While DO applicants are matching at a similar rate to MDs, there are a few intricacies to the process osteopathic medical students should keep top of mind. Isaac Kirstein, DO, internist and dean at the Ohio University Heritage College of Osteopathic Medicine Cleveland is our guest on this episode.
- Isaac Kirstein, DO, FACOI, internist and dean, Ohio University Heritage College of Osteopathic Medicine Cleveland
- Brendan Murphy, senior news writer, American Medical Association
- Todd Unger, chief experience officer, American Medical Association
Dr. Kirstein: What is your story and what really sets you apart? As you're in an interview and you're trying to make a more competitive application and highlighting the things, what is the memorable thing about you? Who are you in that story? And I think part of that, as a DO applicant, that's part of our story.
Unger: That was Dr. Isaac Kirstein, dean at the Ohio University Heritage College of Osteopathic Medicine Cleveland. On this episode of Making the Rounds, Dr. Kirstein shares his insights on applying to residency programs as a DO med student. Here’s AMA senior news writer, Brendan Murphy.
Murphy: Hello and welcome to Making the Rounds. I'm Brendan Murphy, senior news writer at the AMA. Today I'm talking with Isaac Kirstein, DO, dean at the Ohio University Heritage College of Osteopathic Medicine Cleveland. Welcome, Dr. Kirstein. How are you today?
Dr. Kirstein: I'm doing great. Thanks for having me here.
Murphy: We are very excited to have you. Today we are going to discuss the intricacies of applying to residency programs as an osteopathic student. We are a few years, almost a half-decade, into this combined Match now and it's gone pretty seamless. The DO match rate and MD match rate are essentially the same at this point. Is there any reason for DOs to approach the Match differently than their MD counterparts?
Dr. Kirstein: Yeah. Thanks for asking. We're really proud actually of how well we've done in the Match and it's gotten better and better each year and each year has been a new record breaker for placing our students across the country. When we counsel our students, we do have to let them know though that as good as the aggregate numbers are, and we keep saying the Match rates are the same in both, there's still a lot of differences between the two, especially when we look at specific programs and specific specialties where there still is a difference. So, a lot of our advice that we give really has to be geared towards the students' goals and what they're trying to achieve and where they're trying to achieve it.
Murphy: You yourself are an internist. Looking at the data, DOs gravitate toward the primary care specialties. In 2022, DOs filled about a quarter of the spots in emergency medicine and family medicine for instance. Why is that and do you see that trend continuing?
Dr. Kirstein: I do see that trend continuing and it's part of our heritage. Our osteopathic history is rooted in that primary care base of taking care of the whole patient. So, our students who come to us who are interested in a holistic care, tend to gravitate towards more of the holistic specialties, which is why primary care is so well subscribed. That being said, you can bring this philosophy to any specialty and our graduates do. One of the things that really impacts why we still have such a high level of primary care placement is that our training nationally is done in community-based education centers. Most of the osteopathic programs are not in large academic health centers in big urban areas. We do community-based care type training all over the country and actually have a lot of our programs also in underserved areas, both rural and urban.
So the students who train in these places also gravitate towards taking care of these kinds of patients, these kinds of communities, and we reinforce that desire and passion to serve in primary care. And so, we're happy to continue to have that track record for sure. At the Heritage College, we're also proud to say, "Look, if we put a psychiatrist in the middle of an urban area or an underserved area, we're meeting our mission as well." So, we emphasize primary care as a profession, but we also do a great job making sure that we can place all specialties especially for the communities that need them.
Murphy: So, looking at all specialties and all settings, if you have a student come to you and they say, "I want to practice maybe plastic surgery," you mentioned psychiatry, at a large academic medical center, how do you counsel them to go about that process? There might not be as many DOs in those programs certainly.
