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!

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