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Residency Programs: An Inside Look

This online resource guide is a work in process and, as such, our Minority Affairs Section (MAS) colleagues continue to provide materials and add their particular insight.   Following below is a look inside some the the residency programs that you might be considering.   Obviously, this is not an inclusive list, however, we will continue to add information on other specialties as our colleagues volunteer it.   We welcome your contributions.   If you would like to contribute to this piece, send us an e-mail and we will review your topic for possible inclusion.

Anesthesiology

Written by William A. McDade, MD, PhD, Department of Anethesiology and Critical Care, The University of Chicago, Associate Dean of Multicultural Affairs, The Pritzker School of Medicine

Qualities of Anesthesiologists
Candidates who tend to do best in anesthesiology are those who have an affinity for more technical and manually oriented activities. Those who particularly enjoyed anatomy, pharmacology, physiology, biochemistry, biomedical engineering, biostatistics and basic science research are going to find anesthesiology particularly fascinating. While there is a great deal of cognition required of an anesthesiologist, the true passion of the clinician is the ability to perform special skills to a high level. Anesthesiologists are expert in the management of airway and circulatory problems in critically ill patients. They are adept in pharmacology, drug delivery systems, use of blood products, and techniques of regional and central neuraxial blockade. Because decision-making is of the utmost importance, anesthesiologists must be astute clinicians and logical scientists. Anesthesiology is a hypothesis driven field where there is a blend of application of specific knowledge, exercise of clinical judgment and performance of a myriad of technical skills. Further, because time is frequently of the essence in the operating room setting, these decisions are often make quickly, wherein each intervention serves as the instrument to test the next hypothesis.

Frequently, and incorrectly, anesthesiologists are thought of as having only to use pharmacotherapy to allay a patient’s anxiety. However, few anesthesiologists rely on drugs to achieve this end; rather, the competent anesthesiologist is able to use excellent interpersonal skills to inform the patient and ease anxiety. The anesthesiologist typically does not have patients who are soley in their care. Rather, anesthesiology is a consultation practice exercised in the association with a surgeon and/or an internist. Therefore, as a consultant, the anesthesiologist has to be able to communicate with a variety of colleagues as well. Those who seek variety are definitely fulfilled with a career in anesthesiology for it is truly at the intersection of all medical disciplines. Because any patient can have a surgical problem, clinical anesthesiology may involve neonatology, pediatrics, adult medicine, obstetrics, radiology and, of course, surgery. Knowledge in all these areas, as they relate to anesthesiology, is required by the consultant anesthesiologist.

For the individual who wants more of the traditional patient-doctor setting, there is the possibility of a career spawned from anesthesiology in intensive care medicine or pain management. These certified fellowship programs follow initial training in anesthesiology and offer the ability to have a career in which patients look to you as their doctor. Still, you are not the primary care physician for the patient and therefore act in a consultation capacity. However, you have a longer interaction with a given patient and you form a more lasting bond between the patient and their familes. In critical care, continuous relationships with patients throughout a finite critical illness are formed. There are still many procedures to perform and rapid assessment, diagnosis and therapy implementation are vital. In pain management, there are likewise many technical procedures to perform, but the assessment can be less acute and the relationship between the patient and you can be quite long-lasting throughout the duration of a patient’s painful condition.

Medical School Exposure to Anesthesiology
It is uncommon for medical school students to interact with anesthesiologists during the preclinical years. If you identify one early in the medical school curriculum it is most likely in the context of pharmacology, physiology or in research. In addition, many medical schools do not have a required third year rotation in anesthesiology, so as a student, you may not get the opportunity to learn about what anesthesiologists do during your third year unless you venture to the head of the OR table during your surgery rotation and ask questions. Not every medical school even offers academic electives in anesthesiology in the third or fourth years; whereas, a select few mandate an anesthesiology rotation as a clinical requirement. This variability exists because of the way in which anesthesiology has developed as a field.

There was surgery long before there was anesthesiology. When it was invented late in the nineteenth century, surgery without pain was seen as the single greatest contribution to humanity of all time. However, because the emphasis was on the drugs used to cause analgesia, amnesia, autonomic control and surgical immobility and the use of these drugs seemingly could be provided to patients without a great deal of apparent effort, less skilled individuals were enlisted to hold the ether mask. It soon became clear that some skill was necessary, but anesthesia could be delivered by individuals who were less significant in the role of patient care than the surgeons. This impression, fueled by ignorance of the science underlying anesthesiology, led to the slow development of the field and its relative subjugation by surgical departments. The path to forging anesthesiology as a rigorous academic discipline with equality to peer departments within the hospital and medical school has been hard fought. However, due to the nature of this less highly regarded position in medical society, anesthesiology became a land of opportunity for the disenfranchised in medicine.

Surgery is still a mostly white, male dominated field of practice within medicine. The common perception of a surgeon is a strong, demigod, who works inhuman hours and who stands ready with intelligence, skill, and scalpel, ready to tackle the next big case. Women were not easily accepted into their ranks, nor were minorities or the less highly regarded. These individuals could not be the operating room principal in twentieth century America. However, they could work for the surgeon, and administer the gases used to cause anesthesia. That was seen as a minor role, subordinate to the surgery itself, and American society accepted these individuals into the operating rooms so long as the captain was the white, male surgeon. The legacy of this discrimination is a persistent relative overpopulation of women and minorities in anesthesiology. This is a credit to anesthesiology as it is now populated by a great diversity of individuals and it typically one of the most diverse staffs within most medical schools and hospitals. This may provide for a more comfortable environment for the minority candidate and represents a continuing opportunity for fellowship and collegiality.

The Road to Anesthesiology Residency
If you are thinking about anesthesiology residency, then it is good to do a rotation in it. Look for opportunities to take an elective rotation in it during your surgery rotation in third year. You will appreciate the integration of basic and clinical sciences, the hours spent in patient care, the excitement of learning invasive techniques, and the sense of problem solving pace and technique. If you like this, schedule an early fourth year month-long elective in anesthesiology. In the fourth year, you will have the ability to see the various subspecialty areas within anesthesiology and you will then develop an idea of the breadth of the field. You will also have the opportunity to have worked with a number of anesthesiologists as mentors, role models and advisors. Certainly ask them questions but allow them to get to know you too. Choose one as your principal advisor and then a few more of whom you will use as additional supporters. Make sure you have worked with these people and that they know you to be a hard-working, intelligent and motivated candidate fro residency.

