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MD vs. DO vs. IMG: A Harvard Program Director’s Views

Not attending a "top" medical school doesn't mean you can't stand out to the best residencies

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by Alec Palmerton, MD in IMG, Residency
MD vs DO vs IMG Residency Application

Residency admissions feel like stratospheric stakes. Your residency influences every aspect of your future, from your income to your free time. Residency admissions committees scrutinize every detail of your background. What do they focus on most? What if you didn’t attend a prestigious medical school? Do “lower tier” MD schools get a bad rap? How much of a bias there is against DOs, IMGs, or Caribbean med school grads. And if so, how do you overcome it?

To understand how residency program directors make these fate-altering decisions, I interviewed one. Daniel Saddawi-Konefka, MD, is the director of the Harvard-MGH Anesthesiology program. He evaluates students from every possible medical background for residency admissions. Want to know how important test scores are versus other attributes? Looking for answers on what to do as a DO, IMG, or Caribbean grad? Worried that your school isn’t a “top” med school? His perspective helps to maximize your chances of matching at your dream program.

In this article, you will learn:

  • What program directors are most concerned about when evaluating an application.
  • Why program directors may view DOs, IMGs, or Caribbean grads differently. (Hint: it’s not because of prejudice).
  • How to make your application sparkle even if you didn’t go to Harvard or other prestigious schools. (And what pitfalls you may encounter if you did attend a “top” school).
  • When you should do an away rotation, and how to use it to maximize your chances of matching
  • Incredible advice on how anyone can excel in medicine and find fulfillment

Disclaimer: I did my residency training at the Harvard-MGH Anesthesiology program. Dr. Saddawi-Konefka was an attending when I started residency. During my final year, he was also my program director. Here are the highlights of this interview. The views expressed below are his and have been paraphrased and edited for clarity.

Here is the interview with Dr. Saddawi-Konefka:

How Do Program Directors Screen for Interviews?

The numbers of residency applications are staggering. The average residency program received 904 applications for the 2018 Match. Programs immediately rejected 48% of those applications based on a “standardized screening process.” Of the applications reviewed in-depth, programs only sent out 121 interview requests. Of those who interviewed, only 82 were actually ranked. A fraction of those ranked actually matched at a given program.

I asked Dr. Saddawi-Konefka about how programs filter out resident applications to review. He noted that like almost every program, they look at Step scores. However, unlike many other programs, the MGH program doesn’t have a set Step 1 cut-off. (Dr. Saddawi-Konefka only stated they prefer scores “over 200”). That being said, “if someone fails one of the Steps, we generally do not look at the application unless there is a compelling reason to review it.”

The next set of filtering involves looking for evidence of someone being:

  • A fantastic clinician and team player
  • A good communicator
  • Someone who can integrate expertise in a way that is productive for patient care
  • A person interested in improving
  • A person engaged in changing the field. (E.g., research, community service, leadership)

He notes that “integrating knowledge in a clinically relevant way is more challenging to work through [than achieving high scores].” Patient care is a high priority.

The program looks for those who fit with the values of the program. These program values include “growing, improving, reflection, passion, and working hard to achieve goals.”

For Dr. Saddawi-Konefka, Step 1 scores matter (i.e., don’t fail), but not at the cost of clinical growth. “[T]here is a big difference between peak performance and typical performance….we all know people who put up monster test scores. But they do that at the cost of focusing on clinical growth or patient care.” He is interested in what people do every day, “when everyone is not looking, and the pressure isn’t on.” He looks for people with intrinsic motivation “who are passionate about lifelong learning.”

Generic MSPEs Can Hurt Your Application

Medical Student Performance Evaluations (MSPEs) are critical to the evaluation of applicants. The NRMP (the organization that administers the “Match”) surveys residency program directors every other year. The list of questions is extensive. A massive point of interest is how program directors screen applicants for interviews. (Hint: a big part of it is your USMLE scores).

(To read Get Into a Top Residency: 5 Things You Need to Know, click here).

Here are the top 5 factors for receiving an interview invitation, from the 2018 survey.

