Residency applications

• Residency applications are submitted through the Electronic Residency Application Service (ERAS), which connects the student, dean's office, LOR writers, and program directors to ensure a coordinated transmission and review of official documents.
• You can begin editing your application in June.
• Submissions in ERAS open in September.
• Review Freida, ACGME PD reports, and residency program websites for specific information about application requirements.

There are a number of things to keep in mind throughout both your preclinical and clinical years to be prepared for residency applications.

During your preclinical years

Curricular activities

• Your main priority should be learning the basic sciences taught in your classes and getting good grades if your school does not follow a pass/fail grading system.
• Work hard to pass your Step 1 exam and build a solid foundation for your Step 2 CK score.
  • Many programs screen applicants based on their Step 1 score.
  • Several programs have screening cutoffs posted on their website.
  • If your score was low, do not fret! There are still ways for you to match in the program/specialty of your choice. In such situations, it is advisable to:
    • Work with your advisor to find programs that traditionally accept students with scores similar to yours.
    • Expand your application with activities such as extracurricular activities, research, away rotations, etc.

Extracurricular activities

• Interest groups: Get involved with the specialty's interest group at your medical school or local scientific community.
• Research: Conduct research work related to the specialty.
  • Options include basic science research, clinical research, or advocacy/policy research.
  • Going to conferences (national or local) is another great way to further explore your interest in the field and meet potential mentors.
• Other extra-curricular activities
  • Hold leadership positions in the specialty's societies.
  • Create new sustainable initiatives.
• Tip: Focus on quality over quantity.
  • Program directors want to see that you are passionate and have a genuine interest in your specialty.
    • For example, if you would like to pursue a career in obstetrics and gynecology, it is much more impressive to be the leader of your school’s women’s health clinic and start a new IUD program than it is to be a member of multiple organizations that are unrelated to your specialty.
  • With regards to research, program directors like to see that you can complete projects, preferably with a research manuscript or even publication.
    • For example, It is more impressive to have a single abstract and manuscript from a project than to have multiple abstracts from different projects without any manuscripts.
  • If you have a break between 1^st and 2^nd years, use this time to gain further extracurricular experience.

During the clinical years

During 3^rd year

• Clerkship grade: During third year, try to earn an honor grade in your desired specialty's rotation or related fields (e.g., surgery, internal medicine, and OB/Gyn for urology). For some specialties, perhaps all clerkships could have significance for some residency programs (e.g., emergency medicine). While programs understand that grading is very subjective and school-dependent, having a good grade is important.
• Sub-internships: If you do not honor your third-year rotation, try to do a sub-internship early in 4th year and earn a better grade. It is important to complete the rotation early enough for your grade to be included in the transcript that will be submitted with your residency application in September.

During 4^th year

• Away rotations
  • Beneficial for competitive applicants to improve their likelihood of being ranked to match
  • Less competitive applicants have the chance to network with and impress the program to receive an interview call from them.
  • Tip: Remember that away rotations can be high-risk or high-reward scenarios.
    • If the rotation goes well, you have a much better chance of matching at the program than you otherwise would have.
    • However, if the rotation goes poorly you may lose your opportunity to interview or match at the program.
  • Talk to your advisors about your particular goals and geographical preferences when making a decision about away rotations.
• Program list
  • Create your program list strategically and with guidance from advisors.
  • Instead of taking a shotgun approach and applying to dozens of programs without much thought while making your program list, try to consider:
    • Your ideal geographical location
    • Having a good mix of programs that are safeties, targets, and reaches for your profile.
    • Possibilities to get experience related to your career interests
  • If your application is potentially on the weaker side (e.g., grades/scores are much lower than average, lacking extracurricular activities, LORs are weak, or did not study in the US), you might consider being less picky and apply to as many fitting programs as possible to increase your chances for an interview.

• When applying for residency, applicants typically require 3 or more LORs.
• A maximum of 4 letters can be assigned to each program as a part of your application.
• You are not required to send the same letters to each of the programs that you apply to.
• The exact number and type of letters that are required will vary based on individual program requirements.

Types of LORs

Department chair letter

• Written by the department chair of the specialty to which you are applying
• Residency programs vary in their requirements of a chair letter.
• Many schools have standardized processes in place for these letters, making them easy to acquire.
  • For example, the process could involve submitting your personal statement and CV to the chair and discussing your application with them during a short meeting.
  • Be sure to make note of submission dates for CVs and personal statements to give the letter writer enough time to construct the letter.
• Students rarely have an opportunity to work under the direct supervision of the department chair in a clinical setting. As a result, these letters are often the least personal and thus the least important.

