It is obvious to all of us here at Academic Medical Center that you are an outstanding residency applicant, and we would be delighted if you matched with us and would be proud to play a role in your professional development. We have ranked you “to match” in our program and encourage you to contact us to express any specific interest you may have in our program.

Regards,


Academic Medical Center Program Director

You read the email in disbelief and think you are set. Academic Medical Center is your top choice program. You hit the reply button to say that you will be ranking Academic Medical Center #1 on your list and submit your rank list with confidence.

To your shock on match day, you do not match with Academic Medical Center but instead match with your #11 choice. You feel a little cheated and wonder why the program director at Academic Medical Center sent you this misleading email. You start to think that this communication from Academic Medical Center may have been a violation of the Match Participation Agreement (MPA).

In my work with residency applicants from a variety of schools applying for different specialties, I am often surprised that some of the correspondence and communication from programs is remarkably similar to the example above from the fictitious Academic Medical Center. I am even more surprised when applicants receive overwhelmingly positive feedback from programs where they don’t match.

The MPA is designed to make the match fair for everyone involved. Item 6.0 of the MPA, Restrictions on Persuasion of the MPA, specifically states: “One of the purposes of the Matching Program is to allow both applicants and programs to make selection decisions on a uniform schedule and without coercion or undue or unwarranted pressure. Both applicants and programs may express their interest in each other; however, they shall not solicit verbal or written statements implying a commitment. Applicants shall at all times be free to keep confidential the names or identities of programs to which they have or may apply.”

I find that many interviewers and program directors may violate the terms of this agreement, sometimes unwittingly. Interviewers often casually ask applicants during interviews, “So, where else did you apply?” or suggest, “If you are really interested in matching here, please be sure to let us know.” Other programs routinely call applicants who are within “matching range” to recruit them after they interview. Does this constitute persuasion or pressure? The 2010 NRMP Program Director Survey suggests that post-interview contact does not have a great impact on ranking, but is this really true? Earlier research on this topic, cited in an article entitled Manipulation and the Match in JAMA in which the author reflects on his own experience as a residency applicant going through the match., suggests otherwise.

These subtle and not so subtle manipulations place applicants in difficult positions. Applicants are often confused, and these recruitment efforts on the part of program directors create an atmosphere of distrust and suspicion. Applicants are in a subordinate position during these interactions; they feel vulnerable and anxious. Of course, they often feel obligated to tell a program what it wants to hear by saying, “I loved your program and I will be ranking you really highly.” Or, applicants may feel pressured to tell a program that they will be ranking it #1, even if that’s a white lie. Sometimes applicants are so nervous about matching that institutions’ recruitment efforts may influence the way they rank programs.

So, how should applicants deal with these situations? If you receive a residency match “love letter,” take its sincerity and truthfulness with a grain of salt. You certainly will want to respond graciously, but do not say you are ranking the program first if that is not your intention. As for fielding questions or comments that may violate the MPA, I suggest being diplomatic and somewhat vague without confronting or offending your interviewer. For example, if the interviewer asks where else you are applying or interviewing, it is acceptable to answer, “I am applying to and interviewing at a variety of programs, mostly on the West Coast” or whatever situation applies to you. If pressured to express specific interest in a program, it is fair to say, “I am very interested in this program and have not yet decided on my final rank order, but I will be ranking your program highly.” As with the “love letter,” do not tell a program that you will be ranking it first if this is not true.

Although some programs do indeed violate MPA standards, most programs behave ethically in the match, and it is the obligation of all program directors and everyone who interviews applicants to uphold MPA tenets. Values and ideals start at the top so, if those in positions of power do not demonstrate ethical behavior, applicants are also encouraged to be insincere. Such behavior not only violates the MPA but also corrodes some fundamentals of our profession: honesty, good will and professionalism.

Below is an outline of what information you should include in your letter of intent to your top-choice medical school.

1) Communicate that if you are accepted to the medical school you will attend—but don’t write this if you don’t mean it.

2) Write about the specific reasons you are interested in the medical school. Try to reach beyond the obvious on the home page of the medical school’s website and seek out opportunities that relate to your own interests and accomplishments. For example, if you have a demonstrated interest in global health, find out about the medical school’s global health programs and point out that this school will allow you to develop your already established interest.

3) Express why you are a good fit for the medical school. You can often accomplish this via item #2 if you compose this part of your letter effectively.

If you need help with your letter of intent, please contact us. Read sample letters of intent in The MedEdits Guide to Medical School Admissions. We are also starting to work with clients who are applying to medical school in 2012/2013. If you are interested in working with us, please contact us soon because we will get booked once the next medical school admissions season is underway.

“What should I do? I got a prematch offer from a great program but it isn’t my number one choice and I think I would rather enter the main residency match. Should I take the prematch offer? Help!”

