Viewpoint From a Program Director They Can't All Walk on Water

The application cycle experience for current program directors

The good news is that there are many excellent applicants. The bad news is that all applicants look alike on paper, and it is difficult to discern who is a good fit for your program.

There are many reasons for this difficulty. Some medical schools do not give grades for preclinical years, and the knowledge acquired is then, by default, measured by the United States Medical Licensing Examination (USMLE) Step 1 score. Deciphering preclinical and clinical grades for the various medical schools is a time-consuming task, and grade inflation at some schools is obvious (eg, As, Bs, and Cs have been replaced with highest honors, high honors, and honors, respectively). In otolaryngology–head and neck surgery (OHNS), a standard letter of recommendation (SLOR) has been used for the past several years in an attempt to level the playing field. However, this has proven to be of limited utility, as almost everyone is clustered at the high end of the scale.¹ Dean's letters and the Medical Student Performance Evaluation (MSPE) are also of limited benefit because they are rarely less than effusive in praise of the student. A holistic evaluation approach that encompasses USMLE scores, grades, LORs, MSPEs, and a student's personal statement and life experience is necessary to decide whom to interview. However, the lack of meaningful assessment of a student, through letters or grades, makes this process frustrating.

Because the interview process allows a much closer look at the applicant in a personal way, it provides better and much needed information. Programs can design interview questions to elicit the traits that would make the applicant a good fit for the program. Given the uniformity of the submitted applications, the interview takes on an especially important role in deciding the rank list as it allows meaningful interaction to get a sense of the applicant's maturity, motivation, dedication, and personal characteristics. However, last-minute cancellations of interviews by applicants, anywhere from 2 weeks to 2 days prior to the interview date, are also a problem, because other applicants cannot be accommodated with such short notice.

Why are medical students applying to an increasing number of residency programs?

Students worry that either they will not get interviews or that they will not get the interviews they want. Ironically, reduced emphasis on grades and current grade inflation appear to make some students insecure. If everyone gets a pass in a pass/fail course or honors in a graded course, there is no differentiation among students: students may not know how they are really doing. For some students, application to residency is the first time since application to medical school that they have had to compete for something. They do not know how they measure up against others. Thus, students may lack confidence and apply to 65 OHNS programs or more, just in case.

Why are medical students applying to many programs that are a “reach” for specialty or site, given their medical school records? Should the medical schools provide advice?

Students should be allowed to apply to their specialty of choice because it is their professional life decision. If students want to take a chance on choosing a highly competitive field or limit themselves to a specific area of the country, they should have that opportunity. With this freedom, however, comes the responsibility of dealing with the consequences of not attaining the goal. Medical school advisory deans must provide honest assessment and counseling to help students devise a plan B should the student not match. Many students have always or nearly always achieved their dreams. Couple this fact with a lifetime's worth of positive encouragement that one should always strive for personal dreams, and the result is that it is difficult for some students to accept the fact that the dream is not likely attainable. Students need to be mature about the process: apply to the “reach” specialty but also consider a second specialty or a realistic plan B, such as a research year, and thus provide for a softer landing in case of an unsuccessful Match.

Should the NRMP—or another group—place a limit on how many programs medical students can apply to or how many interviews they can attend?

I do not believe there should be a limit to how many programs a student may apply or to how many interviews a student can attend. Some students may wish to apply to many programs precisely because they are not strong candidates. Others may need the reassurance of multiple interview offers to realize that they are, in fact, good candidates. Some students might wish to attend many interviews because they want to acquire as much varied information as possible in order to make the best decisions for their rank list.

However, I am strongly in favor of limiting the interviews that a student can initially accept to 1 per day. Otherwise, students can accept multiple interview offers for the same day and hang on to them for weeks or months, until they must choose among them. This then sets into motion a painful cascade in which programs seek to fill suddenly open interview spots by calling the next applicants on their list, and those students may cancel interviews they already have to accept the new ones that are offered, and so on. This results in applicants canceling interviews within days of the interview date. Consequently, programs may be unable to find another applicant in time, which deprives other students of the opportunity to interview.

Should medical schools advise applicants to apply to a backup specialty, through the Match, if they are applying to a highly competitive first-choice specialty?

