How to be a Strong Applicant – the Big Four
Being a strong applicant for Residency is formulaic in a similar way as applying to medical school. There are hundreds of things you can potentially put on your resume. But everything is ancillary to the Big Four:
USMLE board scores
Clinical Grades & Dean’s Letter/MSPE
Research
Letters of Recommendation
We’ll delve into these one at a time.
The USMLE is the United States Medical Licensing Exam. It consists of three parts, called “Steps”. Step 1 is heavily focused on the Basic Sciences. Depending on the specialty you’re applying for, it can be the single most important part of your application. I’ll say that again. Step 1 can make or break your application. I’m not saying that to scare you; I simply want to emphasize this tests’ importance. Most medical students take Step 1 at the end of their 2nd year, right between the Basic Science curriculum and before starting clinical rotations. A high Step 1 score is essential to be competitive for the most selective specialties. Since most students haven’t had much clinical exposure when they take the test, it’s crucial to study your butt off and dominate Step 1 to ensure you remain competitive for everything…you never know what specialty you may fall in love with once clinics start. Keep your options as broad as possible by crushing this test. Personally, I dedicated five weeks to study and scored a 253, which put me above the 90th percentile.
For some perspective, the NRMP (National Resident Matching Program…the people who actually run the “Match”) puts out statistics every year called “Charting Outcomes in the Match”. The average Step 1 score for all US medical students is roughly 230. The average score for less competitive specialties such as Anesthesiology, Family Medicine, Neurology, Pediatrics, or Psychiatry hovers between 220 – 230. However, the average score for more competitive fields like Dermatology, Orthopaedic Surgery, or Plastic Surgery is in the high 240s – low 250s, a full standard deviation above the mean. Now before people get offended, let me be clear: average Step 1 scores have no bearing on the intelligence of students applying to different fields. Some of my smartest classmates chose fields that are much less competitive, because that’s what interested them. The “competitiveness” derives from fewer available residency positions across the U.S. for certain specialties (you simply don’t need as many Neurosurgeons as Pediatricians). Basic supply and demand. But regardless of whether one’s specialty has a low or high average Step 1 score, getting into top programs in every field is still highly competitive…so do your utmost to dominate this test.
The remaining USMLE exams are Step 2 and Step 3. You don’t take Step 3 until after starting Residency; it bears no relevance to you at this stage. However, Step 2 surely does. In the past, Residency programs did not care much for Step 2. But as students become more and more competitive, further evaluation criteria are being employed.
The reason for increased student competitiveness merits a post of its own, but in brief it’s a function of two factors: 1) improved study resources, and 2) an increasing number of medical schools across the country (and thus more applicants), but without a commensurate increase in total residency positions. This is largely the result of a cap placed on Medicare-funded residency spots by Congress during the 1990s, due to abuse of allocated funds by hospitals…but since this isn’t a political post, I’ll stop there.
Before I digress further…back to Step 2. It’s split into two parts: Step 2 CK (Clinical Knowledge) and Step 2 CS (Clinical Skills). Step 2 CK is similar to Step 1, but with more focus on clinical decision-making rather than on pure Basic Science. Residency programs are starting to care more about Step 2 CK scores (some programs won’t even rank applicants if they haven’t taken Step 2 CK), so it merits adequate preparation. I personally did not take Step 2 CK until after I finished all my interviews, so my score played no factor for Residency consideration. If I could make just one change to my application, it would be taking Step 2 CK earlier so that I could’ve added it to my application. A lot of programs screen out applicants who haven’t taken Step 2 CK, and some of my interviewers asked why I hadn’t taken it yet. I had legitimate reasons for not taking it: during the seven month window when students traditionally take Step 2 CK, I spent nearly two months doing research in Europe, then three consecutive months of away rotations at different Orthopaedic Surgery programs across the country, and then two straight months of interviews. This was sound enough reasoning in person during interviews. But there was no way to convey it in my application, which may have screened me out of some potential interviews. Hindsight is 20/20…so make sure you take Step 2 CK (and do well) before applying!