I hear these types of comments throughout the residency match process from United States and non-United States citizens who are considered “independent applicants.” Many independent applicants hope to receive prematch offers to guarantee they will earn a residency training position which can alleviate stress. For other independent applicants, however, prematch offers actually cause stress since giving up a guaranteed residency training position to enter the main residency match in hopes of matching at a “better” program presents a dilemma.

Under current National Residency Matching Program policy (NRMP), international medical students and graduates, osteopathic medical students and graduates, and past US allopathic medical school graduates, all of whom the NRMP considers “independent applicants,” can accept “prematch” offers from residency programs. What this means is that programs can offer residency positions to independent applicants before the main residency match, which takes place annually in March. However, the NRMP may modify this policy, which would completely change the landscape of the residency match and, based on the opinions of many individuals involved in the process, make it more equitable.

Before exploring the proposed change, let’s consider the history of current prematch policies and review some data regarding how many applicants may obtain prematch residency training positions.

In 2001, the NRMP proposed that “all sponsoring institutions participating in the Main Residency Match must register and attempt to fill all of their positions in the Match except those specialties or programs participating in other national matching programs.” Some specialties historically do not fill any positions outside the match, and they tend to be the more competitive specialties. Many other specialties and programs that traditionally accept independent applicants try to fill some spots outside the match and also fill spots through the main residency match. So, while some programs and specialties adopted this proposal in 2001, others did not.

The main concerns of programs that offer prematches is that non-US citizen international medical graduates (IMGs) might have difficulty obtaining visas by July 1st (which is required to start their training) if they have to wait until March to obtain a match. NRMP determined that 92% of IMGs requiring visas in 2009 received them by July 1st, but the impact that prematching early might have had on this statistic is unknown. Programs that offer prematches were also concerned about “losing” their most desirable independent applicants if those applicants entered the main residnecy match because, in theory, these independent applicants could be ranked highly by more desirable programs where they might ultimately match.

The NRMP reviewed data carefully to ascertain how many applicants actually obtained residency positions outside the match in 2008. Of 28,633 new residents who entered graduate medical education programs, 1,588 withdrew from the residency match. Of these, 791 individuals indicated they had obtained a “non-NRMP” position and 567 indicated they withdrew at “applicant’s request.” It is likely that both of these groups obtained prematch offers. Interestingly, 2,577 residents in NRMP specialties did not participate in the main residency match; it is likely that these individuals also obtained prematch offers. In total, 3,935 individuals probably accepted prematch offers, and only 94 of these individuals were US allopathic medical school graduates in 2008.

Under a new policy to take effect for the 2013 match, the NRMP requires that all institutions participating in the main residency match fill all of their residency training positions through the NRMP residency match or another national residency matching program. In other words, institutions (and not specific programs or specialties) will be held accountable and will not not be allowed to offer prematch offers outside the match. This is why the NRMP is calling this an “All-In” policy; institutions will need to decide if they would enter all of the institution’s residency training positions in the match.

Like the two applicants with divergent views quoted at the beginning of this article, many people will be in favor of instituting change while others won’t be too happy about it.

Note: The data in this article is from the official document published by the NRMP: Proposed NRMP Policy Change: All Positions in the Match.

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 1st 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.

Interviewers often will ask you, “tell me about yourself” or “why medicine?” – this is your cue to tell your story. The better you know your story, the better you will tell it.  A great answer can convey how insightful you are, how thoughtful, how reflective. Are you familiar with yourself on a deep level? Have you reflected on your decision to pursue medicine and discussed it with a few trusted friends or family? Have you journaled about it, even your concerns? Every good story has a beginning and an end, one or more problems or dilemmas, and high and low points. To captivate your interviewer with how you arrived at this moment of pursuing medicine or residency, you need to go back a ways – to the beginning wherever that is for you – and be open to sharing some personal information that led to your decision. Think about your favorite work of fiction or non-fiction, or your favorite movie. Now go a step further and figure out why it resonates with you. Take cues from that story and craft your own.  

Students often worry that whatever their story, the interviewer has “heard it before.” Not true. Just as every patient has a story uniquely his own, so too does the applicant. Before your interview, spend some time thinking about what your story really is. If you prepare for this question and then answer it honestly and engagingly, your story will be compelling.

By Laurie Brown Tansey, MA
Senior Consultant, MedEdits Medical Admissions

I GOT IN!!!!
Thank you SO SO SO much Dr. Freedman!!!!!!!!
I can’t believe it!

This is a broad strokes overview to get you started. MedEdits would love to partner with you this year to help you create an individualized plan so you reach your goals in 2012 – please get in touch!

By Laurie Brown Tansey MA, MedEdits Medical Admissions Senior Consultant