A Harvard Program Director’s Ideal Residency Applicant

by Alec Palmerton, MD in Residency

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When you think about landing your choice of a residency program, these are the top things that likely come to mind:

1. USMLE scores
2. USMLE scores
3. USMLE scores

You’ve got Board scores on the brain. As a whole, that isn’t far from the truth. However, after a lengthy interview between Dr. Palmerton and the director of the Harvard-MGH anesthesiology residency program, Dr. Daniel Saddawi-Konefka, we found out there’s a lot more to gaining entry into a top residency than just high Step scores. (The minimum score was a lot lower than we expected!).

Here, we look at some of those hidden factors that go into acceptance at a top-ranked residency.

Of course, some of this will be balanced against the all-important issue of test scores, so don’t take this the wrong way. After all, Step 1 scores are still the #1 most commonly cited factor for giving interviews. But residency committees look at a list that goes to 4, 5, 6, 7, 8, 9 and 10 or more different factors, as well.

In this article, you will learn:

• The “black boxes” program directors see in your application, and how to address them
• “Red flags” that will sink your application
• How a top program thinks about IMGs (and why they doesn’t consider it “discrimination”)
• The minimum cutoff the Harvard-MGH Anesthesia program uses (it’s a lot lower than you think!)
• The programs “type,” and
• Much more

“Black Boxes” and How to Address Them

What does a residency program director think when they look at your application? Not only are they trying to assess “fit” with the program. A lot of what they are doing is trying to address “black boxes.”

A “black box” is an unknown, something that they can’t answer until you become an actual resident. Imagine going to a restaurant where all you know is a name. Everything else is a “black box”:

• What kind of food it serves
• How much it costs
• What the dress code is
• Whether it is “child-friendly”
• When are the busy times
• What the best dishes are

Would you go to a restaurant with that many black boxes? Maybe. But there is a high likelihood of unpleasant surprises.

Now imagine, instead of going to a restaurant once, you have committed to go to that same restaurant every day for the next 4-8 years. What may be one bad meal if we choose the wrong restaurant can transform into a years-long ordeal. This is the problem faced by a program if the matched applicant is a poor “fit”: a years-long ordeal for the program and for the applicant.

What a program does not know about a candidate is a “black box,” and the response of the program may seem like discrimination. Think instead about the program’s need to determine fit. For example:

• Why do students from less prestigious schools have a harder perceived chance of getting into a particular residency? They may have more academic “black boxes.”
• What about older students? Their commitment to medicine may be a “black box”. (More on this later).

Next, we’ll look at three of the Havard-MGH program’s “black box” categories, and how you can address them so your application sparkles.

Older Applicants Have to Demonstrate Commitment to Medicine

Dr. Saddawi-Konefka noted that “black boxes” exist for older students. Age isn’t the issue here. Instead, the problem lies in the reason why the older student was just now deciding to pursue residency.

Let’s say you graduated med school 5 years ago but didn’t go to residency immediately. Why now?

Per Dr. Saddawi Konefka, “why are you switching now? What is to say you will not change again? What is your commitment? I think we have some older residents in their late 30s early 40s but not very many.”

Being an older student might indicate a lack of commitment – they wanted to be a doctor at one point, changed their mind and are now changing their minds, again. Whether that older candidate can learn is not the issue. The issue is whether or not they can stick to a commitment.

He continues: “It’s a lot of work but if someone is showing me the interest in applying for residency but the big black box comes in the form of clinical risk, and there is a question of what the motivation is and what the dedication will be.”

IMGs (International Medical Graduates): Does Harvard Discriminate?

One of the most common questions we hear from students is how much of an anti-IMG bias there is. Dr. Saddawi-Konefka’s comments were enlightening. Specifically, he disputed the idea there is a “bias” against IMGs. Rather, he highlighted that there are simply more unknowns, or “black boxes,” with those who trained outside the US.

Here is Dr. Saddawi-Konefka’s statement on foreign-trained candidates:

”The main disadvantage of being internationally trained is the black box issue. There is a potential for cultural barriers, language barriers, not knowing the system of care. It’s often harder for IMGs because they are going to be displaced from families. The idea is that there are all these black box things.”

In other words, this Harvard-MGH Program is just concerned about what is not known about IMGs. If you trained outside the US, there are simply more unknowns you will have to address in your application. Dr. Saddawi-Konefka goes on to say:

“What I recommend for IMGs is to do everything you can to mitigate risk. That means doing a rotation in the states and getting a letter from someone that says their language is great, they fit in the culture well, they are an excellent doctor, they get our system, and are a fast learner.”

High Board Scores Without Clinical Excellence

Dr. Saddawi-Konefka has a lot to say about test scores. The Harvard-MGH program is certainly going to consider them, but it is not the only factor. The reason is simple: the program has so many qualified applicants that they can ignore applicants with significant “black boxes.”

He also pointed out that while USMLE scores are critical, a demonstration of clinical ability is also crucial.

High scores are terrific. However, high scores create the possibility for another black box. Specifically, what if you get excellent Boards scores, but no one ever comments on your excellent clinical knowledge on rotations? In that case, high scores could be a sign the candidate is neglecting other important factors, such as patient care.

Here’s what Dr. Saddawi-Konefka says about this:

“To me, there is a big difference between peak performance and typical performance. I think Step scores are useful measures of peak performance in one domain.”

He continues:

“We all know people who put up monster test scores, but they do that at the cost of [not] focusing on clinical growth or patient care,” he said. “What we deal with on a day-to-day basis when we are trying to grow clinicians is what the people do every day when everyone is not looking, and the pressure isn’t on.”

