"Do you have any questions?" Part 3 of 3 - evaluation, program metrics and well-being questions to the interviewer

In the last 2 blog posts, we looked at questions that I very much encourage you, the residency applicant, to ask the interviewer. These questions pertain to clinical experience during residency and teaching/learning and research opportunities. Here is the third installment to this post where we add more questions to your bag of questions that you can confidently ask the interviewer and show your interest and commitment to the program where you are interviewing.

"How is my performance evaluated during residency?" "Do I get face-to-face evaluations or written feedback?" "Besides the teaching attendings, are there others such as chief residents or nurses who may be evaluating me?" "Do I have scheduled meetings throughout the year with the program director for feedback?" During residency training, your performance as a physician in training and as a person are being closely monitored at work at all times by your colleagues, medical students, teaching attendings, subspecialty consultants, non-teaching attendings, nurses and hospital staff.  Your evaluations during residency are critical in shaping you to be a wonderful physician. If that doesn't motivate you enough, you need to maintain an impeccable profile because residency evaluations are critical in obtaining a fellowship or a clinical practice position in an academic or private setting. Residency evaluations may be available to you in a written form [using platforms such as New innovations] either because of lack of time or interest to have a face-to-face conversation. Make sure you have ample opportunities during residency to receive constructive feedback and do your very best to act on these evaluations.

"What was the boards passing rate for the last class that just graduated?" "Are you satisfied with the boards passing rate for the recent graduates?" "Does the program have separate board review sessions or is it incorporated into the other teaching conferences?" "What resources or board prep materials are provided by the program?" After you complete your residency, you become eligible to take the boards [also called the 'initial certification exam'] administered by ABIM [for internal medicine] and other similar boards to become a "board certified physician". If there is one objective metric that very quickly tells you (and a layman) how effective is the teaching environment and culture in a residency program, it is the Boards pass rate.  Every program cherishes to have a 100% boards pass rate. While some may argue that the individual performance on the boards is a reflection of the graduated resident and his or her test taking skills, if a program has a lower than median boards pass rate for that specialty, it needs to implement changes in the teaching curriculum to improve the performance. Here is a link of publicly available board pass rate in internal medicine and you will find a rare program that had a 64% board pass rate, a very concerning program metric. In my opinion, >90% board pass rate is very good.

"Could you let me know about the previous graduates and what career paths - fellowship, research or private practice have they pursued after residency?"  This is again a good question to ensure that your career path aligns well with the general trend in the program.  For example, if you wish to be a private practitioner in a community practice, then it's not very necessary to work at a large academic medical center that is focused on research grants and publications. To meet your goal in this scenario, you want to be in a community hospital where you will be exposed to different styles of clinical practice. Similarly, if your goal is fellowship or an academic career, then matching at a program that offers no fellowship or limited research opportunities could make you miserable. A lot of programs do provide information on recent graduates on their website or may highlight this information before the interview. However if this has not been discussed, make sure you ask either the program director or any other interviewer. As in my prior post, use all available resources such as the program website, YouTube, Twitter, Facebook to learn as much as you can about the program before you interview.

"Could you let me know how the program helps me match into a fellowship or a clinical practice position after residency?" In the current times with information overload and a lot of noise, it is possible that your stellar application may be ignored by a potential employer.  To avoid this, you need to engage the networking skills of your program director another teaching attendings to help you land the position that you desire.  Asking this question gives you an idea of how committed and invested is the program in ensuring your success. Are they willing to pick up the phone and market your resume and reach out to their contacts? Or are you going to be on your own? Ask any graduating resident and everyone agrees that this support from the program and the program director works wonders.

"How does the program foster well-being among its residents?" " Am I assigned a mentor during my entire time in residency? Is the mentor in the same or a different specialty?" Residency training can be tiring and arduous. The long work hours, nature of clinical responsibilities, electronic medical record use are alleged to be some of the drivers of burnout. Burnout and emotional distress have generated a lot of discussion in the media.  Studies indicate that about 50% of residents experience burnout that some consider to be a precursor to depression. It is absolutely imperative that your mental health and emotional well-being during residency training are in the best shape possible.  This allows you to be productive during the long working hours of residency. After you ask this question, assess the interviewer's response to this question. Do they deny that burnout even exists? Are they willing to work with you?  Is employee and family assistance program [such as a counselor] available around-the-clock? I myself experienced a distressing situation of a patient death and was able to get back to my life and work after reaching out to EFAP at my hospital. There should be absolutely NO stigma in asking for help. Find out how easily approachable are the program director, chief residents and any other teaching attendings. "Does the program have events to promote collegiality between residents such as social events or outdoor events?" You may also add to this question by letting the interviewer know how you choose to maintain emotional well-being. If you family, friends or relatives in the area who can offer you social support, make sure the interviewer is aware of this fact as this is a strong reason to rank you. If meditation, yoga, exercise, music, art or outdoor events such as hiking or skiing helps you build resilience, do let the interviewer know this. In short, be prepared to answer back if the interviewer asks you about your coping mechanisms.