Think about the type of practice in which you would feel most comfortable when you finish training. Is it academic or private, high volume bread & butter cases or low volume challenging cases with critically ill patients?This will help you to decide the level of rigor of the department to which you will want to apply. Some programs are high volume, others are slower. There is good and bad in each. High volume programs give you great exposure to clinical examples, but the high volume makes reading harder to squeeze in and the days longer. Low volume is also good because it allows more time to read and to be taught by the excellent staff in the department you choose. Some departments place heavy emphasis on didactic opportunities and have multiple learning conferences during the week. Others have only one conference per week and an approach to patient care that encourages less supervised and more clinical independence. You have to determine your learning style and which program will be best suited for you.

Anesthesiology has undergone a large swing in desirability among residency candidates in recent years. There was a move favoring it in the late 1980’s fueled by high income associated with the reimbursement rates paid to physicians who billed based on the number of procedures they performed. Anesthesiologists were near the very top of all physician earners at that time. In the early 1990’s there was the institution of the Resource Based Relative Value Scale that was designed to financially reward cognitive activities of physicians to increase fairness in compensation and to reduce health costs at the expense of more procedurally oriented physician reimbursement. Anesthesiologists, being in this latter group saw their real income reduced by Medicare, Medicaid and insurers by a nearly one third decrement. This caused some dynamic changes within the residency training community. Because practicing anesthesiologists were not retiring as rapidly due to the decreased compensation, newly trained anesthesiologists were not being hired when they completed residency. If they were, the track to partnership within a group was greatly prolonged and there were reports of extreme predatory practices. Once again, the less highly regarded and foreign medical school residency applicant looked to anesthesiology for an opportunity, as other areas of medical study remained closed to them. The number of American medical school graduates choosing anesthesiology reached it nadir in 1995, but has been steadily increasing ever since then. In 2002, anesthesiology residency competition is a keen as it has ever been for American graduates and so new elements in selection are being tested each year.

Only a few years ago, residency selection committees did not consider board scores in determining whether to interview an anesthesiology American graduate. Now, a board score above 200 is necessary to be interviewed at select programs. Candidates who have not yet passed the USMLE Step 1 are not even considered by many programs. A few years ago, residency programs paid for the travel expenses and hotel accommodation of interviewing candidates who were American medical school graduates. Today, some programs debate whether to pay for parking. So, times are changing in anesthesiology selectivity and successful candidates will have to adjust accordingly.

Once you choose an advisor, then you must determine where you want to train. This may be based on the institutional/departmental reputation or mission; the population served by the institution; the opportunity to do challenging cases of a certain type at the institution; the character of the department chairman; the teaching interest and ability of the faculty; the ability to place its graduates in excellent fellowship programs; geographical and familial considerations; the volume and variety of cases; the nature and amount of didactic programming; and, collegiality among the residents and the espirit de corps.

You should go online to obtain information about any program you are considering and consider applying widely. Because anesthesiology is a Post Graduate Year-2 specialty field, a separate internship (Preliminary Year) must be obtained. This can be done in conjunction with the residency in anesthesiology or apart from it. Typically, an anesthesiology program has a relationship with the internal medicine department in the hospital that grants them a limited number of PGY-1 positions for their trainees who need just one year prior to their first year of anesthesiology (Clinical Anesthesia Year-1, or CA-1). So, a given anesthesiology training program might have three year and four year positions. The 3-yr positions are for those candidates who obtain their own internship independently of the anesthesiology program. The 4-yr (Categorical) positions are for those candidates who allow the anesthesiology program to schedule them for the internship at the same institution. In general, because it is less of a hassle to move and to worry about applying to multiple programs in different disciplines and obtaining letters for each, most people would opt for the categorical 4-yr program. Therefore they are more competitive, and are often offered to lure the top candidates to a particular institution.

When you have gone to the online listing of programs and seen the selections of departments and availability of 3- and 4-yr programs, meet with your advisors to discuss your choices. Include in your selection of programs only those that you would really want to attend if matched there. Because of the way the match works, you may not get your first choice and you are still obligated to go to where ever you match; so, do not rank a program unless you really want to go there. Put an assortment of programs in you mix including the very best, a few strong programs and then a couple of safety schools. Safety schools are programs in your home state, or of lesser reputation that will ensure that you will have a job on match day. Ask your advisors whether they are able to write strongly supportive letters of recommendations for you. If they hesitate, do not consider them further for a letter and withdraw your offer. You want anesthesiologists who are well-known in the field to recommend you. However, if you do not have that option, then select individuals who know you well and think highly of you. By having an academic anesthesiologist as your advisor, they are typically linked into the community of university anesthesiologists or the national societies of anesthesiology and are known to the community of scholars in the field. This carries weight in program selection committees. However, surgeons and internists who know you well and are supportive to you are also potential letter-writers.

Once your list of advisor-endorsed programs is complete, get your application completed. ERAS has made the application process much easier. Some residency programs may also have an additional supplemental application. You should check with each program administrator to determine this. You should have your personal statement complete by the end of August. It should be read by at least one of your advisors and discussed with you prior to your sending it out. Your ERAS application should contain all of your community service work and the fact that you are a member of the Student National Medical Association or other ethnic medical association. On ERAS, there is no field to indicate your race and so some programs use the excuse that the data are colorblind to limit the offers of interviews to non-minority students. Your indication of participation in well-established minority organizations clarifies this for many program directors and allows them to identify a candidate who could potentially improve their diversity. There should be no attempt to mask your race or ethnicity because it is rarely used against you in selection. Your letter writers should be confirmed by September. It may be necessary to check with busy faculty to ensure they have completed your letters. Minority faculty are especially busy and generally younger with multiple responsibilities, so be kind yet persistent in your reminders to complete your letters in a timely fashion. From October through December national meetings of the major medical organizations are held and faculty use these opportunities to visit with old colleagues and talk about their residency programs. This is how your advisors often learn about what is going on in programs around the country. You are often mentioned in these conversations, one program director to another, or an advisor to residency review committee member, or faculty to faculty in conversation. Information is shared and impressions are shorn up following your visit. Therefore, try to arrange an early interview so that you can be meaningfully discussed. The same conversations by telephone take place among program directors, but the face to face chat is really powerful in helping you make it to the best programs. If you have done research in medical school, you might also seek to participate in one of these national meetings and then you personally get the opportunity to meet the individuals with whom you will soon be interviewing. It makes an enormous difference in your favor if the first time you meet someone from the program you desire to attend, it is at a national meeting and you are presenting your data. When you appear for the interview, it will be as if you are speaking to a friend.

