Planning for Residency Choice
"All of a sudden it was July, and a single burning thought struck fear into the hearts of all fourth-year students — finding the perfect residency. One minute we are studying general pathology and physical diagnosis; the next minute we have to decide what type of medicine to practice and where to do a residency. To compound the problem, even if one makes careful decisions about a specialty and residency program, it is becoming more and more difficult to "match" at a favorite residency program."1
—Billy Katibah, fourth year medical student
MATCHING FOR A RESIDENCY POSITION IS AN ADMISSIONS process like any other admissions process: you send for information, choose where to apply, fill in application forms, go for interviews, and select your choices. What distinguishes it from other admissions procedures is the relative lack of information you have until the end of your third year of medical school and the large number of rumors about the "Match." This chapter should help you sort out "fact" from "fiction" by answering some common questions about matching programs.
THE MATCHING PROCESS
The National Resident Matching Program
Most medical students find a residency position through the National Resident Matching Program (NRMP; Internet address: www.aamc.org/nrmp. ), a service that, since 1952, has been facilitating student and program matches and announcing the results on a uniform date and time. The NRMP was initiated in an era when internship positions outnumbered graduating students two to one and students found that they were being pressured to accept appointments early in their fourth year from less competitive programs while awaiting decisions from more favored residencies. The differences in appointment dates among programs left the decision whether to accept or to wait and hope for a better offer entirely up to the student.2
Today, a computer makes the decision—in less than three minutes — but your planning probably has started months or (hopefully) years before. You should refer to the suggested timetable in Part 1 for tasks to be accomplished in preparation for specialty selection and residency application.
Who Should Participate in the NRMP?
All students should participate in the NRMP, including those who are applying to military and advanced specialty programs that operate their own matches. If you do not match in one of the other matches, you still will be eligible to secure a residency position through the NRMP.
Matching opportunities for shared-schedule positions and couples are offered through the NRMP. These are discussed later in this Part of the book.
Medical schools may sponsor former graduates from their institution who deferred application to residency at the time of their graduation. However, students and graduates of Canadian medical schools and schools accredited by the American Osteopathic Association must register as Independent Applicants. Also included in this category are graduates of non-United States unaccredited medical schools who hold an unrestricted license to practice medicine in the United States or who have passed the necessary examinations offered by the Educational Commission for Foreign Medical Graduates.
What Are the Programs Within the NRMP?
Virtually all civilian first-year postgraduate programs in family medicine, general surgery, internal medicine, obstetrics-gynecology, pathology, and pediatrics, and most of the first-year positions in psychiatry and emergency medicine are offered as Categorical (C) positions in the NRMP. You can enter these programs with no previous residency training and complete all the necessary requirements for that specialty.
Primary Care (M) positions are categorical primary care or generalist positions offered in some internal medicine and pediatric residency programs.
All Transitional (P) positions are offered through the NRMP. These are in a first-year program that offers training in several specialties prior to your applying for a second year in a specific specialty. You may have rotations in surgery, internal medicine, pediatrics, emergency medicine, obstetrics-gynecology, and psychiatry during this year. Be aware, however, that most surgical specialties, family medicine, internal medicine, and pediatrics will not give you full credit for this year of training, and you may have to repeat part or all of your internship year.
Some programs in anesthesiology, dermatology, neurological surgery, neurology, nuclear medicine, ophthalmology, orthopaedic surgery, otolaryngology, physical medicine and rehabilitation, psychiatry, diagnostic radiology, radiation oncology, and urology offer Preliminary (P) positions in internal medicine, pediatrics, and general surgery for one or two years prior to entering training in their specialties. This is essentially the same program as a categorical internship year in internal medicine or general surgery, and, if you choose to continue in one of these specialties, will be counted as a full year of training.
There are also Advanced (A) positions participating in the NRMP. These programs require one or more years of preliminary training in internal medicine, pediatrics, or surgery, or a transitional internship year, but you can apply to them as a senior medical student. Some institutions arrange for preliminary positions for all who are accepted into their advanced specialty programs; others do not. You may have to complete two applications: one for the Advanced positions and one for the preliminary years.