  1. USMLE Step 1/COMLEX Level 1 score
  2. Letters of recommendation in the specialty
  3. Medical Student Performance Evaluation (MSPE/Dean’s Letter)
  4. USMLE Step 2 CK/COMLEX Level 2 CE score
  5. Personal Statement

However, not all schools create their MSPEs equally. Some MSPEs give detailed descriptions of students’ clinical performance. Others, however, may simply be a list of the student’s scores.

The latter category – generic MSPEs – can hurt even the best residency applications. However, med students often have little control over the format of the MSPEs. This is particularly problematic for IMGs and DOs, whose schools may provide limited support.

Overcoming Generic MSPEs

So how can you overcome a generic MSPE? Dr. Saddawi-Konefka recommends, “letters of recommendation saying the things your MSPE might not be [saying].” Despite these letters, however, uninformative MSPEs can be a real problem.

Dr. Saddawi-Konefka:

“Honestly, most competitive programs get so many great applicants. How much time do you put in looking for what could be amazing? Or do you go with the person you are confident would be amazing without looking?

Two applicants could be equally strong. However, let’s say one applicant looks phenomenal in standard ways, with:

    • An MSPE that is full,
    • Great clinical performance,
    • Strong letters and
    • Everything is what I am used to seeing and it all checks out

And let’s say the second applicant:

    • Their medical school paperwork is undescriptive, but
    • They have persuasive letters.

There’s still more risk in the second case.”

One can understand why the riskier applicant will not make the cut.

The issue of risk is particularly relevant for IMGs, DOs, or Caribbean students. As we’ll discuss in the next section, every student has “black boxes” that attract scrutiny. While we’ll discuss IMGs and DOs, the information is pertinent to all med students.

This Harvard Program’s Views on IMGs, DOs, and Caribbean Students

According to Dr. Saddawi-Konefka, the Harvard anesthesiology program is “quite fond of a lot of IMGs and DOs. We have incredible international and DO residents. It’s not a deal breaker.

“Generally, the chances of matching as an IMG or DO are lower. But certain things can set you up for success. It comes down to risk mitigation.” By this, he means that unknowns in a candidate’s application create risk for the program. He terms these risks “black boxes.”

Unknowns, or “Black Boxes,” Create Risk for Program Directors

He notes that the main disadvantage for DOs or IMGs is the number of unknowns, i.e., “black boxes.” When someone comes from a country other than the US, there is a potential for:

  • Cultural barriers
  • Language barriers
  • Not knowing the system of care, and
  • Difficulty from being displaced from families

Two applicants who otherwise look the same, but one is from the US, and one is an IMG, there will be a lot more risk in taking the international student:

“If you have two candidates, every program director will choose the one with less risk. It’s all about risk mitigation.”

MD vs DO vs IMG Residency Application

Program directors see unknowns as risks. The more you can do to mitigate risks, the safer they’ll feel ranking you.

How IMGs Can Mitigate Risk and Maximize Their Residency Chances

One of the key issues, then, is to mitigate risk. Dr. Saddawi-Konefka makes several recommendations for doing so. First, do a rotation in the United States. Rotations provide several things, including the ability to get letters from US-trained physicians. Ideally, these letters should say you:

  • Speak excellent English,
  • Fit in the culture well,
  • Are an excellent doctor,
  • Understand our health care and medical system, and
  • Are a fast learner

These are issues of particular concern for program directors when evaluating IMGs.

Program directors see unknowns as risks. The more you can do to mitigate risks, the safer they’ll feel ranking you.

How Residency Programs Evaluate IMGs and DOs in Light of Risk Management

Dr. Saddawi-Konefka notes that:

“For a place like MGH, we regularly have IMG and DO students. We look at them the same as we look at US grads. We look for:

    • Excellent clinical performance,
    • Cultural fit,
    • Dedication to growth,
    • Team players,
    • Someone who you want to work with, and
    • Interest in advancing clinical care (E.g., leadership or quality improvement)”

He goes on:

“Some programs have to look at their resident Boards passage rates. That’s where the board scores come in. I looked at the NRMP data. If you scored over 230-235 and ranked at least six programs, your chances of matching were certain.”

When considering the need to mitigate risk, candidates need to be especially concerned about ways to address these qualities specifically, emphasizing the value of a clinical rotation in the United States for IMGs.

