How Should I Rank Residency Choices for the Match?

Question

Do you have any suggestions on how to rank residency programs for the Match?

Response from Daniel J. Egan, MD Associate Attending Physician, Department of Emergency Medicine, St. Luke's-Roosevelt Hospital Center, New York, NY

The other day I was interviewing an applicant for a position in our residency program. She told me, "I think that I know who I want to rank at the top of my list." (This program, of course!). "It's the middle of my list that I'm having trouble with. Do you have any suggestions?"

It's that time of year. All of you fourth-year medical students are wrapping up or have completed your interview journey. You may have traveled all over the country. You certainly spent a small fortune for airfare and hotels. Hopefully you accumulated some frequent-flier miles in the process. You also likely have sat through 10-15 sessions describing programs, listened to residency directors try to convince you that their program is the best, and had one too many "night before" social events with the residents in each program.

So how do you make your list? Is it clear to you which program should be first? Is it less clear to you, like my medical student, what to do with the middle of your list?

The most important thing for you to take home from this process is that your rank list should be truly that. You should rank programs in the order in which you would like to match. Many people believe that there is a way to outsmart the algorithm. Or maybe one program has given you feedback that makes you think they really want you. At the end of the day, you are dealing with perhaps the most formidable time in your development as a physician, and you should go where you want to be. So the list should be your own. It should not be the order that your dean or faculty advisor says it should be (they have their own interests in mind as well) but the rank order that would make you most happy.

There are a number of factors to consider as you think about each program. The first and foremost is something that cannot be determined by a formula or list of pros and cons. The question is, Can you see yourself as a resident in that program? As you have gone through the process, you likely spent a day somewhere where you thought there was no way you would fit in. Additionally, there were likely others that left you almost giddy with the feeling that it would be a perfect fit. I still recall the chairman of the program where I trained meeting with us on the interview day. He casually spoke about a gut feeling of whether or not the glove fits. There is something important about your gut. Frankly, it is something that will get you through many difficult decisions in medicine, and choosing a residency is certainly one of those.

Certain criteria should always be considered when evaluating a residency program: patient population, tertiary care exposure, clinic experience for the specialties with outpatient components, resident independence in regard to decision-making, electives, and where graduates go for fellowships or jobs.

Other criteria that should play a role in your decision-making include:

Location. This is not insignificant. There are many glamorous cities in the country, but not every city is made for every person. Do you know anyone in the city that you are considering? Will you have any kind of support system outside of the hospital? You will immediately establish lifelong friendships during residency, and there is something exciting about starting over in a new place. But everyone has a different personality, and some people find it easier if a network already exists during a very challenging time.

Housing and salary. Is housing provided? If not, will the program's salary allow you to rent an apartment and still have money left over for your usual expenses? (See our previous columns on the accrual of credit card debt and how this should be avoided at all costs!)

Are the residents happy? You will hear rumors along the interview trail. Pay attention. Obviously, rumors are rumors, but hearing that residents in a particular program are very happy is an important piece of information.

Do you know any graduates from your medical school who are there? We all have a loyalty to our school. We want the best for students from our school. Often, these residents will be fantastic resources as you try to get real, honest information.

What is the academic vigor of the program? If you have a long-term goal related to academics, you want a program that will help foster that. If faculty members are not doing research and publishing, it may be more difficult for you to find a mentor. What are the daily or weekly conferences like? What are the academic requirements of the residents?

Teaching environment. With shorter work hours and increased patient volumes affecting all programs, many residents feel that the clinical teaching suffers. Ask about bedside teaching. The accrediting agency mandates a core content of lectures and conferences, but it is really the day-to-day operations that help you develop your clinical skills. You may best experience this with a second look. Show up on a noninterview day. See how the residents interact with each other and their attending staff.

Finally, I'll share some advice that I got from my med school dean. He told us to put Post-It notes around our apartments with each program listed in order. Put them somewhere that you will see every day, preferably multiple times. Believe it or not, that gut will start talking again. Imagine yourself opening the envelope with each program named inside, and likely you will have a different response to each one. Looking at this list and thinking about that feeling may help you tweak the order. It certainly helped me solidify my final list, as I grew more excited about the prospect of my first choice. And remember, the formula should work in favor of you, the student. Don't try to play a game. Do not shorten your list because you think you are guaranteed a spot based on program feedback. Take a phone call or email from a program with a grain of salt. Do what YOU want to do with your list!

