Applying for residency is anxiogenic. That’s true for essentially anyone and everyone but perhaps even more so when applying to competitive fields, advanced specialties requiring a preliminary year, or field/location combinations you are not necessarily competitive for. The bright side is that it’s a temporary problem, and in a few extra months you’ll probably have a job and a very expensive piece of paper that says you’re qualified for it. Like other (sometimes more expensive) alternative sources, I have compiled some sage and mostly common-sense advice for how to approach (and succeed in) the match.
Below are some additional thoughts to aid those who are considering pursuing a career in diagnostic radiology. Most of what follows will apply to other fields as well.
Academic “competitiveness” and your USMLE Step 1 score
There is a misconception amongst medical students that the average step score for a given field implies a necessary threshold to obtain a residency in that field. This is wrong. The average score is just that—an average. Where you want to do your residency, the prestige/quality of the program, etc. has just as much if not more to do with whatever “gold star” requirements you might need as the actual field itself. As I’ve discussed elsewhere, the key in applying to a competitive field has a lot to do with finding an appropriate mix and number of programs to apply to for your level of competitiveness. Even people who seem/are “great” may not be competitive at a given program due to idiosyncratic factors, its program director’s preferences, and geographic bias. The bottom line is that if your passion lies in a field with an average Step 1 far above your score, then you need to be willing to apply to community programs, apply to less “desirable” cities, try to woo your home institution, and generate a back-up plan. If you lost the thick skin you earned from applying to med school, it’s probably about time to get it back. No one gets all the interviews they apply for.
In 2011, the mean matched applicant Step 1 score for diagnostic radiology was 240, which is almost as high as it gets (topped only by dermatology, ENT, and integrated plastic surgery). However, the unmatched average was 211. The 30 point difference between matched and non-matched applicants tells you that there’s a lot of room in the middle for people who are below the average.
It is true however that many of the more competitive programs utilize automatic minimum cutoffs, often as high as 240. There are certainly plenty of people with 250+ and AOA applying to radiology, and some programs do have a preponderance of these folks. US allopathic applicants with scores of 250+ and concordant grades/AOA can expect to get interviews at a portion of the most competitive programs regardless of what medical school they attend. (NB: If the radiology program director at your institution feels differently or the track record at your school is different, they’re probably right and I am wrong.)
If you are a US allopathic grad and your score is ~220 or higher, there is almost certainly a job in radiology for you if you’re flexible and apply thoughtfully. The mean number of programs ranked was 13.3 for successful applicants and 3.4 for unmatched applicants. So the take-home message: go on enough interviews that you are statistically unlikely to go unmatched. 12 has been considered the magic number, but a qualified applicant with a good mix of programs (not all ‘reaches’) almost certainly doesn’t need this degree of safety. In 2011, 81% of applicants match at one of their top three choices. As a general match rule, having the “average” Step 1 score for a field or higher actually makes you pretty competitive.
There’s a lot of ego involved in discussing the various “tiers” of programs. Rest assured that outside of ego-stroking, there is plenty of good training to be had. Of note, training quality and prestige are not equivalent. Competitiveness and rankings are multi-factorial beasts that often involve things that are irrelevant to you as an applicant. Some fantastic programs are less competitive based on location. Some less stellar programs are extremely competitive based on location alone. The only reason tiers truly matter is to make sure you apply and interview at a reasonable mix. Interviewing at only nationally-recognized powerhouses and no great regional academic programs is not a fantastic idea. The fanciest programs may require some serious portfolio magic, but radiology is actually a pretty large field with a lot of spots.
…are unnecessary in radiology. The most popular time to do an away rotation is in the early fall, which is coincidentally the best time to do sub-internships, get letters of recommendation, and take Step 2—all more important tasks.
If you do one, it’s because you want to, not because you need to. If so, be on time and don’t be irritating. Many students who do audition rotations are attempting to endear themselves to specific programs or break out of regional biases. There has never been any data on if this helps. Obviously, the majority of programs are interviewing and hiring people who do not audition there. Additionally, if you sound fantastic on paper, there’s always a significant chance that the real thing fails to live up to the hype. (Or vice versa, sure sure).
There is probably no other field in medicine where a medical student is as useless and incapable of shining as in radiology.
