TYPES OF RESIDENCY PROGRAMS
The NRMP offers three types of postgraduate training positions in the Main Match. Medical students should become familiar with the proper terminology. Every residency program has an assigned ACGME identification number containing a single letter—C, P, or A.
1. Categorical (C): These programs begin training at the first postgraduate year (PGY-1), which starts in July immediately following medical school graduation. Depending on specialty, they consist of 3 or more years of graduate medical education. Residents are expected to complete the entire length of training required for board certification. Specialties such as internal medicine, pediatrics, obstetrics and Gynecology
, and general surgery are primarily categorical tracks.
2. Preliminary (P): These programs last 1 year, count for PGY-1 credit only, and are formally available through internal medicine, surgery, or transitional year. These positions exist to satisfy the 1-year prerequisite clinical training required by advanced specialty programs (see below).
3. Advanced (A): These positions begin only at the level of the second postgraduate year (PGY-2), after a year spent in a preliminary program. Specialized fields such as Dermatology
, Ophthalmology
, anesthesiology, and radiology are typically advanced tracks. Students apply to both advanced and preliminary programs at the same time, even though the advanced position does not commence for an entire year after the actual Match. (Your spot will be reserved).
A completed ERAS application consists of the following parts:
1. Profile: This 1-page form contains your name, identification numbers (social security, ERAS, NRMP, and USMLE
), citizenship, medical school, and contact information. The entries can be changed at any time; an updated version is electronically sent to all programs.
2. Common Application Form (CAF): This 12-page form consists of all the basic background information typically found in a resume: degrees earned, research and work experience, extracurricular activities, hobbies, and publications. After completing the form and proofreading for typos, click on certify. The electronic certification process officially submits the CAF and locks out any further changes from being made. Until you cough up the money for your programs, ERAS will not allow supporting documents to be scanned and uploaded by your medical school.
3. Personal Statement: You should type, edit, and spell check the personal statement on a word processing program and then copy and paste it into ERAS. Simply create a blank new personal statement in the MyDocuments section. If you are applying to multiple specialties or preliminary programs, give it an easily recognizable title (e.g., Derm). Program directors will not see your titles. To create multiple personal statements, just click on the New Personal Statement button. Because the formatting of your document in ERAS will not look exactly like your original, print out a copy to view its appearance.
4. USMLE
Transcript: The National Board of Medical Examiners (NBME) will send an unlimited number of USMLE
transcripts to residency programs via ERAS (for a flat fee, of course). You must send all current USMLE
scores and then choose whether or not to retransmit automatically updated transcripts when they become available. However, your decision is irrevocable and binding. If in doubt, do not choose the automatic retransmission option. Most medical students prefer reviewing their USMLE
Step 2 scores prior to submission (in case they are poor). Manual retransmission of these transcripts incurs no additional cost.
5. Dean’s Letter: This document is scanned and uploaded by your medical school. It does not count as one of the four possible letters of recommendation. ERAS transmits the Dean’s Letter to all selected programs on November 1st.
6. Medical School Transcript: The applicant’s medical school also uploads this document.
7. Photograph: Students must provide their Dean’s Office with a wallet-sized photograph for scanning and submission. However, residency programs are prohibited from accessing the photo until an interview has been granted.
8. Letters of Recommendation (LORs): ERAS allows applicants to assign up to four LORs to each individual residency program. However, an unlimited number of LORs can be solicited, scanned, and uploaded into the ERAS system. In the MyDocuments section, simply create a new LOR for each expected writer, clearly indicating the faculty person’s name on the file. Print out the LOR cover sheet, check the appropriate box whether or not you waive your right to review the letter, and give the form to the writer. The faculty member returns the recommendation to your Dean’s Office for scanning and submission. If you complete a stellar rotation in late summer or early fall, a LOR can easily be submitted after the others have been transmitted.
Selecting residency programs and assigning the appropriate documents is the final step in the application process. Your program selection list remains strictly confidential. For every program on the applicant’s list, ERAS will automatically transmit the Profile, CAF, medical school transcript, photograph, and Dean’s Letter. At this point, some personalization comes into play. For every program, ERAS will prompt the applicant to assign one personal statement and up to four letters of recommendation from the total submitted files. This feature allows medical students to customize the supporting documents each program receives.
A STEP-BY-STEP GAME PLAN FOR THE MAIN MATCH
May–June (End of Third Year)
▫ Narrow specialty of choice.
▫ Plan senior year schedule.
▫ Arrange for audition rotations.
