Baking the Residency Application Cake

I like to think of applying to residency like a cake. There’s the main cake and the icing. All icing without cake isn’t ideal, and cake without icing is boring. You don’t like cake or icing? Well, this analogy might not be for you.

Disclaimer: These are simply my opinions and experiences. Specialties are very distinct cultures with their own rules of engagement. I primarily ‘played’ the residency application game for preliminary years (medicine, surgery, and transitional), diagnostic radiology, and interventional radiology. However, I do believe these experiences and opinions are translatable to other specialties.

The Cake:

The residency application cake has 3 primary ingredients: exam scores (e.g. STEP 2), core clerkships grades, and who you know (letters of recommendations, away rotations, et cetera). I know of quite a few residency directors in competitive specialties that put all applicants in a spreadsheet and use a home-cooked algorithm to sort them on these factors +/- some of the icing. The top they interview, the bottom they don’t, and the middle they dig further into personal statements and what not. 

Of course, this depends on the competitiveness of the program. I also like to think of the application process like dating. Everyone is putting on their best face. Programs want to fill all their spots with hard-working, competent residents that they can stand/want to be around. If the program isn’t the most attractive for whatever reason, they can’t necessary only interview the most competitive candidates. Candidates are also trying to go to the ‘best’ program within their preference, which is highly subjective and variable. They can’t only interview at ‘reach’ institutions less they risk not matching. This is the game we’re all playing.

The Icing:

The residency application icing includes everything else used to make oneself look competitive and interested in a specialty. This includes research, public health, leadership positions, volunteer work, personal statement, and other experiences. The icing is where I think competitive/ambitious applicants get into trouble. Websites and otherwise give the same generic advice about the cake, research, leadership positions, and volunteering. The gunners out there do all of this in stride. Which is fine but can come off a little intense and superficial. In other words, everyone tends to get similar advice and check the same boxes, so they tend to look like everyone else. In the application dating game, the objective is to stand out in a positive way, and that is difficult if you check all the same boxes as everyone else.

Another problematic strategy is all icing without the cake. Certainly, icing can compensate for cake to an extent. For example, an applicant may not have the strongest STEP score or clerkship grades, but they have started to make a name for themselves in the specialty or have done a lot of amazing research. However, an applicant with poor board scores, clerkship grades, and lackluster letters is probably going to have a difficult time matching in a competitive spot even if they have plenty of icing. It’s just a little too sweet without substance.

IMGs and DOs:

Whether you agree with it or not, there seems to be tariff on international medical graduates (IMGs) and Doctors of Osteopathic Medicine (DOs). There’s a lot of history and politics behind why that is, which isn’t the focus of this piece. By ‘tariff’ I mean that these applicants seem to have to go above and beyond in order to get a chance to sell their cake, as if some of their cake and icing is taxed when applying into the U.S. allopathic medicine-dominated world of residency. This is something these applicants have to keep in mind because, all else being equal, the allopathic applicants seem to get preferential selection in some programs/specialties. In a sense IMGs and DOs, have to have an extra awesome cake to compensate for the tariff.

Marketing Strategy:

I was fortunate to be taking some business classes around the time that I was applying to residency. In product development, there is a considerable amount of effort put into developing the value proposition/statement. What’s the 2-3 sentence pitch that captures why the product maters? I realized that in medicine we all tend to get the same advice and try to do the same things. What we don’t do well is market ourselves. In order to stand out, we should market ourselves like a product. Do some honest self-reflection about what you’re about, the strengths, the weakness, the goals. Ask for some honest feedback from mentors and others you trust – i.e. do some market research. Also consider what the programs (your customers) are look for – are the places you’re considering more interested in a researcher, a hard worker that just wants to focus on clinical care, or maybe a little of both. With that information, craft an engaging value statement, a pitch that effectively conveys what you’re about and why others should care.

I then constructed the rest of my application and interview approach around that value statement. I only included icing that supported my pitch so I could promote a consistent narrative. Faculty often interview A LOT of medical students. This is done between their other clinical duties, research, teaching, home life. Unless that 5-15-minute interaction stands out, it’s easily forgettable, making your application look like the same cake and icing as everyone else. You can combat this by having a simple and engaging value statement and narrative – if they’re going to remember one thing about you, what do you want that to be?

Interviewing: 

As briefly mention earlier, I do a lot of medical anthropology research studying physicians and taboo topics in healthcare like turf wars. In order to have a meaningful interview, you have to establish rapport quickly and the way you do that varies from specialty to specialty and person to person. A lot of it boils down to mirroring and facilitating a conversation. When we first meet, I try to quick gage their pace, tone, and body language and mirror it. Do they lean back, talk a little slower and longer as though they are settling into a friendly conversation; OR do they sit straight, talk fast and short as though they’re in a rush and want to keep things formal? If you act like the second person with the slow-longer talker, you can come off stiff, awkward, and robotic. If you act like the first person with the fast-short talker, you can come off flippant, arrogant, and like you’re not taking things seriously. 

For facilitating a conversation, it’s a bit like improv – “yes, and….” The more you can get the other person to talk in an interview, the more they tend to think of it as a positive experience and, ironically, think they know you better than if you talked to whole time. If they ask a direct question like “where you went to college,” you might have to give a simple answer: “I went to X.” However, they will ideally ask some more open questions like “tell me about yourself,” “why [this specialty],” “why [this program].” These are opportunities to sell your value statement and get the other person talking. My favorite question is “do you have any questions for me?” I almost always ask them similar questions if I haven’t already – “What about you, why did you come to [program]?” “What’s kept you here?” Once you’ve “flipped the interview,” as the businesspeople call it, you need to keep the conversation two-sided (so not exactly a flip, I guess). They might mention their research in X and you know of a faculty member at your institution that also studies X. You can be like “Oh interesting, I think Dr. Y at [your institution] studies that, can you tell me more about it?”

Final Thoughts:

All of this is easier said than done. People’s journeys through medical education (and life for that matter) are rarely straight paths. I think it’s easy for people with early exposure to healthcare and interest in a competitive specialty to prematurely close themselves off to other things – their parents are neurosurgeons and they always wanted to be a neurosurgeon and the only thing they really spend their time exploring/thinking about is neurosurgery. This certainly works for some people, but most of us have a bit more tortuous journeys and trying to artificial straighten it can cause you to end up in a residency that isn’t the right fit. Like many things, I think it’s a balance. Be willing to meander a bit in medical school and craft your value statement later. For example, my journey of specialty interests in medical school went like this: palliative care -> psychiatry -> interventional radiology -> diagnostic radiology -> psychiatry -> interventional cardiology -> vascular surgery -> interventional radiology. Now I’m an interventional radiology resident heading up the development of applied ethics for the specialty – not something I ever would have predicted at the beginning of medical school.

In summary, applying to residency can be challenging, but I’ve found it helpful to think about it like making a cake. You need the cake, some icing, and a marketing strategy to sell it.

~ Eric J. Keller, MD, MA