Dr. Kirstein: Absolutely. No, absolutely. And it does take a specific counseling and we should say that a lot of these specialties still have a large discrepancy. Even when you realize that one out four students are osteopathic, we're not getting one out of four of them into plastic surgery. So there still is a bias and there still is an overall statistical difference between a lot of these surgical subspecialties. That being said, we are placing them in these programs, albeit at a lower rate. We hope to get them higher. So they need to be very competitive and competitive in the same way that their allopathic medical student colleagues are competitive to really focus, especially on research in those areas and to work closely with a lot of academic programs that we can let them rotate through audition rotations and research projects, and they really have to shine.
So, they have to do very well on licensing exams, unfortunately. It's still a required metric for the decision of getting into a residency. So that is our recommendation for those specialties is that students really have to tell a story, no matter what specialty you go into, but to be competitive in those specialties, they have to do what their MD colleagues are doing and they have to do a little bit more of it, if they don't come from a program where that department is just three floors up.
Murphy: You mentioned that there is still a bias in some programs, some specialties. How might that manifest during the residency selection process and how do you counsel students to navigate it?
Dr. Kirstein: That's a great question. So, the way we do is we have a lot of data, not program-specific data, but on specialty levels, we have all of our students really review the NRMP reports that come out every other year about all of the placement data for each specialty. So, they understand the kind of scores that were the average for all DOs and MDs who got into those programs and how many research projects they had and how many interviews they took and all of that stuff. But we also counsel them, besides that big data set, we say, "Look, you got to talk to the program, if you auditioned there, you know. You can ask them directly, "How many DO students have they taken in the past, have successfully matched? What are their views on it?" One of the biggest areas of bias is on licensing exams.
If they only are going to accept or they mandate USMLE, even for the DO students, which many of them still do. So that's an added burden that DO students have to do and we counsel them absolutely. For those specialties, we wish they didn't have to take both, but we still counsel them that, especially if a program they want to get into is requiring it, obviously they have to do it. And so, that's the biggest thing is what's their track record of taking DOs in the past. We really encourage students to look at programs that have osteopathic recognition already and have a track record of taking a lot of DO students, but every year ongoing we have more and more programs that are taking their first DO student or their second DO student and those numbers we are really hopeful will continue to grow each year as that process continues.
I do take hats off to the NBOME and the AACOM, Association of Osteopathic Medical Schools, and ACGME. We're working with all the programs to show them that the COMLEX is just fine and we're going to continue to work on that area and we hope more and more of them feel comfortable with that licensing exam as a decision point. There's a lot to it. That's how we counsel the students. It's a changing landscape, but one that still has some challenges for DO applicants.
Murphy: So is your opinion that if you, in certain specialties, let's say the surgical specialties, there was a recent research paper about DO matches in surgical specialties and they certainly don't rival the primary care specialties. If you're applying to those specialties, is it just a foregone conclusion that you're going to have to take COMLEX level two and Step Two?
Dr. Kirstein: It's not a foregone conclusion, but at this moment in 2023, it's a likelihood. It's more likely than not. There certainly are surgical programs that will accept the COMLEX and don't require it, but they're the minority. And so we need those to increase. I do want to mention—it's we focus so much on the licensing exams, but everybody in this conversation, I think the students need to know this too, the purpose of a licensing exam is to gain a license. It's not a very good measure of a student's ability to get into a residency. Unfortunately, the GME programs have so many applications that they need something to screen them down by. And so, it's an inappropriate use of a great test that's designed for another purpose and I really always counsel all of our students, and it's really good advice for the MD applicants too, it's not a judge of how good of a resident you'll be at all.
And so it's important as you go into this process with eyes wide open. It's a necessary step. I would love to actually point out as an example, this year DO applicants and MD applicants have to go through a different process if they're going to apply like they did last year, apply to OB, there's a different application service now for OB. And hats off to the AMA, who's supporting APGO and through the Change GME grant, they're ruffling some feathers. They're making some big changes and there's a lot of debate going on about that. And what I can tell you, for our students, it may be a bit of a hassle to have to do another application service. I know they're trying to reduce the burden, but the purpose of it is that the OB wants to take a more holistic look at all students, including the DO applicants, and that's a positive thing for all MD and DO applicants, to take a holistic look at them and that's what we encourage them to continue looking at doing.