Most anesthesiology residencies will invite you to interview on a certain day of the week. If you plan to interview at multiple anesthesiology residencies in the same city or on the same coast, they have often cooperated to hold interviews on days convenient to the candidate to allow one pass per city. For instance, one may interview only on Mondays, another only on Tuesdays and another only on Wednesdays to allow the candidate to fly there just once and cover all the programs on one trip to reduce travel expenses. Take advantage of this and hold off scheduling an interview with one program until you hear from other programs in the same region. While on the interview trail, ask as many questions as you may have and always have a few prepared questions based on your online investigations and conversations with your advisors. Keep a record of the information you obtain at your visit so that you can refer to it later when match lists are being prepared. Most interviews in anesthesiology are low-pressure affairs. Make sure that you get e-mail addresses for key people you meet during the interview day. You may have further questions later or you may want something clarified once you leave. Getting someone’s number from the program also suggests that you are interested in that program, and the program’s belief that you are interested in them helps you tremendously. If you have the chance to speak candidly to residents only, ask them the questions that you really want to know. How is the learning environment?Do you see enough cases of this or that?How do the residents do on the In-Service (Pre-board) Examination and the American Board of Anesthesiologists Certification Exam?Do you feel the chairman really cares about you as the resident?Is there mentorship and support for your ideas?Could I stay on there as faculty?Do the residents really get along this well all the time?The questions about call schedule, vacation time, financial compensation and fairness can be asked, but try not to get caught up in these details. Frankly, one does not choose a program based on any of these factors that are all about the same from program to program anyway. By dwelling on these items in particular, it suggests that you may be far more interested in the lifestyle of the field than in learning as much as you can and being member of the departmental team. This is an immediate turn off for most programs.

On the day of your interview, be there on time, no excuses. Your attire for your interview should be business professional. You are applying for a job in which you are a consultant anesthesiologist. Therefore, you must look the part. Even if you chose anesthesiology because it’s the only job you can go to every day as a professional and never have to own a tie, borrow one for your interview day. Be cordial to everyone, including secretaries and janitorial staff. Everyone has input. Make friends among your colleagues there are the interview. You may want to keep in contact with some of them as well. As a minority candidate, you may not see many other minorities in a given program; and so, by teaming up with another minority student who is interviewing in places similar to you, and therefore has as good a chance of matching there as you do, you increase your chances of not being the only minority resident in your class. If you have the opportunity to meet with minority residents already in the program on your interview day, ask them some of the more difficult questions about race or ethnicity and the community, patient population and program. Do minority residents graduate at the same rate of other residents?What is the demographics of the patient population with respect to minority patients?Is the community in which I plan to live hostile to minority individuals?How many minority faculty and residents are represented in the program?You still need to use caution in “being real” with minority residents and faculty. They typically still give a report on your interaction with them and you want to be perceived and being excellent, so use discretion; but get your questions answered.

Faculty, chairmen or program directors may say many things to you during the interview process. Remember the goals of the program:They want a full residency class to come to work July 1st; they want candidates who help them fulfill their service requirements, academic mission and legacy; they want to be seen as being desirable and selective; they want to be viewed as being honest and inviting; and, they want their residents to graduate without incident. In your interview, do not give the selection committee cause to believe that any of these goals will not be met after having interviewed you. The program, in turn, will sometimes suggest to you that you are a highly desirable candidate in hopes of getting you to commit to them. Because the basis of the National Residency Matching Program’s software strategy is such that everyone gets their highest, first available choice, a lot of baiting between candidates and programs is really unnecessary; yet it persists. Simply put, do not believe it when a person at an institution tells you that you are at the very top of the program’s list, even if you are a superior student. It is illegal, by NRMP rules, for them to tell you or to make an offer, and they are doing it in the hopes that you will rank them more highly because of their expressed interest in you. In turn, another ploy is for them to call you subsequent to your visit and to ask you where you ranked them. Your response should always be cordial and above reproach and should be that you respectfully decline to give exact details because it against the NRMP guidelines, however, you really enjoyed the program and would find it hard to believe that anyone could not see how wonderful it was.

After your interview, always send a thank you note by either snail mail or e-mail to thank your interviewers, program director and chairman. If the chief resident or other residents were especially helpful to you, thank them too. Do not be obsequious, but if you enjoyed yourself and see a place for your career development there, let them know it and why you would be a good fit for them. On ranklist submission meeting day, all your comments have been kept and are brought out for discussion for final rankings in that department. Having shown continued interest is as good as great USMLE scores.

Match Day and Beyond
Interviewing for residency often is useful when you apply for fellowships later, because people know you and they remember. So, if you can afford it, go on all your interviews and meet the program directors. If you had to decline an interview, do so graciously and cordially. Well, that’s it. On Match Day, enjoy yourself because you are about to embark on a wonderful adventure in residency: The last step in a long journey.

The Dermatology Residency

Written by David Nieves, MD, Resident, Department of Dermatology, University of Rochester School of Medicine and Dentistry

Dermatology is among the most difficult specialties in which to match. Dermatologists practice medicine and surgery on patients of all ages. In many cases, dermatologists need only to look at a lesion to arrive at a diagnosis. Dermatologists can immediately assess a skin lesion’s response to therapy and modify a treatment regimen accordingly. Primarily an outpatient specialty, dermatology enables its practitioners to enjoy a less demanding workload than physicians in many other fields.