That is it for now.  I hope that these three posts provide you with a variety of questions and the rationale behind asking the interviewer. You don't need to ask each and every question but would be great if you could ask an appropriate question in the right circumstance. For example, if the interviewer is talking about the collegiality among residents and faculty, a question on resident well-being would be most appropriate and so forth. All the best!

Before you go: Here's your golden opportunity to have your voice heard! Write down your ONE question regarding your US residency program application, personal statement, interviews or anything that has been bothering you and keeping you up at night. You can reply at the end of this post or message at my Facebook page or email me at varun@ed4medus.com

The top 10 popular questions will be featured on my next blog posts at https://ed4medllc.blogspot.com/ and the winners will receive a coupon each for a FREE practice interview at Ed4medus.com ! Put those thinking caps on and hurry up!

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"Do you have any questions for me?" Part 2 of 3 - clinical practice and training questions

In my last blog post, we looked at some very engaging questions in teaching and research that you can and should ask the interviewer. Here's a continuation of that blog post. We will now focus on questions pertaining to clinical practice and training. Let's dive right in.

Clinical questions:
You will be spending an enormous time of your residency training at work. No wonder that your title is going to be a 'resident' who lives, breathes and works long hours in the hospital. You need to make sure the program can cater to your personal and professional needs.

A few years ago a common question was "does the hospital use paper or electronic medical records (EMR)?". But now as EMR is so prevalent in every hospital, more practical questions are "which EMR is used in the hospital?" "Is this the same EMR in the clinic (or at any other locations that you will need to rotate)?" "Do I have access to the EMR from home?" The VA hospital has its own EMR and so if you are in a residency program where you need to rotate in a VA hospital, it is very likely that you will need to learn a second EMR. While the learning curve to master a second EMR is going to be steep, some residents like the idea of exposure to a second EMR in case they have to eventually work at another hospital that has an affiliated VA hospital. Just make sure you understand what you are getting into. Every hospital provides orientation at the start of residency so it's not necessary to ask the interviewer how you would be trained to operate the EMR. I don't believe scribes are available to residents yet.

The cross coverage responsibilities are clearly addressed so that's not really an important question to ask. Also with ACGME duty hour regulations,  the clinical responsibilities in every program are usually standardized.

For IMGs, you want to be sure that patients and hospital staff alike respect you, your hard work, your skills and experiences and willing to work with you despite your accent, personal preferences or skin color. I was once asked "What has been your experience about racism in this community?" I was taken a little aback by this question, probably because I never expected it. In the current times, I think this is a fair question to ask. You want to be in a program that embraces diversity and inclusion among your colleagues and everyone in the hospital. You want to make sure that you will have support if a colleague or patient makes racist comments against you. If you don't wish to be blunt by asking "Has the program witnessed events where racist comments were made to the resident? How was that handled?", you could rephrase to ask "How does the program support diversity and inclusion for residents who come from other countries?"

"Are there any characteristics about the patient population such as insurance coverage, special populations such as refugees or patients speaking a different language that I need to be aware of ?" Now this is not to be a factor in deciding whether to rank the program or not. But if you are interviewing at a program that has a large Spanish speaking population and if you do know Spanish, make sure your interviewer knows about it! Or, if you happen to find out that Dearborn MI, a suburb of Detroit, has a large middle Eastern population and if you have a middle eastern origin, letting your interviewer know this fact assures the interviewer that you will fit and settle down well in the community. When I interviewed at my current program, I was told about a large refugee population from Nepal and Bhutan in the community. So I asked the interviewer whether "interpreter services are readily available?" Thanks to this wonderful service available anywhere in the hospital through iPad, taking care of non-English-speaking patients is not an issue at all.

"I am very interested in developing point of care ultrasound (POCUS) skills as a resident. Could you let me know about the resources available for me to learn this skill? Are there dedicated faculty members to train me in POCUS? Is there a way for me to get certified in POCUS?" Point-of-care ultrasound training is being increasingly available to medical students and residents and is a fantastic skill to acquire. Some programs are just starting to incorporate POCUS in their curriculum. So make sure you will have some training in POCUS. "What procedures will I do as a resident? Are there a certain number of procedures that I need to do for graduation?" If you are in a procedure based specialty, make sure you know your responsibilities in doing procedures and the kind of  interventional radiology or surgical support and backup available to you.

"Is there a simulation lab for me to learn codes or CPR training?" If they have already talked about the sim lab in the morning introduction, you may choose to ask more details such as "Which scenarios are simulated in the sim lab such as the ICU, cardiac arrest or line placement?" or "Who leads the sim lab for residency training?" or "How accessible is the sim lab at different times of the year?" Residents commonly have access to a simulation lab, especially if there's an adjoining medical school.

