08 May 2008

Specialty Selection and Matching (Part II)

This post is a continuation of the previous post and will feature more aspects choosing a specialty and matching into that specialty.

How competitive are you for your chosen specialty?
Medical student love to entertain the idea that once they have graduated from School X or School Y, they are going to be sought after for by program directors across the country. This might be true if you have done extremely well in your studies and on your board exams but in general, program directors look for people who have a solid work ethic, have an interest in treating patients and have the academic ability (as evidenced by performance in medical school/board exams) that they are going to be able to master the knowledge that the specialty demands.

If you have done the “bare minimum” to get through medical school and have just above the minimum pass on your board exams, you are not going to be very competitive for high end university programs or the surgical specialties. Many of the high end university non-surgical specialty residency programs are not going to be interested in you if you have attended medical school overseas unless you have multiple publications and extremely high board scores (even in that case, Americans who have graduated from medical school in this country are likely going to have an advantage.) Every program director in this country is looking for the best potential residents out there period. It is your job, no matter what your medical school performance, to convince the program and faculty that you are well suited for them.

Along those same lines, every program that interviews you is not going to rank you. If you have applied for residency and received under 10 invitations for interview, it is likely that you are not going to match into that specialty unless you either apply to more programs and to a greater variety of programs across the board. This situation usually happens when a candidate is marginal for a particular specialty and applied to high end programs only in that specialty.

If you are again, not a particularly distinguished graduate of your medical school, apply to programs across the board (community and university affiliated). Make sure that you have received at least 10 solid interviews in those programs across the board. There is nothing wrong with applying to some “reach” programs but you need to apply to some “non-reach” programs too. On the other hand, if you have applied to 20 programs and you have 20 interviews, you can probably cancel some of your later interviews as long as you have enough programs to rank the ones that you would seriously want to be your future residency program.

Some of the things that you need to take out of the equation are the comments from your fellow medical students. Everyone “hears” things about programs but if you visited the program, had a great interview experience and feel that you loved the program, location and all vibes, then rank that program. Even though you only get to see what the program “wants” you to see on interview day, unless you felt there was something very sinister that remained hidden, your impressions about a program are generally fine.

Program Problems
Programs that have undergone a leadership change are not necessarily bad programs. Sometimes leadership changes are the “shot in the arm” that a program needs to go from good to excellent. If you happen to interview at a program that has a recent change in leadership, look carefully at the enthusiasm for training and education of the new (or interim) program director/chair. If enthusiasm is lacking, avoid the program.

Programs with a large turnover of residents are definite red flags. If you see a program were most of the people who start do not finish there, something is wrong. It may be problems with workload, administration, resident support, working atmosphere or any number of things. Be sure that you ask any program about the percentage of people who start that finish. If they change the subject or even hedge on this question, mark them in the “questionable” category.

Programs that use the resident staff as “assistants” rather than programs that are dedicated to resident education and professional advancement are also problematic. Residency is teaching and the attending staff should have some strong teaching ability. A good measure of this is how the residents conduct themselves during your interview day. They should be unhurried and available to you for questions. They should be able to answer your questions without hesitation. Make sure that you speak with a good cross section of residents at every training level especially the PGY-1s and the ones that are about to graduate from the program. Speak with the lab residents too.

Places that have very poor facilities can also be a major problem for you. Try to see where the call rooms are located and if they are private and clean. As a resident at any level, you do not want to share a call room with either medical students or other residents. As an on-call resident, you should have meals provided and a place to keep your things such as a locker. Residents are employees but they have a crucial role in the running and management of hospital patients. If the rule is that the attending calls the resident, tells them what to write and then completely manages the patient while the resident does the paperwork and discharge dictations, you are not going to have a good learning experience at that program.

Some Final Thoughts
Application for residency is NOT the same as application for medical school. Program directors know that if you have finished medical school, passed your boards without too much difficulty and have a good work ethic, you are likely going to be a good resident. You don’t have to “pad” your curriculum vitae with things like extracurricular activities and club memberships but you should have good solid interest in the specialty that you hope to enter.

You should also have a very objective assessment of your competitiveness for a particular specialty/location. If you are not competitive, research (only if it is meaningful) can help you a bit but all of the research in the country (with the exception of a Nobel Prize) will not get you into Dermatology if you are in the bottom half of your class.

Also, don’t choose a specialty because your father and grandfather expect you to be a particular specialist. If they were orthopedic surgeons and you would rather die than be in the operating room, then don’t choose orthopedic surgery. You will be miserable and you will likely become a miserable orthopedic surgeon. If you love family medicine, then carefully choose good family medicine programs that seem to be a great fit for you both program size and location.

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