Academics
Interest in a career in dermatology is strong, yet the number of training positions is limited to approximately 270 positions nationwide. Although it is difficult to know precisely how many applicants fail to match in dermatology, it is estimated that as many as 33% or more may be unsuccessful. Because competition is keen, successful applicants must prepare for their desired career well in advance.

When considering a career in dermatology, applicants must realistically assess whether their academic credentials to date would place them at a disadvantage. At many programs, the majority of persons selected to be interviewed are AOA and have USMLE Step I scores of 230 or higher. While there are no absolute cutoffs and there will always be special cases, applicants who are not in the top half of their class or who have USMLE Step I scores that are below the national average are at very high risk of not matching.

The Dermatology clerkship
Although the third year is generally reserved for “core” clerkships, it is highly recommended that potential applicants confirm their interest in the field early by doing the dermatology elective during the third year. This can often be done by scheduling a clerkship such as psychiatry for the fourth year. Try to do the dermatology rotation in the late winter or spring -- if it is done too early, lack of clinical experience may cause a negative impression to be made on residents and faculty (remember that most students take dermatology as a fourth-year elective).

At the end of the rotation, approach a faculty member with whom you had the best rapport and ask to meet to discuss your interest in dermatology as a career. You should be prepared to explain the reason for your interest in the field just as when applying to medical school you had to explain your interest in a career as a physician. In the meeting, ask the faculty member for his/her advice on the application process.

Research
During your meeting with your faculty advisor, ask about research opportunities in the department – not just laboratory research but also clinical projects as well. Doing research enables you to demonstrate the ability to contribute to the advancement of the field. It also enables you to build a close relationship with a faculty member who will then likely go to bat for you with a strong letter of recommendation. When selecting a research project, factors to consider include:

Do you have time to do a reasonable job on the project?

If it’s a lab project, do you have sufficient background in laboratory techniques to be efficient? If not, are there technicians or grad students in the lab who can help you along?

Does the project make a meaningful contribution to the understanding and treatment of skin disease?

Will you enjoy what you’re working on?

Will you enjoy working with the person directing your work?

Is the faculty member directing your work well respected in the field, so that a letter from this person catches the attention of an application review committee?

If the project is based in a laboratory, plan to set aside the summer months between third and fourth year to work on the project full-time. If it’s a clinical one – such as writing a case report or review article – it may be possible to work on it during other clerkships. Regardless of what you do, it is recommended that you have some result in place by the time you send out your application.

Recommendations
Aside from academic excellence, strong letters of recommendation are essential. Academic dermatology is a very small field, and an applicant who is recommended by a senior faculty member who is well-liked by members of an application committee will stand out of the crowd more so than one who is recommended by an unknown junior faculty member. Of course, a letter from a junior faculty member who likes you and knows you well is much more desirable than one from a giant in the field who writes a few terse sentences that just rehashes your CV.

It would also be a good idea to do a sub-internship in medicine before applying, and to include a strong letter of recommendation from the attending you worked with. In many cases, a sub-internship is the only rotation in which the student is an essential part of a team with real responsibility. A letter stating that your were prepared, responsible, and dependable when it really counted says a lot about your potential to be a good resident.

Grand Rounds
Start going to Grand Rounds whenever possible. This demonstrates your solid commitment to the field to the faculty in your school’s own department.

Internship
In the past, dermatology was a late match in which the application season took place during the summer/fall of internship. Dermatology program directors judged applicants not only on the caliber of their performance in medical school, but also on the prestige of the internship that they secured.

Today, dermatology is part of the standard match, and so no one knows where you will wind up for internship. Nevertheless, program directors will often ask you where you have been interviewed, and will be favorably impressed to hear that well-regarded academic programs are considering you, generally in internal medicine. Most program directors encourage the internship to be in internal medicine, though in the end if you match into a transitional program there is little they can do to prevent it.

Incidentally, applicants interested in a career in pediatric dermatology should consider doing an internship in pediatrics. While there are few if any one-year-only positions offered in pediatrics, this can often be possible by special arrangements, such as working out an arrangement at your medical school or by applying to pediatric categorical programs but explicitly stating in the personal statement that you only want a one-year position. In the very near future, a special track 5-year will be available leading to board certification in pediatric dermatology (JAMA, April 25, 2001, p. 2065).

Applications
There are roughly 100 residency programs in the United States, most of which receive over 250 applications for only 1-3 spots. As a general rule of thumb, the total number of interviews granted by a program tends to be 15 per opening (i.e., a program with 2 spots might interview 30 people). You should apply to a large number of programs, and set a goal of securing 10 interviews.

Interviewing
Dermatology operates on a slightly later schedule than other fields, and invitations to be interviewed are not sent until mid-December. Before interviewing at a program, make sure to thoroughly read the application brochure and check to see if a web site exists. Dress conservatively. Also, if you have any personal cosmetic problems – acne, significant unwanted facial hair, etc – consider getting this corrected well in advance of interviewing season. Dermatology is a field that is focused on appearance, and it is important to look good for interviews.

The questions asked most commonly are:
Why do you want to be a dermatologist?

What makes you interested in this program specifically?

Tell me about your research?

Do you have any questions about our program?

How do you like working with so-and-so (a well-known professor at your school)

In addition, many programs sponsor informal activities with residents to provide an “inside guide” into what it’s really like to be at a program. It’s a good idea to attend these events to learn the things that the faculty won’t tell you – things that may ultimately influence your rank list. Also, after the interview date, sometimes faculty may informally ask residents about their impressions of the applicants.

The rank list
Follow your heart!

Have a backup plan in case you don’t match in dermatology. If you interviewed for high-quality preliminary programs in medicine, you can rank them at the end of your primary list after derm programs. Medicine programs are flexible enough that at many places, someone can match as a prelim and be allowed to stay on as a categorical resident (assuming, of course, that they perform well during internship). However, the downside to this is that if you in fact match into a prelim program, then this is still considered a “match” and you will NOT be eligible to participate in the Scramble (or even know of your eligibility for it). Of course, there rarely are Scramble positions available in dermatology anyway, so you’re probably not missing out on much.