Whom Should I Ask for a Letter of Recommendation?

Question

When I apply for residency, whom should I ask to write a letter of recommendation? Are these letters really important?

Response from Daniel J. Egan, MD Associate Attending Physician, Department of Emergency Medicine, St. Luke's-Roosevelt Hospital Center, New York, NY

As someone who routinely reviews applications to our residency program, I can tell you that letters of recommendation are very important to a successful match. The initial screening process typically involves board scores, rotation grades, medical school grades, and Dean's letter summary statement. However, after an applicant has made that cut, letters of recommendation play an important role in the evaluation process and truly give insight beyond the standardization in the rest of the application.

Several approaches to letters of recommendation can be taken. The most obvious person to ask for a letter is a mentor who knows you well. If you have worked with a mentor on a research project or have formed a relationship outside of a rotation or the classroom, this person should write a letter on your behalf. Most likely, his or her letter will provide more personal insight about you as an individual and capture the reader's (ie, the interviewer's) attention. I often pull interview questions from these letters to ask about the mentorship or project on which a student worked.

The second most obvious “letter writer” for you should be someone involved in a position of leadership in the clerkship of your specialty choice. Hopefully you have done well in the clerkship of your future specialty, and you will need to have someone from the faculty speak on your behalf. If you do not include a letter from someone in your specialty, it will be a glaring red flag to those of us reading through your application. In fact, some specialties have requirements about a certain number of letters from staff in your specialty. Be sure to find this out. Additionally, some specialties (such as emergency medicine) require a specific form letter; obviously, it is important to make sure you follow these guidelines.

The question becomes, Who should write your letter within a given rotation? A letter from a resident is not an option. A brand-new attending in his or her first year out of residency may also not be the ideal candidate. It may be to your advantage to approach someone who is more senior within the department. Ultimately, the content of the letter is important, but supportive statements from a chair, associate or full professor, or residency director will be taken seriously. Additionally, many of these faculty are nationally known, and the reader next to me may know them personally or by name, giving more credence to the letter.

Faculty members are frequently asked to write letters. People who routinely write letters include the medical student director for a rotation and members of the residency leadership. Those of us reading a letter look for certain phrases and comments. If a faculty member is not familiar with letter writing, he or she may not include these statements and it may be hard for an interview committee to interpret the letter. A medical student clerkship director will also probably include statements or at least a summary from multiple faculty members and give a consensus opinion. One individual faculty member can only speak for himself or herself. Another tip: if you are unsure of a person's opinion of you, avoid asking him or her to write a letter. Clearly, you do not want a “bad” or even mediocre letter in your file.

Some tips for deciding whom to ask:

• Speak to upperclassmen who have completed the rotation. Some faculty members in your school have letter-writing reputations.
• Consider your approach to the faculty member. I have been asked explicitly, “Do you think you would be able to write me a strong letter of support?” Many faculty will tell you that they are not comfortable writing a letter even without this specific question, but it is always hard to say "no" to someone. However, if you deliver this more directed question using the adjective "strong," it gives someone an out to say "no" if they do not think they can write you an adequate letter.
• Ask the residency director at your school for advice. Tell the residency director whom you are considering asking to write letters for you. He or she may steer you in another direction if that faculty member may not be the best option.
• Speak openly with your Dean of Student Affairs. The medical school is acting in your best interest, and the leadership wants students to be successful and match at competitive programs.

One last piece of advice: Ask for your letter as soon as possible after your clerkship, when you are still fresh in the mind of the faculty member. Also, remember that every letter you collect does not ultimately need to be included in your application. Better to have more than you need than not enough.

How Should I Plan an Audition Rotation?

Question

Can you tell me about audition rotations? When should I apply, and how can I ensure a successful rotation?

Response from Megan L. Fix, MD Assistant Professor, Tufts University School of Medicine, Portland, Maine; Director, Medical Student Education, Maine Medical Center, Portland, Maine

Also called an "away externship" and "away rotation," an audition rotation is defined by the McGraw-Hill Concise Dictionary of Modern Medicine as "a clinical rotation by a 4th year medical student interested in a specific residency program and/or target specialty in a location other than that of his/her medical school."^[1]

More simply stated, an audition rotation is a chance for you to shine and show the residency program of your choice that you are top notch.