▫ Meet with Dean to review academic record and discuss competitiveness.
▫ Talk with graduating seniors about specific residency programs.
▫ Select an advisor in the department of your chosen specialty.
July–August (Fourth Year)
▫ Begin drafting the personal statement.
▫ Take application photos.
▫ Contact faculty members who will be writing your letters of recommendation.
▫ Register on-line for the NRMP Main Match—$40 fee.
▫ Gather information in residency programs through the Internet. Use general search engines or FREIDA.
▫ Pick up your ERAS token from the Dean’s office to begin working on your on-line application.
September
▫ Complete final draft of personal statement.
▫ Finalize list of possible residency programs.
▫ Complete and submit the ERAS application on-line. The ERAS system does not allow electronic submission until September 1st; however, it is in your best interest to apply as early as possible.
▫ Your Dean’s Office will upload your transcript, recommendation letters, Dean’s Letter, and application photo.
▫ Use the Application Document Tracking System (ADTS), a feature of the ERAS website, to verify document transmission to each of your programs.
▫ Follow-up on any missing documents.
November–January
▫ ERAS releases the Dean’s Letter to all applied programs on November 1st.
▫ Respond to all interview offers promptly and arrange a schedule of dates.
▫ Complete all interviews.
February
▫ Discuss your highest program choices with your advisor or department chairperson and determine whether or not a phone call can be made on your behalf.
▫ Send letters to your highest-ranked programs.
▫ Complete Rank-Order List (ROL) on-line through the NRMP Main Match web site. Rank lists are due by midnight on the third Thursday in February.
March (3rd week)
▫ Monday: Un-Match Day—All applicants are notified of their match status (matched or unmatched).
▫ Tuesday: Scramble Day—Unmatched applicants contact programs with unfilled positions.
▫ Thursday, 12:00 PM, EST: Match Day—All applicants find out where they have matched.
List Guidelines
1. RANK THE PROGRAMS IN ORDER OF YOUR TRUE PREFERENCES Always place your number one dream program, even if it is a long shot, in the #1 rank position. The student-favored computer algorithm will first scan the applicant’s rank list in an attempt to match the highest choice. It is impossible to predict your position on a program director’s rank list. And, where you rank a program on your list will in no way affect where you stand on that program’s own list. Never place any program above the one that you really want simply because you think your chances for matching at your second choice are better. Because it is impossible to game the system with such a strategy, always follow your heart and make a ROL based on the order that will make you happy. Medical students who speculate too much about program directors’ rankings, or who place too much trust in their promises, often find themselves burned on Match Day.
2. DO NOT RANK A PROGRAM ON YOUR LIST THAT YOUWOULD NOT ATTEND UNDER ANY CIRCUMSTANCES All medical students are committed to entering the residency program at which they matched. Choose wisely. Do not place an undesirable program on your list simply for the sake of extending the length of the ROL. A long rank list does not affect the likelihood of matching to programs high on the list.
3. DO NOT SHORTEN YOUR RANK LIST BECAUSE OF PROMISES MADE FOR POSITIONS Every year there are disappointed medical students who failed to Match into programs despite having been verbally assured of their very high ranking. Be appreciative of positive FEEDBACK
, but never take verbal commitments seriously. Students should always create a rank list without these promises in mind. After all, program directors, who have to interview about 10 applicants for each position, are anxious to make every applicant feel special.
4. NO MATTER WHAT SPECIALTY, RANK ENOUGH PROGRAMS TO ENSURE THAT YOU WILL MATCH All medical students should rank at least five programs (of any type) on the primary ROL. The NRMP allows applicants to rank up to 15 programs before incurring additional fees of $30 per program. In 2002, matched US seniors ranked an average of 7.96 programs; unmatched applicants had ranked 4.62 programs. The actual number really depends on the competitiveness of the intended specialty, the competitiveness of the desired programs, and the qualifications of the applicant. Even for noncompetitive specialties, like Pathology
or physical medicine and rehabilitation, there is fierce competition for the highly sought after top programs.
TEN SURE-FIRE WAYS TO GUARANTEE THAT YOU WON’T MATCH!
• Earn a USMLE
Step I score of 180 (barely scoring above the 179 pass level).
• Choose a competitive specialty having earned mediocre grades in the corresponding rotation.
• Avoid doing an audition rotation or away elective because you are scared that they will think less highly of you.
• Apply only to the “top ten” programs in your specialty.
• Don’t consult with a faculty member, advisor, or dean to help plan a realistic match between you and your possible list of programs.
