There is more to the USMLE than the requisite volume of knowledge, and you can take the test efficiently by acknowledging outright the things your subconscious probably already knows. This is a somewhat randomly chosen question from the official 2013 USMLE Step 1 information booklet:

A previously healthy 48-year-old man comes to the physician because of fever and cough for 2 days. He attended a convention 10 days ago, and two of his friends who stayed in the same hotel have similar symptoms. His temperature is 38.3°C (101°F), pulse is 76/min, respirations are 20/min, and blood pressure is 130/70 mmHg. Crackles are heard over the right lung base. A chest x-ray shows a patchy infiltrate in the right lower lobe. A Gram stain of sputum shows segmented neutrophils and small gram-negative rods that stain poorly. A sputum culture grows opal-like colonies on yeast extract. Which of the following is the most likely causal organism?

(A) Campylobacter jejuni
(B) Eikenella corrodens
(C) Legionella pneumophila
(D) Proteus mirabilis
(E) Pseudomonas aeruginosa

Once you’ve done enough Step questions, you will already know the most likely answer at the word “convention” (it’s C). Not every question can come as a knee-jerk reaction, but one key to Step preparation is not just overall knowledge but rather pattern-recognition and memorization.

What separates the massive scores from the excellent scores boils down to intrinsic genius, test-taking voodoo, and tons of studying. The first you can’t change; the third you have to do (and should do efficiently). The second you need to be clever about (and doing questions is key). You can lay a strong foundation by making questions like the one above comically easy. Knowing the key phrases and patterns can allow you to literally “feel” the right answer even without having conscious knowledge. If you can get in the head of the question writer and know the tip-offs, you can often make a reasonable guess even if you don’t actually know the “basic science” details the question is supposedly trying to test. (more…)

Rules for the Rank Order List (ROL)

• Put them in the order you actually want them. There is no reason to change how you will rank programs based on post-interview communications or voodoo. Your number one should be your dream program.
• You must “certify” your ROL when you first make it and whenever you make a change to it.
• Rank every program you interview at unless you absolutely hate the program and would rather not have a job. There is no harm in ranking programs just in case unless you would rather not match and try to scramble for whatever scraps are left.
• The Match algorithm guarantees that you will get the very best job you can get based on your preferences.
• Try to avoid any plan that involves the SOAP. The number of spots in your field of interest cannot be predicted and should not be relied upon. Additionally, if a program has spots in the SOAP, that could be an interview fluke…but it could also be an indication that it might not be the best place to spend 3+ years.

For advanced specialties:

• You must create additional supplemental ROL for internships (PGY1 positions).
• You can create different supplemental ROL for each advanced position you rank, which allows you to coordinate geography appropriately (i.e. you can rank Texas prelims above California prelims for your Texas programs and vice versa).
• You can also list PGY1 programs as backups on your primary rank list in the event you do not match to an advanced position. You will still have the chance to enter the SOAP for an advanced position; you just won’t then need to try to obtain two jobs at once.

For couples:

• You coordinate your ROL on your own (their #1 is your #1 and so on), and the software itself doesn’t confirm that you guys did it right. Double check every single selection to make sure that you did match up your choices correctly.

NRMP Rules concerning correspondence (that are sadly and awkwardly broken all the time):

•  A program may not ask you how you will rank them
•  You may not ask a program how you will be ranked
•  It is perfectly okay and common to tell a program how you feel, and some programs may send you love letters as well.
•  No coercion!

Talking to programs

The amount of contact expected of applicants in order to show interest varies widely across programs. Some programs demand to know that you want to be there (using the words #1), others will flat out inform you that they rank the applicants accordingly to how they want them (with no regard to where they fall on the applicant’s rank list). And of course some may say that and have it be a boldfaced lie. There are egos involved. Be cognizant of program personalities and cater to them when possible.

If you tell a program they are your #1, it’s best to do so late in the season after you are absolutely sure. Do not lie. Don’t be that guy/gal.

If you aren’t sure, you can express “strong” interest but save #1 for your real #1.

Keep in mind however the reality that most seasoned program directors shouldn’t/won’t take these comments at face value. They’ve been lied to so much that they believe no one. Your lies may hurt the chances of future students from your school, however. Likewise, you should continue to doubt even the most sycophantic of praise until it’s confirmed by match day. There are no benefits to being duped.