The NRMP offers Physician (R) positions starting in the year of the Match for those physicians who have already completed some residency training. These positions are not available to senior U.S. medical students.
There are also Fellowship Positions for those who have completed a residency and wish to subspecialize further. The Medical Specialties Matching Program (MSMP) currently offers positions in all the internal medicine subspecialties described in Part 2 of this book. In addition, there are numerous other subspecialty matches managed by the NRMP (see www.nrmp.org/fellow/index/html for the full listing).
Another option for residency is the Combined Training Programs that lead to Board certification in more than one field. These programs are detailed in individual specialty chapters earlier in this book, and a complete listing is found in the American Medical Association Fellowship and Residency Electronic Interactive Database Access System (AMA-FREIDA). The table below details the combined programs.
When Do I Apply to the NRMP?
Assuming you have decided on a specialty, you need to find out whether the specialty has its own match outside the NRMP (currently, child neurology, ophthalmology, plastic surgery and urology), whether some programs in your chosen specialty are in the NRMP and some are not (some programs in anesthesiology, orthopaedic surgery, and otolaryngology), or if all the programs participate fully in the NRMP. Each option will involve different timetables because the military and some specialties match earlier.
You need to register and "sign" the agreement on-line, and it must be submitted by November 30. Your school's Dean's office verifies that you are eligible to participate in the Match once you have applied. Your agreement must be accompanied by a nonrefundable application fee that allows you to rank ten hospitals on your rank order list; if you wish to rank more, there will be an additional fee for each.
What Are My Obligations by Participating in the NRMP?
If you participate in the NRMP process through Match Day, you are obligated to accept the position that is offered to you. However, if you are accepted at a military or advanced specialty program, you can withdraw from the NRMP.
If you are participating in both the Canadian Resident Matching Service (CaRMS) and the NRMP, you will be expected to accept a position if matched into the Canadian Program, which has an earlier schedule for matching than the NRMP. The CaRMS will inform the NRMP that you have matched, and your name will be deleted from the NRMP match.
Other Matching Programs
The US Armed Forces Match. Medical students who are members of the Army, Navy, or Air Force programs participate in a separate match for residency positions in the military programs (military programs are discussed in a later section).
Advanced Specialty Programs With Their Own Matching Programs. Some specialties have matching programs for residency positions at the second or later years outside of the NRMP. At present, most or all of the programs in ophthalmology and plastic surgery participate in the San Francisco Matching Program, P.O. Box 7584, San Francisco, CA 94120. Telephone: (415) 447-0350. Internet address: www. SFMATCH.org. Urology match information can be obtained from the American Urological Association Residency Matching Program, 2425 West Loop South, Suite 333, Houston, TX 77027. Internet address: www. auanet.org.
These matches are conducted earlier than the NRMP and you will be required to register with the NRMP for the required preliminary training (for example, one or two years of general surgery prior to otolaryngology).
Nonmatch Programs. A direct application process is currently used by most programs in preventive medicine, nuclear medicine, and a few programs in psychiatry. Also, you will need to apply directly to newly approved programs that are not yet listed in a match program.
Osteopathic Programs. Osteopathic medical students apply to the Intern/Resident Registration Program (the "AOA" Match) conducted by the National Matching Services, Inc. on behalf of the American Osteopathic Association (AOA). However, not all students participate. Those with military commitments participate in the military matching program (see later chapter in this Part of the book). There are declining numbers of funded osteopathic internship positions and increasing numbers of osteopathic graduates. As a result, about half of the osteopathic graduates enter accredited osteopathic residencies. Since 1985, a residency program can be dual-accredited by both the ACGME and the AOA. The topic of dual-accreditation is controversial. Since 2001, a Doctor of Osteopathy resident in any MD residency program can apply for osteopathic approval of their training, but MDs are generally not permitted to train in osteopathic (AOA-accredited) residencies, although this is being studied.3,4,5
There are osteopathic residencies in a large number of specialty areas, and they are listed annually on the AOA Opportunities database. Applicants register with the Electronic Residency Application Service (ERAS) to apply to programs. The Match results are released in February, a month earlier than the NRMP.