Letters of Recommendation
I recommend one letter from radiology—probably from the PD at your institution saying how much (s)he loves you and wishes you would stay—and no more. Medical students generally do not have significant clinical performance in radiology. Clinical rotations, specifically medicine and surgery, provide more meaningful letters. As for research letters, if you can tie together radiology and research together, great. Otherwise, unless your research is superlative or you were a rock star in the lab, a random letter from a random PI isn’t as meaningful as letters from clinical faculty. Many programs specifically request clinical letters for this reason, although occasionally a research letter can be included as a fourth (optional) letter.
Since you are applying to preliminary and transitional programs, it likely betters your chances to have three meaningful non-radiology letters when applying to these programs. Some internal medicine prelims will request a chair’s letter from medicine. So, most applicants should aim to net four LOR total: send the radiology letter and two best clinical letters to all radiology programs; send non-radiology letters to preliminary years.
Your application should be submitted on day 1, end stop. Many programs, particularly on the coasts, tend to interview late, so don’t panic when you don’t have interviews instantaneously when your peers applying to pediatrics and internal medicine do. You are likely to receive a preliminary medicine interview substantially before you’ll hear back from the radiology program at the same institution if you apply to both, which can make scheduling frustrating/irritating and expensive. You can browse forums at Aunt Minnie or SDN as gunners post their successes to find out if your favorite programs have begun sending out interviews, but this will probably make you absolutely miserable.
Don’t forget about intern year
The majority of Diagnostic Radiology programs are advanced (start PGY2). While there are categorical programs (those that include your internship), be very wary about the composition of the intern year. An advanced program leaves you the opportunity to hunt out and find a delightful (by comparison) intern year, either in the same location as your categorical program or another one if you want to try out a different city for a year. There are good categorical programs with good internships, but historically many of these internships are painful. If you ask current residents about their feelings about PGY1, they will tell you to find the easiest program possible. I have a hard time imagining any internship that would not give you an idea of what’s it like to be a clinician and the clinical basis you need to place radiological findings into clinical context. There is a competing theory held by some IR folks that persons interested in interventional radiology should pursue a surgical internship to help them learn the management of surgical patients. If that’s something you want and actively pursue, then by all means. Surgery and emergency/trauma experience are nice to have, but overall the majority would still agree that it’s unnecessary to subject yourself to a whole year if that idea doesn’t spark joy.
Typically the most desirable internships are Transitional Year programs, though the relative desirability is highly variable. I think a traditional rotating internship like a classic TY is the very best broad foundation for a broad field like radiology, though it seems that most TYs these days are basically medicine internships with a couple of electives. You simply have to ask around to find out which ones are “good” or “cush” or not. Be warned that the best TY programs are often more competitive than the advanced specialties themselves. The bulk of TY interns are entering dermatology, radiology, and ophthalmology, three of the most competitive fields in medicine. Don’t neglect your internship.
Further reading: Preliminary Medicine vs Transitional Year Internships
How important is research?
You’re probably wondering if your lack of research will preclude your success in the match. While research can “make” your application, its absence is unlikely to break it. Except at a handful of specific high-powered research-centric programs, research isn’t a prerequisite for all program directors. Even some “top” programs have gone as far as to say things like, “We don’t care if you do research or not. We care about you being a leader in the field,” and other statements of the sort. That said, research never hurts. And in some (rare) programs it is an absolute requirement. The stratification goes something like this:
research with publications >> “real” research with posters or nothing > a case report done the summer of fourth year when you realize you don’t have any research and panic ≥ nothing.
So not having research in radiology or an MD/PhD will not prevent you from getting an interview/job in the broad sense. If you happen to have a long-standing interest in radiology, by all means do some radiology research. Clinical diagnostic radiology research is generally flexible and approachable time-wise as a medical student. Ask the program director or medical student coordinator at your home institution if they know anyone who needs help with a project (especially a poster, which would probably net you a free trip for literally formatting together a single big Powerpoint slide). Research in other fields counts just fine, of course. Programs know that many students may not have been exposed to radiology early enough to do radiology research. Note that if you mention research in your application, you will be discussing it come interview day.
This bit of advice doesn’t translate quite as well into certain surgical fields and dermatology, by the way, which do tend to be a bit more fanatical when it comes to paying your research dues.
The bottom line
Generalizations are dangerous and opinions should not be construed as prescriptive, but reasonable advice can be difficult to find, especially from the internet. Some other resources for applying to radiology, which are a bit intimidating, include the very thorough AMSER guide and this discussion from UT Houston. Again, a relatively inclusive collection of my all-encompassing thoughts on fourth year can be found here.
Best of luck in the match.
You might also be interested in learning radiology for medical students. Then, when you get a book fund to spend, here is my recommended reading for first year radiology residents.