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Get Into a Top Residency: 5 Things You Need to Know

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by Alec Palmerton, MD in Residency

Recently I tried to open a door, but it wouldn’t budge. I tried the next door. Nothing. Eventually, I realized I was pushing from the wrong direction. This is not an uncommon experience (I’m clumsy). However, I started thinking about how medical students seek their dream residency. It’s an apt analogy. Pushing from the wrong direction will always lead to a closed door.

Getting into a top residency by pushing the wrong way

To open a door, the key is to know what direction to push from.

The stakes for residency applications are stratospheric. The typical 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.

And those are averages. The numbers are more bleak for the most competitive specialties, cities, or hospitals.

How do you stand out from the hordes of brilliant, hard-working medical students? Do you volunteer at the free clinic? Shadow? Take on extra projects, do research, or focus on Step 1?

What exactly are programs looking for?

Not all hard work is equal. 10 hours doing research isn’t the same as 10 hours of Step 1 studying or 10 hours of volunteering. We all have the same 24 hour day. How we apportion that time will determine our residency chances.

In this article, we will enter the minds of residency program directors. We will explore the exact criteria they use in deciding who to interview, and who to reject. Only 13% of applications receive an interview. As such, this is often the the biggest hurdle in residency applications.

The great news is that we have the exact means to read program directors’ minds. It’s called the NRMP Residency Program Director Survey. To compile it, every 2 years, the NRMP surveys every single residency program director. Their purpose? To identify the most important criteria program directors use when offering interviews. It’s from actual program directors. NOT your sister’s friend’s uncle who used to serve on an admissions committee twenty years ago. Not that senior who claimed they had no connections, but secretly was doing research with the program director. From the actual people holding the keys to your residency fate.

In this article you will learn:

  • Five actionable program director insights so they can’t wait to offer you an interview
  • How much time you should be spending on extracurriculars vs. Step 1 studying
  • How they use Step 1 as a cutoff, and the “magic score” above which you are virtually guaranteed an interview
  • Other effective ways to stand out, even if you have a disappointing USMLE score

The data: how to get an interview

First, the data. Let’s start by looking at the combined responses of all program directors. Combining these responses allows us to see broad patterns. This is particularly important if are considering multiple fields.

FactorPercent Citing FactorAverage Rating of Importance
USMLE Step 1/COMLEX Level 1 score94%4.1
Letters of recommendation in the specialty86%4.2
Medical Student Performance Evaluation (MSPE/Dean's Letter)81%4
USMLE Step 2 CK/COMLEX Level 2 CE score80%4
Personal Statement78%3.7
Grades in required clerkships76%4.1
Any failed attempt in USMLE/COMLEX70%4.5
Class ranking/quartile70%3.9
Perceived commitment to specialty69%4.3
Personal prior knowledge of the applicant68%4.2
Grades in clerkship in desired specialty67%4.3
Audition elective/rotation within your department64%4.2
Evidence of professionalism and ethics64%4.5
Leadership qualities61%4.1
Alpha Omega Alpha (AOA) membership60%3.9
Perceived interest in program59%4.1
Other life experience58%3.8
Passing USMLE Step 2 CS/COMLEX Level 2 PE56%4.2
Volunteer/extracurricular experiences54%3.8
Consistency of grades54%4
Lack of gaps in medical education53%4
Awards or special honors in clinical clerkships52%3.6
Graduate of highly‐regarded U.S. medical school50%3.8
Gold Humanism Honor Society (GHHS) membership47%3.8
Awards or special honors in clerkship in desired specialty46%3.8
Demonstrated involvement and interest in research41%3.7
Visa status (IMG only)40%4.1
Applicant was flagged with Match violation by the NRMP37%4.8
Away rotation in your specialty at another institution26%3.8
Interest in academic career24%3.8
Fluency in language spoken by your patient population24%3.7
Awards or special honors in basic sciences22%3.3
USMLE/COMLEX Step 3 score16%3.4

Source: National Resident Matching Program, Data Release and Research Committee: Results of the 2018 NRMP Program Director Survey. National Resident Matching Program, Washington, DC. 2018.