• Never send a letter of intent to your top program stating that you plan on ranking them as your #1 choice.
• Don’t have an advisor or chairperson make any calls on your behalf because you are afraid of inconveniencing the program director.
• Rank fewer than five programs on your rank-order list.
• Shorten your rank list because you received a flattering recruitment letter making you believe that the residency program was going to rank you at the top of their list.
• Don’t select a preliminary year or other back-up option to place at the bottom of your primary rank-order list (for very competitive specialties).
TOP SECRET! THE ULTIMATE GUIDE TO A SUCCESSFUL MATCH
For students currently in medical school, those tough premedical years may seem like a distant unpleasant memory. As a doctor-in-training, you have become accustomed to the competitive nature of medicine. Beginning in high school—and progressing all the way through college, medical school, residency, and fellowship—all aspiring physicians learned that they had to be the best. This is the only way to achieve one’s career aspirations in medicine successfully.
To become a pediatrician, radiologist, or any other specialist, every medical student must earn a training position in a residency program. The competition for certain specialties and residency programs, however, can be rather intense. While trying to figure out which specialty is best for them, medical students still have to work very hard academically during these 4 years.
Unfortunately, many students rule out some specialty choices for fear of not being accepted. Everyone knows that some fields of medicine only have a limited number of coveted residency spots and an overwhelmingly large number of applicants. Other specialties are not as tough to match in. Instead, the fierce competition exists for the most highly regarded hospitals and institutions within that specialty.
RISING ABOVE THE COMPETITION
The residency application and matching process has become a discouraging series of obstacles. Regardless of specialty choice, planning for residency is a 4-year process. It takes a great deal of strategy (and luck) to make yourself the most mar ketable candidate. Why is all this advanced preparation necessary? For each field of medicine, there are many myths and rumors regarding the criteria necessary to obtain a particular residency. There are subtle and hidden requirements that students must meet to match into the specialty, such as board score cut-offs, personal statement topics, published clinical research, and more.
Due to the increasing competition for certain specialties, there is less latitude for mistakes. Whether you are a first-year student wondering what type of doctor you will become, or a fourth-year veteran starting the residency application process, careful planning is a must to enhance your credentials and ensure success. This chapter will prevent any career-related regrets by showing what it really takes to match into each specialty and into the residency program of your choice. For each specialty, I have summarized the advice provided by a number of medical school seniors, residents, faculty members, and residency program directors. For medical students interested in the extremely competitive specialties, this inside information will allow you to plan far in advance. There should be no excuse for not doing all the right things and being the strongest candidate possible. Pay close attention, and heed the advice of those who have come before you: successfully matched residents from all the major medical specialties.
Based on statistical information from the 2002 NRMP, San Francisco, and Urology Matches, I have ranked the 20 medical specialties into four tiers of competitiveness. The unmatched rate (percentage of US seniors who fail to match into their desired field of medicine) serves as an excellent indicator of the difficulty of obtaining residency in a given specialty. The numbers represent those US seniors who applied to that particular specialty only—without any back-up choices. The 20 major fields of medicine are categorized in order according to these data.
You should, however, interpret these rankings with a grain of salt. Many aspects of medicine are cyclical. The relative popularity (and therefore competitiveness) of any field of medicine can change over time. While assessing their level of academic achievement, medical students go through a great deal of selfselection before committing to a specialty. Ultimately, only the most highly competitive students apply to the ultra-competitive specialties, which can skew the final unmatched rates. Also, the difficulty of matching to a specific residency program may differ significantly from the overall competitiveness of the specialty. Remember, even in the less-competitive fields of medicine like family practice, the few positions in the top programs can be incredibly difficult to obtain. Competition, therefore, exists for all residency applicants, no matter the specialty of choice.
SPECIALTY RANKINGS BASED ON 2002 UNMATCHED RATES FOR U.S. SENIORS
UNMATCHED RATE (%)
Although the number of American medical graduates entering anesthesiology reached a low point in 1995, interest has steadily increased again. Program directors seek candidates who demonstrate excellence in one or two areas of interest— either an extracurricular activity, research, hobby, or academic achievement. Do something that makes you stand out from the rest. The pursuit of research is neither a requirement nor a prerequisite for matching at a top residency program.