When to Apply

Many students ask when they should plan their fourth-year audition rotations. As important as it is to plan when to do the rotation is when to apply for the rotation. Popular rotations fill up quickly, and many require a formal application. Some rotations even require an essay and a letter of support. Students should start thinking about planning an audition rotation as soon as a career choice has been made -- early to mid-third year. Ask graduating fourth-year students and mentors in your chosen specialty which rotations are desirable. Look online for the deadlines and application processes for these rotations and work with your home institution to make sure the dates will work with your required fourth-year clerkships.

When to Complete the Rotation

Most audition rotations are best completed after at least 1 solid rotation in your chosen specialty at your own institution. This valuable clinical experience allows you to perform well during the audition rotation. Schedule your audition rotation early in the fourth year before interviews, but close enough to interviews that the faculty will remember you. Typically, the months of July through December are best.

Some students choose to do an audition rotation during interview months in the hopes of doing a residency interview during the rotation. This saves money and helps the residency director really remember you when it comes time to make a rank list. Avoid scheduling your audition rotation in February because that is when most Match lists are due.

Where to Do the Rotation

Where you plan to do your audition rotation is just as important as where you plan to do your residency interviews. Remember, many graduating residents tend to practice close to where they completed their residency. Think about what is important and make your priority list first. For example, if geography is the most important priority for your residency choice, then you should make every effort to obtain an audition rotation in that geographic location. Residency directors tend to be close with their regional counterparts and frequently call each other to discuss candidates. So, even if your top rotation is unavailable, try to arrange for a rotation in that region. Alternatively, if program reputation is the most important priority for you, then you should apply early to get into an audition rotation at a particular residency.

How to Stand Out During the Rotation

An outstanding performance during your audition rotation may increase your chances of matching at that program, and a poor performance may reduce your chances of a match. Almost as important as your clinical skills during the rotation are your interpersonal skills. Know that you will be watched by everyone: the clerkship director, the residents, the residency coordinator, the nurses, the faculty, and the staff in the hospital. They want to make sure that you will be a good colleague for the next 3-7 years.

Before any audition rotation, it is a good idea to meet with a mentor in your chosen specialty and ask for specific feedback on your strengths and weaknesses. Make sure you bring a good textbook to read while you're on your audition rotation so that you can research your cases. You may be asked to give a presentation. Make this count! Consider using evidence-based articles and include handouts on your presentation topic. Everything you do during this month will be important. Be reliable. Be on time for everything, complete all tasks, and do your absolute best.

Letters of Recommendation

It is very important to obtain a strong letter of recommendation from a faculty member at your audition rotation. Some clerkships will extend offers for letters to all students on the first day. If this does not happen, try to wait until a week or so has passed and then ask a key member of the faculty (clerkship director, program director, associate program director, research director) after you have met this person. Be prepared with your CV, personal statement, and release form for your letter of recommendation.

Details

• Arrange for travel and start dates to fit with your home institution. Missing days on your audition rotation can look very sloppy;
• Ask early about housing options: Some rotations offer free or reduced-cost student housing. If that is not available, ask the residency coordinator for residents' addresses and email a few of them to ask for suggestions.
• Be appreciative of the clerkship director and coordinator;
• Be a good team player with the other students on your rotation. Do not try to sabotage other students to make yourself look good;
• Attend all didactic sessions;
• Arrive on time and plan on staying late;
• Ask for feedback early in the month so that you can correct deficiencies before your grade is assigned. Make all efforts to earn honors during your rotation;
• Try to socialize with residents and attendings outside of the hospital during your month;
• Attend journal club even if it is not mandatory;
• Be prepared for your first day. Make sure you have the proper identification, passwords, attire, parking, mental map of the hospital, etc.; and
• Be professional and respectful toward everyone during your rotation. Ask if you can do anything to help others, be kind to your patients, and communicate well with your supervisors.