Part-Time and Shared-Schedule Positions
Part-time and shared-schedule residency positions have existed since the 1960s. They are of interest to an individual who wishes to extend his or her residency beyond the usual length (four years rather than the customary three years of a family medicine, internal medicine or pediatrics residency) or two persons sharing a single residency position, each working a reduced schedule over a proportionately longer period of time. An applicant may negotiate a part-time or shared contract with any residency program. Previously, residencies in the primary care specialties (family medicine, internal medicine, obstetrics-gynecology, and pediatrics) were required to offer a shared position if they received federal monies and admitted 12 or more residents per year. This law was repealed in August 1981.6
For a shared residency, the partners enroll individually in the NRMP and submit a "shared residency pair form" (available from your medical school or the NRMP), which assigns the pair one match number and one name, e.g., "Smith/Jones Ann/Michael." The pair submits one rank order list that they agree on. The program ranks the pair by their "name" and number just as they would individuals who are doing "solo" residencies.
Common Arrangements for Shared-Schedule Residencies*
* Modification of an article originally published in the Dual Doctor Families Newsletter 1983;2(1):1,6-7. Used with permission.
Interdigitating Format. The residents are on the same clinical services together, and care for the same patients simultaneously. Through careful communication and cooperation they take turns with call, chasing down lab results, and managing patients. They probably will stay on a particular ward service several weeks or months longer than their colleagues in order to achieve the same level of experience. However, they also should be able to take alternating afternoons off. They may take their vacations separately or together. They are collectively responsible to their supervisors. This plan is job-sharing in the true sense of the word!
Alternating Format. One resident works while the other one is off. The "on" resident works full-time and keeps the same hours as colleagues on the ward team. Meanwhile the partner enjoys the benefits of being off. It is possible in some residencies offering shared positions to work more than half-time under this format and to finish proportionately sooner. In certain residencies, including all family medicine programs, the off-resident is required to return several half-days per week to provide continuing care for his or her patients. Thus, in the alternating format, the "off" person may want or be required to attend to the ongoing care of patients.
Salary Arrangements. Anything is possible; negotiate and then get it in writing. According to the repealed federal law, a shared resident was to work at least two-thirds time for at least half-pay and full benefits. Some argue that a person should receive pay in direct proportion to hours worked. Others argue that a resident should pay extra for the privilege of not working as much as other colleagues and that because a residency program is inconvenienced in order to coordinate the shared-pair's schedules, the program is therefore entitled to more "doctor per dollar." In addition, many programs do not have the dollars to pay a shared-resident pair more than one full salary.
Strategies for Applying and Interviewing. Rule number one is: have your act together! To propose a part-time or shared-schedule residency position, you will need to be able to state your reasons. A common reason to work part-time or share a residency involves family responsibilities. Other people may want time to do research, to pursue a second profession simultaneously, to reduce stress, to increase recreational opportunities, or to "be a whole person and not just a doctor."
For a shared-schedule position, decide carefully what you want your shared residency to be like and write a concise plan. A written agreement between the co-applicants detailing their goals and aspirations is wise. When you apply, each applicant must fill out a separate application and obtain a separate dean's letter. Consider the benefits and disadvantages of discussing the shared-residency proposal in your personal statement and of having the writers of your letters of recommendation support your plan. Remember that in addition to selling your proposal as a good and practical idea, you must also convince them that you are individually better-than-average for their program.
Before an interview is arranged, try to "feel the program out" about your proposal. You may waste time and money going where a part-time or shared-schedule residency is not workable. For a shared-schedule residency, arrange interviews on the same day and, if possible, try to arrange at least one joint interview with a powerful person, ideally the residency director, so you can discuss the proposal together. Both applicants should contribute to the discussion equally and should complement each other's remarks. Do not be surprised if the interviewer has never heard of a shared residency. Memorize a brief outline of the important points of your proposal. The interviewer will be impressed that the "team" is organized, and time will be saved by not having to hear two similar versions. Be sure to talk to current residents about the program and your proposal, and ask if it sounds feasible. Get detailed information about the residency's scheduled rotations so that after the interview, you can design and submit a sample shared schedule to fit their program. Be willing to be flexible about scheduling if your plan does not quite fit what they think they can offer. At some point, they must have your proposal in writing. It never hurts to remind them about the match rules for shared applicants one more time just before you expect them to fill out their rank order form. You wouldn't want to risk not being ranked simply because they didn't remember how to do it.
