Meet Your Match: A realistic approach to applying with Deborah Spitz, MD

Making the Rounds

Meet Your Match | A realistic approach to applying with Deborah Spitz, MD

Jul 21, 2023

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As aspiring residents narrow options, how should one get a comprehensive view of the strength of their residency application? Deborah Spitz, MD, who directs residency training in the department of psychiatry and behavioral neuroscience at University of Chicago Medicine, offers her thoughts on a realistic approach to both choosing a specialty and which programs to apply to.

Speakers

• Deborah Spitz, MD, board-certified psychiatrist; vice chair for education and academic affairs and director of residency training, University of Chicago
• Brendan Murphy, senior news writer, American Medical Association

Host

• Todd Unger, chief experience officer, American Medical Association

Listen on the go to the full episode on Apple Podcasts, Spotify or anywhere podcasts are available.

"We looked at how people do in rotations, any problems they've had, any honors they've gotten, any accolades. We looked at if they've published anything, if they've done any research. We do take very seriously their leadership involvement. So I think medical knowledge is one of many data points that all programs use and some programs rest more heavily on that medical knowledge piece, but all programs are interested in other things as well."

Unger: That was Dr. Deborah Spitz, a board-certified psychiatrist and a vice chair for education and academic affairs and director of residency training at the University of Chicago.

In today’s episode, Dr. Spitz shares solid insights on how to realistically apply to residency, including how to plan the number of applications you should submit and how to effectively use signaling in ERAS®. Doctor Spitz shares all this and more with AMA senior news writer, Brendan Murphy. Here’s Brendan.

Murphy: Hello and welcome to Making the Rounds, a podcast by the American Medical Association. I'm Brendan Murphy, senior news writer at the AMA. Today we continue our Meet Your Match series with Dr. Deborah Spitz. Dr. Spitz is vice chair for education and academic affairs and director of residency training at the University of Chicago's Department of Psychiatry and Behavioral Neuroscience. Thank you so much for joining us today, Dr. Spitz.

Dr. Spitz: Thank you for having me.

Murphy: We're very glad to have you and we're very excited to continue our ongoing discussion about the residency application process. Today we're excited to gauge how residents can realistically apply and what that looks like from your perspective.

Dr. Spitz: Okay. I think I want to start by saying aim to do what you love. I've had a resident who recently came to me because she didn't match in surgery and her advisors had told her, why don't you go match in psychiatry? So she came to talk to me and when we talked it was clear that she had no interest in psychiatry. And I said to her, "Do you want to do psychiatry?" And she said, "Well, actually not really." And when she talked with more people, it became clear that she had not handled her applications as well as she might have and that she was going to be able to reapply in surgery and I think she has a very good chance of matching in surgery, which is a much better idea than applying in a field that you don't want.

Murphy: Well, that's a great baseline for our applicants, and I think that that applies to every stage of this―your passion is going to drive your career, right?

Dr. Spitz: I hope so.

Murphy: So I think a good place to start out is what would you define realistic applying as?

Dr. Spitz: Well, I think that nobody knows that as a medical student out of the gate. The way you figure that out is by talking to advisors in your medical school whose job it is to know about that. And also speaking with people who are in the residency that you're interested in, in your hospital if there is somebody like that. So for example, if you want to go into surgery you need to talk with the medical school advisors, but you also could probably benefit by speaking with a number of people in the department of surgery. Being very frank about how well you did in the rotations. What problems, if any, you might have had, what you really want to do, what do they think of you, what can they tell you about the kind of people who they've matched with and what can they tell you about other programs that might work well for you?

So there are a lot of things that people think about when they think about matching. They certainly think about what field they want to apply. And although there's some data recently that a lot more people than we realized are actually applying in two fields, which to me is very interesting. They think about what part of the country they want to live in. Maybe they don't care where they want to live or maybe they have some very particular preferences. They think about what kind of a program would feel right to them. Remember, wherever you go, you're going to be there for a couple of years or maybe seven or eight years, so it's going to be home. So don't go to someplace that you can't stand. Don't go to a rural program if you can't live in a rural area for a few years. Don't go to a big city if you're not a big city person.