I don't have the actual data, but I heard from APGO that in this last cycle, they actually interviewed a higher percentage of DO students as they first started this and they're just getting this process going and that shows some progress. Now the total percentage and who matched and the rank was about the same, which shows there's still some bias, but my hope is that we continue in those directions. Now I'm not saying that every specialty should get their own application service or anything like that. That's the worries. But I really do hope that, I think the students should know that these conversations are ongoing with AMA and AOA and all of our big associations really do want the best. We want the right students to wind up at the right GME programs and these conversations are ongoing.
Murphy: And that OB application is going to take hold in full effect next year, I believe. For our listeners now, that's one thing they don't have to concern themselves with, which I think is a relief for this cycle.
Dr. Kirstein: Yes. No, thank you. We are ahead of that for sure. But I think it's good for our listeners to understand that, boy, it's a moving target and it's evolving quickly and these conversations are changing too and I'm optimistic as a whole for osteopathic applicants as well. I think the directionality we're looking at is very good.
Murphy: Absolutely and that was evidence in level one and Step One, moving to pass-fail, which I think has been a relief to students. You talk about applications, what about application figures? Do you have a specific target you advise for? For the 2022 Match, DOs submitted an average of 92 applications compared to 68 for MDs. That is going to vary so widely on specialty though. Do you have a target number? Is it just highly individualized? How do you advise that part of the process?
Dr. Kirstein: Both those numbers are ridiculously too high and nobody would agree with that more than the program directors themselves and ACGME and it's just created nationally in aggregate just a traffic jam, for sure. I don't have a specific target to say. What we do use, obviously you mentioned it does vary by specialty. So the NRMP report does, for students who DO, students who successfully matched in each specialty, it does give the data that we provide our students and all our students can get it from their schools. What was the average number of applications filed for each successful person? We use that as a target, but we definitely try to make sure that they don't feel a need or stress out to go way above that number. The reality is that the system, they just can click whatever they want.
It is a very low friction system to apply. The difference between 60 or 90 applications is big in its impact, but for the applicant itself, it's kind of a no-brainer. So we do need to get the entire system to a better place. I wish I had a clear out advice to say, "Oh, just do 10. Just do 20." But we don't have the data to back that. So we really are just using the last Match performance report we get from NRMP and saying, "This is a general guide of what's been successful and what people who were successful before you, what they did." And I hope we continue to evolve this conversation in a better place, so our students don't have to send so many applications.
Murphy: And that number has been on the rise for years, that application total, but the increase was accelerated by the move to virtual interviews. It's just the reality, which is I think most people would say very advantageous to students to have those virtual interviews, but this might be a small adverse byproduct of that.
Dr. Kirstein: Yeah. It's multifactorial. Absolutely. And there's cost involved and all the interviews, even if they are virtual, and there's a lot of conversations about hybridizing those and I do think overall for the students it is much better and the program directors, for very good reasons actually, would like to see them face-to-face. Wish they still had some of the face-to-face as well. But that's going to continue to evolve as well. And it is geographically specific and specialty specific, which is why it's so important. I know our residency advising team does such a great job, but it really is so case dependent and we really have to tailor our advice for each student in a unique way based on what town they want to go to, what specialty and their background.
Murphy: We've done about 20 of these Meet Your Match episodes and the most universal advice is to work with your team at your school. That is not applicant dependent. That is just the obvious and most helpful tool at your disposal seems to be the consensus in speaking to a couple dozen people about it.
Dr. Kirstein: Well, I couldn't agree more. I always joke with my students to that pretty much deans—I have a very vested interest in the Match. I love my job, but I want to keep it. Right? And so, it's a tongue in cheek joke also that the last person who a program director wants to hear from is the dean 'cause we're only going to talk about how wonderful each and every applicant our students are and are supported. But knowing that, yeah, absolutely. From the senior leadership on down, we're very vested in admissions and Match, the input and the output, major inputs and outputs of medical school.