During your preclinical years, strive to earn high grades in Physiology
and Pharmacology
. Several years ago, most residency programs did not consider board scores when evaluating applicants. Today, do your best to earn higher than 210 on the USMLE
Step I to obtain an interview at the most competitive programs. During the clinical years, audition rotations at other hospitals are generally discouraged; they do little to improve your chances of matching at that program. Instead, spend your senior year learning medicine other than anesthesiology, like cardiology or critical care. Of course, you should take, at the minimum, one rotation in anesthesiology to confirm your interest and to collect letters of recommendation. Among your three to four letters, submit no more than two from an anesthesiologist; the rest should come from faculty in internal medicine or surgery. As always, a little name who knows you well is better than a big name who does not.
In your application, the personal statement should be a good read that clearly outlines your understanding of an interest in anesthesiology. Remember that poor grammar and spelling reflect on attention to detail, which is extremely important for this specialty.
In this extremely competitive specialty, most programs interview about 30 or so candidates (out of hundreds of applicants) for only two or three spots. Because of the stiff competition, future dermatologists must identify their interest very early in medical school. Because many students go into Dermatology
for the wrong reasons (lifestyle, money, etc.), interviewers screen for those who are passionate and truly committed to this challenging specialty. Get involved with the department as early as possible. Clinical research and publications in journals are extremely important for your candidacy, so find a research mentor during the preclinical years.
Board scores are also critical; earn the highest Step I score possible or else you may not make the cut. Nearly all programs heavily emphasize membership in AOA (the medical school honor society). In the clinical years, you will have to get lots of honors grades in your third-year clerkships to have the right numbers for interview selection. Take several electives in Dermatology
early in your senior year. Scheduling audition rotations at programs of highest interest can improve your chances of matching. During these rotations, work hard to portray yourself in the best possible light to the faculty and, in particular, the program director. Remember, connections are important in this specialty. Often, who you know will provide the greatest chance of matching Dermatology
.
Most candidates submit applications to nearly every program in the country (upwards of 40 applications!). Three strong letters of recommendation from dermatologists are preferred, particularly with words like outstanding, exceptional, and the best I’ve ever seen. In the personal statement, explain how you arrived at the decision to enter Dermatology
and why your personality attributes are a good fit with this specialty. Be articulate and engaging, tell a compelling story, and use this opportunity to stand out from the crowd in a positive way. Above all, do your best to get into Dermatology
at the first shot. Candidates who are rejected and reapply the next year (retreads) are rarely successful.
Selection committees like to see evidence that you are a healthy, well-adjusted person with interesting hobbies. During the preclinical years, it is highly advantageous to pursue research. Any specialty of clinical medicine is fine; program directors give bonus points for emergency medicine-related research. Immerse yourself in medical school and community activities, such as serving on committees, exploring emergency medicine interest groups, and volunteering Mother Theresa-style at local clinics. One successful candidate at a top program emphasized the importance of extracurriculars, especially “things that are outdoorsy, wild, crazy, or can kill you.”
For this very competitive specialty, strive for USMLE
Step I scores above 220. If your results are low, program directors recommend taking Step II early during senior year and earning higher scores. During the clinical years, earn high grades in medicine and surgery. Competitive candidates should then complete at least two rotations in emergency medicine—one at their home institution, the other at an audition hospital. The most desirable away rotations fill up quickly, so plan these fourth-year electives very early.
Because emergency medicine is a small community, obtain two letters of recommendation from EM faculty physicians. A strong letter from a community preceptor carries less weight than one from a program director or departmental chair. Most programs also prefer to see letters from every emergency medicine clerkship completed. Otherwise, their absence will raise concerns over your performance in those rotations. Finally, program directors place less emphasis on the personal statement, but it still should be well-written. The essay should convey how you selected emergency medicine, why your personality and temperament are well-suited for this specialty, and what you plan to do with your training.
Although family practice is a relatively noncompetitive specialty—with plenty of residency positions nationally for everyone—the most desirable and highly ranked programs are intensely competitive and still get their share of stellar applicants. Program directors like students who are heavily involved in extracurricular activities, particularly clinically related pursuits in which they interact with members of their community (volunteering at local clinics, education in schools, etc.). Make sure to work hard and obtain leadership roles in these organizations.
Although research projects look nice on paper, it is not essential to publish an article or present an abstract to match into family practice. You should study hard for the USMLE
Step I, but stellar scores are not necessary. Aiming for the mean is perfectly adequate for success in the match. In the clinical years, complete a community-based family practice elective, in addition to your medical school’s core clerkship. Work hard to impress your attendings. If you are interested in a particularly competitive residency program, it is advantageous to complete an audition elective there. Because family practice is such a broad specialty, the remainder of the senior year should be spent in a variety of medical fields, from obstetrics to critical care.
