Like most things in life, following exactly what some internet blog tells you may be a bad idea. However, I write this with the hope that some of this information may be helpful in tailoring your medical school experience and allow you to become an extremely desirable candidate for residency. Trends come and go but most of what I will say will hopefully stand the test of time.
I will first make some general statements and then break it down by year.
Residencies want students who will not be a liability to the program. This means that they will work hard to screen out "trouble makers". They don't want someone who will clash with patients, other residents, staff or attendings. You have to understand that training is an extremely stressful environment. If a student is difficult to work with right now, imagine what that person will become under tremendous amount of stress.
When we pick students for internship and residency, we first screen all candidates by reviewing USMLE scores, clerkship grades, personal statement, and extracurricular/research activity. We want to make sure you will not fail your residency because you cannot academically succeed within that specialty. If we think you can do this, we invite you for an interview.
Most directors do not have a formula that calculates whether a particular candidate fits some type of residency criteria. That is because this process is not an exact science. Every year, there are so many different candidates from all walks of life that it would be a disservice to have a “standardized” algorithm. They would lose many fantastic candidates with so much potential if they did. Most of the time, the departments get an overall feeling from the entire application whether a particular candidate is “good” for the program. I can’t emphasize enough that the personal statement does play a big role in many cases. Many directors I have spoken to argue that if you cannot convey yourself in writing well, they question whether or not you will be able to converse with patients effectively and write an appropriate medical note detailing the patients’ stories.
If you get past the initial screening, the critical component begins. Imagine we have 50 students with similar USMLE scores, research experience, and clerkship grades on a list. Everyone looks and sounds about the same on paper. Everyone seems “nice”. They know that the candidate can cut it academically. What's critical at this stage is whether at some point during residency, that person will get into a fight (I have seen fist fights), endanger patients with their incompetence, or conflict with other services. If we think that you are a decent human being who will be a good advocate for patients and become a team player, you will be ranked. We will go back to the committee, look at the interview scores and comments all of the faculty have given during the visit, look at all of your test scores and research, and decide how to rank you. Your personal statement will be used as tie breakers if there are any doubts or questions.
Year By Year Breakdown
There are ways to get through medical school without being labeled as a gunner or a complete a**hole.
Year 1
This is your study year. You need to learn or relearn the basic sciences. Learn your anatomy and learn it well. You WILL be pimped on this (pimping in medical school and residency is when your senior (resident or attending) quiz you in an impromptu fashion in an effort to “teach” you something... or just humiliate you, depending on who you meet). One who knows anatomy will be far superior to any other student or even resident.
The most critical aspect of your first year to me is the summer break. Some people take this time off to let off steam, relax or just do nothing. I think there is nothing wrong with that. However, most of my colleagues and friends used this time to get involved in research. Those looking to enter extremely competitive residencies (ie. dermatology) use this critical time to position themselves with a mentor in a field with the hope that they can publish something. Actually, some students looking toward ultra competitive fields or competitive residency programs ally themselves with a prolific mentor from day one of medical school.
Now the problem is, the majority of you will NOT know what specialty you want to go into. Therefore, it is difficult to predict which mentor would align with your passions. If you’re in that boat, my advice would be to pick a research project that has broad implications. I picked infectious disease and social policies regarding sexual assault victims as my research projects because these fields can be applied to most specialties. I had originally thought emergency medicine was my calling and that’s why I picked these two projects. I pivoted in 3rd year to Neurology but these were still relevant. Plus, these two experiences really helped me solidify my topics for personal statements.
Year 2
Study for your Step 1. No matter what people say, the residency directors will rank you initially according to your USMLE scores behind closed doors. Every specialty and each program has an unofficial minimum score they are looking for. You will never get an exact cutoff on this. Depending on how desperate (or not) they are in recruiting residents for the match, this score will fluctuate from year to year. But these scores are important so you need to start early.
My recommendation is to buy a Question bank early and slog through it. People put this off until 2-3 months before the exam but you should get started early because most qbank programs allow you to reset all the questions at least once. Therefore, you should plan on getting through it once, and reset a few months before the test to go over the questions. I think First Aid is helpful. Many swear by Goljan and USMLE World. I used all three.
Hopefully, you are still continuing the research project you started in your first year. Hopefully, you are staying sane. Prepare for your clinical year. Hone your “people skills”.
Year 3
Be enthusiastic.
Keep your head down and work hard.
Be an asset.
Do not be annoying
Do not be an a**hole to your fellow classmates
Do not screw over your fellow classmates
Do not make your intern or resident look bad in front of the attendings.
The Wards
Your primary role as a medical student is to learn. Your secondary role is to be helpful in everyway. Do not be a liability. Help your intern and residents. Make them look good.