Thank You Notes

It is customary to send thank you notes, though it is unlikely that this correspondence generally makes a significant difference. It’s simply polite to thank people for taking the time to speak with you. Typically, one should write thank you notes at the very least to the Program Director and Program Coordinator, though it seems most applicants still also write letters to all interviewers. Write them and send them immediately after your interview, as the interactions will be freshest in your mind. And it’s polite.

You may not want to bother. And that would be okay in most circumstances. However, an anesthesia program director once told me he doesn’t rank anyone who doesn’t write him a post-interview thank you letter. He especially likes Christmas cards. This is a dramatic (and ridiculous) example, clearly, but I found that helpful motivation.

To facilitate writing personal thank you notes, it is advisable to jot very brief notes after your interview encounters. By doing so, you can specifically reference interesting (wink wink) conversation topics you had with different people. Most people still write thank you notes by hand, but email is becoming more popular. Some programs will express preferences (follow them).

Hearing from programs

Programs vary widely also in how much (if at all) they contact applicants. You may receive emails or phone calls with warm fuzzy feelings of varying significance.

Some programs will outright tell you are “ranked to match” (take with a grain of salt). Some may tell you that you have a job. Others will vaguely tell you that are “ranked competitively” (double grain of salt alert!). People have been burned by even the most specific and seemingly failproof promises.

Some programs do not contact applicants at all and hate the mind games of the match. Do not take silence the wrong way. Simply rank your programs the way you want them, not the way they want you.

The first question for many students to ask (themselves) is where? Because the majority of physicians practice in the same location they trained, some would argue that residency is about Location, Location, Location.

Using FRIEDA, you can search all accredited programs by field and location to help you find potential residencies.

Are you considering enough programs?
Is there a reasonable mix in the competitiveness of the programs you are looking at?

• Certain locations (California, NYC) tend to be competitive based on location regardless of program quality
• There are three broad types of residencies: big name programs, university-based academic programs, and community programs.
• Depending on how competitive you are for your chosen specialty, it will be important to at have programs in at least two of the three broad categories.

The AAMC provides a lengthy but excellent list of questions to ask residency programs (including “what is the call schedule?” and “how are the residents evaluated?”). Read it early to get an idea of what factors might play into your decision. It will help you make the most of the information you receive over the coming year.

Some things to consider when applying:

• Program setting (urban, rural)
• Program size (large, small: affects both social aspects and call)
• Program location (close to family/friends, climate, sounds good on Facebook)
• Program reputation
• Program benefits

Some things to ask:

• Any upcoming changes? (new chairs, changes in funding, new call responsibilities)
• Any Red flags? (probation, residents leaving, etc)
• Patient population (indigent, community, private)
• Number of program sites/hospitals (will you be commuting across town frequently?)
• Where do residents live? (Is it close to the hospital?)
• Can they afford it? (Or are they budgeting like crazy?)

You can look at:

• Program marketing materials and websites (be wary)
• The internet forums (take with massive grains of salt)
  • studentdoctor.net, urologymatch.com, auntminnie.com (radiology), etc.

You should talk to:

• Recent graduates in your field of interest

Just to be clear:

• Conventional wisdom states you’re most likely to make your Rank-Order List based on location first and reputation second, with gut feeling coloring the whole thing so profoundly that you can rationalize your list seven ways til Sunday.
• You will forget everything else about these programs over the course of the interview season unless you take meticulous notes. Even then, nothing else outside of the big three (location, reputation, “feel”) will really matter. After all, you’re not really going to pick one program over another because they have a bigger book fund; it’s just a factor in your overall impression.

You could read the rest of the interview series:
How to schedule your residency interviews and How to succeed in your residency interviews.

Interviews for residency are generally unlike those you are familiar with. They tend to be more conversational and are at least as much a marketing session for the residency programs as they are an evaluation of you (the applicant). The most common question you will receive on the interview trail is “do you have any questions?” by a country mile.

By receiving an interview, you are qualified academically for that program. It means you have a reasonably good chance of ranking there (on the low end, probably 10%). Just be yourself and see if it’s a good fit. If you had a good interview impression of the program, the converse is probably also true. It’s just as important to strike the right number and balance of interviews as it is to be a charming almost-physician on the big day.

The easiest way to hurt yourself in the interview process is to fulfill a pathological stereotype: the jerk, the know-it-all, the creepshow, etc.