Case Presentation

http://www.medscape.com/viewarticle/720219?src=mp&spon=25&uac=147602PZ

Case Presentation

A 61-Year-Old Woman With Intermittent Worsening Abdominal Pain:

http://www.medscape.com/viewarticle/720150

Which Drugs Pose Greatest Risk of Birth Defects?

http://www.medscape.com/viewarticle/719966?src=mp&spon=25&uac=147602PZ

Restrictions on Residents' Work Hours Not Helping, Study Suggests

Allison Gandey

April 14, 2010 (Toronto, Ontario) — New Institute of Medicine recommendations designed to reduce work hours and encourage sufficient sleep are failing to protect residents, a new study shows.

Reporting here at the American Academy of Neurology 62nd Annual Meeting, investigators suggest residents are no more well rested or prepared now that restrictions are in place compared with before. And many residents are complaining their work is less satisfying now.

Why would fewer working hours and more time to sleep leave residents feeling unfulfilled in their job? Study author Andrew Southerland, MD, from the University of Virginia in Charlottesville, told Medscape Neurology that his team found residents are now at higher risk of burnout.

"Residents are checking in and out on patients like shift workers and are feeling less connected," Dr. Southerland said. "There is less continuity of care, and our program is not running as smoothly."

To assess the situation, investigators led by Lori Schuh, MD, from the Henry Ford Hospital in Detroit, Michigan, questioned 30 neurology residents.

They found that contrary to the intentions of the new recommendations, they do not appear to be improving learning or patient safety.

Surprisingly, the mean weekly time spent at work and in lecture, studying, and sleeping did not differ before the restrictions and after. However, quality-of-life measures suggesting an increased risk of burnout significantly increased after the new rules went into effect (P = .03).

Table 1. Mean Difference Before and After Institute of Medicine Recommendation

Residents	Baseline Month	After Recommendation	P Value
Sleepiness after work shift	3.56	3.55	.99
Sleepiness after on call	5.88	5.62	.69
Weekly hours slept	51.1	53.7	.16
Weekly hours at hospital	56.6	58.3	.56
Weekly personal study	7.1	8.0	.28
Weekly hours in lecture	5.0	5.0	.97
Weekly study hours at hospital	1.5	1.5	.93

Table 2. Maslach Burnout Inventory

Variable	Mean Baseline Month	Mean After Recommendation	P Value
Emotional exhaustion	23.3	28.7	.16
Depersonalization	8.7	12.8	.03
Personal accomplishment	35.6	34.8	.87

During an interview, William Hicks, MD, chief resident in neurology at Henry Ford Hospital in Detroit, Michigan, said, "Institute of Medicine panelists have made recommendations and extrapolated them across the board as though neurology would fit in the same model."

Neurology residency programs are usually small, and Dr. Hicks said the institute initiated recommendations based on no evidence. "At the very least, we should have been at the table," he said.

The problems, residents say, are having an impact on everyone. "Nurses are having to brief us as we come and go and this isn't their job," he said.

Coauthor Heather Harle, MD, from the University of Virginia in Charlottesville, said there are no data showing that the recommendations have improved patient safety. "Evidence suggests there are no fewer mistakes now compared to before, and the rate of medical errors has remained static."

Fewer Days in Clinic

Investigators report a 21% reduction in the number of resident clinic days in 1 program as residents were pulled from other rotations to provide additional night time coverage.

Pediatric residents have reported similar concerns (Journal of Graduate Medical Education. 2009;1:181-184).

Asked by Medscape Neurology to comment, Orly Avitzur, MD, a neurologist with offices in New York, said she agrees there are problems with the Institute of Medicine restrictions.

"The new recommendations propose changes for maximum shift length, minimum time off between shifts, and maximum number of in-hospital night shifts. They make the assumption that if residents get a regular opportunity for sleep each day, this will reduce fatigue-related errors. However," she added, "this focuses on only one process and one potential source of error. The unintended consequence is that it creates more transitions of care."

One of the biggest sources of error occurs because of patient sign-outs, Dr. Avitzur emphasized. "The more you change hands in patient care, the more opportunity exists for errors." Dr. Avitzur said this also creates more stress for residents because they have to pick up a whole new service of patients on a regular basis, and stress can, in itself, cause errors and workplace dissatisfaction.

The researchers have disclosed no relevant financial relationships.

American Academy of Neurology (AAN) 62nd Annual Meeting: Poster 1.296. Presented April 13, 2010.