Since I believe in honesty and full disclosure, I’ll be forthcoming and divulge that I scored a 223 on Step 2 CK. Although I passed, this is a TERRIBLE SCORE because the average for my testing period was roughly 240. However, since I took the test after interviews were over and my score report wouldn’t come back by the time Residency programs finalized applicant “rankings” (more on the “Match” process below), I simply did not care about my score. For me it truly made no difference whether I scored a 290 or the bare minimum to pass. Thus…I spent a total of 2 days studying. That may sound stupid and risky (probably was haha). But I was completely aware that my score did not matter, and I additionally knew that I could at least pass with little to no studying. But again, I would highly recommend that you NOT do the same. Allocate 3-4 weeks to study and take Step 2 CK prior to submitting applications. Follow my advice (and not my footsteps) in this case!
Step 2 CS is quite different. There is no numerical score. The test is marked on a pure Pass/Fail basis. It’s a practical exam, where you go through timed stations consisting of interactions with “standardized patients”, actors hired to pose as patients with certain conditions. You elicit a history, do a focused physical exam, counsel them, and decide what imaging/lab tests are needed to confirm your diagnosis. It’s honestly a joke of a test (and costs $1250 to take!!), serving mainly to screen out foreign medical graduates who don’t have strong spoken English (English communication skills and demonstrating empathy are the biggest factors in passing). The pass rate for U.S. medical students is around 98%, making this test nothing more than an expensive formality. In fact, when I took it there was a petition with thousands of signatures lobbying to eliminate the exam for U.S. medical students. If you’re a foreign medical graduate (passing rate around 70%), there are resources available with examples of patient cases and scripts of common interactions you’re likely to encounter. A book called “First Aid for the USMLE Step 2 CS” is a good place to start. Personally, I did zero preparation and passed easily. If you can speak English and have prior clinical experience, this test is just a mandatory and boring way to spend nine hours. Don’t sweat it.
The second item in our menu of Big Four is Clinical Grades & the Dean’s Letter. I already spoke above at length on how to do well in clinics and ensure high grades and evaluations. Go read it again if you forgot. The Dean’s Letter (also known as the MSPE, Medical Student Performance Evaluation) is a composite document prepared by your school’s Dean’s Office providing your clinical grades for all clerkships, comments from attendings and residents, and mentions any scholarships, publications, extracurriculars, or certifications that your Deans think highlight your unique and significant attributes. It also includes your class rank and any honors such as AOA and Gold Humanism Honor Society. More than anything, it’s a snapshot of your grades and other major activities/accomplishments in med school. Different specialties (and different programs within each specialty) place varying emphasis on things like class rank, AOA, etc. Just as with Step 1, strive to do as well as possible to be competitive, even if your preferred specialty doesn’t really care about something like AOA. I personally was not AOA, and I have no idea if it hurt my application or not. There’s nothing to specifically aim for to ensure an awesome Dean’s Letter. Rather, just do well throughout clinics and be involved in things that interest you (and probably don’t piss off your Deans haha).
Research. The importance of research varies a lot by specialty. For instance, students that Match into Plastic Surgery on average have 12 research experiences, whereas the average for Family Medicine is only 2…that’s a huge difference, considering how time consuming it is to do research while simultaneously balancing your course-work and social life. In the NRMP’s “Charting Outcomes in the Match”, you can find the average number of Research Experiences for applicants in each specialty. I’ve italicized “research experiences” because there are many different types of research, many ways to gain recognition for your work, and many avenues to get multiple “experiences” from a single research project (at the end of the day, it’s all a numbers game). I’ll give you a real example:
In the summer between my 3rd and 4th year, a classmate (Dr. Raahul Ramakrishnan) and I both received a scholarship from Baylor College of Medicine to travel to Norway for six weeks and perform research relating to Orthopaedic Surgery. In particular, we focused on differences in Orthopaedic surgical practice in Norway vs. the United States (part of my trip is detailed here). In those six weeks, I had a total of 11 research experiences (2 publications, 4 poster presentations, 4 abstracts, 1 oral presentation). To put in perspective, the average applicant to Orthopaedic Surgery has 6 total research experiences. So just from this one scholarship, I was almost double the average, and I had a lot of other research projects in addition to this. To be perfectly honest with you, those 11 research experiences had nothing to do with me being exceptionally smart or laboring for countless hours at the expense of fun. On the contrary, I actually had a phenomenal time and explored a lot of Norway in those six weeks. But I made sure to get maximal recognition for the work I did. And there’s nothing wrong with that. One of our projects from this trip was about the differing Orthopaedic Registry landscape between the two countries, and was published in the journal Current Orthopaedic Practice. In addition to that publication, our work on Orthopaedic Registries was accepted for two abstracts at academic conferences and also for poster presentation at two conferences. Thus…just one of my research endeavors from this trip resulted in a total of five “research experiences” that appeared individually on my application.