A very brief list of rules to interview by:

• Be on time (or reasonably early)
• Look professional (bathed, clean-shaved if applicable, suited). Your appearance should be generally unremarkable (but well put-together).
• Avoid checking bags (it costs money on most airlines anyway). People show up suit-less every season because of this. They really do. Yes, it actually happens.
• Be warm and pleasant. Be excited. Look people in the eye. Smile frequently (your cheeks will ache, be strong)
• Be someone you would want to work with.
• Don’t be a sycophant, however.
• Do not complain. Ever. Be nice to all residents and ancillary staff. The secretary is one of the most powerful people you will interact with.
• Don’t play on your phone. I know you won’t during an actual interview—because you’re not an idiot—but I encourage you to not pull it out to fill inevitable dead time either.
• Have a repertoire of standard “I am interested” questions. You will be asked for your questions by every person you meet. Don’t be combative in how you ask them.
• Ask nitty-gritties to the residents and not to faculty: call schedules, moon-lighting, benefits, etc.
• Do not ask questions that are answered on the website or in the Powerpoint talk. It means you’re lazy or fell asleep or both.
• When possible, research the program ahead of time and have specific questions/discussion points.
• Go to the dinner the night before (don’t drink too much) if you can. It is an excellent time to meet residents. The residents are what you will probably base your decisions on (along with location and reputation; not the Powerpoint). Do not fail to RSVP to the interview dinner if one is requested, and do not no-show without notification if you then can’t make it. Some applicants do this, and the programs always notice. It’s rude.
• The residents will tell you that the dinner is a safe space. It is not if you’re an ass.
• Trust your gut.

Get Practice

Go over common questions with a loved one or friend to make sure you have solid (but not overly rehearsed). Take feedback seriously. You can also look at my Interview Question Compendium for examples.

If your school has a mock interview night or analogous event, you should go. You may not be aware of interview ticks or nervous habits you’ve developed since your last rodeo.

Further Reading

There are some well-reviewed books on this topic (e.g. The Residency Interview and The Successful Match [which is long, good but repetitive, and pretty exhaustive]) but truthfully, I sincerely doubt most American medical graduates with a reasonable student affairs department and a modicum of common sense have very much to gain from any book-length treatments of this topic. A shorter treatment by the AMA is quite readable, and I largely agree with medfools. A more gunner-like approach is advocated by these folks.

As with all how-to resources, so much of it truly is common sense.

You’ve sent in your application. Your anxiety increases. You begin to compulsively check your email account. Your heart skips a beat when you have a new message. Welcome to interview season.

Getting the interview

You will be contacted via email (very rarely by snail mail) if a program wishes to interview you. They will generally provide options for dates, which tend to fill up very quickly (sometimes within minutes).

Respond promptly. An invitation to interview is not a guarantee to interview.

Do not make the mistake of holding onto a less desirable interview without responding while you wait to see if something better comes along. Schedule all interviews at first. Then, as your list fills, you can begin being more discriminating. You may have to cancel interviews. That’s fine, as long as you do it properly (see below).

It is common but somewhat awkward to inquire about your application status to programs. This is especially advisable in the following situations:

• In a couples match when one partner has received and scheduled an interview but the other has not.
• If there is a particular reason you want to go to a program that may not be clear in your application. If you have not heard back from a program after they’ve sent out invitations, it’s common to send a love letter detailing your special desire and asking about the status of your application.

There are often threads on sites like studentdoctor.net where posters share when different programs have sent out invitations. This can lead to substantial neuroses but can be helpful in scheduling interviews and timing queries.

Picking the date

Ideally, you should schedule interviews during the period in which you have taken vacation. You should attempt to cluster interviews geographically when possible to save on travel expenses, though this is often not possible. Join rewards programs for airlines, hotels, or sites like Expedia or Hotels.com. Compare prices with AirBnB if that’s something you’re comfortable with (signing up via a referral link gets you $65 off your first stay). Car rentals are less common in the age of Uber or Lyft, but in more suburban or sprawling cities, a car rental may still be the best way to get around or actually see the place (especially if you’re making a trip of it and are not just there for the day).

December tends to be the heaviest month, though this can vary by specialty.

