U.S. Residency Application Advice

I've received some really great advice from colleagues, residents, faculty, and online sources over the last year about the U.S. residency application process and the couples match. I attempt to compile the most helpful tips here and add my own insight (as a Canadian IMG from Saba entering my first choice family medicine residency) as a means to "pay it forward." 

Choose electives wisely: You can really focus on networking and finding a residency during fourth year. My strategy was to do rotations at hospitals that had a family medicine residency program even if my rotation wasn’t in that specialty. While I was there, I would ask for a meeting with the program director or try to get in on some of the family medicine lectures. I ended up interviewing at 3 places I rotated at plus I received interviews in all 6 states that I did rotations in. For example, I did 6 months of rotations in Louisiana and then received 4 interviews in that state. I was told by a program coordinator that programs look for where you've spent your time to assess if you would be happy in their area.

Personal Statement: I started writing this several months in advance whenever a moment of inspiration found me. I poured over it so many times I probably could have verbalized it word for word at some point. The take away point being to take this step very seriously. I also had someone with strong writing skills read it over and make edits. I made sure to take the corrections that gave me better structure and grammar but to do away with the corrections that didn’t reflect the traditional structure of the personal statement. There are lots of templates online (a quick google search will bring them up) that suggest to start with something catchy, say anything relevant that happened before your clinical years early in the statement, then spend the rest of the time talking about you and your strengths in the clinical years. Strong points to include would be why you are choosing your specialty, why you would be an asset to your specialty, where you see yourself in the future in a professional sense, and a memorable clinical scenario that shows how great you are. Don't list things from your CV - they have that information already. I made use of the comments on my preceptor evaluations so that I was presenting a clear and consistent picture of my strengths. Another source would be letters of recommendation if you happen to have access to them.

Letters of recommendation: I asked for a reference letter in person from almost every preceptor I had on the third last day of each rotation. That gave me a couple of days to make sure I had their contact info and for them to ask me any questions. I made sure to have more letters than I needed which worked well for me because one of my preceptors left the hospital that we worked together at. I sent each of my letter writers 4 documents: the ERAS letter request form, my CV, my personal statement, and Saba's cover letter. Ideally you could send them this information 6-8 weeks in advance and then follow up with them 2 weeks in advance. The date I suggested that they upload the letter by was one week before ERAS's recommended date. One letter had an issue ("too blurry") and needed to be re-uploaded, so I was happy that I had the extra time.

Photo: ERAS tries to be cool here and give you the option to upload a selfie right from your smartphone, but get a professional headshot taken if you can swing it. I decided on my interview outfit and hair style before getting the photo taken so that it would be easy for the program to associate who I was with my photo. 

Researching and applying to programs: I credit a lot of my success with receiving interviews to this. I spent most of my time researching on FREIDA which programs to apply to. I also made use of matcharesident (a paid service) and the individual program’s websites. I decided to apply very broadly in family medicine. Any program that sponsored visas and had >10% international medical graduates aka IMGs (>5% if it was an ideal locations for us) made it to our first draft list. We also screened out certain programs for more specific and personal reasons (like a strong religious affiliation not consistent with our beliefs). Pay attention to step score cut offs as well. I also looked at Saba’s match list and selected programs in my "back up specialty" that our alumni have matched at over the last 3 years (that met the visa/IMG criteria above). Then, perhaps this was overkill, but I applied to several programs in a third specialty. 

I cross referenced the list to ensure that I didn’t apply to more than one specialty at any one hospital. This is contested advice as some people do choose to apply to 2 specialities (example: family medicine and internal medicine) at the same hospital. I printed off charts and filled in information on programs manually in a binder because I like to see it in front of me. 

This worked out to a grand total of 181 programs across 3 specialties and it cost me $3600USD and I received 30 interviews from that. I was given the advice to attend 12-15 interviews max, but my anxiety is a little higher than that so I went to 17 plus one program had an essay requirement instead of a personal interview. I’ve heard that IMG’s have an average interview rate of 10% of programs that they apply to, but I have no idea how accurate that is.

One thing I obsessed over was WHEN the interviews were offered. I followed forums closely to see where we were throughout the season. They say October is peak season which was true for me too - I was invited to 8 interviews during the month of September, 20 during October, and 2 during November. I know that some of my peers received interviews into January.