View from Dalsnuten, Norway
I truly believe that research is extremely important because it advances the body of scientific knowledge, with the potential to benefit many. As Isaac Newton said, “if I have seen further, it is by standing on the shoulders of giants.” But I also believe that good work deserves credit. Since research is one of the metrics employed to gauge your competence and ability for Residency selection, it’s vital to get maximal recognition. That’s why for every project I did, I not only tried to write a paper for publication but I also submitted my work for poster and oral presentations at scientific conferences, compendiums of abstracts, etc. Of course, peer-reviewed publications are the most valuable and sought after, especially in high impact journals. But as I said above, research is a numbers game when applying to Residency programs. So it would behoove you to maximize the recognition you get for your hard work. Every single program I interviewed at inquired about my trip to Norway and the research I did there. You have to paint yourself extremely well because you’re competing against a very accomplished pool of applicants for a very limited number of positions. Research is a great way to make your application stand above the rest, and creates excellent talking points during your interviews.
A final comment on Research: HOW DO YOU GET INVOLVED? You don’t need a scholarship to Scandinavia to do research. Simply be curious. If you hear about an attending physician or Ph.D. who is doing interesting work, go talk to them after class/clinic. Show up to their office. Shoot them an email. If there are residents or even other students working on a cool project, ask if they need help. Together you’ll get the work done faster and also mutually benefit. The worst that can happen is someone says “no”. So what? Keep asking and stay curious. Just like with clinical rotations, don’t be afraid to take initiative.
Even more importantly (and again just like in clinics), SET EXPECTATIONS. Don’t jump blindly into a research project that may not get published for several more years. This unfortunately happened to me during my first year of med school. I was excited to jump into any project (I essentially had zero research experience in college). I stupidly agreed to do chart reviews of hundreds of patient charts for a retrospective study. It was extremely time consuming, boring, and non-educational. To top it off, once I finished all the charts, the attending decided to delay the project because he wanted more data. Needless to say…I was pissed, and also appalled at his complete disregard for my time and effort. To this day, almost four years later, I have nothing to show from that project except a lesson learned: establish what you want from the start. Since then, for every project I’ve done I’ve made certain to establish that I expect authorship in the publication in exchange for my work. If I’m not going to get something to put on my application, it’s not worth my time. But also keep up your end of the bargain. If you give your word, see it through to the end in a timely fashion.
The last of the Big Four are Letters of Recommendation (LORs). This can be a wild card for students if they haven’t made conscious efforts to build meaningful relationships with faculty members. Three to four LORs are required by most specialties, and many programs require that at least three (preferably all four) be from physicians in the field to which you’re applying. Some specialties even mandate that one letter be from the Residency Program Director or Chairman of the Department at your medical school.
LORs can really boost your application by providing personal insights about your aptitude and ability as a student, potential as a future colleague, and generally about what kind of person you are. LORs can be home runs if they’re written by big name researchers or clinicians in that field, or if some admissions committee member at a particular residency program knows your LOR writer(s) personally (for instance, if they trained in residency together). Even if your LOR writers are not so-called “big names” or former colleagues of admissions committee members (most will not be), they can still carry a lot of weight.