"Could you let me know how does the program provide balance between learning and clinical work?" "Are there any specialties that have a non-teaching service?" "Is there a non-teaching service?" While the goal of residency training is learning while working, sometimes it is debatable whether a resident would attain any educational value from taking care of a patient with chronic stable issues or who is waiting for placement into an outpatient nursing home. Some programs have  hospitalists or nurse practitioners take over care of a patient as a non-teaching service. Do be careful when you ask this question as you don't want to sound to the interviewer that you are lazy.

"Is Uptodate easily available?" Uptodate is this wonderful resource available to physicians in the hospital commonly at every computer terminal (or even on phones and tablets nowadays) that serves to provide the latest evidence based information on any medical condition. It is also very helpful while you are preparing your case presentations for morning report and need help with a comprehensive summary of the research literature. You can also look up drug doses. In the current times, I can even say that any hospital that does not provide access to uptodate is doing disservice to its physicians and residents.

A question that can lead to more questions:
"Is there anything you feel I need to do so that I can best prepare myself if I were a resident at your program?" Now this is a tricky question. You are subconsciously putting in your interviewer's mind that he or she should accept you into their program. Some interviewers may fumble as this would mean a critical review of your application to identify deficiencies or areas for improvement. But some may counter your question with "Nothing that sticks out right now. What exactly do you have in mind?" Caught in your own trap? How do you answer this? "I was wondering if I may need an accent reduction program?" or "I was wondering if being able to observe the residents a few weeks before the start of residency can help me get off the ground quickly especially with learning the EMR?" Don't over do this. I would suggest asking this to just one interviewer (probably the program director).

That's all for now!  The next blog post will have questions on resident evaluation, the back well-being and other questions that you can ask the interviewer at the residency program.  All the best! Do join the mailing list to get the latest blog posts delivered right to your mailbox and leave any comments below.

Before you go: Here's your golden opportunity to have your voice heard! Write down your ONE question regarding your US residency program application, personal statement, interviews or anything that has been bothering you and keeping you up at night. You can reply at the end of this blog or post a message at my Facebook page or email me at varun@ed4medus.com

The top 10 popular questions will be featured on my next blog posts at https://ed4medllc.blogspot.com/ and the winners will receive a coupon each for a FREE practice interview at Ed4medus.com ! Put those thinking caps on and hurry up!

Photo credit for image on top of blog post: http://www.spellerinternational.com.au/wp-content/uploads/2014/07/shutterstock_180206270-1000x445.jpg

'Do you have any questions for me?' Part 1 of 3 - teaching and research questions

So you have made it to the residency interview. Congrats! The interview is going well and you have said everything to the interviewer that you planned you say. As the interview comes to an end, the interviewer then throws "Do you have any questions for me?" at you. How should you tackle this question - should you choose to be modest and not trouble the interviewer or is this another opportunity to shine at the interview? Read on.

On the surface level, 'Do you have any questions for me?' seems a a very benign question. In my opinion, the interviewer is giving you yet another chance for you to show your interest in the program and your critical thinking skills.

Before you go for any residency interview you have a lot of information accessible to you through the programs website, emails sent to you by the program coordinator, YouTube, twitter, PubMed, local information about the town, climate, jobs, schools, safety and so on. So while you don't want your questions to be redundant and boring, asking the right questions can demonstrate your interest in the program and commitment to excel in your career.

In my online practice interviews at Ed4MedUs.com (schedule your practice interview here), these are some questions that applicants have practiced asking me (and I would like to be asked) as an interviewer.

General questions:
The best questions in my opinion are in the form of “I read on your program's website that your program does such-and-such – could you tell me more about that?” Again, this shows that you're interested in the program and have taken the pain and effort to review the program website or materials.

It is nice to ask the program director as to "what major (or significant) change are you anticipating in the next few years?". Here you could also ask about any changes in the teaching methods or research opportunities that may become available in the near future. But do remember that some of these changes may not happen during your time in residency, so take this with a grain of salt.

Teaching:

"What are the teaching conferences that I will be attending (or participating) in?". This question may be partly answered during the morning introduction to the program by the chief resident (or the program director). "How frequent are the morning report and noon conferences?" - these are the traditional bread-and-butter teaching styles in any residency. However, lately there has been a lot of debate on the educational value of these conferences as residents usually get paged by the nurses and honestly because of our rapidly declining attention span. Some programs have chosen to have academic half days where the residents have protected learning time and are not to be disturbed during these conferences. If the program that you're interviewing at does not have academic half days, ask the program director if they are considering this in the future. Or if they do have academic half days that they started very recently, asking them a question such as "I noticed that the academic half days were just started last year. How is that working out for the residents and are you planning to continue it or make any enhancements?"

Other teaching activities include sub-specialty rounds, grand rounds and M&M (mortality and morbidity) rounds. See if the program is engaged in any of these teaching activities. A schedule of teaching conferences is usually handed out to every applicant and does not need to be asked to every interviewer, especially a sub-specialist consultant. Make sure you are fully aware of all the learning opportunities as well as your teaching responsibilities as you certainly will be asked to present cases at morning report or a paper at journal club.