• APPLY EARLY. This year, there were a few days between when you could submit applications (September 1st) and when programs could access them (September 15th). Make sure that all of your documents are in and you can apply during this time frame. This includes step scores being available. Program staff have mentioned that they would not be likely to give an interview to a person without their scores over a person with their scores with all other things being equal. Keep that in mind if there is any way to take the steps a bit earlier. Programs are excited too - they may start downloading applications as soon as ERAS opens. You want to be among that first batch of applicants.
• Reply to interview offers as quickly as possible in order to secure a date that works for you. 

Asking for interviews: I know some of my colleagues e-mailed and called programs to let them know that they were available for any interviews if there were any openings. I’ve heard that most of the time it does not work, but the odd time it does, so it is worth it to try. There is a balance between being available to programs but not being annoying. This is much more difficult for our situation because we would be asking for 2 spots. I did e-mail one program but did not receive a response.

Declining interviews: I accepted and scheduled almost every interview and then chose to cancel some after the fact. My fear was that I would decline some interviews and then I would miss some interviews due to weather/illness and then I would be left with very few. We wanted to keep a range of less competitive and more competitive programs. Our choice to decline was mostly based on the couples match and location and then sheer fatigue towards the end. Reading advice online suggested that cancelling at least 2 weeks in advance was ideal, 1 week in advance was decent, but absolutely do NOT skip an interview without giving notice to a program. It is rude and who knows if the program director to that program is best friends with the program director to your top choice program. Medicine can be a small community, especially within specialties.

Interview day: 

• Make sure to read the programs website +/- the FREIDA page before each interview. You do not want to be asking questions like “how many residents do you take per year?” when that information is so easily accessible. You want your precious moments with your interviewer to be spent on questions like “Can you tell me about how much autonomy residents receive?” or “Can you comment on the faculty-resident relationships?” 
• Remember that anything on your application is fair game so be prepared to talk about it. Failed a class? Graduated in 5 years? Make sure to have an answer that puts you in a positive light. 
• Saba told us to prepare to discuss our RLRA. Not one person even mentioned it. Not. One.
• Practice sample interview questions. I had many questions lists from various google searches in a document and I typed out answers to them as practice. Craig and I also asked questions back and forth to practice them verbally. I never used my written answers word for word, but this exercise really helped with deciding what stories and experiences were most appropriate to use. I did this before my first interview and didn't really go back to it once I started interviewing except Craig and I always went over the answer to the question "Why this program?" the night before the interview. 
• Top 10 questions I had were: Why family medicine? Why medicine? Why this program? Why this state/location? Tell me about yourself. What are your weaknesses? What are your strengths? Why would you be a good fit here? Why Saba? How do you work in a team? 
• We attended every resident dinner. Some programs told us that residents didn’t give input to applicants and some programs told us that residents were big decision makers, but we didn’t know which was which beforehand. Dress is business casual unless otherwise stated. These dinners can be very casual but don't fall into a false sense of security. They might be watching you more carefully than you think. I often had one glass of wine if I saw that residents were having drinks. I didn’t see anyone get drunk, but I heard stories, so don’t do that. Seriously.
• Do not speak negatively. You are doing well today. You had a great drive into the city. The weather is beautiful. You totally respect everyone you ever worked with. You get the idea.
• Show up early. But not TOO early. 15-20 minutes early.
• Know your audience. (Example: Don’t ask the program director about vacation time.)
• I always considered it a good thing when the conversation went off topic during interviews because that meant that the interviewer and I were connecting. I have no evidence to confirm this.
• Be professional: Make eye contact. Have a good handshake. Smile when appropriate. Wear your best black/grey/navy pant or skirt suit (I got mine at Calvin Klein). Don’t smell bad. Make sure your phone is on silent. Don't be texting during any presentations. Don't be rude to other applicants. Don't admit to anyone that this program is your back up. You would think that some of this stuff would be common sense but I've been proven wrong here. You are being evaluated from the moment you step/drive on campus.  I've even heard of programs placing one of their own staff among the applicants to listen in.
• One of the best pieces of advice I received was to have literally 20 questions prepared for an interview day. People ask you all day long: Any questions? And you need to appear engaged so you need to have a range of questions for situations from casual conversations with residents to professional scenarios with faculty. There were a few interviews where the first question I was asked was if I had any questions.
• We were told that if you get asked medical questions (which we were in only 1 of the 17 interviews) that it is a red flag. I won't get into the theories of why this is said to be true, but I'll leave it here for your own judgement.
• No one told me that interviews could actually be fun, so that was a surprise to me. Family Medicine interviews have lots of perks too - like free hotels and great food and welcome gifts. 
• Primary care interviews are generally laid back. They made me feel like they really just wanted to get to know me to see if I was a good fit. It was definitely stressful but overall a positive experience. 