There are several theories about scheduling interviews:

• Interviewing at a program you are very interested in early in the season is bad because you won’t be polished
• Interviewing at a program you are very interested in late in the season is bad because you will be tired
• Programs will forget you if you interviewed early
• Programs will be exhausted and uninterested by the end

The bottom line is that many programs have looked at their own histories and found no correlation between interview timing and likelihood to match. Residency interviews are very different in content and style than medical school interviews. The programs are often auditioning just as much as you are. Don’t worry.

If you are applying to an advanced specialty like radiology or dermatology (requiring a preliminary or transitional year), you will likely need to take a full two months to interview. The same may true for other fields if you plan/need to interview at ≥ 20 programs (such as marginal candidates in competitive fields).

How many is enough?

The bare minimum of interviews varies by specialty. As a general rule, 12 contiguous ranks in a single specialty will give you an extremely high chance of matching. For most applicants, especially in less competitive fields, even that number isn’t strictly necessary so long as there is a combination of programs of different tiers. Like college, you don’t want to interview only at the ivy leagues. You need a balanced mix of programs for your competitiveness.

Programs will make you feel loved, so don’t let generic praise wash away your due diligence. Interview until it hurts.

If you have fewer than 7 interview offers by late October, you will need to schedule a meeting with whichever dean at your school oversees the match and your mentor to address the possibility of adding a backup plan.

Of successfully matched US students in 2011, 55.4% got their first choice, 16.1% got their second, 9.9% got their third, 5.8% got their fourth, and 12.8% got a choice beyond their fourth. This means that 81.4% of successfully matched students got one of their top three choices. Even including unmatched applicants, the top three number only falls to 77.2%.

Canceling

If you cancel an interview (be polite!), make sure to receive a confirmation of your cancellation. A short gracious email to the program coordinator is usually sufficient, and they will typically respond back promptly. Do not simply no-show at an interview, as it makes you and your school look bad! People actually do this! Give as much notice as possible, at least one week if possible. Programs remember when people no-show and sometimes hold it against the institution in future years, not to mention that someone else could have used that spot who actually wanted it.

There is a tendency for many students to cancel their later interviews (mid-to-late January) because they feel they have likely interviewed at enough places to match and are generally very tired of traveling. Don’t misinterpret positive feedback from programs as an indication of your place in the match, no matter how blatant or explicit. Students get burned every year. Make sure to have enough programs on your rank list before canceling interviews, because you can only rank programs you’ve interviewed at!

During my fourth year I asked my peers to submit questions they received on the interview trail. Some (most) were banal. Some were bizarre.

Doing my best to keep the list short and readable, here are some results.

Overall, the take home message is this: if you have a bad experience on interview day—when both you and the program are putting your best face forward—maybe that says something about the likelihood of a good residency experience.

Single most painfully common question on the trail:

• What questions do you have for me?

Every single time:

• What’s your story?
• Tell me about yourself
• What kind of things do you like to do for fun?
• Tell me about [random thing on your CV]
• Ten years from now, what do you see yourself doing?
• How did you become interested in medicine?
• When and how did you decide to become a [blank]
• What are you looking forward to the most in residency? The least?
• What was your most memorable patient? (yes, what; not who)
• Why this program?
• What are you looking for in a program (cue list of program’s description)
• What fellowship do you want to do?

Brain-busters (time for some BS):

• What has been your biggest disappointment in medicine?
• How do you think the changes in health care policy will affect you in the future?
• Describe a disappointing event in your life and how you coped with it?
• What did you find hard during medical school?
• What would you say is your greatest strength? Weakness?
• Tell me about a time when you made a choice that ended with a good result.
• Tell me about a time when you made a choice that ended with a bad result.
• What accomplishment are you most proud of that’s non-academic?
• When you look back at your career, how will you be able to tell if you were successful?
• What person have you met in medical school who has inspired you?
• What do you want me to know about you that didn’t fit in your application?
• Tell me about a situation in which you have had to work with someone you didn’t like. How did you handle it?
• Tell me about an ethical dilemma you experienced as medical student.
• What do you think we should look for in our applicants? (I think this is actually a really good question)
• Tell me about your best and worst residents.
• What do you think is the biggest health issue in America today?
• What do you want me to remember about you at the end of this interview?
• How would your best friend describe you?
• Describe your ideal day.
• Tell me about a time someone on your team was not pulling their own weight?
• If you were chief resident on a service and one of your interns forgot to or just didn’t place an order which compromised patient care, how would you handle the situation with the faculty who expects the order to be completed, and how would you address the intern?