If not answered already, ask the interviewer "I have an interest in teaching medical students. Would I have opportunities to do so?" This can be a very enriching experience and is great for your resume if you're considering an academic career. Some residents volunteer in an adjoining medical school to facilitate small group sessions. If you have a flair for teaching, go ahead and make sure your interviewer knows about it.

Research opportunities

"What research projects have residents completed?". 
"What research opportunities are available?". 
"Is there a research rotation or protected time for research?" "If so, how many weeks is that?"
"Are there specific faculty members to guide research planning and work during residency?" Every residency program needs to have every graduating resident complete a 'scholarly activity'. This can range from a poster presentation all the way up to a manuscript publication. A resident may choose between an actual research study or a quality improvement project. But to do any of these research activities require a huge investment of time and effort by the resident and commitment by the teaching faculty.

"What are the resources for research or scholarly activity available in the institution?" Some University programs have a Teaching Academy that serves as a formal resource where you can become a protege under a research mentor who guides you through various stages of research such as coming up with a research question, applying to IRB, data collection and analysis, completing the study and presenting the data. You need to realize that you have limited time in residency so please only choose projects that are feasible. PubMed is an excellent resource for all research publications that came out from the institution where you are interviewing. If  you are considering an academic or a research career after residency, make sure that the program where you are interviewing can make you a great doctor and also an excellent researcher. Make sure you are aware of this before the end of the interview day.

Before you go: Here's your golden opportunity to have your voice heard! Write down your ONE question regarding your US residency program application, personal statement, interviews or anything that has been bothering you and keeping you up at night. You can reply at the end of this blog or post a message at my Facebook page.

The top 10 popular questions will be featured on my next blog posts at https://ed4medllc.blogspot.com/ and the winners will receive a coupon each for a FREE practice interview at Ed4medus.com ! Put those thinking caps on and hurry up!

Photo credit for image on top of blog post: https://maria.gorlatova.com/2015/02/pm-job-candidates-please-ask-questions-in-your-job-interviews/

'Tell me about yourself' - the classic icebreaker question in any interview

'Tell me about yourself'. Often called an 'icebreaker' or 'elevator pitch', this is an open-ended question you are almost guaranteed to be asked. Lets face it, a residency program director has a lot of applicants to interview (on average, a residency program with 7 spots interviews 95 applicants - click to see my previous blog post). There is no way he or she can remember each and every application. This is of even greater concern for 'guest' faculty attendings who serve to interview intermittently throughout the interview season.

'Tell me about yourself' is an opportunity for you as the applicant to put your best foot forward i.e. say everything you had prepared to say and that you wanted to make sure the interviewer has heard. Did you have an exciting research project or a case report that you are working on? Did you have a very moving experience like working in a disaster area or how you discovered your passion for teaching? Here's your chance to shine.

What exactly should you say? Here is a framework:

(Source: https://www.amazinggoodwill.com/hs-fs/hubfs/Marques%20Clark/Elevator-speech-02.jpg?width=564&name=Elevator-speech-02.jpg)

Here is an example from a practice interview that I conducted online at ed4medus.com (schedule your practice interview here)

"I am an international medical graduate from India. After I graduated from med school in 2018, I looked closely at my future career options. Fortunately, my brother who lives in California encouraged me to explore medical residency in US. I talked with graduates from my medical school who are in US and I then decided that the high quality of training, education and research opportunities in US residency would be best for my career.  I took Step 1 and Step 2CK and then landed in Atlanta for US clinical experience. I am currently a research assistant at Emory University in the Endocrinology division. My role is to survey patients with diabetes on their knowledge of hemoglobin A1c. I ask patients if they know what their A1c is and what should be the target A1c. We hope to correlate this data with their actual A1c. I also observe the attendings in their diabetes clinic. Now the reason why I got very interested in internal medicine is that I love pathophysiology. I find it very interesting that I can apply my knowledge of pathophysiology to understand a patient's problem and come up with a treatment plan. I particularly enjoy talking to patients and explaining complex diagnoses in simple terms while being honest and reassuring to them. I am very interested in training in a community hospital program that is just not too big or small and where I can have opportunities for research and fellowship. In fact, I was recommended to apply here by J_ J___ who graduated from this program 4 years ago and spoke very highly about the training he received. I haven't decided which fellowship yet but I find myself drawn to nephrology. I believe that my passion to work hard and train hard in a warm and supportive program will greatly help me grow as a physician." - A.K.

Red flags: Don't make it sound like you gave the exact same speech at another program. You need to personalize your 'elevator speech' to every program. Maybe you have a friend where the program is located. Maybe you know a former grad in that program. Maybe you are interested in the location for your spouse. Maybe you are interested because of school system for your children. Try to give the interviewer as many reasons as possible as to why you would be the perfect fit for their residency program. 

So that's it - what is your favorite response to 'tell me about yourself'. Share your wisdom in the comment box below and I will offer my feedback to your response.