You of course have to waive your right to read your LORs to ensure that your letter writers can be totally honest. However, several of my interviewers read me direct comments from my LORs, and I was very happy and humbled that my mentors had written such high praise (I almost thought they’d confused me for another student!). In reality, I was confident that my LORs would be strong endorsements for my application because I did my utmost to build significant relationships with my mentors. I’ll describe what worked for me, and hopefully it’ll help you as well.
Your LORs will hopefully convey more information than this
Of my four LORs, one was from the Orthopaedic Surgery Program Director at my med school (a Program Director and/or Chairman letter is required by all Orthopaedic Surgery programs, and many other specialties as well). A lot of students don’t have much significant interaction with their desired specialty’s Residency program director, so the LOR ends up being a fairly generic template, not offering much personal insight. However, I worked with Baylor’s Orthopaedic Surgery program director on a weekly basis for six months in order to build a relationship. We interacted professionally in the clinic and operating room, and also got to know one another quite well and joked around a lot. I made sure to keep regular contact with him even after we stopped our weekly sessions.
Similarly, another LOR was from the Orthopaedic Surgeon I worked with daily during my month-long Ortho rotation at Baylor. I was also working with him on a pretty extensive Orthopaedic basic science research project. We met regularly, got to know each other very well, and I valued his advice a lot. He was able to write about me as both a student rotating on his Orthopaedic service and also as a researcher.
My third LOR was a combined Orthopaedic Department letter, compiled and written with input from all the surgeons and residents I had worked with at Baylor and signed by our Department Chairman. I made it a point to work with as many attendings as I could, and took regular night call with the residents. This was all during the period where I was evaluating Orthopaedic Surgery as a possible specialty choice (detailed above), and it allowed me to get to know and work with most of the Department at Baylor.
My fourth LOR was not written by an Orthopaedic Surgeon. Although it’s recommended that all four LORs be from physicians in that field (especially for Orthopaedics), I had good reason to go against the grain. I was enrolled in the Space Medicine track at Baylor, which is a set of additional course-work and research requirements focusing on changes in human physiology upon exposure to the microgravity environment of outer space. Baylor’s strong partnership with N.A.S.A. makes this supplemental course-work possible. Many of our professors have research or teaching affiliations at both institutions because of their proximity in Houston, TX. I was very involved in the track (I’m an insufferable space nerd) and did a lot of research with my mentor on several projects, ranging from wound healing derangements, immune dysfunction in microgravity, and the application of non-thermal argon plasma in mesenchymal stem cell differentiation. We developed a very collegial relationship, even traveling to Disney World in Florida for a week to present our research at the Aerospace Medical Association’s annual conference. Because of the shear uniqueness of Space Medicine, and the number of projects I’d done with my mentor, I knew this would be a very strong letter despite not being from an Orthopaedic Surgeon.
How I did Space Medicine "research"
So those are the four LORs that I had, and how I developed relationships to make sure my letter writers knew me as more than just another student who was passing through. A final comment I’ll make about LORs is HOW TO REQUEST someone to write you a letter. You must be professional and courteous, but it is imperative to make it clear that you want an exceptional letter. For all of my LORs, I scheduled a formal meeting with each professor in person. I reiterated my strong desire to become an Orthopaedic Surgeon, and directly asked them “do you feel that you’re in a position to write me a very strong letter endorsing my application for Orthopaedic Surgery?” All my writers readily agreed and assured me that they would write glowing letters on my behalf. I also provided each writer with the following:
Up-to-date resume (including formal education, research, work experiences, honors & awards, relevant extracurriculars)
My Step 1 score report
Draft of my personal statement (which of course is also part of your Residency application)
Some students feel shy about being this direct. But timidity will only hurt you. Some faculty members will agree to write LORs, and just use a canned template that carries no weight. Even worse, every now and then you hear the horror story of a student receiving a negative letter because they didn’t set expectations from the start. If you are this honest and forthcoming, people will respond in kind and respect you for it. And do not feel bad about following up on your LORs by REMINDING YOUR WRITERS OF DEADLINES for letter uploads to the application system (your writers have to upload your LORs themselves). I sent several reminders to my LOR writers (after all, they’re busy and may forget). This is the most important application of your life, so take charge.