And so at my school and most schools, we've invested in really good people who have set up systems of advising and we have a gem of a team here at our school and they have great experience and the other real strength they have, and this is both, and for the DO applicants, I can tell you this firsthand, all of the residency advising directors at all of the osteopathic medical schools get together on a Zoom call monthly and compare best practices and are sharing best practices for advising just so that they can give the very best advice. And so, information is disseminated. And the MD applicants who may be listening, AAMC has a very similar structure as well. And so yeah. I can't underscore it enough. Listen to the advice. I think that the challenge we always have, I'll be very frank too, the challenge we have are for students who their aspirations may be a little bit higher than their applications will allow.
And so, sometimes also listening to your school and listening to stuff, sometimes there's some tough conversations also. I can speak from personal advice, I tell all my students to shoot for their dreams, but we use the NRMP data, I say, "This is your chances. Your odds are low that you're going to be an orthopedic surgeon or a plastic surgeon. I'm not saying it won't happen, but based on all this data, this is the reality." And I counsel them very strongly then to look at a plan B. And so I think that's really strong advice and I know that many applicants at all of our schools are going through those kinds of conversations. So if somebody is listening and you get that conversation, I hope that you could have a very honest discourse and conversation with your advisor as well.
These are few and far between. I think most people, they find their space and they find their right level of competition. But these tough conversations that we have, it's important that you can be in a place to receive them and be as productive as possible and not take it all as a personal judgment on yourself.
Murphy: And I'll throw a little bit of a plug in here. If you're listening to this on one of the many podcast mediums, you can scroll down in the feed about three episodes and we have an episode on realistic applying. So if you want more information on how to understand your standing, listen to that episode and I'd advise you to listen to all our episodes. We were talking about how individualized things are, and I do hate to ask these broad questions, but we're a few weeks away from the deadline for programs to begin accessing applications. And then after that, in review invitations will go out. Do you advise students to accept every interview invitation? The convention is usually you want to be in double digits to feel good about your chances of matching. What do you advise DO students about that part of the process?
Dr. Kirstein: Right. So this is a pretty generalizable piece of advice I think and that is we really encourage early in the process to take them as they come in early in the process. And then where it starts to individualize is, and if you feel like you're starting to get enough interviews so that you could build a good rank list, we then start telling students to consider to not accept every interview. And we also have that data. What was the average number of interviews successful applicants received for a given specialty? And we use that as a guide. As it gets later in the process, that's when we tell them to tailor back on the numbers. And the one big thing I say too is a caveat is absolutely attend every interview you accept. And if you would like to cancel an interview, do it with a lot of prep time so that it's not last minute cancellations. That actually does not reflect well on you and I am very honest with our students, it reflects poorly on the overall program and if we have one or two students who can be a no-show, deans sometimes get a little email from that program director because it's unprofessional and they want to let us know. So that's another bit of counseling we always do with interviews as well is to be professional about it and it's okay to cancel an interview, but do it with plenty of notice.
Murphy: And I should say, the average number of interviews for matched applicants in 2021, and it was fairly similar in 2022, was 14. So you're looking at around 10, 12, you're feeling pretty safe there. As far as the actual interview, we talked about biases against DOs or things they might have to confront relative to bias. What about some of the unique aspects of training as a DO and how should you highlight that in your interview?
Dr. Kirstein: I think very positively they should highlight what they value about their training. That's kind of generalizable advice to MD applicants as well as DO applicants. What is your story and what really sets you apart? As you're in an interview and you're trying to make a more competitive application and highlighting the things, what is the memorable thing about you? Who are you in that story? And I think part of that, as a DO applicant, that's part of our story and I think that be authentic. "What I really appreciate about the DO training was," and for some people it's having this added skill of osteopathic manipulative technique. It's having the added palpatory experience and being able to do a more thorough physical exam 'cause you got 100 hours more training in this area and you value it.
