Preparing for Residency Interview Selection Starts With the Externship Application Process

“What Is a Residency?”

A medical residency is placement for graduate medical education following medical school. First, before selecting a residency, realize one key aspect of the transition: you go from being a medical student, and paying a great deal of money for an education, to being paid to perform a job. As a resident, you are there to finish your journey to becoming a practicing physician. The program provides that education so you can become a responsible, diligent, capable, and contributing member of the profession upon your graduation.

You are, nevertheless, being paid to do a job and still owe your program and your patients the best you can offer. You are contracted to perform a job and entrusted to perform that job at the absolute highest level possible.

“How Do I Know What Residency to Go To?”

Where do you want to be on the worst day of your life? It’s a surprising thought, and it sounds harsh, but is meant in the best way as your situation will be directly dependent on your environment. This does not mean that this worst day is caused by the program or academic institution itself, and in contrast, you may have a good support system in the program. You will have days that are tough because your job is exceptionally difficult—that is intrinsic to your discipline, or it may be because of personal challenges. This is particularly important when you are at a program that is far from where you’ve lived or from other important family members and friends. Get the absolute best education you can, but in our opinion, it is best to choose the location based on the people— as it is the people around you who support you that will make the difference.

When I (Dr. Campbell) went to residency, I was more than 2000 miles from home, but any other resident or attending there would offer to help me, check in with me, and provide that much-needed support when addressing the emotional growth of a resident and residency’s challenges. It was humanistic, and their support was unmatched. These are the people who will help you with decision-making and new philosophies to better your patients’ health for years beyond your training. We would argue that it is even more important in fellowship because you work with the same one or two people daily and mentorship within education and health care is absolutely crucial for personal and professional success.

“What Do I Look For?”

Considerations for residency selection include how many residents there are; how many residents there are expected to be over your time in the program; and what growth or challenges are anticipated within your institution, professional relationships, and direct training by the attending faculty and director.

Do you want to train at a program that provides direct resident surgical training with multiple residents scrubbed into cases or do you have a different preference for learning? Do you want to learn from a multitude of physicians or are you partial to a smaller group of teachers with a similar doctrine? Is there male and female representation? What other resources are available? Do they have a library, a cadaver lab, and academics that teach beyond the material, bridging the clinical perspective of many years of expertise? You are entering a comparatively short period of surgical training and so you need to maximize this time.

Put Yourself in the Position of the Resident, Not the Student

How are the residents taught? How much responsibility do they have? Can you see the incremental difference as they progress over the years? If you have an intuition on which program you would really like to match to ahead of selecting clerkships, try to schedule that for May or June to see the residents as they hand over responsibilities and the quality of the graduates. Do the residents function with the level of expertise that you desire?

At my residency, I didn’t require students to perform my job and personally don’t believe any institution should be absolutely dependent on students or even residents to perform quality medical care—but that can be the exact type of program that is most boring to students because it is less hands-on. If you can have the perspective and openness to see yourself in the future residents’ shoes and their comfort in managing their job duties, particularly for when they don’t have that extra help, it can help keep that as an option for you.

At the conclusion of each clerkship, we recommend writing one page on the pros and cons, the surgical focus of a program, and the best case you saw there. Prior to selecting residencies to interview with, look back at your notes and be honest with yourself about where you want to work and where you felt good. Do not misremember a place or talk yourself into a place that is not a fit, because three years is a long time for “middle of the road” or a compromise. Mastery does not come with being too comfortable.

You are most likely to match to a residency program with which you have externed due to the one month of exposure you have had at the institution. An externship is essentially a month-long interview, so every moment counts. The interviewer will assess what you say, what you do, how you act, and your attitude. Showing up early and staying late will always go a long way. The residents will be on various rotations during your time there. Be sure to meet each of the individuals and learn more about the rotations. You likely will not see some of these outside rotations unless you also have a core rotation there, or a rotation of many months to complete required student electives.

Residency Interviews

In our experience, residency interview submissions are typically scheduled in October of each year, with interviews taking place in January. For this reason, we found September to be a good month to visit a program, as this is before the programs make their interviewee selections. This gives you about 5 to 7 programs to take a deep look at, depending on which school you attend.

I have, however, had many students come to me and say they did not feel they were a fit for any of the 7 programs they had been to as the interview application cycle approached. They instead planned to apply to other programs that they discovered along the way that sounded more suitable, as their preferences had changed. You must get a seat at the table. While the number of spots that you can apply to is plentiful, it is not a guarantee of an invitation to interview. You have to consider that some of these programs do not have enough room to interview all the candidates who came to visit their program, whom they know quite well. Thus, there is even less room for candidates who have never demonstrated interest until this point. Over time, if you come to learn of a program that you think would be a best fit for you, reach out to that program prior to submitting your application to improve your chances of being considered for an interview. Simply, if you do not obtain an interview, you cannot obtain a spot at that residency program. This is based on the match ranking system serving both the student and the program for best fit.