Take some time to really ask yourself, aside from the qualities of the program that I want, where would I be happy living? And then within those areas, what kinds of programs are there because there are so many different kinds of programs. There are highly research-oriented programs, there are academic programs that are less research oriented. There are community hospitals; there are rural programs. You need to think about what kind of a physician you ultimately want to be and where will you get the kind of training that will help you do that. And I think there are so many programs that when you begin to think about that, you'll have many, many choices.

Murphy: So you touched on this a little, but when you're looking for that honest assessment of where you stand as an applicant, is it just talking to people in the specialty in the program? Are there other actions you would recommend taking for students?

Dr. Spitz: Well, there's no one way to make that assessment, and so I do think that talking to several people and being very transparent about how you've done in medical school is helpful because you may get different ideas. Schools are struggling with how to assess applicants and applicants are struggling with how to find the right place and it's not straightforward. I think if you're in a very competitive specialty and you haven't been at the top of your class, you need to think about applying to less competitive programs within that specialty and maybe having a backup plan of a different specialty to apply to. And I think that perhaps accounts for the number of people applying in more than one field. But again, I would recommend that the plan B, be a field that you could live with. You're not going to be happy if you end up in a part of medicine that is foreign to you and that you never wanted to be involved in.

But there are, in every specialty, highly competitive programs and less competitive programs, and I think it is important to find out from your mentors, not only how competitive are you, but what are the highly competitive programs, what are the middle programs and what are the safety schools or less competitive programs so that you can apply across the range of programs. It would be a mistake if you really want to get into orthopedics to only apply to the most competitive programs, even if you are a highly competitive applicant because we know there are so many applicants. So I think that one needs to be realistic about the field, how competitive is it.

We know for example, that last year emergency medicine didn't match in a lot of programs. And so if you're interested in emergency medicine, that's actually a good thing for you because it's less competitive now for some reason that we maybe don't understand. So we have some data and applicants will have some data when they see how many programs in their particular areas of interest filled, for example. But you can also find out how competitive a program is by speaking with people who work in that area.

Murphy: So, specialty competitiveness is generally defined by the percentage of spots that are filled, correct?

Dr. Spitz: Right, and in these days, most spots in most specialties are filled.

Murphy: How is program competitiveness defined?

Dr. Spitz: Well, probably, I know psychiatry the best because that's my area, and in psychiatry there are almost no unfilled programs. So every program fills, every program is competitive, but if you speak with a psychiatrist who knows the lay of the land, you'll find out that there are a number of programs―and usually they're the big city academic programs―that are thought to be highly competitive and they get many, many applications. And there are other programs in smaller cities, maybe places that are less well known that are less competitive, where you would have a better chance. So sometimes you can find out, for example, what the board scores were in different programs. Sometimes you can't and that's disappearing as the Step scores disappear.

But I think that your advisors can tell you within a specialty what some of the more competitive programs are and what some of the less competitive programs are. And also another good source of information is the students who graduated a year ago. So in your medical school, is there somebody who went into the field that you want to go into? Talk to them, find out where they applied, find out what they thought about the programs, find out whether they liked them. Maybe you have an idea that you want to go to a program and they interviewed there and they thought it was really unappealing. That would be useful to know. So you can find out a lot from people who are in the programs themselves and from your peers who graduated a year before you.

Murphy: And what's the best way to measure your competitiveness both within individual programs and within the larger specialty?

Dr. Spitz: I think that that's the $64,000 question. I think that's really hard. There are programs that look predominantly at scores and by scores or numbers, I mean Step 2 scores, how many honors did you have, have how many high passes, what does your medical student dean's letter say about you in all of the different rotations that you were in?

There are other attempts that some specialties are making to try to operationalize a kind of numerical grading system. For example, some specialties are using the SLOE, which is a standardized letter of evaluation in the hopes that that will get away from the many letters that just say, “This guy is great; I really like him; you should take him.” Because training directors don't know what to do with those letters. The letters are all laudatory so how can we make those letters more usable to indicate something more than you're a nice person and we like you.

So in internal medicine, for example, the standardized letter of evaluation asks the rater to place the student in the top, the middle or the bottom third of all students that they have rated. In emergency medicine, they ask whether the entrustable professional activities, or EPAs, are partially filled or fully filled. Can this student really do X or Y or Z or can they do it only in part?