Taking notes: I had a notebook that I used for every interview. I took my pre-interview notes in it and jotted down some questions that I wanted to ask. I tried to ask similar questions at every interview so that I would be able to compare programs easier. After the interview, I would write in some more subjective things like how happy the residents seemed and how much I felt like I fit in.

Thank yous: We wrote and mailed thank you cards to everyone who interviewed us unless the program suggested not to. We had custom thank you cards printed with our pictures inside them that we sent to specific programs (on the advice of a faculty member at one program) and otherwise used a simple black and white card. Some people recommend thanking the program coordinator, person who took you on your tour, people you had lunch with, etc, etc but we kept it simple with interviewers. An alternative would be sending a thank you e-mail. It is up for debate whether it makes a difference or not but I figured I would do it just in case it mattered for even one program.

Social media: I changed my name on Facebook to exclude my last name and hid any potentially inappropriate or controversial pictures/posts. I had my instagram as a private account so I had to approve any followers and I didn’t accept anyone I didn’t know. I shut down my blog from September to March. Even though my social media presence is very PG13, I think there is something to be said about access to too much information.

Professional organizations: I was told that you could be asked about your membership in professional organizations so I made sure to be a paying member of the American Academy of Family Physicians (AAFP). I wasn’t asked about it.

Couples match: A common misconception about the couples match is that significantly hurts your chances of matching. But from what I’ve read, it is supposed to be a neutral factor on your application. And from what I’ve experienced, it was actually very well received and appeared to be a positive factor. Perhaps my personal view is biased because I only interviewed at couple-friendly programs and I didn’t meet anyone who threw out my application. Craig and I also have very similar applications and we both applied to a couples/family-friendly specialty so I’m sure that played a big role in our experience. Many programs talked to us about how it creates a built in support system for coupled residents which makes them more likely to be happy during their residency. 

We were advised to make sure to register as a couple on both the ERAS and NRMP websites. It costs an extra $15 per partner. Whenever one of us received an interview, the other person would e-mail the program coordinator to introduce ourselves, let them know we were couples matching, and say that if the opportunity came up to interview then we would like to arrange our travel plans together. I received 5 interviews that way and Craig received another 5 interviews that way. That’s 10 common programs just by e-mailing. I was so nervous to e-mail programs, but it paid off so much that it was definitely worth it.

You can set up your rank list however you want, but generally you would pair every program that Partner A interviewed at with every program that Partner B interviewed at. Craig and I chose to rank all the programs where we could be together first and then rank the programs that were a reasonable driving distance apart (<5 hours), and then move on to other combinations in order of how much we liked the programs individually. We would rather have one of us matched than neither of us matched, so at the end of our list we ranked all our programs with the other partner unmatched (NRMP code 999999999). This worked out to 339 matches. I wrote out each pair of programs on a piece of paper and we put those pieces of paper in order on our coffee table. It is a bit old school but it worked for us. We then put them into an Excel document with the NRMP codes and transferred it directly from there to the rank list. We certified that list 2 weeks early and didn't make any last minute changes. Apparently if you have a duplicate pairing then the system will notify you, which is why they recommend that both partners do not certify at the same exact time.

The most significant disadvantage to the couples match would be that either partner could miss out on their top choice in order to both match at the same program. A strategy to avoid this could have been to rank our individual top choices and then if we didn’t get those then have programs where at least we were together. Another strategy would be applying and interviewing individually and then doing the rank list as a couple to try and get similar geographic locations. I met couples along the interview trail who chose those strategies. Our personal preference was to stay together even if that meant not going to our preferred programs.

Communicating your rank preferences: The program is not allowed to ask you about your rank order intentions, but if they do, play it safe and say that you will "rank them highly." You can also volunteer this information if it is indeed your first choice. Just don't say it to everyone or if you don't mean it. We told our first choice that they were our first as soon as we were done interviewing.

Rank list: It is so important to realize that the rank list favours the applicant. Make sure to rank your first choice as your true first choice and not where you think is most likely to rank you first. Also remember to certify your list to make it official. Do this early if possible since the computer system can be fussy.

I read "The Successful Match: 200 rules to succeed in the residency match" and I found it to be very helpful from writing my personal statement to practicing interview questions to emphasizing the importance of networking with the faculty wherever I was. 

Disclaimer: This information is based on my own research and experience. I didn't do everything perfectly (I asked for one LOR via e-mail, I didn't send thank you cards to my last interview, etc.) but I didn't see the utility in highlighting those things here. This advice is most applicable to family medicine residency and IMG applicants. Your results may vary.