhat more balanced approach with better developed outpatient experiences. Some programs have 20+ bed Neuro-ICUs, some have 8 bed Neuro-ICUs, some have a 4 bed “Neuro-ICU” separated from the MICU by a curtain, and some have no Neuro-ICU at all. Some programs have 17 residents, some have 5-9 residents, and some have two. Some programs have faculty numbers in the hundreds, some in the dozens or tens, and some about a dozen. Some programs have great relationships with their Neurosurgery, Psychiatry, and Medicine departments, while others have very contentious relationships. In all my searching, I never found a “perfect” program, but I found many that had advantages that I valued and disadvantages that I felt I could overcome.

Besides seeing how different programs and departments operate and how medicine is practiced differently across the country (in style and attitude), traveling also affords one the opportunity to meet future colleagues: fellow incoming residents as well as potential future mentors and employers. During my travels, I found at least four or five different departments I would absolutely love to work in as a junior faculty member (based on my observations of the community, the support structures, the energy level, the hospital culture, etc.). I also met a number of my future co-residents.

If that’s the case, does it matter where you train for residency?

Some people will say “no,” just as they say it doesn’t matter where you obtain your medical education. Some people say “yes,” that people won’t take you seriously unless you train at a place or with people who have respected names and reputations. In the end, both are probably true. What really matters, though, is that you can operate independently under your own steam: you are not a piece of wood floating in the stream, and you are not just a name or the collection of labels that is your résumé. Is your only value that which is given and assigned to you by others in the form of diplomas, medals, and stripes on your jacket? If so, by all means, apply only to programs with top-notch reputations and big-ticket names. If not, look for programs that will help you get the training you need and also provide the resources and means to get you to the next level at the angle of ascent of your choosing.


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