Another way of approaching that is OB, where they've used the standardized letter and they've asked the rater to say, this student is functioning in these areas at the level of a third-year medical student or at the level of a fourth-year medical student or maybe at the level of an intern or maybe at the level of a PG-2 resident.

So these are all attempts to find ways to differentiate among students when we don't have Step 1 scores or we don't have Step 1 scores for everybody. And I think actually there are better ways because Step 1 scores only measured how much knowledge you had and your ability to perform on a test. Asking about can you perform certain EPAs, certain entrustable professional activities, is of much greater relevance to most residency training directors. We want to know what is a student capable of doing, not only how much knowledge they have in their head.

Murphy: The vast majority of students were probably excited about Step 1 moving to that pass fail grading. But it does present this conundrum that you touched on and even for students to understand their standing, that numerical score was an asset in this one arena. How can they understand their standing better without it?

Dr. Spitz: Well, I think it's important to realize that it was only one data point, and there's been a lot of discussion recently about doing holistic review of applications. And I can tell you that like in psychiatry, we've always done holistic review. In my program, your Step 1 score was never important unless you failed it three times. Then we worried about you because we thought this is a person who has some difficulty with test taking. We didn't even see the failures as a measure of a lack of knowledge. We thought there's a test-taking skill here that's problematic. In psychiatry we certainly look at the kind of leadership the person has exhibited in the community among their peers. Have they run an organization, have they volunteered? And of course, ERAS gives you a chance to tell all of those stories. But please, ideally, don't tell about every volunteer activity you did for three hours.

What we really are looking for is a sustained commitment to leadership, to volunteering, to a job. What have you done that you've really invested a lot in that you can talk about? So I think that Step 1 is one data point. So is being the head of SNMA or organizing a charity or working for years with kids with autism. Those are all data points, and I think that for people in many fields, Step 1 was only one small data point although for students it was reassuring to have that. But I guess I want to say that we are looking for other data points about medical knowledge. We looked at how people do in rotations, any problems they've had, any honors they've gotten, any accolades. We looked at if they've published anything, if they've done any research. We do take very seriously their leadership involvement. So I think medical knowledge is one of many data points that all programs use and some programs rest more heavily on that medical knowledge piece, but all programs are interested in other things as well.

Murphy: So Step 1, possibly being non-numerical for at least some of the applicants going forward, it'll be most of the applicants, everyone is going to have a Step 2 score. If I have a middle-of-the-road Step 2 score relative to my peers, does that mean I'm a middle-of-the-road applicant? How should that shape the way I apply?

Dr. Spitz: Let's just say you have a middle-of-the-road score. I don't know that that translates into being a middle-of-the-road applicant. It depends very much on the field. Some fields will, and some programs will think as long as you're not really just barely clearing the bar, we’re okay. Other programs will focus on a particular number or a particular level of achievement. But again, I would say a Step 2 score is only one data point. There's also your performance in medical school in the preclinical years. Now increasingly medical students are getting pass fail grades and that further compounds this issue because it means there's less data.

So if your school has gone to pass fail, you have a middle-of-the-road Step 2 score. Maybe that will be a problem in some of the most competitive fields like orthopedics or dermatology. I don't know. I think you should try, but maybe you want to have a backup. It would never be a problem in psychiatry. There will be many other things that we're looking for. The score on Step 2 when it's high, that's nice, but that's not the most important thing in a holistic assessment of a trainee. We're looking for ability to engage with others. We're looking for how somebody performs on an interview, can they talk easily with other people? We're looking for how ... we're looking for evidence of leadership in college and in medical school. We're looking at other things the person is interested in doing and so are many fields. I think the middle-of-the-range score on Step 2 in and of itself won't keep you out of many fields.

Murphy: And it certainly won't keep you from being a front-of-the-line, top-of-the-line doctor. We always like to point that out.

Dr. Spitz: Oh, absolutely. I mean, that's the important thing that people need to remember, that these scores don't predict who's going to become a great doctor. They might predict who's going to get into the most competitive school or residency program, but that has nothing even to do with are you going to be a great resident? And that's the other thing to think about. What does it mean to be a great resident? In different programs it means different things. If you're a person who really is not interested in being a researcher, then maybe you don't want to go to the most research-oriented academic program. On the other hand if research is a passion of yours, absolutely you want to go there. So you have to think about who you are and what you want to be. If you want to be a community physician, then you should go to a place that will train you to do that very well.