If you don’t match…
There are essentially three options at this point:

1. Do an internship. Re-apply either during internship or while doing research the following year.

2. Do a year of research and reapply during that year.

3. Give up on dermatology and select a different career.

Choosing between 1 and 2 is tricky. On the one hand, doing a year of research gives you additional opportunities to enhance your CV, whereas reapplying during internship doesn’t give you much of a chance to improve your application. On the other hand, occasionally derm spots open up with short notice, and can only be filled by someone who has already done an internship. Getting that out of the way puts you in the running for these positions, because you would be able to start working at a moment’s notice. Of course, finding out about these openings can often be tricky – they may be publicized by word of mouth, a mass mailing to department chairmen, or an announcement at a national meeting. It’s important to have a strong advocate in dermatology circles who will keep an eye out for these for you.

Universities that offer formal research fellowships in dermatology include UCSF, Harvard, UT Galveston, and Mount Sinai School of Medicine.

Emergency Medicine

Written by Jocelyn Freeman Garrick, MD, Assistant Professor, Department of Emergency Medicine Kings County Medical Center

Emergency Medicine is a relatively new field. The American Board of Emergency Medicine was first recognized as a specialty board just 22 years ago. Despite its novelty, Emergency Medicine (EM) has become popular as a specialty and thus competitive. Emergency Medicine allows one to be a “jack of all trades” while giving the freedom of a flexible schedule and healthy lifestyle. As with most specialties, being prepared and having a mentor in your field is key to a successful match.

A few items should be highlighted prior to creating a timetable for successful matching:

Three (3) year versus Four (4) year residencies. As you begin to make your list of residencies in which you may be interested, you will notice that some are three-year programs and some are four-year. Are there advantages and/or disadvantages to each? Most people who want a career in academic EM will choose to do a four-year program. This does not mean that you will be isolated from a career in academics if you attend a three-year program. The elective time in four-year programs tend to be more spread out and gives one more opportunity to work on interests and research. Three-year programs are packed with a lot of ER time and less electives. However, residency is completed sooner. Approximately 2/3 of the nation’s EM residencies are three-year and the remaining 1/3 are four-year.

Academic versus Community Emergency Medicine. Prior to applying to an EM program, one should have an idea of what type of setting in which to practice. Academics requires one to work in the Emergency Department, perform research and administrative duties, lecture and supervising residents and medical students. Most academic positions are at large teaching hospitals with EM residencies. Community positions offer clinical responsibility and a more flexible schedule. Administrative tasks are usually present. Community EM also offers opportunities to travel via locum tenens. Teaching opportunities may still be present.

Choosing a Residency Program. There are over one hundred emergency medicine programs recognized nationally by the Residency Review Committee. If you plan well and are realistic in your goals, you should be happy with your program selection. Selecting a program should not be limited to the reputation of the program and quality of training. The dynamics of the city where the hospital is located, cost of living, patient population, and quality of life outside the hospital should be considered.

Research. Many students ask whether they should do research and if it is required to match in a competitive program. It is not required but it can only help. Most EM departments have ongoing research projects and love to have eager medical students help with data collection, chart review and study design. While conducting research with an emergency physician, you will have the opportunity to work with an attending one-on-one and form a relationship. In a few months you may be able to ask that attending for a letter of recommendation.

Memberships. Join the Medical Student section of the Emergency Medicine Residents Association. This should be done early in the third year. Besides getting a handbook, which is useful for the application process, the monthly literature you receive will keep you abreast of issues in the specialty. There is also a national conference where most residency programs will be recruiting.

Timetable

1st and 2nd year.
Study hard! Make good grades and pass the boards. Participate in research and extra-curricular activities.

May-July of Third/Fourth Year.
Obtain an advisor in the Emergency Department (ED). If your medical school does not have an Emergency Medicine Department or Residency then seek one at a neighboring school or hospital. This is not the time to be shy. Go to a neighboring hospital and find out where their ER physicians trained. Ask one of them if they would be willing to mentor you during this process or if they can recommend someone. If you have a neighboring medical school with an ED, arrange to visit for a day. Speak to the Chairman of the department, the Director and the Residency Director. Explain that your school doesn’t have a department and you need an advisor. ER physicians tend to be team oriented and willing to lend an extra hand.

Create your list of residencies for which to apply. The list should be based on the type of environment in which you want to be (urban, community or rural), the career you have set forth (academic or community), your personality, and your family structure. What if you like a program but its location will limit opportunities for your spouse or significant other? In addition, you should consider the diversity of the program, patient population and city. For example, if you’re considering a program that’s in New York City but you hate the snow, the program shouldn’t be on your list.

When your list is complete, contact the programs to obtain an application (most now are electronic) and program material. Narrow your list and work on the materials needed for your application- the Curriculum Vitae, personal statement, transcripts, Dean’s Letter, letters of recommendation and photos. The personal statement and CV should be reviewed by at least four (4) people including your advisor.

Consider Doing an Outside Elective You may be at a medical school that requires ER as an elective or at a school with a strong EM residency and choose to do an elective at your teaching institution. However, some students may not have this opportunity and/or may want to experience how another institution operates. Doing an outside elective may be beneficial. It allows you to meet and work with ER-trained physicians, to meet other students going through the process and hopefully you can form good relationships with the attendings during your elective and obtain letters of recommendation. Before the elective, become familiar with the administrative heads (Chair, Director, Residency Director). Network during the elective and arrange your schedule so you may work with key individuals within the Department. Come early, stay late, be a willing worker, participate in and attend lectures. This is your time to shine and make an outstanding impression.

August-September of Fourth Year
Final revisions of your CV and personal statement should be completed and your letters of recommendation should be obtained. At least two letters should be from well known or highly regarded Emergency physicians.

Apply early -- I cannot stress this statement enough or in any other way. Apply early!

Early applications get first choice for interview dates. Some competitive programs fill all their interview dates and applications received later in the process may not receive interviews (even if the application is strong).

