Being “Backable” for Residency Interviews

After reading stories of match success and failure on social media this spring, I’m already thinking about another set of virtual interviews this fall and contemplating how applicants can shine.

Here are some takeaways from Backable: The Surprising Truth Behind What Makes People Take a Chance on You. While this book and its many examples mostly center on entrepreneurship and how startups can get money from investors, there are some nuggets that cross domains nicely. The interview is in some ways a pitch meeting where you’re selling yourself.

The power of unique perspectives and experience

[Investor Ben] Horowitz responded that great ideas typically stem from an “earned secret”—discovered by going out into the world and “learning something that not a lot of other people know.”

Everyone says the same things in personal statements, is drawn to their chosen fields for the same reasons, and has largely similar clinical experiences. When you have rare real-world experience–frankly in any context or domain–that makes you different.

Share how those insights have changed you and inform your approach to medicine.

Earned insights are rare

What’s the single best piece of advice that would help them succeed?” [Oscar-winning producer Brian] Grazer paused for a moment, then said, “Give me something that isn’t google-able. I want an idea that is based on a surprise insight. Not something I could find through a Google search.”

An idea that stems from hands-on experience is way more backable than the same exact idea if it simply originated sitting behind a desk. But the catch is, without being boastful, you have to make that effort shine through your pitch. It can’t be hidden.

Here’s an open secret: a few months of clinical experience don’t make you an expert in your chosen field just as even less time in other specialties doesn’t make you an expert in those either. Bringing fourth-year swagger to interviews often isn’t a great idea.

That said, real insights–whether about your specialty, health care, or even just being a human being and having a good attitude about showing up to work every day for your patients–are a breath of fresh air. I love when I can tell an applicant has an active mind and thoughtful approach, when I can really see their gears turning.

Why should someone be scared to miss out on you?

As creators, our job isn’t to use FOMO to manipulate backers, but rather to neutralize their fear of taking a bad bet. Though it may sound strange, FOMO can make a risky bet feel safe because it shields us from the risk of being left behind. This feeling of inevitability rarely comes from the argument that we should change the world, but rather from the argument that the world is already changing—with or without us.

If there’s a knock on your record and you’re scared people are going to pass you over, own it. The typical advice is to talk about what you learned after your failure, how you’ve changed, and other such bland platitudes, but the fact is that I expect anyone who has messed up to tell me they’ve grown.

That’s all fine. Go ahead and do that.

But…don’t just approach your candidacy from a position of weakness. What about you is unique or special? Why should a program director be scared to lose you? Why are you backable despite (or because of) that setback?

Connections are powerful

Salman Rushdie once wrote, “Most of what matters in our lives takes place in our absence.” While we’re present for the pitch, we’re most likely absent for the hallway huddles, backroom meetings, and email threads that decide the fate of our ideas. Backers become fierce advocates when they are on the inside of an idea. They crack their own egg and add it to the mix.

Stronger-than-average connections with your interviewer will cause people to go to bat for you in the post-interview huddle. So many interviews are bland Q&A. True connections are rare. If you can get an organic discussion going and the time flies, everybody wins.

Each interaction is an independent variable

We don’t typically win people over in one conversation, but through a series of interactions that builds trust and confidence. Even if the last conversation went poorly, you can use the next one to show them how they influenced your work. This type of follow-up is so powerful that it can often change a backer’s response from no to yes.

You can’t really do this with your interviewer (post-interview correspondence doesn’t carry that kind of power), but you can take each interview as a fresh start.  Don’t let one sour interaction spoil the day.

Interviewing is a skill that requires practice

We’ll spend hours researching, outlining, pulling together slides—but very little time practicing what we’re going to share. The feeling seems to be that if we have the right content and we know it well enough, then there’s no need for practice. But I’ve found that backable people tend to practice their pitch extensively before walking into the room. They practice with friends, family, and colleagues. They’re rehearsing on jogs with running partners, in the break room, and during happy hour. They prepare themselves for high-stakes pitches through lots of low-stakes practice sessions—what I now call exhibition matches.

You need to practice. The common approach is to do practice interviews, often with residents and faculty at your home institution (and potentially online organized on social media). You should do those things.

But I’d take it a step further.

You should talk to strangers. Practice having genuine interactions and conversations with people who don’t know you.  Practice really listening to your patients. Get to know them as the three-dimensional human beings they are.

The easy flow of conversation is a delight to interviewers.

You are a process, not an outcome

The other techniques in this book got me comfortable with content, but I still had to learn to get truly comfortable with myself. I had to learn to let go of my ego—to express, rather than impress.

So much of your identity feels tied to your success in school, the match, and your developing career as a physician. But internal validation is always superior to external validation. You don’t and can’t control outcomes. You–at best–control yourself and your approach.

You will enjoy and likely be more successful in the match process if you are content with yourself, happy to do your best, and try to find a good fit. We call it “practicing” medicine, but living life is also the practice of showing up each day working on being the version of ourselves that we strive to be.

When you receive an interview, your goal is not to impress your interviewers. It should be to express yourself and be open to others so that you can find the best place to live and grow in your practice.

Shallow versus Deep. Prolific versus Profound.

From Rest: Why You Get More Done When You Work Less:

We see work and rest as binaries. Even more problematic, we think of rest as simply the absence of work, not as something that stands on its own or has its own qualities. Rest is merely a negative space in a life defined by toil and ambition and accomplishment. When we define ourselves by our work, by our dedication and effectiveness and willingness to go the extra mile, then it’s easy to see rest as the negation of all those things. If your work is your self, when you cease to work, you cease to exist.

What fraction of doctors (and miscellaneous business workaholics) do you think still believe rest is for the weak and that the ability to slog and hustle is not just good but truly enviable?