Be familiar with the main physicians in each program. Know their areas of expertise and the typical procedures performed. Look up and read articles they have published (for some doctors with significant contributions to the literature, this can be a daunting task but still worth the effort.)

Have respect for the doctors training you—the vast majority are not compensated for their time to train you. These physicians are vested in your future as they have a responsibility to their profession and patients for you to be competent and capable. They are investing in their program and even with limited time with them know that the attendings are always inquiring about your experience, knowledge, and work input. The everyday workings of things are not as unnoticed as you may think.

Future residents are selected as medical students based on an ability to be teachable. A basic academic foundation is necessary but having good intentions and an openness to learn is valuable to the whole team.

Avoiding Errors in the Residency Process

The greatest error you can make in this process is not speaking up for yourself on where you want to go. Tell the people at the program you want to go to that they are your number one choice. Be truthful and be confident in your selection. Every year after the residency match concludes, we hear from students that they really wanted to go to a certain program and that program’s director, residents, and coordinators had never had such an impression of that student’s desire to match there so the student was not even ranked. I know of candidates with great personalities and academic strengths who got their fifth or eighteenth choice. In these cases, they admitted with respect to the program they thought they would match to; they didn’t have a conversation with them about their intentions and what they could do as a resident there.

Some Interviews Are Tough

Sometimes, the top candidates for a specific program feel like their interview was poor or so challenging they couldn’t possibly gain a residency spot there. Sometimes, those interviews are more challenging because the program understands your strengths and knows you a bit better to ask the tough questions, but also they want to see you advance through that challenge to the next level. Do not quit during that interview—because you may be doing better than you think. Do not change the entirety of your rank list if your clerkship and all other encounters went well but your impression of the interview was less than expected, unless you have a new feeling that you absolutely should. Consider making a mock rank list prior to interviews after you go through your notes, prior to a formal rank list to help make your decision.

You Can’t Sneak Into a Program

“What if I tell a program I want to go there and that program doesn’t want me?” Then you will not be going there. This is a mutual, symbiotic relationship. Ultimately, you want to go to a program that wants you as badly as you want to go to that program.

Upon applying to residency interviews, do not accept programs you know you will ultimately say no to. You don’t want to take a seat from another student and you do not want to waste your time. You will have practiced interviews prior to formal interviews and do not need interviews “to practice.” Maintain your professionalism throughout interviews. Further, it takes a lot of prep work to look into a program you haven’t been to and interview. However, if you know that a program looks promising to you and you are new to that program you have a chance at matching there and doing great work.

Do not forget to rank programs that do not participate in the Centralized Residency Interview Process (CRIP) and hold their interviews independently, because they are still a part of the CASPR match.

We found most interviews are scheduled for 15–20 minutes, although some can be 30 minutes to an hour or multiple, staged interviews. Interviews can vary from being completely academic to completely social to a mix. In my experience, most were about a 40/60 percent ratio of academic and social. Again, most of the interviews are potentially places you worked for a month of clerkships, so they have already determined things about your knowledge base and want to learn more about character and background. One should prepare for the social part of the interview. It can be enlightening to practice out loud. You will learn a lot about yourself and what you want or do not want.

Finally, do not miss interview fee deadlines. Send them as early as you are able leaving time to make sure they get to the coordinator. Residents are tasked with a myriad of responsibilities and paperwork, and this is one of your first opportunities to demonstrate your ability to be dutiful as you advance to that next level.

Summary

In the authors’ experience:
    1.    Gaining a residency position starts early in the process. Choose clerkships that you feel you could match into residency. This will give you more selection when it comes time to choose.
    2.    Evaluate your programs at the end of every clerkship with the pros and cons and review these lists before submitting for interviews.
    3.    Tell the people at a program they are your number one; they are not asking you. Go after what you want. You will be most happy and perform as the best resident you can at a place you want to be above any other.
    4.    Do not sign up for more interviews than you can handle.
    5.    If you don’t want to go to a certain residency, do not rank it. This is in your hands.
    6.    Pay close attention to deadlines and apply early
    7.    Don’t get too comfortable.
    8.    Attitude is as important as aptitude. Do not be too casual. Maintain strong integrity and work ethic. Remain teachable.

Dr. Campbell is a Fellow at the University of Health Sciences Center of San Antonio, TX.

Dr. Pehde is a Faculty Attending of the University of Health Sciences Center of San Antonio, TX. He has previously taught students at Des Moines University (DMU), teaching students for nearly two decades.

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