October- December of Fourth Year
Arrange Interviews. Most programs begin interviewing in late October and proceed through early February. Some people have a strategy to interviewing and believe you shouldn’t interview very early or very late. I will suggest that you NOT interview on the last interview day. The Directors are burned out and tired and may not even recognize your star quality. November through January are safe months. Try to arrange electives during this time. For interview day, I have two points to make, which may seem obvious to most but are missed by many:

1) Remain warm and friendly during the day. Act interested and ask questions. Interview days can be long and exhausting especially if you traveled a distance the night before. Plan ahead, get adequate rest so you can arrive early and be prepared. I can’t say that enough.

2) Stay the entire day. If the program offers you a tour and you don’t want to go, you don’t want to go to the program. Participate willingly in all activities.

Take notes. You’re not only being interviewed, you should be interviewing the program as well. (It is important to take notes because after six or seven interviews, you can mix up the programs). If you’re not comfortable writing things down during the day, sit down as soon as you leave the program and write everything you remember. Ask questions. Create a list of standard questions to ask the residents and a separate list of questions for the attendings. Create a rank list with pertinent questions for each program. (See Exhibit III. )

Spending Time in the ER Consider spending a few hours after your interview in the evening or the night before in the ER. It gives you the opportunity to interact with the staff, to see how responsibilities are divided and get to know some potential interviewers. Most tours are held at 10 or 11 AM when the ER is clean and relatively under control. It can be the complete opposite a few hours later. Always send thank you letters and get the correct spelling of your interviewer’s name. Remember, express real interest in the program of your choice with frequent notes, telephone calls, visits and e-mail.

February of Fourth Year
You’ve successfully matched in Emergency Medicine. Congratulations!

Obstetrics and Gynecology

Written by Joanne Quinones, MD, Resident, Department of Obstetrics and Gynecology, Hosptial of the University of Pennsylvania

Why Obstetrics & Gynecology?
If you are interested in an exciting, fast-paced field, caring for patients at the office and the OR, Ob Gyn is the field for you. The one thing that I think all medical students should realize is that most of your residency you will be operating. Sure, primary care is emphasized in our training but you still need to like the OR and should not mind the hours too much. You should enjoy both surgery and office level care. After residency training, you can choose to subspecialize in Maternal Fetal Medicine, Reproductive Endocrinology and Infertility, Gynecologic Oncology or Pelvic Reconstruction/Urogynecology.

Where to apply?
Ob Gyn programs are available in both academic centers and community hospitals. Academic programs are affiliated with major hospitals and offer the opportunity to work closely with individuals renowned in the field. These programs tend to be competitive and sought after by students interested in a future career in academics. From a community program you can also pursue a career in academics, but it might take some extra work to get acquainted with mentors who are academically active in the field. When applying to programs, get a feel for what the general atmosphere is, and ask the residents about their career goals and the research.

What should I know

  • Remember that Obstetrics and Gynecology is a competitive match. Programs take into consideration not only the grades from the clinical years but also your Step I score, your involvement in research, and any memberships to societies such as Phi Beta Kappa and Alpha Omega Alpha (AOA). During medical school you should aim for honors in medicine, surgery and Ob Gyn rotations. You should demonstrate not only a strong knowledge base but also an interest in performing procedures. Be pro-active during your rotations, helping the residents during call and during office hours.
  • Find an advisor within the department. This individual could be the chairman of the department but it could also be someone you worked very close with during your core clerkship. It should be someone you feel comfortable with. He or she should guide you in what you need to do in order to achieve matching at your place of interest. Finding an advisor early in the process is important in order to ensure taking action in anything that you need to work on (grades, CV, essay, interview skills, etc).
  • Apply to subspecialty electives within Ob Gyn (Maternal Fetal Medicine, Reproductive Endocrinology and Infertility or Gynecologic Oncology). It is extremely helpful to participate in these advanced electives (one or two at most). Your participation demonstrates commitment and enthusiasm to the Ob Gyn faculty at your school. The electives can also help you figure out if the field is really for you. I recommend applying for an elective at the hospital in which you wish to match. Some people consider this to be a “double edge sword” since people can really get to see if you are a good match for them (potentially affecting your chances if you happen to not perform as well). But I feel that this offers an opportunity to figure out what life outside of your medical school is like. I ended up doing that and it was an outstanding experience.
  • Don’t forget that you will be working pretty hard for the next four years. With this in mind, keep an open mind when interviewing. Talk to the residents about their experiences and get a sense of whether they like the program. Sure, they will be at times tired and overworked, but overall, you should be able to get an idea of whether the individuals enjoy their work. Enthusiasm is hard to fake, so make sure you talk to different residents about their time at that particular hospital.

When do I apply?

Spring:
Find an advisor and work on your fourth year schedule. Your goal should be to participate in one or two electives within the field. These experiences will not only give you the opportunity to shine but also should help you figure out whether the field is right for you.

Summer:
-Meet with your advisor to review your potential list of programs. Many times advisors know individuals in the other programs and may even know the “inside scoop” giving you yet another perspective on a potential program.

-Decide which faculty members will write your letters of recommendation (both within ObGyn and within other departments). Let faculty members know ahead of time since many of them are extremely busy with other responsibilities

-Start working on a personal statement – your advisor should review and comment on your essay. Work on the essay until you are completely satisfied.

-Start working on your Curriculum Vitae – again have your advisor review it.

-Request applications from programs (you need to do this in order to receive each program’s packet).

Have your personal statement and CV ready by the end of the summer.

Early Fall:
-Complete and submit application through ERAS.

-Await emails and/or phone call from programs inviting you for interviews

Winter:
-Schedule interviews. This process may take up to two months. I strongly encourage to interview at the sites were you are really interested in matching. The process is expensive (travel by car, plane or train; hotel; meals; car rental; suit; shoes; bag…) so make smart financial decisions when deciding where to apply and thus interview.

-Prepare preliminary rank list and discuss with your advisor if you so desire.

February:
Submit match list to NRMP.

March:
Match Day!

In conclusion, keep an open mind during your application and interview process. Ask many questions during the process and ask for advice from attendings and residents. There’s a lot to learn from people who have been through the process once already.

1 Duff P. Development of a guidebook for senior students applying for residency training in Obstetrics and Gynecology. Obstetrics & Gynecology 1995; 86: 140-143.