What exactly do these numbers mean? The first number is the number of programs who said this factor was important. The number in parentheses is the average importance rating. In other words, USMLE Step 1 (or COMLEX Level 1) was used by 94% of all residency programs who responded to the survey. Those programs gave Step 1 an average importance of 4.1.

1. Step 1: a minimum score is often necessary – and a top score sufficient – to get an interview

What do the numbers tell us? The first thing you’ll notice is how important Step 1 is. Virtually every single program requires that you take it. Even more, when you drill down into the data, about 2/3 of all programs said they have a target score for their Step 1 exam.

Why would Step 1 be so important? An obvious reason is that programs need a way to compare vast numbers of students on an equivalent basis. As stated before, programs only offer ~13% of all applicants an interview. Of the 1,208 programs who responded, 736 (61%) stated that there was a score under which they generally don’t grant interviews. The mean cutoff score? A Step 1 score in the 210s.

Conversely, 623 (52%) stated that there was a score above which they would generally invite applicants to an interview. In other words, many programs will give you an invite based off a high Step 1 score alone. The magic score? The mean was in the 230s. (Note that the spread was broad, ranging from about 220 for the 25%ile to 240 for the 75%ile).

If you’re below a program’s Step 1 cutoff, your extracurriculars won’t matter. It won’t matter how many committees you served on, doctors you shadowed, or times you volunteered at the free clinic.

Have you ever told yourself, to stand out, you need to do more than “just study for Step 1.” If you’re mastering the material and learning how to apply it, then by all means start doing research. However, be careful that you’re not doing these things INSTEAD of studying for Step 1. Many people hope to do well on Step 1 AND excel at other things. Yet, by spreading themselves too thin, they end up struggling at everything.

This squared with my experiences. When I applied, I had only taken Step 1, and had scored 270. Despite not having taken Step 2 CK or CS, all but one program I applied to granted an interview.

Getting an interview is important. Being among the first to receive an invitation – to secure your preferred dates – is equally important. On the strength of my Step 1 score, I received my first-choice date at all my interviews. I grouped all my interviews together by location. This saved time, money, and hassle. I completed all my California interviews within two weeks. I bought a one-way ticket to New York, and had all 4 of my New York interviews within the same week. Then I took the bus to Boston and had all 4 of my Boston interviews the week after that. My last interview was December 13, before most programs had seen half their interviewees.

The take-away? Don’t sacrifice your Step 1 preparations in trying to stand out with extracurriculars.

2. Where are the preclinical grades??

Another item is significant for its absence. While core clerkship grades are the #6 most cited item, preclinical grades aren’t even on the list.

Wait, so our preclinical grades don’t matter?

What gives? More and more schools have “pass-fail” grading for their preclinical years. As such, it would make sense that program directors would ignore preclinical grades. For many schools it’s just a bunch of “Pass’s.”

Still, while it’s not cited as a factor by itself, there are ways in which it may matter. First, the MSPE (formerly the Dean’s Letter) can vary widely in what it includes. Some schools have “pass-fail” grading, but they could include rankings in the MSPE. Second, student rankings may determine AOA (medical honors society).

My takeaway? Ask your school how the MSPE presents preclinical grades/rankings. If it’s not included, stop worrying so much about them! Most students waste time worrying about maximizing the scores on preclinical exams. Instead of doing their Anki cards, they’ll cram for midterms. Or they’ll memorize PowerPoint minutiae for their tests, rather than understand it.

This short-term approach can hurt your residency chances. They will be scrutinizing Step 1, not your preclinical grades. Med school exams focus on memorizing information. Step 1 focuses on mastery/application of material. If you learn the Step 1 material properly, you can still do well on your med school exams. However, cramming for your preclinical tests will only hurt your Step 1 score.

3. Residency programs rely on high-level, summative assessments to screen applicants

A successful application begins with considering each program’s goals and limitations. Remember, a typical program can only offer interviews to 13% of applicants. Their goal is to find the best applicants who are a “fit” for their program. However, their time is limited. This is particularly true when deciding who to interview.

A careful reading of the survey further confirms this sobering fact. Every program surveyed has a “standardized screening process.” This screen eliminated 48% of all applicants.

Fewer than 50% of all applicants received an “in-depth review.”

We’ve already seen that Step 1 is used as a screening tool. Low Step 1 scores may lead to outright rejection, while high scores may lead to an automatic interview.