I once had a med student make the intern on our service perpetually look really bad. In a poor attempt to impress the attending, he would make some snide comments about how “the person taking care of this patient did not realize this or that or observe something, et cetera” during rounds. The student never identified the intern by name but used what he probably considered “witty” ways of alerting us that the specific intern wasn’t doing everything he/she was supposed to accomplish in a given day. This behavior did not make him look smart. Rather, it just reinforced the idea that he was not a team player. Instead of helping the intern with these inadequacies, all he did was belittle him/her.
Little did this person know, that at the end of the rotation, the attending he wanted to impress did not remember this student at all. But as you can imagine, that intern and the senior resident remembered vividly. Guess who makes the recommendations for grades at the end of each rotation? In an attempt to “show off” during rounds, he pretty much lowered his chances of getting a great grade. I don’t know why students forget that interns and residents were med students once. They remember all of those classmates they hated. If you reflect a personality that they abhorred in the past, do you think they will think highly of you when you act this way?
I often get asked how students can excel in these clinical rotations. I think that 99% was attitude. I was never the smartest on the team but I was willing to do everything I could to learn. I was enthusiastic but I made sure my classmates didn’t look bad. If a resident asked me if I wanted to do “so and so”, my answer was always yes. Sure, I had do some scut stuff here and there but when the residents and interns found out I could be counted on, they gave me more and more responsibilities. I became an asset.
It’s crazy how some students (just because they are not interested in a particular specialty) just blow off the rotation and do the bare minimum. This is a bad idea. The medical field is a small world. Don’t burn bridges and don’t build a reputation that you are lazy. Plus, you NEED to learn these things. Make an effort!
Step 2 CK
While you are having fun on the wards, you need to start preparing for Step 2. Purchase some type of Question bank and go through each subspecialty section while you are rotating through said specialty. It’s a great way to pass the shelf exam as well as study for USMLE Step 2. Again, most qbanks allow you to reset at least one time so after you go through each section during your rotations, reset it before the test and go through it again. Pre-test, Case Files, Blueprint, etc all have strengths and weaknesses. Most people I know (who did really well) picked two study materials and a qbank. Don’t bother trying to read textbooks. You just won’t have the time. Get through the high yield stuff.
Step 2 CS
This is a tricky one to cover. I’m not going to get into the politics behind this but I will just say that for this test, you need to find someone to practice with. The scenarios that you will face are pretty straightforward. Within a few seconds, you will know what pathology you are tackling in each room. From what I gathered from my patients who volunteer for this test, there is a standard checklist they go through to see if you have covered the basics in terms of history. But that checklist is pretty much the same across the board. What I find helpful is to practice over and over again the standard questions you will be asking for all of your patients (ie. How old are you, what medical problems do you have, what makes the problem worse/better, etc) . The trick is to be able to get through these questions as efficiently as possible. This process has to sound natural or else the patients will dock some points. The patient volunteers have been trained to aid you, not hinder this process. So if you practice the standard list with a partner, you should have no problems.
Practice the physical exam on each other! Doing exams on the wards is different from the test. The test is standardized. On the wards, depending on the specialty, you were taught various non-standardized ways that are relevant to that field. You have to get through the physical exam fast. Time each other! Wash your hands before and after the exam! WASH YOUR HANDS!
Learn to type. Seriously, you need to type fast. As of this writing, this is what they allow you to write:
History - 950 characters or 15 lines
Physical Examination - 950 characters or 15 lines
Diagnosis - 100 characters for each diagnosis
History Findings and Physical Examination Findings - 100 characters for each field
Diagnostic Study/studies - 100 characters for each study recommendation
I asked most of my colleagues how much they wrote and it was pretty much a consensus that they used all of the character allotment.
Writing the dreaded personal statement(s).
Everything I have said in my tips for pre-med personal statement apply here. The only difference is that you are now focusing on why you want enter a particular specialty. Hopefully, if you followed my advice above, a combination of your research experience, experience volunteering in the past as well as your clinical rotation gave you enough experience to write a stellar paper about yourself.
Please do not write your resume in prose form. Do not recap what you wrote on your CV. I cannot believe how many students just re-list all of their accomplishments they spelled out on their CV in their personal statement and leave it at that. (All of my friends who are on the admission committee complain about this all the time). Weave a tale. Tell me about yourself. What makes you tick? What are your motivations? Why are you a passionate person? Why would I like you as a human being? How did you get to where you are at now? Who or what inspired and continue to inspire you? What aspects and experiences from your life keep you going during the stressful times?
Read short stories from famous authors. Read pieces from the new yorker or inspiring mini biographies from various sources online. Read over what you wrote in your application to medical school and expand on that.
Apply Early
Do not put off applying to programs. You have to do this early. Interview spots fill up FAST. With more and more medical students (domestic and international) every year in combination with pretty much a static number of residency spots, the competition is furious. You want to plan your travel early because many of these interviews may fall during the holiday season. Prices are expensive. Get a head start. I applied on the first day.