Extremely narrow:

• If you could have dinner with any 3 cardiothoracic surgeons, dead or alive, who would they be and what are their greatest contributions to the field?
• How do you know that you have the hand skills to be a good surgeon?
• Ortho trauma is a very busy service. How are you sure you can handle it?
• Who is Brad Aust?

Awkward or obnoxious or both:

• What is your class rank?
• Tell me about medicine in your country.
• What is something unique about you that will help me remember you amongst the other applicants?
• Can you explain any small problems on your application that could bring you down on our rank list so that I can explain it to the committee?
• Tell me your impression of this program
• Are you ready to move away from [X]? (clearly entertaining the idea…)
• What is one thing you do not like about this city based on what you know? (city was not Baltimore, haters)
• What are the CXR findings in heart failure?
• Tell me you how you work up a GI bleeder
• Describe the technique for putting in an arterial line.
• Tell me how you would work someone up for chest pain.
• A colectomy patient becomes tachycardic the night after the operation. All other vitals are normal. What is your immediate workup and differential?
• You are interested in [X] research. We don’t have any active projects like that. What are your research plans if you come here?
• What do you plan to do with your MPH? (nothing of course, I just like collecting degrees!)

Unapologetic Match Violations:

• Where are you going to rank us?
• Tell me what you thought about program X.
• You did an away rotation at X school. Where do you feel you fit in better, here or there, and why?
• Would you really come here?
• Which other places have you interviewed at or are you going to?

Oddest set (came from PM&R, by the way, not psychiatry):

• Who do you like better; Tigger or Eeyore?
• Would you say Eeyore is happy?
• Would Eeyore say he is happy himself?

The AAMC has their list of 40 frequently asked questions, which feels about right.

Residency programs generally require three letters of recommendation (LOR) in addition to your Dean’s Letter (MSPE). Some programs/fields will request four, and some programs will have stipulations concerning their make-up: one may need to be a so-called “chairman’s letter” or come from an outside institution or research mentor.

Obtaining a LOR:

The most important thing in choosing your letter writers is to choose someone who knows you well (and has worked with you clinically). Most people agree that a detailed and specific letter from a lesser-known faculty is superior to generic one from a more distinguished one. If a letter doesn’t say anything special about you that a reader can’t find from your grades or CV, then it doesn’t mean anything. Generic is a wasted opportunity.

Feel comfortable asking directly if your potential writer is comfortable writing a strong letter for you (awkward as that may be). You should generally have an idea who loves you enough to write you a good letter. You can ask graduating students at your school if they have worked with particular attendings that wrote good letters and attempt to work them early during the fourth year if possible.

You will provide each letter writer with a folder containing:

• Your Name
• Your ERAS Letter Request Form (LRF) (available when ERAS opens in June)
• CV
• Personal Statement
• Photograph

This means that you should have your personal statement and CV ready by July.

Give them advance notice (ask as early as possible) and don’t be afraid to disclose the relevant deadlines when the time comes. July is earliest date letters can be submitted. It is ideal to have all letters in by September 15 along with your application. Some letter writers will require gentle reminders. Do not be too afraid to do so politely, as your application and future are more important than the awkwardness of writing and sending an email. How early you get your application submitted can and does make a difference, particularly in fields that interview early (e.g. psychiatry, pediatrics, medicine, transitional years).

Letters of Recommendation and ERAS:

• Your letter writer uploads their LOR into ERAS via the Letter of Recommendation Portal (LoRP). Historically, your school would upload the LOR on behalf of the writer, but this middleman step just resulted in more delays.
• A maximum of four (but nearly always three) can be submitted through ERAS. Do not send 4 to programs that request 3. (That means that you should actually check the websites of all programs you apply to.)
• You can collect as many letters as you want and then choose which LOR to send to each program. This can be insurance against a flakey faculty member. No one will know if you don’t use their letter.
• Letters of Recommendation should mention your specialty. If you are applying to more than one, then you should have slightly different letters for each (can be nearly the same). “So-and-so will make a fine pediatrician” is an awkward line to read if you are the program director of a psychiatry program. ERAS allows you to pick and choose so don’t squander it by sending the wrong letter.
• You should always check the box saying you waive your right to see the LOR. It implies a level of trust and confidence in your writer that both programs and especially writers appreciate (if you are worried about the quality of the letter, then you should be asking someone else).