Pediatrics

Written by Malaka Jackson, MD, Resident, Department of Pediatrics, Children's Hospital of Philadelphia

Considering Pediatrics?
Pediatrics is not just “medicine for kids,” rather it is a broad field in medicine that encompasses the complete care of individuals from the pre-verbal, neonatal period through growth and development into late adolescence. As a future pediatrician, you will have the opportunity to care for and manage many aspects of health care for well, ill and medically complex children. You will also be charged with promoting healthy and safe development of your patients through preventative care and anticipatory guidance. You will have the opportunity to be an advocate in the local community in which you practice and/or in the policy-making areas of local, state and federal government promoting health care laws that directly affect the pediatric population. Finally, by deciding to be a pediatrician, you have selected a career in which you can choose to be a primary care physician, a subspecialist, a hospitalist, a principle research investigator or a full-time pediatric advocate.

 Applying in Pediatrics…

Following the timeline as outlined in the “Medicine” section by Jeff Gonzalez, MD (above) is also appropriate when applying to any of the 200+ pediatric residency programs in the country. Early application is most advantageous when applying to top programs or if you are restricted geographically, but applying early is recommended for all applicants. When reviewing program information prior to and during your interviews, you may want to consider the following:

1)What proportion of time is spent in both general pediatric and subspecialty training?

2)Does the program have separate primary care and general application pools (This can become important in two scenarios. First, if you know that you want to be a primary care pediatrician, then you can forward your application to the program designed to offer more training hours in general pediatrics. Second, this separation can be beneficial if you are really interested in a particular program that offers both “tracks” because many programs will permit you to apply for a position in each, thus increasing your chances of acceptance into the program. )?

3)How much time is designated for primary care/continuity clinic (Many programs schedule one half day/week, but this can vary)?

4)Is there an opportunity to participate in off-site and abroad rotations?

5)Is research available and/or encouraged during residency training?

6)How much elective time is there throughout the residency training and when can it be scheduled(i.e., as a PGY-1 vs. PGY-2, etc. )?

7)Does the residency program offer any formal teaching/exposure to healthcare policy and management systems?

8)What role does advocacy play in resident education/training experience?

9)What teaching techniques are in place to enhance resident education – hands-on training, lectures, journal clubs?

10)Are residents directly involved in medical student education?

Want more information?
Further detailed information regarding Pediatrics can be found on The American Academy of Pediatrics (AAP) Web site.

In addition, the AMA’s FREIDA Web site lists pediatric programs which you can use to guide your search in residency selection.

Psychiatry

Written by Mariana Mendez-Tadel, MD, Resident, Department of Psychiatry, Hospital of the University of Pennsylvania

Psychiatry is a field of medicine that combines the practice of psychodynamic therapy with a
medical and psychopharmacological approach to behavioral health. Psychiatrists can enjoy a career that includes long term patient care, many practice and subspecialty options, a good lifestyle and reasonable work hours. Even though there have been concerns over the limitations put on treatment coverage by many insurance plans, recent public awareness about the need for better mental health treatment in this country is likely to positively influence the practice of psychiatry.

Recent changes:
Though psychiatry was not a very competitive residency in the 90's, recent changes show an increased interest in this field by medical students. For instance, the 2001 match saw the highest fill rate in 5 years, and it is likely that the trend will continue. Not only does there seem to be more interest for a career in psychiatry, but with the adoption of the ERAS application system by most residency programs, the number of applicants per program has significantly increased. However, it is still very unlikely that a good candidate would not be able to match in psychiatry.

Core clerkship and electives:
If you are interested in the field, early on, try to obtain as broad an exposure as possible during your core clerkship, by choosing your rotation site carefully. Work hard, do well on the written
examinations and get a feel for the specialty. Also, because such a large part of Psychiatry is outpatient work, it is a good idea to at least try to arrange for some exposure if it is not part of your core rotation (for example by spending a few afternoons in the resident's outpatient clinic). For electives, try to choose at least one where you will get to have significant participation and responsibility over your patients, so you can show you are a good doctor and diagnostician. Naturally, if you are interested in a particular subspecialty, try to do an elective in that area. A good performance in a medical, pediatric, neurological or other non-psychiatry sub-internship will be expected in any good residency program.

Advice and Advisors:
As with any other area of interest, it is essential to develop a good relationship with a resident or an attending who can help you define your career goals. Their advise will be invaluable in choosing residency programs, recommending electives and giving you a feel for what you should look at when the time comes to rank programs. It is also important to get to know your local psychiatry department. Whether you want to remain at the same institution for residency or you want to go elsewhere, the head of the department, the program director or a well regarded attending can be a great ally.

Letters of recommendation:
In general it is a good idea to achieve some balance in terms of who writes your letters. It is often said that a letter by a well-known professor who does not know you well is not helpful. This is partially true, but relationships and peer recognition are major forces in academia. It is probably best to do a rotation with the well-known professor and ask for a letter, but also get one or two from junior attendings who know you and can give detailed opinions about your
work. Balance is also most important in that you should not get letters only from your psychiatry attendings, but also those from medicine, neurology, or pediatrics, particularly if you are considering fellowships in areas that are related (such as child psychiatry, consult and liaison etc). In fact, many programs will require one non-psychiatry letter.

Choosing a program:
Most residencies nowadays are four years in length. Internship is now integrated into the categorical psychiatry program and includes a minimum of 4 months of medicine or emergency medicine, 2 months of neurology and various other combinations of rotations. The majority include at least a few months of inpatient psychiatry. However most programs will still allow candidates who have already done an internship in another specialty or a transitional or preliminary year to join the residency program as second years. Second year is usually entirely devoted to inpatient rotations. The third and fourth years are mostly spent in the outpatient setting. Some programs will allow residents to graduate in the third year as long as they continue a fellowship immediately afterwards. Also there are a few combined programs in Psychiatry and Medicine, Pediatrics, Neurology or Family Medicine- (not many, but can find them listed in FRIEDA).

A few things to keep in mind when choosing where to apply are: career plans, intended sub-specialty, location and naturally, any family or personal obligations. When it comes to career plans, consider whether you want an academic career. If this is the case, you should definitely apply to major academic centers where the research opportunities will be plentiful. Some programs have dedicated research track spots or residency-into-fellowship research opportunities. Naturally, this must be taken into consideration if you already know you are interested in a sub-specialty.