And then also just the philosophy and understanding that really we're trying to guide people back to health. It's not about curing disease and that go back to the basic core tenets of what it is to be a DO. Be proud and confident in your DO training and that you are a DO for sure and the one advice I get is don't ever make an excuse. Don't ever say, "Yeah," or try to say, "I'm equal. I got all the good training." It is who you are and be proud of it and I think people are proud of osteopathic physicians who are proud of their heritage.
Murphy: We spend a lot of time talking about what to do. What not to do? What mistakes to avoid as a DO applicant?
Dr. Kirstein: There's a couple of things. I think over interviewing and over applying is a mistake that I think is universal as well and to caution against that for sure. It's not as strong as a not to do, but it's just not effective. I think a lot of the applications are what I call wide and shallow. "I need research experience." So they work on seven different kind of quick research papers and they get maybe an authorship, maybe they got four posters or they got to do one presentation, but there are different projects everywhere and I did eight of these different service projects. And the fact is, it's not your story. It's just like, "Okay. You were just trying to very much build your CV."
You want a story that shows what you're passionate about. And so I really, as students are trying to build their CV, when it comes to research, find research that's passionate for you and go deeper. Find social causes, public service, community service things that are true to who you are and go deep on those. So I really caution, I've seen this pretty frequently with these students who just have what I call CV filler and I want the authentic application. I also have to remind my students too, before I became a dean, I was an internship program director at DMEDIO. I was on the other side before I came here.
That's what they want. They want to know who you are. So that's the do not do is don't set up an application and an interview that is just a broad display of activity without really getting to the truth of who you are. I think that's a key area. And the other don't dos is, luckily it's very rare, but I tell students, "Don't rank a place you really don't want to go." And at the end, "Oh, I'm just going to throw a couple at the end just in case, but I really didn't want to move to this town. I come from a rural background and everything else and I applied to all of these different kind of small towns and midsize towns and all of the sudden I got this one position in this inner city urban area in a program that's my third specialty choice."
If you match, you got to go. So I tell folks all the time, really make sure that you have a good connection to the programs and that you're confident that you can go to any of them on your rank list and would be happy to go to any of them on your rank list.
Murphy: Do you have any other advice or insights you'd like to offer our listeners?
Dr. Kirstein: Yeah. I think the theme that I always have is for the DO applicants, we're good at it. We're good at matching, we're good at getting into programs and our Match placements are very strong. And to be confident in that and be confident in who you are and really know your story. As you set up your audition rotations, know that you are telling your story and every day is that. So be the first on rotation, be the last to leave, make sure the residents love you, do all the reading. Everybody's doing that. Be yourself. Don't be who you think they want you to be. Be yourself. Be why you're there, why you're interested in their program and rank them the same way in your application the same way.
I've found that my authentic true student, my students who truly understand their North Star, match very well and have very meaningful careers. It's a great job and I wish everybody the best of luck on this journey. It's very stressful, but there's also a big party at the end and we love celebrating with all of our successfully matched students, soon to be graduates.
Murphy: That's good to remember. That come St. Patrick's Day, you'll have many reasons to celebrate. I know for many students that probably feels like an eternity from now, but it does come every year.
Dr. Kirstein: We haven't missed one yet, which is great.
Murphy: Well, we appreciate you taking the time for being with us today, Dr. Kirstein. This has been so valuable for our listeners.
Dr. Kirstein: Oh, thank you so much and thank you for all the great work you guys are doing at the AMA.
Murphy: I am AMA senior news writer, Brendan Murphy. Thanks for listening to Making the Rounds.
Unger: Don’t miss an episode of this Meet Your Match series. Subscribe to Making the Rounds on your favorite podcast platform or visit ama-assn.org/podcasts. Thanks for listening.
Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.