MD vs. DO: Why Residencies May Look at Applications Differently

Dr. Saddawi-Konefka notes that assessing MD vs. DO applicants also has a lot to do with risk. He notes that generic MSPEs are a significant source of risk for DO applicants.

“MSPE’s from DO schools vs. MD schools are very different. A lot of times, all I get from the DO schools is a comparative ranking and no words. I don’t know what they value. If it’s pure test scores, it’s not all we are looking for…

To be fair, there may be a stigma, but it’s not a stigma that I believe is present at the hospital level. I would guess if I asked the average MGH faculty which students are MD vs. DO, they couldn’t tell the difference. That means we got the right target…

DOs we accept often have robust descriptions of their clinical practice. When I am looking at a DO school, I am looking for the same things I look for in other applications.”

Why IMGs and DOs “Need” More Publications and Higher Scores: Bias or Risk-Reward?

The issue is risk mitigation. Programs do not want to take unnecessary risks. There must be some reason to balance the risk against a reward. Dr. Saddawi-Konefka: “If you look at the data, IMGs and DOs often have more publications and higher scores. That is a reflection that there is some risk here. It’s logical for programs to look for more rewards in exchange for taking on more risk — it makes sense.”

(To read The IMG’s Guide to Obtaining Residency in the United States, click here).

He goes on to note that “I wouldn’t classify that as bias. If there is bias, it might be at an unconscious level. Instead, I think in terms of risk-reward and not stigma.“

Why “Brand Name” Schools Help Residency Applications

Graduates from prestigious schools who did well are less risky. On the other hand, graduates from a prestigious school, like Harvard, will not get far if they did poorly. “The school’s name will only take you so far. You must hustle, work, and do good things to help yourself along.”

When Away Rotations Are a Good Idea

One way to help address the concerns about risk is to do an away rotation. This would be a good idea if you are:

  • Interesting in going to a particular program
  • Trying to mitigate risk because you anticipate a there will be a lot of unknowns (aka, “black boxes”) on your applications for those reviewing it
  • If a program interests you
  • You want diverse experiences
Most Common Concerns to Address on Away Rotations

“Doing an away rotation in one of the institutions you are interested in would give you an idea of what it would be like. Questions you may ask are:

  • Would I do well?
  • Am I too far from family or what I am familiar with?
  • Will I burn out?”

Fit is one of the most important aspects of doing an away/visiting rotation. Fit may come in the form of cultural similarities with how you’ve trained previously. This is true even for those within the US.

Dr. Saddawi-Konefka: “Say you’re interested in one of the big schools on the coast. However, you are from a tiny school with a small population, and you’ve never lived outside the Midwest. Programs will wonder about your interest in going there and how you would do when you arrive.”

“Both you and the institution will get information about fit. For example, at MGH, our residents tend to ask us a lot of questions to challenge and discuss things. Visiting rotations help our attendings get a better sense for applicants’ cultural fit.”

Answers to these questions help to fill in the “black boxes” that lead to a sense of risk when evaluating an application.

Away Rotations: How to Stand Out

Dr. Saddawi-Konefka gives his advice on how to stand out on away rotations.

“Away rotations are a little counter-cultural. I don’t like recommending things for peak performance. My advice would be to:

    • Be humble,
    • Be kind,
    • Work hard,
    • Care about your patients,
    • Care about your learning,
    • Invest in your knowledge, and
    • Ask questions

Normal stuff. Be a good human and try to make yourself better. Those things go a long way.”

Advice for Medical Students at Any Stage: Love Learning

Finally, Dr. Saddawi-Konefka emphasizes the importance of finding joy in being a doctor:

“My advice for anyone: focus on the joy and the intrinsic motivation of being a doctor. Stop focusing on tests and looking good. Figure out what drives you and what you’re passionate about. Find the joy in learning.

When you go and learn things sometimes, you do it because you want to look good and sometimes you do it because it’s fun. The best learning comes when it is fun. That is the way you stay well in medicine, and that is the way you avoid burnout.

My best advice for medical students is to find joy in learning and find joy in medical care. Focus on that.”

Overcome Residency Pressure to Cultivate Intrinsic Motivation

Intrinsic motivation yields better results than extrinsic motivation. Yet it is difficult to do because of the multiple “counter pressures.” “Studies show that extrinsically motivated people learn less than intrinsically motivated people.”