Second, most scientists assumed that long hours were necessary to produce great work and that “an avalanche of lectures, articles, and books” would loosen some profound insight. This was one reason they willingly accepted a world of faster science: they believed it would make their own science better. But this was a style of work, Ramón y Cajal argued, that led to asking only shallow, easily answered questions rather than hard, fundamental ones. It created the appearance of profundity and feelings of productivity but did not lead to substantial discoveries. Choosing to be prolific, he contended, meant closing off the possibility of doing great work.

Just like many jobs are bullshit jobs, much of our research is bullshit research. If we reward volume, we disincentive depth.

As Vinay Prasad was quoted in the Atlantic, “Many papers serve no purpose, advance no agenda, may not be correct, make no sense, and are poorly read. But they are required for promotion.”

When we treat workaholics as heroes, we express a belief that labor rather than contemplation is the wellspring of great ideas and that the success of individuals and companies is a measure of their long hours.

And this is one of the tough parts about almost everything written about deep work, rest, the power of no, when to say yes, and everything else in the modern business/productivity/self-improvement genre. The approaches just don’t apply very well out-of-the-box to service workers.

Doctors are primarily service workers. If we work more hours, we see more patients. While there is almost certainly a diminishing return in terms of quality care, there is no diminishing return for billing. A doctor generates more RVUs when they have more clinical hours, and that means more profits for their handlers (until someone burns out and quits).

William Osler advised students that “four or five hours daily it is not much to ask” to devote to their studies, “but one day must tell another, one week certify another, one month bear witness to another of the same story.” A few hours haphazardly spent and giant bursts of effort were both equally fruitless; it was necessary to combine focus and routine. (He lived what he preached: one fellow student recalled that in his habits Osler was “more regular and systematic than words can say.”)

Cramming is bad. Overwork is bad. A reasonable concerted effort over a long period of time is good.

Studying 4-5 hours a day was apparently a reasonable amount to Osler’s sensibility. Olser, if you recall, founded the first residency training program at Johns Hopkins.

Do you remember when the heads of the NBME and FSMB suggested in 2019 that a pass/fail USMLE Step 1 would be bad because students might take the decreased pressure as an opportunity to watch Netflix? Because I do.

MDforLives Physician Surveys (increased signup incentive)

MDforLives is the newest addition to the pantheon of physician survey companies that I’ve been keeping up to date over the years.

They just yesterday let me know that they’re increasing their new physician sign-up bonus to $20. They’re currently offering some big payouts for survey offerings as well. If you’re a doctor with an NPI number, check them out (it also supports this site, for which I am grateful).

Focus on the drive, not the distraction

NYT Columnist David Brooks writing about “The Art of Focus” back in 2014:

If you want to win the war for attention, don’t try to say ‘no’ to the trivial distractions you find on the information smorgasbord; try to say ‘yes’ to the subject that arouses a terrifying longing, and let the terrifying longing crowd out everything else.

There are whole books written about The Power of No, but I wouldn’t discount how our environments shape our behavior. Whether or not willpower is muscle or decision fatigue is real, there are plenty of data to show that making suboptimal activities harder improves outcomes in a variety of contexts.

I can tell you, for example, that the proximity of a Panera to one of the imaging centers I work at is not helping me make good lunch choices (bread bowls are my kryptonite).

But Brooks does reframe the classic “If you do what you love, you’ll never work a day in your life” adage to make it more approachable.

I think “find your passion” is generally terrible meaningless advice in most circumstances. If you have one, great. But if you don’t, it’s not exactly straightforward to meditate for a few minutes, analyze your innermost desires, and manifest your calling.

However, there’s also no denying that having a “pull” to do something (say, teaching others or writing) is the antidote to other less impactful activities. If you are drawn to something that matches your desired identity and goals, then it automatically makes it easier to avoid the “trivial distractions.”

As in, it’s easier to focus when you don’t want to escape the thing you’re trying to do.

Diganostic FOMO

From Suneel (brother of Sanjay) Gupta’s Backable: The Surprising Truth Behind What Makes People Take a Chance on You:

Apply the following quotation to why doctors don’t want to make the call:

If the fear of betting on the wrong idea is twice as powerful as the pleasure of betting on the right idea, then we can’t neutralize the fear of losing with the pleasure of winning. We can only neutralize the fear of losing with…the fear of losing. Enter FOMO, the fear of missing out. For backers, the only thing equally powerful to missing is…missing out.

Gupta goes on to discuss how potential backers initially too scared to be the first investor eventually pile on to avoid missing out on rare unicorns.

The fear of betting on the wrong idea in medicine manifests through overtesting and hedging. More than our desire to be right, we really don’t want to be wrong. But we can’t use the usual FOMO to our advantage, because medicine isn’t about making pitches or raising money but about directly helping individual people.

We don’t want to miss anything and so are forced to entertain everything, even if that means everyone in the ED gets a CT scan or a radiologist gives an impression a mile long with the words “cannot be excluded” featured prominently next to something extremely scary.

The true solution is this: we need to disentangle the outcome from the process. You can have good outcomes from bad decisions (dumb luck) or you can have bad outcomes after good decisions (bad luck). Luck and uncertainty are part of life, and they’re a big part of medicine. We should expect some bad outcomes even when doing the right thing, and we shouldn’t forget that overtesting and overdiagnosis have their own costs, risks, and harms. Passing the buck to the future doesn’t mean it won’t be paid.

By not making the call, we are making a decision: a decision to abdicate the diagnostic yield of an encounter or examination.

There are absolutely times when uncertainly is prudent. There are true “differential” cases. But the FOMO of diagnostic medicine should be passing up an opportunity to clearly define the next steps in a patient’s care.