Planning Your Residency Application for 2017-18

It's that time of year when some folks are awaiting their Match, while others are getting ready for the upcoming ERAS season. Here's a piece by Dr. David Presser and me, "Choosing a Specialty: The Generalist vs. the Early-Committer," originally published on the Student Doctor Network site, regarding the huge endeavor of making the first critical step in preparing your candidacy (and future career!):

Many students arrive at medical school with a bias that their liberal arts education has instilled, namely, that they should survey everything before deciding on their specialty. Before medical school, students matriculate at colleges that pride themselves on providing a diverse exposure to a variety of subjects: Computer science majors experience the canon of Great Literature before pursuing a life of code, and English majors can take “Physics for Poets.”

For a generalist student sampling from the buffet of medicine, it can be jarring to sit in lecture next to a classmate who declares on the first day of school that she intends to become an orthopedist. These early-committers appear to have whittled down their choices from day one. They magically become apprentices to a faculty member in their chosen specialty by the first quarter, have a publication by their first year, and seem to possess an intuitive roadmap for applying to residency that the generalist cannot read.

So who is right, the generalist or the early-committer? In life, as in medicine, the answer is – it depends. For clarification, let’s start to explore the problem by seeing what residency directors prioritize in their selection of candidates:

The 2014 NRMP® Program Director Survey, which amassed responses of the directors of all programs participating in the Main Residency Match, demonstrates that – in all specialties – 69% of programs cite “perceived commitment to specialty” as a factor in selecting applicants to interview. That 69% is more heavily favored than reputedly important factors like Honors in the specialty clerkship, Audition elective in the residency’s department, and even Pass USMLE Step2 CS. Furthermore, on a mean importance ranking scale from 1 (not at all important) to 5 (very important), those directors ranked perceived commitment as 4.3. The 4.3 mean importance ranking is greater than USMLE Step 1 score, Letters of recommendation in the specialty, and Honors in clinical clerkships. For certain competitive fields, demonstrating commitment is even more important. Take neurosurgery at 80%/4.6.

So, one could make the argument that making the specialty decision early is the way to go. If a generalist ends up deciding that he will only be happy in a hyper-competitive specialty like dermatology or orthopedics, and finds himself compared to early-committers with a slew of same-specialty letters of recommendation and multiple publications, it seems he is at a disadvantage.

However, being a gung-ho early-committer has its problems too, and those headaches can last a lifetime. Some of these future doctors find out too late that they have dedicated themselves to the wrong field, and that their motives for pursuing a specific specialty (my mother and grandmother were both general surgeons) were not enough to warrant life-long regret over not entering pediatrics. This issue is not a small one. While data regarding the number of residents who switch specialties is lacking, websites for off-cycle residency positions have proliferated, including forums here on Student Doctor Network. And while physician dissatisfaction is not an exact proxy for specialty-specific miscalculations, it is notable that certain specialties have much higher rates of burnout, and that the ability to control work hours (much harder in certain specialties) is increasingly found to play an important role in reducing stress, and therefore, burnout among physicians. The Medscape Physician Lifestyle Report 2015 showed that U.S. physicians suffer more burnout than other U.S. workers with 46% of American doctors surveyed reporting the problem. Critical Care and Emergency Medicine doctors have the highest burnout at 53% and 52%, respectively. Psychiatry and Dermatology have the least at 38% and 37%. If a student commits to the “wrong” field too early and sticks with it, she may make enduring mistakes in job fulfillment and a suitable lifestyle.

Moreover, anecdotally, the authors have seen many doctors switch fields. Personal acquaintances through our emergency medicine residency programs included residents who matched in orthopedics and plastic surgery, only to transfer into emergency medicine residencies several years into the game; several emergency medicine residents who switched into other fields (orthopedics, psychiatry, pediatrics); an internist who completed his training before undertaking an additional residency in emergency medicine and pursuing an academic career; and a former chief resident in emergency medicine who, after serving in the armed forces during the Iraq and Afghanistan campaigns, returned from his tour of duty and re-trained in dermatology, in part, so he could spend more time with his family.

The bottom line is that there is no right answer about whether to be a generalist or an early committer when selecting a specialty, except if a highly competitive specialty is even remotely in the cards. In that case, a medical student should position herself accordingly and early.

Ideally, one would know for sure what his perfect specialty is on arrival at medical school and pursue appropriate faculty mentors and research opportunities. But life is not that simple. How, then, should a medical student go about selecting a specialty, a choice that will affect his job satisfaction, future income, and lifestyle?