Location and personal interests should concern you also-fortunately, because you will have a reasonable amount of time to enjoy them, particularly after 2nd year. One last bit of practical advise about this matter: find out what the opportunities are for moonlighting and when can you start taking advantage of them. This can make an enormous difference in pay (and again remember that most psychiatry residents are likely to have enough free time to afford a few nights a month of paid call).

Interviewing for psychiatry residency should be an enjoyable process because (for reasons mentioned earlier) even the most prestigious programs want to make a good impression and secure the best candidates, and they will go to great lengths to make the experience a nice one for them. Most psychiatrists are nice, and agreeable people- big bells should ring if you
find that the residents seem unhappy, or the attendings are distant or disagreeable.

A final note on training as a minority psychiatrist:
As a minority physician you can bring a different perspective into the practice of a specialty of medicine which is, more than any other, dependent on an understanding of the patient as an individual with social and cultural as well as physical heredity and circumstances. When choosing where you will be spending the next four years, do not undervalue the importance of diversity in your education as a resident.

Surgery

Written by Patricia Turner, MD, Resident, Department of Surgery, Howard University Hospital and Vikisha Fripp, MD, Resident, Department of Surgery, Howard University Hospital

Once you decide on making Surgery your way of life, the process of obtaining a residency position assumes highest importance. The preparatory phase can be very involved and intense; however, keep in mind that every surgeon has successfully maneuvered through it before you. The timeline for gathering letters of recommendation, finalizing your CV, and putting ERAS together is the same for most specialties. . . the early bird catches the worm.

End of 3rd Year and 4th Year

Spring/Summer
Senior surgery elective in the area of surgery you want to specialize in (i.e., Plastics, Vascular, ENT),

Choose an advisor. Someone who is honest, available, supportive and most importantly knowledgeable in the area of your specialty.

Consider a SICU elective to familiarize yourself with surgical management of burns, trauma and critically ill patients.

Like every specialty letters of recommendation are important. Be selective about who writes your letter, keeping in mind the person who knows you best will write the best letter. A letter from your chairman is a MUST. Make an appointment to meet with your chairman… have your CV and personal statement with you.

Early Fall (August, September)
Obtain information from FREIDA (i.e., addresses, contact names and phone numbers) regarding programs.

Make a list of what you are looking for in a program. Match these criteria with what each program is offering and get a defined list.

Finalize CV and personal statement for completion of ERAS.  

Check your ERAS information to make sure that all materials are present and factual.   Remember Dean's Letters don't go out until November 1st.

Send off ERAS to the list of schools you have gathered from FREIDA. ERAS costs, so send to schools you truly have an interest in interviewing with. There is no specific number; however, most agree that at least 10-15 are a safe number.

As mentioned before, send Thank You letters to all persons who wrote you letters of recommendation. . . whether you used them or not.

Late Fall (October, November
Interviewing (late November through early February)

The interview process is by far the most stressful portion of this process. The major areas of focus are WHEN to interview, HOW MANY programs to interview with, WHAT TO WEAR to the interview, and WHAT QUESTIONS to expect. All these questions have different answers depending on whom you talk with. Therefore, I strongly recommend that you speak with your advisor, talk with those who have interviewed before you at the institution and review frequently asked question in the ‘First Aid for the Match’ and all other published materials.

The interview months are designated late November through early February. Most people reserve December or January off from clerkship to interview. December interview season is truncated because of the holidays, so January may be the best month. Also, keep weather in mind when in interviewing in the northern states; you may want to interview early in these states.

There is no perfect number. I suggest interviewing with at least 5-10 schools. Toward the 10th or so interview fatigue becomes a factor, therefore, I recommend interviewing at your top schools somewhere in the middle of the list. This allows you to become familiar with the process before you have to put your best foot forward.

What to wear?
The conservative black or dark blue suit is ideal. Females can wear pant suits; however, the conservative two-piece skirt/jacket combination is favored. Males should not wear distracting ties; this is not the forum to exhibit your personality.

What questions to expect?
Every program asks their own special questions and has at least one hard-nosed interviewer. Stay calm, focused and remember they asked you to interview with them. Be ready to ask questions about the program. Look over the brochure provided to get information about the program; this prevents asking questions that have already clearly been answered.

Deciding
Many factors go into choosing the best residency position for you. As mentioned before location, length of program, family, institutional climate, placement, research and other requirements of the program are very important and each has to be weighed. I recommend establishing a scoring system for each and using this calculation to rank your residency programs.

If geographically restricted then it is imperative that you apply to as many programs in the area as possible. Secondly, it becomes important that you inform each program of your interest to stay in that area only. Have a PLAN B AREA that is close to your selected city.

Most surgery programs are 5-years, many are not; however, many factors can lengthen the total time. Make sure there are no hidden pathways or obligatory research paths. Also ask about each program’s commitment to finishing the same number of interns they accept as chief/5th year residents (Pyramidal program).

Family
Those students with families have more aspects to consider. Area schools and communities have to investigated and visited before any final decision is made.

Institutional Climate
This topic may be one of the most important areas to consider. Speak with the residents at every level and ascertain how they honestly feel about their fellow residents, the program, the Chairman and the Program Director. Is the program stable? Are they expecting a change in the Chairman, Vice-Chairman or Program Director position?

What is the program known for?

Have they matched any residents in the area you want to specialize in?

Research and Other Requirements
Research can be a very sensitive topic. Again, I suggest that you speak to multiple people before making any decisions. Research is important if you are pursuing the tougher fellowships (i.e., Oncology, Transplant, Vascular, Cardiothoracic) and academic surgery. However, research may not be as important for fellowships such as Plastics, and Critical Care. I can not overestimate the importance of doing well on the ABSITE, mastering your surgical skill and being well thought of by both your peers and your professors. Though research lengthens the total time in residency, it allows for a break from the grind of residency. The research lifestyle is not as stressful and most residents moonlight at area hospitals. Research areas have recently been expanded to include pursuits of MBA, MSPH and Ph.D. degrees.