Murphy: So we like to give advice on this podcast series and one piece of advice is what not to do. So I'd ask you, what would an unrealistic approach to applying to residency programs look like?

Dr. Spitz: Okay, well here, I think we actually know some information through the signaling data. So first of all, common sense. If you're going to apply to 15 or 20 or 30 programs, apply to a third of them that might be challenging for you to get in, apply to a third that are quite realistic based on what you know and apply to a third that are easy. That gives you a cushion. That means even if for some fluky reason you don't get into a reach program and you don't even get into a middle program, there'll be a cushion where you'll get into a program in your field that was less competitive.

So one of the things that we've learned in the data from obstetrics and gynecology around signals is that most students use their signals in reach programs. That doesn't make sense. Maybe use one of your signals for a reach program; use most of your signals for programs that you have a realistic chance of getting an interview in.

Because what we know in most fields is if you have “X” number of applications, you'll get “Y” number of interviews, and if you get “Y” number of interviews, you'll probably get in. So the data from OB for example, is if you apply to 18 programs that are realistic, not 18 reach programs, but 18 programs with a few reaches and some cushions and places in the middle, you'll probably get 12 interviews and that will probably be enough for you to match. We know that. Now we know that, and people are still applying to 60 programs, but it's unnecessary based on the data.

That data is probably equally true for psychiatry, more or less. If you apply to let's say 20 programs, you'll get 12 interviews, and that's probably enough to match, but only if they're realistic programs, not if you apply to the 20 most competitive programs in the country, that would be foolish.

So we have some very interesting data from orthopedics, which as you know is extremely competitive. And they say that if you signal ... first of all, they use 30 signals in orthopedics and what we know is that like in psychiatry, we have only five signals. And I don't think that is a good idea because that means that a small number of programs―the highly competitive programs―get a lot of signals and some programs get almost none. But in orthopedics with 30 signals, everybody got a bunch of signals. The most competitive programs got more signals, but the less competitive programs got 17% of the signals. So everybody got some, so that's a good thing. If you signal you have a four to five times chance of getting an interview in orthopedics when compared to the signaling times when you just applied. So the signals, now we know in orthopedics people might apply to 80 programs, but they only have 30 signals. Those are powerful things. So if you signal and either you have no geographic preference or you have a geographic preference that syncs with the program, you have a pretty good chance of getting an interview.

Murphy: And when we are talking about signaling, we're talking about a feature on the application that allows applicants to express explicit interest in a given number of programs. This year that'll be available in 22 specialties. So the vast majority of applicants will have the opportunity to use that, and it really does make sense to make it a targeted approach.

Dr. Spitz: Right. I don't see how it can hurt you. It can only help you, but it can help you most if you use those signals with realistic and not reach programs. If you have five signals and you really want to reach somewhere, reach one place, but use the rest of the signals in a realistic way.

Murphy: You mentioned orthopedic surgery. In 2022, the average number of programs U.S. graduates applied to in that specialty was 90.

Dr. Spitz: I know, but it's interesting. The signaling has worked a little bit like an application cap, because if it improves your chances of getting an interview, then the schools that you signal are going to take you more seriously.

Murphy: So would you recommend applying to less than 90 programs then?

Dr. Spitz: Well, I don't want to stick my neck out with orthopedics. Actually it seems from their data that signaling reduced the number of applications by 12%. That's not as much as they would've liked to reduce them by, but they were happy that it happened. I don't know what to say in orthopedics because people are very interested. It's a very popular field. It's hard to say that it's really necessary to apply to 90 programs, but I understand people's anxiety.

So I think we're in a place where it's hard to make firm recommendations about what to do, about how many programs to apply for. But I would say use signals, use them thoughtfully, not too many reach programs, use them for the middle programs and a couple, maybe even a couple of the easier programs if you have that many signals. In psychiatry where we only have five signals, I would say probably one reach program and four middle programs, and that's how many training directors are going to begin to look at who to invite. They're going to look at who signaled them.