Before you go: Here's your golden opportunity to have your voice heard! Write down your ONE question regarding your US residency program application, personal statement, interviews or anything that has been bothering you and keeping you up at night. You can reply at the end of this blog or post a message at my Facebook page.

The top 10 popular questions will be featured on my next blog posts at https://ed4medllc.blogspot.com/ and the winners will receive a coupon each for a FREE practice interview at Ed4medus.com ! Put those thinking caps on and hurry up!

Photo credit for images in this blog post: https://www.successco.com/images/2008/06/25/meeting_success.jpg; https://www.sacmeetings.org/files/images/students/elevator-pitch.jpg

How do Program Directors decide which applicant to interview and rank? Here are the data from a national survey

Have you ever wondered what is a residency program director (PD) really looking for in a residency applicant?  Are they looking for stellar USMLE scores? What about research experience? How important is US clinical experience? Let's look at the available data to answer these questions.

NRMP surveyed PDs in 2018 and scored a variety of factors that a PD looks at when he or she receives a residency application.

Disclaimer: The survey had a response rate of about 30%.  This means that more than two thirds of the program directors did not respond to the survey and there is no way of knowing if those non-responders would act differently from the data summarized below. Also there are subtle differences in how each specialty values these factors in selecting applicants for interview.  You can look up the details pertaining to your specialty of interest in this link.  The following summary takes into account all specialties and is a valuable starting point.

1.  USMLE scores.  94% of residency program directors cite USMLE Step 1 score as an important factor in selecting an applicant to interview with an average rating of importance of 4.1. To me, this was interesting. I wondered if performance in a standardized exam in the 2nd year of US medical school that tests knowledge and application of basic sciences and pathophysiology could reliably predict how good a resident you are likely to be. It's possible that in residency training, having a good foundation of knowledge can help residents build their diagnostic and management skills quickly.

Also 30% of these responding program directors indicated that they would not consider an applicant who failed step 1 on the first attempt.

These data indicate that USMLE Step1 score is very important in enhancing your chances of getting an interview offer.  So what score should you be targeting? The responding PDs in 2018 indicated that Step 1 score of about 235 and above almost always qualifies for an interview, while a score less than 218 generally disqualifies that applicant for an interview.

What about Step 2CK scores? Fewer PDs [80%] considered Step2 CK score important while 94% of the PDs gave more weightage to Step1 score. However, it is difficult to know if this is truly the case (see the above disclaimer about non-responder bias). Similar to Step 1 data, 35% of the PDs would not consider an applicant for interview if he or she failed Step2 CK on the first attempt. Again, a median score of 235 and higher resulted in an interview offer.

My interpretation of this data is that a score of 240 or higher (greater than 75th percentile in this report) should remove any doubts in your mind about your USMLE scores impacting your chance to get an interview. Again remember this is just one of the many other factors in your application that is considered by the PD. 

2.  Letters of recommendation. Letter of recommendation were second most popular among PDs in deciding whether to interview an applicant. PDs certainly want to get a feel for the applicant's professionalism, commitment and their actual performance in clinical rotations.

Think for a moment from the shoes of a PD.  On average, for 7 residency positions in the match, the program receives 904 applications of which 121 qualify for an interview. That is, for every 10 applicants, only about 1 gets an interview letter. Besides using the USMLE scores as discussed above, the PDs also review the letters of recommendation in making this decision.

I would consider it very essential to obtain letters of recommendation from a US physician.  If you are an IMG, these letters are highly regarded and carry much more weight than that from a physician from your home country. While letters from a community physician are helpful, I would recommend working with and obtaining a letter from a teaching faculty member at an academic medical center through an observership, clinical rotation or research opportunity. This also increases your chance of interviewing in that academic medical center and other teaching hospitals especially if the faculty member is well known.  Four letters of recommendation are golden.

The Dean's letter (or MSPE) is also very important as it summarizes the course of an applicant's entire four years in medical school including the basic and clinical sciences.  Here are some examples (example 1, example 2).  The dean's letter also states class rankings as every medical school has its own way of grading the performance of its medical graduate. The Dean's letter typically includes snippets of written evaluations by teaching faculty members and grades to offer a 360 degree evaluation. If you are an IMG, chances are that your dean's letter is going to be very different. See if your medical school is willing to draft a dean's letter as in the specifications and examples above.

3. Commitment to specialty and evidence of professionalism and ethics: This should be evident from your ERAS application, work, research or volunteer experiences and personal statement. Remember that the personal statement should not repeat what you stated in ERAS - it should describe what skills you gained from an experience or how you became a better physician (and person). For example, as an IMG, you should offer details on your observership in your ERAS application. And also, you should describe how the observership prepared you for residency by giving you a glimpse of the interactions between residents and attendings, patient communication, EMR and team management.

4. Grades and class ranking. Are you someone who is just good at taking exams and scoring well? Or have you done well the entire time in medical school? This will be evident by your scores and MSPE/Dean's letter.