It can be terrifying to have years of your life summarized in a three-digit score. For program directors, Step 1 is a tool they use to sort between large numbers of applicants.

The other top-cited factors for extending interviews share a similar summative quality. Let’s look at the top 5 cited factors again (mean importance ratings in parentheses).

  1. USMLE Step 1/COMLEX Level 1 score – 94% (4.1)
  2. Letters of recommendation in the specialty – 86% (4.2)
  3. Medical Student Performance Evaluation (MSPE/Dean’s Letter) – 81% (4.2)
  4. USMLE Step 2 CK/COMLEX Level 2 CE score – 80% (4.2)
  5. Personal Statement – 78% (4.2)

What do you see? More than half of the factors cited are summative – Step 1, Step 2 CK, and your MSPE. The others look to assess “fit” with the specialty. Your Personal Statement assesses your motives. Your LORs tell them and how specialists in the field think you’ll do.

What does this mean for you? I remember obsessing about the perfect way to phrase my experiences as a French camp counselor in my residency application. Now I know that was a waste of time. They’re busy. They are looking for high-level summaries of what you’ve done. One interviewer told me all he looked at were the school and Boards scores. That is an extreme example, but it speaks to how pressed for time the people evaluating you are in many ways.

4. The quantity of volunteer/extracurricular experiences aren’t important

One of the first days as a medical student was our activities fair. Older medical students set up tables, explaining the various organizations they ran. There were groups for everything you could imagine. Groups for specialties, for research, and for student government. There were groups devoted to meditation (a group I started), business, and many others.

All the groups had a common theme. The second-years leading them would begin their Step 1 studying/enter clerkships soon. As such, there would be a need (nay, an opportunity!) for eager first-years to participate and take on leadership positions.

You could see the frenzy of first-year students hoping to stand out in some way rush to participate in various groups. I was one of them.

In retrospect, particularly when looking at the cold, hard data of the program director survey, I regret some of my earlier decisions. Some of the extracurriculars I participated in were things I genuinely was interested in, like meditation. Others, however, I did because I was afraid of “missing out” on an opportunity to stand out later. Some of my classmates volunteered at the free clinic because of a belief in social justice. Many others, including myself, did it because it felt like something we were supposed to do.

It’s these one-off sorts of experiences that I regret. They never came up in my interviews, and likely didn’t pass as a thought by the program directors.

The data bear this out.

Volunteer/extracurricular experiences rank as #19 on the list. Only about half of programs said it was significant in deciding who to interview.

The same is true when we look at people who actually matched vs. didn’t match in their chosen specialty. There’s no correlation between the number of experiences, and the chance of matching.

 Step 1, US Senior (Matched)Step 1, US Senior (Unmatched)Mean number of volunteer experiences, US Senior (Matched)Mean number of volunteer experiences, US Senior (Unmatched)
Dermatology2492419.17.5
Plastic Surgery2492397.57.3
Orthopaedic Surgery2482407.36.3
Otolaryngology2482387.68.1
Radiation Oncology2472386.67.4
Interventional Radiology2462426.86.1
Neurological Surgery24523476.9
Diagnostic Radiology2402236.45.4
General Surgery23621976.6
Vascular Surgery2362196.48
Internal Medicine/Pediatrics2352178.77.6
Child Neurology2332116.94
Emergency Medicine2332207.36.3
Internal Medicine2332076.85.5
Pathology2332165.55.5
All Specialties Combined2332247.36.6
Anesthesiology2322126.46.9
Neurology2312136.56.8
Obstetrics and Gynecology2302188.58
Pediatrics2272098.36.6
Psychiatry22621576.2
Physical Medicine and Rehabilitation2252157.86.6
Family Medicine2202067.76.1

Source: National Resident Matching Program, Charting Outcomes in the Match: U.S. Allopathic Seniors, 2018. National Resident Matching Program, Washington, DC 2018.

My takeaway? I’d choose one, at most two non-research extracurriculars you want to participate in. Even then I would be careful to choose only things that were personally meaningful. Unless it’s truly spectacular, it may not move the needle for residency programs.