One suggestion is to start thinking about specialty choice earlier than third year. Granted, there is a lot on the to-do list the first and second years of medical school. But in the summer after first year, most students have some freedom. That summer would be a good time to do some shadowing or commit to a project to see if being in the operating room is enjoyable. Starting a research project in an appealing field (especially if it is competitive) is a good option as well. If a student has whittled potential interests down to a few specialties, erring on the side of tailoring the first summer experience to prepare for a candidacy in the one that is most competitive is wise. In other words, it’s easier for a would-be dermatologist to become a born-again internist than the other way around. But even if a medical student can simply start to decide whether a surgical or non-surgical field is more suitable for her, something will have been accomplished.

Another suggestion is to arrange meetings with multiple doctors in different practice settings in appealing fields. This tactic is best started early (first or second year), but even during third year, it’s a plan worth pursuing. A medical student should interview physicians about the worst parts of their specialties and listen carefully. Then, that student should try to find someone in a field who embodies the life she envisions for herself. If – after speaking to a good number of doctors in varied practice settings – she cannot find a role model who fits the life she hopes to lead, it may be worth avoiding that field entirely.

Finally, if it’s affordable, consider a year “off.” Schools are increasingly flexible with their curricula, allowing students to take a year to pursue research scholarships, travel grants, and other academic pursuits. Considering how little exposure medical students get to different specialties in third year, asking them to choose their field at the end of it seems demanding. Taking extra time to make a considered decision is a reasonable option.

The statistics show that program directors are seeking commitment to their fields, which is understandable, considering their goal is retaining and training residents. However, committing early can be a treacherous path. Until the medical education system changes, students are stuck between a rock (of residency application strategy) and a hard place (of potential job satisfaction). Seeking resources outside the conventional system through extracurricular exposure, research, faculty mentorship meetings, and even a year away from school can help a student make a critical life decision.

Remember: Finding the right specialty is in many ways a matter of luck – mentorship, early exposure, and fortuitous experiences. As the ancient Roman philosopher Seneca famously stated, Luck is when preparation meets opportunity. Whether generalist or early-committer, the wise students evaluates the pros and cons of each approach, deciding with eyes wide open and leveraging the opportunities that luck provides.

NRMP Rank Order List Deadline Fast Approaching

Residency applicants, please note that the NRMP rank order list deadline is this Wednesday, February 22. Rank order lists must be certified by 9 am EST. After that, you can sit back and relax because there is little to do except wait.

Geography is Giant

When I was a medical student applying for emergency medicine residency programs, a well-meaning dean gave me some bad advice. I was determining the order of my rank list and was particularly concerned about one program that had an excellent reputation but was in a city I didn’t like. The dean told me, “You’ll be so busy during residency it won’t matter where you live.” Luckily, the advice rubbed me the wrong way, and I wholeheartedly disregarded it. As I've said in a recent blog entry (and others in the past), where you live for your medical training - medical school, residency, or fellowship - is as important as the quality of your training program. The reasons are several-fold:

1. Medical training is extremely time-consuming, and you want to be in a city you can enjoy fully when you’re able to blow off steam.

2. Medical training is extremely stressful, and you want to be in a city where you have social support.

3. Medical training is not completed in a vacuum. Your personal life continues. If you’re single you may meet someone and end up staying in the city where you have trained for the rest of your life (gasp!). If you’re in a long-term relationship you may decide to have children or may already have them. Down the road you may not want to relocate your family.

Not everyone gets the opportunity to go to medical school or train in residency and fellowship programs in a city s/he likes. But you can make choices that will increase your chances.

After Your Residency or Medical School Interview: What's the Value of the Second Look?

After interviews - if permitted by the institution - there are several ways you can communicate with a medical school or residency. My favorites are brief thank you notes and well-written letters of interest.

But what about the "second look?" I've had many mentees ask me if re-visiting a school or training program after the interview day is valuable. Unfortunately, there may not be a definitive answer to this question because how a second look is perceived varies by institution.

The cons of the second look are cost and time. And perhaps even worse, there is the risk that you are imposing on the school or program. You don't want your request for a second look to work against your candidacy. On the other hand, the pros of a second look are that demonstration of interest and enthusiasm that many schools and programs are seeking.

If you are a pre-med and are wait listed at a medical school, I would generally recommend a second look if you can swing it. After all, you have every right to visit the institution you may be attending. If you go for a second look in this scenario, make sure to do a formal visit: Let the admissions office or dean's office know you would like to spend the day and ask if you might have an opportunity to meet with students and even an admissions officer to support your candidacy.

If you are a residency applicant, it's hard to say if a second look will help or not. A residency director friend of mine says that a visit from someone who travels from far away might improve a candidate's standing by a few slots on the rank list at her program. That sounds like a tepid endorsement at best... If you are considering a second-visit, make sure to speak to the program coordinator. S/he might advise you against it or, on the contrary, let you know it's appreciated by the residency director.

As we all know, the residency and medical school interview scene is already stressful and expensive, so unless you are a wait listed pre-med - with all other things being equal - I generally would not push yourself hard to do that second look.