Intrinsic Motivation Leads to Better Results

While extrinsic motivation can lead to outstanding fact-based education. But conceptual understanding and transfer of knowledge to their application require an internal drive. As Dr. Saddawi-Konekfa says, those with an “internal drive do better.”

“They have more flexible thinking, more creativity, less burnout, and more psychological wellness. Hundreds of studies in cognitive psychology support the benefits of intrinsic motivation.

Intrinsic motivation will help even if you have high extrinsic goals. You can still walk in the same direction. It’s magnetic north vs. true north, especially when you are first starting. Studying for your tests might be magnetic north. But if I walk towards the true north – learning because I love it – I walk in the same direction and accomplish more.”

Framing Can Improve Intrinsic Motivation

“A lot of it has to do with perception. When you are studying for these tests, you can learn because you need to get a good test score. Or you can reframe it in your mind and say, ‘I need to study, and I love this and look how much I am learning.’”*

Intrinsic motivation is hard to gain and easy to lose. “Outside pressures can quickly stamp out that bright light within of ‘I want to learn and get better.’’ By reframing, you don’t have to change what you do fundamentally. Instead, you change the way you frame it. When you learn something, instead of reflecting on your exam results, say “look at all I learned. That was a lot of fun!”

(To read Motivation 101: Can You Learn To Love Med School? (Part 1), click here).

Alec’s Concluding Thoughts

Where you go to residency is one of the most critical influences on your future career. A great way to maximize your residency chances: think like a program director. So it pays to understand how program directors think.

In our discussion, one of the most striking paradigms was risk-reward. Specifically, program directors must measure the risks, or “black boxes” of each candidate.

Matching an applicant commits the program to them for years. (Dr. Saddawi-Konefka didn’t say this; however, you can read between the lines. A wrong fit can create numerous problems for both resident and program). Thus, program directors must “mitigate risks” as much as possible.

A Rose by Any Other Name

You may be wondering: what’s the difference between “bias” and “risk-reward”? I found myself wondering the same thing. Does it really matter what we call it? If the results are the same – IMGs/DOs need higher scores/more research to stand out – why does the term matter?

I’ve experienced the spectrum: from “lower tier” public schools to “prestigious” institutions. Growing up, I went to Minneapolis public schools you’d never describe as “top schools.”

These “top” schools had better facilities. Our school’s lockers were literally hand-me-downs from a wealthy suburban school. Their counselors knew admissions directors on a first-name basis. Princeton had never admitted someone from my school. Ever.

Was that “bias”? Perhaps. Although when I think about it now, I can also see it from an admissions committee’s standpoint. Admitting someone from a school they don’t know means they are taking more risks. Ultimately, it’s my job to show them taking me is as risk-free as taking someone from a “top” school.

Are Residency Admissions Fair?

Are residency admissions fair? In a cosmic sense, perhaps not. But by those standards, ANY job interview is intrinsically unfair. Program directors have to look out for the program’s best interests.

(To read Interviewing to Match Into a Competitive Residency, click here).

My biggest takeaway is that residency admissions are about getting to know you. They want people who will do well, are easy to work with and make the program proud.

Wonder why students match at institutions where they shine in away rotations/research? Because admitting them has become a no-brainer. Programs know you and can predict how you’ll do if you match. There’s no risk.

I’ve tutored many students from less “prestigious” schools who matched at top residencies. In every case, they made it clear to those programs that they would thrive. Some did research there. Others used impressive Boards scores. Many did away rotations. But in every case, it was clear to me, and the programs admitting them believed that they were risk-free.

*(Alec’s side-note: this is exactly how I looked at studying in med school. Yes, I wanted to do well (extrinsic motivation). But I also reminded myself daily about what a privilege it was to attend med school. I got to learn as my job (intrinsic motivation). Many of my friends were working jobs they hated – but I got to learn!).

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Cardiology is key for impressive USMLE scores. Master cardiology from a Harvard-trained anesthesiologist who scored 270 on the USMLE Step 1 with these 130+ high-yield flash cards. You’ll be begging for cardio questions - even if vitals make you queasy.

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