5. Research experience: Interestingly, only about 40% of PDs chose to consider research experience in their decision making. That seems quite low. It may be because PDs know that not much meaningful research can be completed during medical school, let alone that it be presented in a conference or published. It is very difficult to complete any solid research in 1-3 months. The most you can do is a survey or retrospective chart review. Quality improvement is another feasible option.

Some other notable findings:

1. Program directors were very clear that if the candidate was 'flagged by NRMP' for irregular behavior or match violation, they would not interview or rank that applicant. Don't get yourself into any trouble.

2. Visa status for IMGs: This was important for some PDs (about 40%). Now this does not mean that PDs are not worried about visa status for IMGs and will call an IMG for interview without looking at their visa needs! You wish. It means that the PDs who didn't need to bother about visa status either (a) are not planning to invite IMGs or (b) are not planning to sponsor a visa anyway or (c) will sponsor only J1 visa that requires little work and expenses from the program standpoint.

3. Personal prior knowledge of applicant: More than 2/3rd of the responding PDs strongly considered this factor in their decision to interview an applicant! This just goes to show that NETWORKING is key! Use all your resources - friends, family, medical school alumni, just anyone really. I remember a shopkeeper once approached me as his nephew was looking for an observership!

That’s all for now. Hope you like this blog. I would love to hear your thoughts and comments. Join the mailing list for the blog or my facebook groups and check out Ed4medus.com to learn more about personalized services to help you get into a US medical residency program.

Before you go: Here's your golden opportunity to have your voice heard. Write down your ONE question regarding your US residency program application, personal statement, interviews or anything that has been bothering you and keeping you up at night. You can reply at the end of this blog or post a message at my Facebook page.

The top 10 popular questions will be featured on my next blog posts at https://ed4medllc.blogspot.com/ and the winners will receive a coupon each for a FREE practice interview at Ed4medus.com ! Put those thinking caps on and hurry up!

Photo credit for image on top of post: http://digitaluniversity.elis.org/wp-content/uploads/2018/04/smart_recruiting.jpg

How to decide where to apply? Things that applicants look for in their desirable US residency program.

Selecting which residency program to apply to is an arduous task.  How does one decide which ones among the thousands of residency programs in US should he or she apply to?  You cannot possibly apply to ALL the programs. While limiting the number of programs to apply to, also consider the fact that the costs go up considerably beyond 30 programs.

For example, if a medical graduate applied to 80 residency programs (this being the median number of applications submitted by an independent applicant in 2019), the cost of submission would be about $1800 (use the official residency fee calculator here). Also, it would be very difficult to interview beyond 12-15 programs because of travel costs, interview scheduling and your personal stamina.

It is very difficult to know how many programs to apply to without risking the chance of losing a potential interview by applying to fewer residency programs.  This becomes even more challenging for an IMG.

As discussed in my previous blog, independent applicants [that is US citizen IMG, non-US citizen IMG, or former US medical graduates] applied to a median of 78 residency programs as compared to 39 programs by US seniors. This is to say that, independent applicants had DOUBLE the number of residency applications as that of a US senior.

The NRMP data table provide information on how medical graduates decide to apply to a residency program and rank a program for matching. Here is a summary of the top 5 factors from the NRMP survey (ranked in order of importance):

1.  Desired location.  Location, location, location! This is the most important factor for applicants to decide which program to apply to. This comes as no major surprise as you will be spending three or more years of your professional life, living, breathing and working in a hospital. What is it about the location that is so important? Everything! Consider the safety of the neighborhood where you would be living and where the hospital is located, having family and friends in the area, cost of living, rents, climate, time spent on traffic, ease of getting to and from your workplace, activities for yourself and family such as restaurants or jobs for spouse, schools for children are some of the essential factors in deciding a location.

For example, a friend of mine chose not to apply to New York City even though he knew of the many IMG friendly programs in that city as he was turned off by the high cost of living, questionable safety and traffic difficulties. This is a very personal decision, but an excellent starting point as your start to narrow down the list of programs were you intend to apply.

2.  Perceived goodness of fit.  There is a lot of subjectivity in deciding whether a program is a good fit for you are not.  Some applicants prefer a small program that allows closer and more personal interactions with the teaching attendings as opposed to a much larger program in major teaching hospital where you maybe just a "person in a white coat". The goodness of fit is best assessed at the time of the actual interview day. A residency program with two or more IMGs is looked upon favorably by IMGs. So ask yourself if you will be happier in a program with 8, 20 or 50 residents.

3.  Reputation of program and academic medical center program.  Residency training at a reputable program is likely to increase your chances of landing a satisfying position after graduation, and more importantly helps you get into fellowship programs or academic careers. This is because of greater research opportunities in academic medical centers as compared to community hospitals.

Now this may be less of a concern if you choose to be in private clinical practice after residency graduation or are unable to get interviews because of your residency application (such as low USMLE scores, second or more attempts or long time since graduation). As alluded to in my earlier post on five reasons to pursue US residency training, training in an ACGME accredited program and obtaining board certification are adequate for one to have a thriving clinical practice. So, take it easy.