If the student is not a strong candidate, then a backup specialty is appropriate. However, this needs to be done thoughtfully and with advanced planning. The backup specialty should be a “sure thing.” A mediocre student applying to multiple highly competitive specialties is still unlikely to match. Subinternships should be done in both the primary and the backup specialties so that the student can be sure he or she will be happy doing the second specialty. Personal statements and the rest of the application need to be as strong as possible for each specialty. However, a student should not prevaricate about any perceived dual interest because that will ensure failure if a program thinks the student is dishonest.

I think a better option for a student who is not a strong candidate, yet who is determined to apply to a competitive specialty, is to defer graduation for a year to do research and to improve their clinical skills in the desired specialty. This will not erase a low USMLE score or lower grades, but it can allow a student to impress the home program and testify to goal setting, problem solving, insight, reception of constructive criticism, and willingness to work hard toward a desired goal. This increases the chances of matching through being ranked highly by the home program and by generating strong LORs. Deferring graduation also avoids the stigma of not matching and having to reapply. This approach requires insight and humility on the part of the student and honesty on the part of the faculty and deans, but it may prove to be the more successful option.

For those applying to very competitive surgical specialties, there are other surgical fields (eg, general surgery, vascular surgery, and obstetrics and gynecology) that may be considered, as well as other procedural specialties (eg, emergency medicine, gastroenterology, and interventional radiology) that can also be highly satisfying. Advisers and deans should counsel students with more modest school records to choose elective experiences and to consider these career options for those who are certain that they want a career filled with procedures, but who may not be the best candidates for an extremely competitive surgical specialty.

When faced with huge numbers of applicants, how can program directors approach each applicant in a holistic way and avoid using cutoffs, such as USMLE score, class rank, or type of medical school?

With experience, one can read between the lines of LORs and personal statements, but the electronic application overall is not transparent. Every part of the application has to be considered—USMLE scores, grades, extracurricular activities, LORs, MSPEs, personal statements, and life experience. It is essential for residency programs to prioritize their most important applicant qualities and then consistently assess every applicant for those qualities. Application reviews by multiple faculty members or a designated committee are vital to ensure broader input than just the program director making all the decisions. Programs can also advertise their desired applicant qualities on their websites or through e-mail communication to help focus applications to particular programs.

How can the current application and interview process be improved?

Standard letters of recommendation should have defined terms (not just numbers or vague terms such as excellent, good, or average) in order to provide more meaningful assessment. For example, the OHNS SLOR category of manual dexterity could be defined as follows: 10 indicates the student can independently close an incision well; 7 means they can do it well but need direction; 4 means they can do it poorly, thus it needs to be redone; and 1 means they cannot do it despite instruction. This could be applied to all categories, such that the SLOR allows for differentiation among students.

Students must be limited to accepting 1 interview offer per day, rather than accepting 2 or 3 interview offers on the same day and then waiting weeks or months before relinquishing those spots. This could be handled through either the Electronic Residency Application Service (ERAS) or the National Resident Matching Program (NRMP) in a fashion similar to the way the NRMP administers the Supplemental Offer and Acceptance Program. Programs would submit their list of interview offers and interview dates by a certain date. The ERAS or the NRMP would collate this information. Every applicant would then receive interview offers in a poll type format that would allow them to accept only 1 interview offer per day. Applicants could be given 2 weeks to submit their answers because they might have several interview offers that fall on the same day and would need time to decide. Programs that do not fill all of their interview spots would then go through a second or third round until all their interview spots were filled. It is possible that a student might not receive an interview offer from a desired program in the first round but might do so in the second round, which could lead to canceling a previous interview. This would result in an opening on the first program's schedule that could be addressed by the program in the next round. This process could be limited to 2 or 3 rounds, after which the usual process of programs reaching out to individual applicants would occur.

In addition, students who do not match would benefit from knowing where they were ranked by all of the programs at which they interviewed. This would help them decide if they should pursue another attempt the following year or change their career plans.

The NRMP could send a report to the student and to the dean delineating the student's position on the programs' rank lists; no program information (including the length of the rank list) would be included, just that the student was ranked at position X, Y, or Z. This would give the student and the dean valuable information. If the ranks were all low or the student was not even ranked by some programs, then it is unlikely that the student would match if they were to reapply the following year. However, if the rankings were mainly in the single digits or teens, then the student may need to cast a wider net the following year and augment their application with research or clinical experiences, or consider pursuing a related specialty.