As always, be mindful of the opportunity cost. Every free evening, afternoon, or weekend you give up is less time you can spend on other goals. Don’t ask yourself “if I did Activity X, would it help me?” Instead ask yourself, “what priority am I willing to sacrifice to do Activity X?” Only do an activity if there is you can give up a different activity.

5. Research and personal connections help you stand out in competitive specialties

Residency programs care little for extracurricular activities. However, they care a great deal about research and personal connections. This is particularly true for the most competitive specialties. Let’s look at the two most competitive specialties in the 2018 Match, based average Step 1 scores: dermatology and plastic surgery.

The average Step 1 score for both specialties for successful US Seniors was 249. (ENT and Orthopedic Surgery, the next two on the list, were both 248). That is insanely high. Even more surprising? The average Step 1 scores of those who didn’t match: 241 for dermatology, and 239 for plastic surgery.

Does that mean that if I score a 241 I can kiss my derm chances goodbye? No. Rather, it means that a high Step 1 score is necessary, but not sufficient, to get into a competitive residency.

One of the most important non-Boards factors is research. Here is a comparison of matched and unmatched US seniors, sorted based on Step 1 scores. Often, the Step 1 scores are similar between matched and unmatched applicants. Rather, there is a significant gap in the numbers of research abstracts, papers, etc. they published.

 Step 1, US Senior (Matched)Step 1, US Senior (Unmatched)Mean number of abstracts, presentations, and publications, US Senior (Matched)Mean number of abstracts, presentations, and publications, US Senior (Unmatched)
Dermatology24924114.78.6
Plastic Surgery24923914.214.9
Orthopaedic Surgery24824011.56.7
Otolaryngology24823810.45.3
Radiation Oncology24723815.612.2
Interventional Radiology2462428.47.3
Neurological Surgery24523418.38.9
Diagnostic Radiology24022363.9
General Surgery2362196.24.7
Vascular Surgery2362198.33.3
Internal Medicine/Pediatrics2352174.84.9
Child Neurology2332116.30
Emergency Medicine2332203.72.9
Internal Medicine2332075.12.9
Pathology2332166.76.8
All Specialties Combined2332245.75
Anesthesiology2322124.52.6
Neurology2312136.37.3
Obstetrics and Gynecology2302184.93.3
Pediatrics2272094.13.2
Psychiatry2262154.83.7
Physical Medicine and Rehabilitation2252154.23.4
Family Medicine22020632.3

Source: National Resident Matching Program, Charting Outcomes in the Match: U.S. Allopathic Seniors, 2018. National Resident Matching Program, Washington, DC 2018.

Another thing that stands out about the program directors survey is the emphasis on personal knowledge of the applicants. For example, 83% of dermatology program directors cited “Personal prior knowledge of the applicant” as significant in deciding who to interview. Even more important, the average rating of importance given was 4.7.

What’s my takeaway if you want to get into a competitive specialty? First, while a top Step 1 score is critical, it isn’t enough by itself. Second, to stand out, research continues to be a differentiating factor.

Note that the dedication to studying required to do well on Step 1 is often at odds with doing proliferative research. Unless you’re a savant, it is difficult to do both well. Instead, many people choose to take a year off to focus on research, and to shadow/build connections in their given specialty.

Concluding thoughts

Getting into your dream residency may feel overwhelming. It doesn’t have to be. Knowing what program directors are looking for in applicants is clarifying. You don’t have to work until exhaustion on everything, trying to do anything and everything to stand out. Instead, be clear what your goal should be at every stage.

If you’re a preclinical student, your emphasis should be squarely on doing well on Step 1. In your clerkships, while your grades matter, so does Step 2 CK. At any stage, Anki is a fantastic means of working towards mastery of these long-term goals.

If you’re interested in the most competitive specialties, not only do you need to do well on your Step 1, but you will also likely need to stand out in some other way. Research is a common approach, but if you are struggling to do both simultaneously, it’s ok to focus on your curriculum now, and plan to do a research year later.

My most important takeaway from the program directors’ survey is about prioritization. I’ve found in many different areas that the most successful people are those who have a clear idea of their end-goal, and focus on the few levers that deliver outsized likelihood of achieving it. With data, we can make better decisions, so that when we push on the door, it opens the first time.

Want FREE Cardiology Flashcards?

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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