Programs offering shared-schedule positions are identified in the AMA-FREIDA computer system and should be contacted directly. A national survey of pediatric residency programs7 reported that 24 percent of 190 programs on AMA-FREIDA indicated that they offer part-time and/or shared residency positions, but only a few residents held such positions during a 3-year period.
Larger programs were more likely to offer such positions and most of them are in family medicine, internal medicine, pediatrics, psychiatry, and child psychiatry.
SEEKING INFORMATION
Gather information as early as possible on both the process of applying to residency and details on the residency programs in your chosen specialty. The premier website resource on both choosing a specialty and applying to residency is the Association of American Medical Colleges' Careers in Medicine site, www.aamc.org/cim .
In addition, you should go directly to the residency program's website and the website of the major organization for the specialty (listed at the end of each chapter in Part 2 of this book). Most specialty societies have posted listings of residency programs in their specialty on their websites.
For a complete listing of all residency programs, there is the annually updated computer program known as AMA-FREIDA (http://www.ama-assn.org/go/freida) for which each residency program is asked to provide information on over 100 items, including: characteristics of residents and faculty; call schedules; benefits provided; curriculum; availability of "shared-schedule positions"; and name, address, and telephone number of the program director.
The American Medical Student Association (AMSA; Internet address: www.amsa.org) offers the Student Guide to the Appraisal and Selection of House Staff Training Programs; this is a valuable resource that offers advice on resumes, letters of recommendation, interviewing, and evaluation of residency programs.
Resources at your school—graduating seniors and residents—can offer opinions on various programs, some of which will be subjective. A career counseling service may provide evaluations from alumni, a library of brochures and directories, and personal counseling. Websites are sources of information about specific residencies with reviews written by both applicants and residents in the programs. Look at the websites for Student Doctor Network and Scutwork.com listed in the Appendix of this book.
APPLYING TO RESIDENCIES
What Should I Know About Filling Out My Residency Program Applications?
Applications vary in format and information requested; you will need plenty of time to complete them. Students use the Electronic Residency Application Service (ERAS) at www.aamc.org/eras to apply. The application fee for up to 10 programs is $92; 11-20 programs, $9 each; 21-30 programs, $15 each; above 30 programs, $25 each.
Here are some tips:
Your curriculum vitae and personal statement should be thorough but concise, allowing the reader to learn about your most favorable qualities and achievements. Be sure to emphasize areas of common interest; for example, if a program is located in a city where you have family members or if you have participated in activities such as research or community service that are pertinent to that program's focus of interest.
Your Medical School Performance Report, formerly called the Dean's Letter, may be written by the Dean of Student Affairs alone or in conjunction with a clinical advisor. It will be based primarily on your grades and clerkship performance with a stated purpose "... as an evaluation of a medical student's performance (rather than a recommendation or prediction of future performance)."8 Some specialties will weigh grades more heavily than others, but I cannot emphasize too strongly the increasing importance of grades, especially those in the clinical rotation of your chosen specialty, but also, for some specialties, those from the first two years of medical school. This letter will also provide personal bibliographic data; the key feature is that most letters have a final sentence that gives a summary evaluation of you as an applicant relative to your peers.
Request a letter of recommendation from at least one physician faculty member in your chosen specialty. Other letters should come from faculty members who know you well and who can write enthusiastically about your abilities. If you approach someone who hesitates about writing your letter, do not press the matter—ask someone else. If a faculty member has a connection with a program that interests you, that is an added bonus—"old school ties" are very helpful.
When your application is completed, submit it. The sooner it arrives, the sooner you can be invited to schedule an interview. It is possible that the more competitive programs will have full interview schedules if you wait too long. It is especially important to plan ahead if you are trying to coordinate interviews at a number of nearby programs.
