residency

The match, residency, ERAS. These terms become part of our everyday vocabulary, either as MS4 or IMG applying into residency. A cumbersome, long application process in which oneself that is going through seems lost most of the time. It is no wonder that our family or friends who are not in the medical field get confused about how the process occurs. To alleviate my anxiousness prior to the match and help our loved ones understand better what the process of applying to residency in the USA entails, I will make this quick 101 guide to understand it. And before we start, I will address a very common preconception; passing the steps1 and 2 does not mean we got into residency.

The beginning

Hello! If you are reading this behold, as a friend or family relative is about to embark into a couple of stressful, exciting, doubtful several months starting early June/July until matchday in March, yes, it this long, so please gives us love.

The process starts earlier than you might imagine. Before applying, you should have already decided what specialty you want to go into. Specialties in medicine could be divided in 3 big groups medical specialties (internal medicine, pediatrics,dermatology), surgical (neurosurgery, ophthalmology, plastic surgery), diagnostics (radiology, pathology). Once you have decided what specialty you want to apply to, the process begins.

Around June, ERAS will become the most searched website on your applicants one’s laptops. ERAS stands for Electronic Residency Application Service. This is the website where we will have to do a lot, so I will bullet point all that we have to get done on this website that gets quite stressful even with the calming blue colors of the ERAS banner.

1. CV: LONG standardized CV format where we will have to write in excruciating detail all our accomplishments, education background, hobbies (yes, super important). This is an essential part of the application because we have to look attractive for programs. Your applicant will spend several hours witting, re writing, and writing again this application for several months.
2. Letters of recommendation (LOR): It is pretty standard to put references down for a job, right? Well, I wish this was just to put down a name. The LORs are probably one of the most stressful parts of the application since it does not depend entirely on us. Our professors write these letters, mentors that want to support our residency application, and every word they write is taken very seriously by programs one applies to. There are two ways to upload a LOR as they are so important. One is to waive the right to see the letter (which is usually preferred) so that the person can freely write about you or upload the letter yourself (not recommended). So we reach a point where many students are asking the same attendings for LOR’s, that in addition to their busy clinical schedule, they have to write and upload in a platform for which they have to create an account. So you can imagine the stress one could go under while catching our mentors and pressuring them to write the LORs and upload them. Tip for future applicants, do this early in the season if possible.
3. Personal statement: I think my non-medical readers might be familiar with this part, as you must have read a couple of versions of the personal statement. In less than 28’000 characters, convey who you are, why you want the specialty you are applying to, and seem interesting enough to catch the attention of the selections committee. One goes on and on, and one writes several versions (I think I did about ten versions) and gets inputs from many people. So, brace yourself as you will be receiving personal statements any time soon to revise.
4. Medical School Performance Evaluation (MSPE): For American graduates, you are blessed; you don’t have to do much here as your medical schools are in charged. For my fellow IMG’s, this is where we go back to our alma mater across the world to ask for our medical school performance, and we all know how slow administrative requests are. Please do so in advance as we need to request them and translate them to English. I enjoyed this part as I got the chance to remember great memories from medical school.
5. Programs selection: Decision burnout, yeah, it might happen. How do I choose from so many programs? Which ones to apply to? This is where applicants will go over more than > 100 programs and read what each has to offer to decide which ones they want to apply. Usually, the limitans is, yes, you guessed it: money as applications to around 100 programs could cost up to $2000.

Congratulations! Once you have gathered all items on your ERAS application and decided which programs to apply, all is left is to use that plastic to pay thousands of dollars in applications and wait for the next phase of the match season.

The interview invitation season: two rules

1. ALWAYS HAVE YOUR PHONE TURNED ON WITH NOTIFICATIONS ON
2. Have a proxy that will be receiving emails when can not

Your application rests now in the people’s computers that might decide your future career. It is only normal that your applicant seems anxious during this time and is waiting impatiently for that [email protected] email at any time for an interview invitation.

Most programs will send out interview invitations at any time during the day, hence you will see your applicant glue to their phones, with an special alarm ready to receive these emails, and in constant cycle of checking to see if the email is working. This tends to become stressful for many reasons, as sometimes programs might send more interview invites than slots to interview, or if you don’t respond fast, you might have scheduling conflicts.