After grades earned in third-year clerkships, program directors place the greatest emphasis on your three (or four) letters of recommendation. At least one should be from a family practitioner, but the remainder can be written by virtually any other specialist—internist, surgeon, or obstetrician. (Some programs may specify certain departments from which the letters should originate, so make sure to check carefully ahead of time). Above all, pick references from physician who know you very well, particularly when it comes to your clinical abilities.
Selection committees also highly value the personal statement, second only to letters of recommendation. The essay should be very well-written, personal, and engaging. Appropriate topics include a description of your involvement in significant extracurricular activities or other relevant personal experiences, the reasons for choosing a career in family practice, and the specific aspects of a training program you are most seeking. A good personal statement allows the program director to have a good sense of your character, values, and goals. Overall, there is little specific preparation for a successful match in family practice, so enjoy your medical school years and make an effort to become a very well-rounded physician.
Over the past several years, there has been a steady decline in the number of applicants (particularly US seniors) to general surgery programs. Although you do not have to be the most elite medical student to enter this specialty, the competition still remains fierce for the most prestigious academic programs. Your academic credentials are most important. At some point during medical school, students should get involved with surgical research that could lead to a publication. If you want to be competitive for any program in the country, make it your personal goal to earn high clerkship grades (especially in the core surgery rotation— this is crucial!), election to AOA, and ranking in the top quarter of your class. Strive for Step I board scores well above the mean (>215). It is also very helpful to take the Step II examination early and score well—it reflects your application of clinical knowledge.
In your senior year, work hard during a month-long subinternship at your own institution. If you are interested in a particular program, sign up for a senior audition elective there (a maximum of two) and work hard to impress them on-site with a stellar performance. If you do, you will improve your credentials and look better than your fellow applicants, which could help you match. From all of your surgical experiences, choose three senior surgery attendings to ask for strong letters of recommendation. Ideally, they should be people who have worked directly with you and know you well, especially if they know your personal strengths in addition to your surgical skills. Letters from basic scientists or residents carry much less weight than those from the chairperson or program director at your medical school.
After applying, it can be helpful to use contacts to increase your chances of matching, so have your departmental chairperson make some phone calls on your behalf. Selection committees are looking for candidates with desire, work ethic, and the ability to get the job done. For this reason, some programs may be more open to review your complete record and overlook any academic deficiencies by valuing any other accomplishments, like volunteer and community work or other significant extracurricular activities.
Because there are hundreds of internal medicine programs, your chances of matching into this specialty are quite high. The stellar candidates all apply to the most prestigious hospitals; here, the competition is quite stiff. If aiming for these top-ranked academic programs, you need to strive for the strongest academic record possible. Earn high scores on the Step I boards and honors grades in your medicine rotations. Research is not essential, but can be helpful. Passion for nonmedical activities and interests is also important, so get involved in your community through leadership positions or other commitments.
In the senior year, audition rotations are unnecessary and sometimes risky. After all, simply getting stuck with a bad attending could ruin your chances of matching at that program. The selection committees read your letters of recommendation closely, so make sure to request references from physicians who know you well. For the most academic programs, it is imperative to obtain a recommendation letter from the departmental chairperson at your school. You should also submit two other letters from senior medical faculty (either third- or fourthyear rotation attendings).
Although the personal statement is less important, an excellent essay could clinch an interview for a borderline candidate, and a poorly written one could exclude a superior applicant. Successful residents in internal medicine recommend all candidates to be honest and enthusiastic throughout the entire process, complete their applications early, and notify their first choice program about their genuine interest.
This specialty is becoming more popular among medical students. During medical school, research experience in neurology (either clinical or basic science) is very helpful, though not required. Your extracurricular activities are less influential factors, but you should try to score well on the USMLE
Step I. In the clinical years, honors grades in neurology clerkships and subinternships are essential for matching at your top choice program. To prove your interest and commitment to neurology, get as much clinical experience as possible.
Away rotations are helpful in checking out any highly desired programs. When evaluating applicants, however, the three letters of recommendation carry the greatest weight among program directors. Two should be written by neurologists. The more renowned or senior the faculty member, the better. Addition ally, the letter writers may have personal contacts at hospitals where they completed their residency or fellowship, which could increase your chances of matching. But make sure that you have worked with them enough to elicit a good letter; a lukewarm one may actually hurt your application. Although the personal statement is less important, a poorly written essay—especially if filled with bad humor or philosophical diatribes—would undermine an otherwise stellar opinion of your candidacy.
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