Red Flags That Sink Residency Applications

Buyer beware: Dr. Saddawi-Konefka did mention two absolute deal breakers that will sink your application to get into the Harvard program. The first is obvious: persons with misdemeanors or felony convictions on their record would not get in.

The second? Any failure on a USMLE will likely eliminate you from consideration. Anyone who failed any of the USMLEs would need a “very compelling case” to be considered, he said.

We just discussed some of the black boxes and red flags that can sink your application. Next, let’s discuss the positive characteristics you will want to highlight in your application.

What is Harvard’s “Type?”

The residency programs falling under the Harvard-MGH umbrella are numerous. However, Dr. Saddawi-Konefka’s description of what he looks for helps clue you in on what other programs may be looking for as well. Here’s the ideal “type”:

• Great team communicators
• Leaders engaged in shaping their fields
• Fantastic clinical team players
• People interested in improving
• Not mavericks; they know medicine takes a group effort
• Respectful of people with more experience and listen to them
• Lifelong learners. Medicine is an evolving field. No one is exempt from having to keep up with new techniques and information
• Passionate. (Dr. Saddawi-Konefka even uses the word “joy” to define the ideal candidate.”)
• When it comes to extra-curricular activities, Dr. Saddawi-Konefka said, “I love them.” Yes, people who find “joy” in life are appealing to Harvard.
• Strive to make a difference in their field, who will actually make a substantial contribution to their field at some time in their lifetime
• Not prima donnas, but they know how to take the lead when it is important to do so.
• Know the culture of the U.S. medical system. Specifically, Dr. Saddawi-Konefka said that foreign students are most welcome, but understanding the medical culture is key.

What do you notice? None of these things are Board scores! Instead, you can highlight these things in your personal statement, MSPE, and letters of recommendations.

Are great recommendations from your clinical rotations more important than high test scores? Possibly not. But Dr. Saddawi-Konefka is giving you a great big hint right here. He is, in fact, describing “the Harvard type.” You need to fit this mold just as much as you need to nail the tests. (Interestingly, he mentioned only a minimum “cutoff” of only 200 or higher to be considered).

Other Memorable Quotes

Here are some other quotes from the interview to absorb:

“[We want to] select people who are passionate about lifelong learning, that are intrinsically motivated. I don’t think it comes from wanting to put up the big test scores solely.”

“There is an overlap where people who have an excellent day to day performance and correlates with them doing well on Step 1. Some people do well on Step 1 because they know they need to do well, but that doesn’t represent their day to day dedication to becoming an expert or master.”

“I think there is a difference between education and patient care. If you have the choice, all things equal, you will take both, but it is rare that all items are perfectly similar.”

What’s Missing?

One of the most interesting parts of the interview was how carefully they scrutinize the absence of certain things. Dr. Saddawi-Konefka mentioned quite a few items that would be noticed if they were NOT included in your application.

Yes, that’s correct. There are many things you know you should include. But there are also items that stand out like a sore thumb if you forgot to include them or – even more ominously – if someone writing you a recommendation omitted them. Here are a few of these:

1. Specific Details in Letters of Recommendation:

Some letter-writers may write dozens of recommendations every year. Busy letter-writers often use generic wording by sticking to a template or a form letter. Or they could be half asleep when they write them. They all have the same opening sentence. They all praise the same things.

Beware the generic letter of recommendation. What’s missing? The personal touch is missing. Any attempt at being truly convincing is missing. Generic letters usually have the right signature on the bottom, but that doesn’t mean they are great letters.

That said – you may still want that letter in your file. Look at “Missing Letters,” below to see why.

2. Great Rotation Reviews:

You could be at the top of your class. You could post world-breaking Step scores. Your rotation reviews could even say you were competent. But competent doesn’t cut it at Harvard-MGH. You need letters that say you are full of questions, eager to learn, communicate well and work well with others. Harvard doesn’t want you if you’re clinical and cold. They want you if you can balance your expertise with your human qualities.

As Dr. Saddawi-Konefka put it, “Someone who has all the comments about medical knowledge and ethical decision making, but none about professionalism and communication … that is also a notable absence.”

3. Missing Letters

There are several types of missing letters, Dr. Saddawi-Konefka explained. One of these is a letter missing from some who was obviously a key part of your medical training or development. If they show up as an important influence on your CV, it might be a red flag if that person did not write a letter of recommendation.

Another missing letter would be a letter from someone in your field. If you got great letters from someone in internal medicine, but you wanted to go into dermatology, Harvard would wonder why you didn’t get a letter from a dermatologist.

OK, remember that boring, generic letter from the Chair of the department, who writes so many of them he can write them in his sleep? Admissions teams, says Saddawi-Konefka, know who these people are. They read letters from these guys year after year. So if the Chair of the department for some reason did not write one for you, Harvard would certainly wonder why.

The Harvard-MGH program looks not only for what your application says, but also what it doesn’t

Concluding Thoughts: What Does the Bottom of Your Canoe Look Like?

Years ago, I read a story about members of Britain’s royal family who had come to the United States for a visit. During the visit, they bought a canoe. The reason they chose the canoe they purchased is that someone looked under the bottom of the deck of the canoe and found it had been varnished.

Nobody looks under the bottom of the deck of the canoe. There’s no earthly reason for doing that. So, the royal family purchased this canoe, because they found out the builder had gone the extra mile even when there was no earthly reason to expect anyone would ever notice.

That’s what this Harvard program wants. They want candidates who go the extra mile even when there is no other reason to do so – especially when no one is looking.

What do you think? Are these recommendations what you expected? Let us know in the comments!

Photo by mostafa meraji.