You will hear funny stories such as people jumping out of the shower once they hear an email notification. Thus, having a proxy answering your emails and scheduling your interviews when you won’t be able to be on your phone, like when flying on an airplane or while you are in other interviews. In my case, the funniest story was that I received an interview invitation while in the middle of taking step3, good energy boost but terrible timing. Shout out to my proxy Sebastian Gallo for scheduling that interview for me.

This time is mixed with extreme rushes of energy and enjoyment once you get that email that says you are invited to interview, sadness when a program you liked rejected you, and uncertainty when most of the programs you will apply for will neither invite you nor reject you.

Interviews: Game ON!

While the most stressful part is the first month and a half to receive interview invitations, by this time, your applicant will most likely start to interview. We will all do our interviews virtually as we are going through the COVID-19 pandemic, which makes things somewhat more accessible. Before the pandemic, applicants had to travel all over the United States to interview their desired programs, wild, right?

Before the interview, applicants will carefully study the program, the attendings that will be interviewing them, and reviewing their own application as anything they have written could be asked whether that been a hobby or a paper. This period is full of excitement, they are interviewing for their dream job! You will probably be asked to help them with mock interviews and to practice with them for a few times to be able to shine during the interviews. So be there for them and cheer them through this interview season that will last from October until probably mid-February.

Ranking order and match day

The interviews are over, by this time you probably have a sense of which programs your applicant liked more and you have asked, so when do you get the job offer? Well unfortunately this is not a direct hiring process. After the programs have interviewed the applicants and applicants have interviewed at all of their programs, each one of them well sit down and write something called the Ranking Order List (ROL). This is a list of preferences in descending order of which one is the program they liked the best to the least, or even not rank places they did not like. Programs will do the same to rank in order of preference applicants or not rank them at all if they did not seem like a good fit. Once the lists are done, they will be submitted to the NRMP platform. On this platform, the Gale-Shapley matchmaking algorithm, which earned them the 1995 Economic Nobel Prize, will dictate where you will spend the next 3 to 8 years of your life and be the most crucial part of your training as a physician; an algorithm will be determining our life’s.

So, the best way to explain this is to make an analogy with Tinder or any dating app. You swipe right when you like someone, and if the other person also swipes right, you will both match! It is similar in that if the number 1 ranking in your list is a program that also ranked you first or within the number of positions available, you will have a perfect match and train in your most desired program.

But if that program ranks you in a lower position than there are available slots, things get a bit complicated. So let’s set a fictional hospital, Greys Sloan Memorial, and our two dear applicants, Derek and Meredith.

Let’s say Greys Sloan Memorial has eight spots for General Surgery, and our imaginary applicants Derek ranked Greys Sloan as his number 1 residency program and Meredith as her 4th choice. Derek was ranked in the position 9 and Meredith was ranked as their # 1 out of the 60 people they interviewed. He was certainly ranked high, but for Derek to match in Greys Sloan Memorial, at least 1 of the other applicants that are above him must have either matched elsewhere or not have ranked Greys Sloan. Meredith on the other hand would have directly matched into Grey Sloan, right? They have 8 spots, and she was first! However, Grey Sloan wasn’t her first choice. Since the algorithm favors applicants, the system will first try to match Meredith into her other top 3 hospitals. For Meredith to match into Greys Sloan, she must not have been able to match in her top 3 choices. She would go ahead and match at Greys Sloan.

As you can see, Meredith matching into this program might mean that Derek will not be able to match into his top choice thus the outcome of the match is dependent on the ROL from each of the hundreds of applicants and the programs.

MATCH week: The reveal!

After submitting and editing the ROL endlessly, the second week of March of each year will be a life-defining week for most applicants. On Monday, we will receive an email stating if we were accepted for residency or matched into a program. If so, we will receive another email on Friday, AKA Match Day, that will tell us where we will be doing a residency for the next 3-7 years.

Of note, the match in March occurs only for most specialties, except for urology that happens in January and ophthalmology that happened this past Tuesday.

This was a brief overview of the tumultuous process of applying for residency. It goes without saying that having friends, significant others, and family through this time is paramount, and I take this opportunity to say thank you for the unwilling support anyone has brought me until this point.  I want to specially thank my mentor Dr. Nestor Gonzalez, my family, and my friends (Sebastian Gallo, Sandra Saade, Andy Serrano and Juan Esteban Velez) for putting up with my anxiety through these months.

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