4.  Collegiality among residents and teaching faculty and quality of educational curriculum. This may be difficult to judge just by browsing through a website. Some helpful information to learn about a program include fellowship match rates or boards passing statistics. 

On the actual interview day, one should get a feel for the collegiality among residents. What is the morale of the residents? Do they look troubled at work? Are they willing to help each other out? Are many attendings approachable and easy going or are they malignant or aggressive? Do you think the program director would be a good friend for the next three years of residency (or even many years later)? 

Look for any teaching initiatives or changes in educational curriculum (such as academic half days or point-of-care ultrasound) that the program is proud of. Are the chief residents and faculty responsive to feedback from the residents?

You surely have heard of the highly prevalent burnout and emotional distress among US resident physicians. Choose to train in a learning environment where your colleagues can look out for each other and the faculty is approachable and helpful to you as a person and a physician. This is very important. You want to be training at a place that is comfortable to you but at the same time that does not leave you stressed and emotionally drained. Try to find out how the program is invested in your well-being.

5.  Work-life balance (or work-life integration).  Again this is specialty specific. Find out if the program encourages or even actively participates in out-of-the-hospital social gatherings and activities such as the events found in my hospital. Look on Twitter or Youtube. Get a feel for the kind of documentation responsibilities while you take care of the patients. Also, look at the number of electronic medical record systems (for example, a VA hospital has a separate EMR system if you also round in the VA hospital or clinic). While this should not be a deal breaker, it is best to be fully aware of the extra effort you may need to put in.

TWO additional points to be noted:

1. Salary and benefits are very similar in all residency programs. This should not really be a consideration when choosing between ACGME accredited programs.

2.  For IMGs and those requiring visas, visa sponsorship is of the highest priority (if you need a visa and the program will not offer you one, there is no way for you to work in that hospital). Visa sponsorship would be an important starting point for IMGs as they narrow down their list.

That’s all for now. Hope you like this blog. I would love to hear your thoughts and comments. Join the mailing list for the blog or my facebook groups and check out Ed4medus.com to learn more about personalized services to help you get into a US medical residency program.

Before you go: Here's your golden opportunity to have your voice heard. Write down your ONE question regarding your US residency program application, personal statement, interviews or anything that has been bothering you and keeping you up at night. You can reply at the end of this blog or post a message at my Facebook page.


The top 10 popular questions will be featured on my next blog posts at https://ed4medllc.blogspot.com/ and the winners will receive a coupon each for a FREE practice interview at Ed4medus.com ! Put those thinking caps on and hurry up!

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The ONLY reason why you should FOREGO your dream of US residency training

In a previous blog, I discussed five reasons why aninternational medical graduate (IMG) should seriously consider pursuingpostgraduate medical education in US. But what might be absolute contraindication(s) i.e. are there some reasons one should totally give up the thoughts of US residency training?

After a lot of thought and search, I could find just one potential problem: Having a cause for the state medical board to not authorize you to practice medicine would be this sole reason.

So having a criminal history, being involved in litigation or a medical malpractice case, irregular behavior on the exams, history of drug or alcohol use jeopardizing your ability to practice, being dismissed or withdraw(n) from medical school, medical school not being in the world directory of medical schools, multiple attempts at USMLE (maximum 3 attempts for my state of VT https://www.fsmb.org/step-3/state-licensure/) are serious red flags.

Here is another blog post with more details. 

Any information pertinent to the above needs to be revealed to residency programs (in ERAS) when you apply and to the state medical licensing bodies. If you have any of these red flags, you really need to weigh whether it is worth applying to a US residency training. 

Psychiatric or physical disability is something that you cannot be discriminated against and need to provide the information to residency programs and the medical boards. 

Other factors below are not insurmountable: 

1.  1. Specialty choice: maybe you were an orthopedic surgeon, ophthalmologist or neurosurgeon in your home country and looking to be one in the US. If you choose to pursue a competitive specialty (as in my previous blog post), you would just need to be prepared to go through a long steep road with many bumps and have the resilience and patience to ‘stay the course’. You would really need to strengthen your portfolio through research, publications, networking. I personally know two general surgeon IMGs who after trying for a few years to get into general surgery, then chose to pursue internal medicine residency and move on with their lives. This might work for some and not for some - you need to decide.

2.   2. Need for visas: yes this does make it onerous to get interviews and match, but again you need to buff up your portfolio as best as you can through research, clinical observerships etc. Some get lucky to marry and have a spouse with US citizenship that opens a lot of doors for their careers.

3.      

4.   3. Low score on USMLE or a second attempt: What are your chances of getting into a US residency? Again, this is not an absolute contraindication. Some just are not good exam takers and still do very well. 

So that’s it – I would love to hear your thoughts and comments. Join the mailing list and check out www.ed4medus.com to learn more about personalized services to help you get into a US medical residency program.