Now, if somebody signals me and their geographic preference is someplace else, I'm not going to know how to understand that. So I recommend that if you have a geographical preference, you signal within that area. Otherwise, if you have no geographical preference, you won't be hurt by signaling anywhere. But if you have a geographical preference in the west, don't signal in the east because that will make the programs confused.

Murphy: And when you say geographical preference, that's an actual field on many applications that applicants are allowed to but not required to fill in?

Dr. Spitz: That is correct. That is correct. So when you go into ERAS, you can indicate a geographical preference, but you don't have to and you shouldn't if you don't care.

Murphy: So if you are very competitive on paper, that could include Step 2 and Step 1 scores. It could include outstanding clerkship grades. Should you still apply to the average number of programs?

Dr. Spitz: If it's possible to get realistic advice about what the number of programs you need to apply to in order to match, I would follow that. So that's not the average number of applications. So for example, orthopedics would argue if the average number of applications is 90, you really probably don't need to apply to 90 in order to match. But I don't know what number they would suggest.

In OB, they have some data which is if you apply to 20 programs and you get 12 interviews, you will likely match. That's pretty true in psychiatry too, but I know that there are people in psychiatry that apply to 50 programs. So how to understand that? First of all, maybe they're applying to a lot of reach programs. I'm not sure that's worth their while. Secondly, maybe they're afraid, but the data suggests that if you are realistic about the 20 programs that you choose, you don't need to apply to 50 programs.

Murphy: This concept of safety schools, it originates in undergrad. We often hear about safety schools for undergraduate applicants. Is it prudent for an applicant to consider a safety specialty if you're applying to one that is considered highly competitive? Why or why not?

Dr. Spitz: So first of all, I do think that more people are considering a safety specialty, and I think that accounts for the larger number of people who are applying in two specialties. And I guess that's prudent if you're applying to a very, very competitive specialty. In terms of a less competitive specialty, I still think it's important to have a group of safety schools. I suggest that people apply to a few reach programs, a larger bunch of middle programs and a couple safety programs at the bottom. Why not?

Murphy: And again, as we talked about with Step 1, just because you match at a safety program does not mean you're not going to become an excellent physician, and it does not mean that that's not going to be an excellent fit for you.

Dr. Spitz: Well, that's a very important thing for people to think about because some very highly prestigious, highly competitive programs are not very comfortable places to be. And that goes back to what we were talking about at the very beginning. You're going to spend several years of your life in a program. So when people interview, they really need to pay attention to the residents they speak with and what those residents say. Does it feel good to be in this program? Do they feel that they're getting the attention that they need? Do they feel that they're getting teaching? Do they feel that the teachers care about them? Those are all things that matter whatever field you go into. If you go to a very high-pressure program and the residents are not happy, I would pay attention to that because that tells you something about what it's going to be like for you to be there. You want to go to a place that will be intellectually stimulating, that will help you become the kind of doctor that you want, but also where people treat you respectfully, where they support you, where they create a learning environment that you can really function in.

Murphy: This has been so wonderful. Is there anything else you'd like to add on this residency application topic?

Dr. Spitz: Well, I started out by saying do what you love. I really think that's important. The other thing that we didn't discuss but is relevant for some applicants is that in the current political climate, not all residencies are able to offer training in all areas. And this is particularly true in OB. So I think that people applying in OB-GYN need to be mindful of the fact that in large groups of states, they're not going to be able to get comprehensive training, and their programs in those states are going to be sending them to other states to get training in providing abortion, for example. So this is the harsh political reality that nobody ever had to think about. And it doesn't only affect OB, it affects psychiatry because we see those people who come into the emergency room and they want an abortion, and are we going to be allowed to say anything about that? Not in some hospitals in Texas. So trainees need to be mindful that politics, which they may or may not pay a lot of attention to, have now entered into residency training in a way that was never true before and the house of medicine does not know how to respond adequately. So that's yet another issue that muddies our waters here.

Murphy: All food for thought. You are very insightful. Thank you so much for joining us today, Dr. Spitz.

Dr. Spitz: You're very welcome.

Murphy: Thank you all for listening. I am AMA senior news writer Brendan Murphy. This has been Making the Rounds.

Unger: Don’t miss an episode of this special series as you prepare to apply to residency. Subscribe to Making the Rounds on your favorite podcast platform or visit ama-assn.org/podcasts. Thanks for listening.