Be sure to keep a record of all your applications, including photocopies of correspondence and notes on telephone conversations. As you start to schedule visits to programs, names and dates will start to accumulate and an organized record keeping system is most helpful.
What Advice Can You Offer About Interviewing?
The interview may be the most important part of the application process—both for you and for the program. There is an old saying: your record gets you the interview; your interview gets you the job. It is not only a chance for the program to evaluate you, but an opportunity for you to evaluate the program, the hospital, and the geographic location. Some programs interview all applicants; others select those they will interview on the basis of grades and National Board scores. Most students interview in November, December, and January of their fourth year. Your spouse or significant other should be included in this process, if not by actually accompanying you as you interview, then at least being involved in the post-interview evaluation of programs and their geographic locations.
You will have many questions, but first read the program material so you do not ask what is already provided. Be sure to talk to residents currently in the program—they will probably be your best source of information. You will find suggestions on questions to ask in the AMSA Student Guide to the Appraisal and Selection of House Staff Training Programs, Iserson's Getting Into a Residency, and Katta and Desai's The Successful Match.
Try not to schedule your interviews too close together—you will find that you need time to assess what you have seen before jumping into the next interview. If this is not possible, keep as many notes as possible—even though it seems you could not forget how unhappy the residents were at a program, two weeks later you may find yourself wondering which program it was.
You may be asked by an interviewer how you plan to rank the program; this is acceptable. However, verbal agreements are not binding and should not influence your ranking of programs. Some unmatched students have discovered this sad fact too late.
After the interview you may be sufficiently impressed with a program to write a letter indicating so. This is perfectly acceptable - send the letter to the program director if you met him or her and to the faulty who interviewed you. Also, write a note to thank the administrative assistant/residency coordinator who does the behind the scenes work to make the interviews runs smoothly. Personalize each letter, either referring to something you discussed in your interview or something specific about how you feel the you would be a good match for the program.
If you decide not to keep an interview appointment or, for some reason, cannot get there, call as soon as possible so that another applicant can interview in your time slot. If possible, you will be given consideration for rescheduling. Remember, if you are unmatched, you may wish to make contact with this program if they have an open position.
How Should I Rank My Choices?
Students spend a great deal of time discussing various strategies—all supposedly guaranteed to secure your first choice program. The rank order list is confidential for both the student and the program and must be submitted by both to the NRMP before the end of February. The student's wishes are the basis upon which the computer makes close choices; that is, the program is tilted in the student's favor. Therefore, what you want most should go to the top of your list. You can list more than one specialty on your rank order list, and this may be wise if you are applying for a highly competitive field of medicine. Most of all, you need to include a spectrum of programs: those that may be too competitive but are most desirable; those that are realistic and acceptable; and those that are even below your abilities, but are also acceptable. It is probably better to go unmatched than to list unacceptable programs just to be safe. For further information, see the chapter on What Happens If You Don't Match.
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Katibah B. Student newsletter. Tar Heel Practitioner, September-October 1983, p. 12.
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www.nrmp.org/about_nrmp/new_policies.html, accessed September 14, 2002.
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http://en.wikipedia.org/wiki/ Comparison_of_MD_and_DO_in_ the_United_Statesaccessed January 6, 2011
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Schierhorn C. Educators at summit frame future of Osteopathic Graduate Medical Education. The DO magazine. American Osteopathic Association. June 2008. p.22-27
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Schierhorn C. Slumping Osteopathic Graduate Medical Education piques educators at summit. The D.O. magazine. American Osteopathic Association. Feb 2008. p.22-28
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Carling PC, Hayward K, Coakley EH, Wolf AMD. Part-time residency training in internal medicine: Analysis of a ten -year experience. Acad Med 1999;74(3):282-284.
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Holmes AV, Cuff WL, Socolar RR. Part-time residency in pediatrics: Description of current practice. Pediatrics July 2005; 116(1):32-37.
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A Guide to the Preparation of the Medical Student Performance Evaluation. Association of American Medical Colleges, 2002.