Before you go: Here's your golden opportunity to have your voice heard. Write down your ONE question regarding your US residency program application, personal statement, interviews or anything that has been bothering you and keeping you up at night. You can reply at the end of this blog or post a message at my Facebook page.

The top 10 popular questions will be featured on my next blog posts at https://ed4medllc.blogspot.com/ and the winners will receive a coupon each for a FREE practice interview at Ed4medus.com ! Put those thinking caps on and hurry up!

Opinions in this blog are solely of the author and Ed4Med LLC and not the employers or affiliations of the author. 

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FIVE reasons to pursue US residency training.

I was once asked in an interview (for a faculty position!) as to why I chose to train in the US? That question took me for a surprise as it forced me to reflect upon the choices I made in my graduate medical education.

The following five reasons would satisfy any interviewer or friend or family questioning you and your intentions to pursue US residency training:

1.       Advanced and cutting edge technology, medications and procedures available to you as a resident. Training in India, I was very proud of my diagnostic abilities such as making a diagnosis of pleural effusion even before a CXRay was obtained. But that’s being half a doctor as disease management is an equally important skill to learn to be a superb clinician. A great example is point-of-care ultrasound that is revolutionizing medical practice and has generated a huge interest in educational research.

Having access to diagnostic tests in labs and radiological studies, medications, consultation services and, most importantly, having the patients closely follow-up with you to see the effect of your recommended treatment offer unparalleled learning opportunities. I can confidently say that as a doctor in training, this is one of the most important reasons for US residency training. You could also say to your interviewer as to how you loved these aspects of residency training in US that you were exposed to during your observership or clinical rotation.

Patients love what you do as a resident and appreciate your time and effort to talk with them. This results in many of them following through on your recommendations and follow-up appointments. Access to wonderful educational resources such as Uptodate through your residency program to get the latest information and learn the practice of evidence based medicine is an amazing perk in US residency training so that you are not in the dark.

No health care system is perfect. Yes, medical care may not be beneficial at times and occasionally brings up ethical and moral dilemmas. Wouldn’t it be great to be exposed to how experts handle these challenging circumstances? Physician burnout is a serious concern worldwide and electronic medical records may have a role in impacting well-being. Numerous initiatives to address burnout are being studied and implemented to improve well-being and for the first time, a survey of US physicians found a decrease in burnout, that to me is a very encouraging finding.

2.       Residency training in US is regulated and standardized. ACGME is the authority that ensures high quality of residency training and oversees the programs and residents. Important policy changes such as duty hour changes for residents and monitoring feedback from residents are under the purview of ACGME. ACGME accreditation of a program ensures that an internist, for example, can competently suspect MI or CVA at the end of residency training. This means that one can train in essentially any ACGME accredited program and come out as a well-groomed physician to practice medicine or surgery.

3.       ABMS (American Board of Medical Specialties) certification is recognized both nationally and internationally. After completion of residency training, the newly minted attending needs to take a certifying exam such as ABIM board certification for internal medicine. Many hospitals in US, especially teaching hospitals, require ABIM certification to ensure well qualified doctors in their staff in their efforts to maintain high standards of clinical care.

4.       You become a high-income earner after graduation. Now don’t say this to your interviewer as you are not really in the medical practice to make money (you should be in business or real estate if your intention is to make money). But, it’s hard not to think about financial returns of your hard work especially in the current climate of financial uncertainty. The nature of your specialty practice, location, type of practice and a host of other factors decide your take home pay. The bottom line is that from a financial perspective, you will do very well as a US trained physician. Even during residency training, you get paid around $60k per year that allows you to take care of basic expenses (esp if you have minimal or no loan).

5.      Numerous doors open for your after US residency training. While many choose to pursue fellowship or start clinical practice in a private or academic setting after residency, there are numerous exciting opportunities in research, industry, teaching, administration, leadership, MBA, MPH and even non-clinical careers such as medical writing, expert witness and many others that become available to you.

US residency training is very much admired and respected internationally and ABIM certification is even recognized in other countries such as Singapore and the Middle East. Some IMGs have personally decided to return to their home country to contribute and enhance the medical practice.

That’s all for now. Hope you like this blog. I would love to hear your thoughts and comments. Join the mailing list for the blog or my facebook groups and check out Ed4medus.com to learn more about personalized services to help you get into a US medical residency program.

Before you go: Here's your golden opportunity to have your voice heard. Write down your ONE question regarding your US residency program application, personal statement, interviews or anything that has been bothering you and keeping you up at night. You can reply at the end of this blog or post a message at my Facebook page.

The top 10 popular questions will be featured on my next blog posts at https://ed4medllc.blogspot.com/ and the winners will receive a coupon each for a FREE practice interview at Ed4medus.com ! Put those thinking caps on and hurry up!

Photo credit for image on top of blog post: http://weekender.com.sg/entertainment/wp-content/uploads/2019/06/esta-1-670x447.jpg