Year 4
Scheduling the interview
If you took my advice, you should have received all of your invitations early and have the advantage of picking the interview day of choice.
In my opinion, from the residency program’s perspective, the timing of the interview is not that important. There are plenty of candidates that interviewed very early or very late and was ranked at the top of the list. Some say that going early helps your chances because you are showing initiative and interest. Some say that going late allows the staff to remember you better during the ranking. A good candidate is a good candidate, regardless of when he/she interviews. I really think the timing is not that important to most programs. But do not put off making the interview appointment. As I have said, the spots fill up fast.
From the candidate's perspective, however, the timing may matter. Some people say your first few interviews should be programs that are not at the top of your rank list so you can get some practice. This may not be a bad idea if you get nervous during interviews. One or two under your belt may allow you to build confidence. Although I think using the actual interviews for practice is not economical or a good use of time, some people do this to prepare themselves. I think that practicing with a friend or colleague before the interviews is a better way. Also, interviewing late may not be great because the process is really tiring and expensive. Toward the end, many candidates get burnt out. You may not be so enthusiastic. So if you left your top choice until the very end, you may not be able to bring your so-called “A” game in late February. You may not be able to shows much enthusiasm. I would take these into consideration when planning for the season.
Rock that Interview (again).
It’s time for you to shine (again). You have everything that the residency committee wants (on paper). They are now going to figure out if you’re a good, decent human being who can work well in a team and flourish as a newly minted doctor in their program.
Relax. The interviewers want to get to know you. They want to know your motivations. They went through your personal statement and want to talk about some of the things you wrote. Expand on those points. Talk about things that are not on your CV. Tell them about your passions. Show them you are a good person.
I once had a student blow off the interview in an epic manner. It’s cringeworthy just thinking about it again. This person had his/her sights on only one particular program; the candidate wanted to match into the residency affiliated with her med school. This student had already interviewed there and was confident he/she was going to match. The interview with me was late in the season. During the entire interview process, he/she had a look of disdain, was apathetic, and was really pretentious. This irked many members of the committee as well as residents who interacted with the candidate. It was pretty clear that he/she wasn’t going to be ranked in our program. Personally, I think the candidate really didn’t care either way.
This is bad and unprofessional on multiple levels. First, if you’re going to blow off the interview, why are you there in the first place? It would have been easier to just cancel. Plus, because you had selfishly taken an interview spot, you deprived another candidate a chance. Second, the world of medicine is surprisingly small. It’s so small that most doctors are probably connected via 2-3 degrees of separation. Therefore, you are essentially setting yourself up for possible failure in the future. You may not like the residency program now, but who knows where you’ll end up. Perhaps you’ll need to interview for a fellowship position or a job. Perhaps the people you are interviewing with will move to your current hospital.
This candidate probably expected that we would not rank him/her. This person was right about that. But this person probably did not count on our chairman knowing all the people in his/her home program because he went through residency together. Because we were so perplexed by this person’s demeanor, the chair called up his friends at the candidate’s home program. Long story short, it did not end well for this person.
So the moral of the story is: be professional, cordial, and tells us your story!
Follow up
I think this is VERY important. This is more important than the timing of your interview. You should send a thank you card or email right after the interview. This is standard practice and courtesy. If you love a program, you should follow up with them in some way. Write another letter explaining why that program is number one. Be specific. Schedule a second look with the program and try to see if you can get a 5 minute meeting with the residency program director/chairman when you go back. Explain to them in person that you really would like to join that team. When I went for an interview at my top choice, the chairman was out of town that day. Therefore, I asked to do a second look and asked nicely if I can interview with the chairman since I missed him during the first visit. They accommodated me and I was able to have a really good talk with him. I matched into my first choice.
Take a vacation
After the match, you need to take a vacation. Get out of medicine for a bit. Travel. Do something other than medicine! You’re about to embark on an amazing but stressful journey. This will probably be the last time you have a carefree break. Take the time to reconnect with family and friends. Enjoy your life.
But don’t get arrested. This will not look good during the credentialing process.
This is a brief(?) overview of the medical school process. I hope some of this advice will be useful. Again, not everyone will be able to use all of the advice but I hope I have given you a small insight. I hope that all of you become successful, amazing doctors. I hope I can work with all of you in the future!
Good luck!
Posted by Han Lee, M.D.
Dr. Han Lee, M.D. is a neurologist and movement disorder specialist. He has trained at UCSF, Harbor-UCLA, UCLA and USC. After completing his neurology residency at Harbor-UCLA/UCLA, he has completed two fellowships in Neurophysiology and Movement Disorders. He is interested in Parkinson’s Disease and Deep Brain Stimulation research.
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