Specialty letter

• Written by attendings you worked closely with from the specialty to which you are applying .
• Residency program applications typically require at least two specialty letters.
• Many students are concerned that they did not interact with attendings enough to create a lasting impression during their clerkship. Keep in mind that there will also be a lot of time at the beginning of 4^th year to interact with faculty and ask for letters.
• Most important for your application as they typically highlight your interest in the specialty and important aspects of your personality

Supplementary letter

• Most residency programs do not explicitly request a supplementary letter.
• They do not have to be written by attendings from the specialty to which you are applying. The letter can be written by:
  • An attending from a different specialty
  • A preceptor/mentor/advisor from your medical school
  • Research mentor for students who did a significant research project
  • A faculty member with whom you have formed a strong personal connection and who can write about your personality or dedication to the specialty of your choice.
• These letters can add value to your application by highlighting important aspects of your personality or further clinical strengths.

Away rotation letters

• If you complete a specialty-specific away rotation at another institution, you can consider asking for a letter.
• LoRs obtained from away rotations are especially beneficial:
  • If you are interested in a program with that specific institution
  • When a program has a sub-rotation in your preferred specialty that is not available at your home program

Requesting a LOR

During the rotation

• In some cases, you may have to inform your preceptor early in your rotation that you hope to receive a LOR from them.
• Be sure to clarify their expectations of you, and do your best to exceed these expectations.
• The more you work with your preceptor, the more comfortable they will be with writing a detailed and personalized letter.

End of the rotation

• Arrange a short meeting when they are available, to discuss their feedback and your future plans.
• During your meeting with them:
  • Explain your interest in the specialty to which you are applying.
  • If possible, submit a paper or report outlining the cases you followed during the rotation.
  • Provide them with a copy of your personal statement and CV.
  • Thank them for the opportunity to work with them and politely ask them if they would be willing to write you a LOR in support of your residency application.
  • Do not forget to inform your preceptor about the deadlines for your letter.
  • Tip: If it is early in the year, you can request that they write the letter, save it, and submit it when the ERAS portal opens .

Follow-up

• Send your writer the supplemental materials that you prepared for them to use as a reference (e.g., your personal statement and CV).
• Be prepared to send them reminder emails 1–2 months prior to the ERAS application deadline .

It is better to be declined a letter altogether than it is to receive a very generic or poor letter. There will be other opportunities to get a better letter!

Extra considerations

Taking extra time

• Some students choose to extend medical school to pursue a dual degree, conduct research, or engage in other scholarly activities.
• If you took extra time, it is a good idea to get a letter from your mentor/thesis advisor who supervised you during this time. It can be a red flag on your application if you spent significant time on scholarly activities, and then you did not ask for these to be highlighted in your application with a LOR from your mentor.

Deciding on a specialty late

• Do not worry if you decide on a specialty late! This is the case for many students, and there is still time to get letters.
• As detailed above, you only need 2 letters from the specialty to which you are applying. Even if you are not able to get any LORs from your clerkships, there is ample time at the beginning of 4th year to do elective rotations and secure letters.
• At many schools, there are certain faculty members that are known to write strong letters for students regardless of the circumstances. Talk to your advisors as well as your upperclassmen to connect with these faculty members.

Overview

• Research work can be a great opportunity to gain additional inside into a specialty, connect with attendings of the respective field, and increase your chances for residency interviews.
• There are lots of ways to be involved in research, ranging from basic sciences to clinical projects to medical education.
• If you think of yourself as someone who “doesn’t like research,” make sure you are not dismissing the idea based on a premature conclusion or a specific experience. Keep exploring and try to find the right kind of research and project for you!

Inquiring about research opportunities

Timing

• Rotations are a great time to seek out research opportunities if you are interested in a specific field and have some extra time to get involved.
• If you do not have the capacities at a particular time, you can still reveal your general interest: Ask for contact information from residents or attendings that offer involvement in research projects to students and inquire about the kind of projects and participation that they offer.

Approach

Whether or not there are existing research opportunities already available, tell your residents or attendings that you want to start working on a new research project. A lot of them will be happy to help you get started.

• Asking residents
  • Consider starting the process by asking the senior residents on your team. A lot of them are going into different fellowships or are going to work in the academic field and will usually be working on some research projects. Most of them will be happy to accommodate interested medical students in their existing projects.
  • Working with residents also allows you to work on existing projects, which gives you the chance to participate with a small contribution without being responsible for the administrative work and the concept development.
  • Residents will usually introduce you to their supervising attending with whom you can develop a formal mentor-mentee relationship.
• Asking attendings
  • If the residents in your clerkship do not have any current research projects, ask the attendings directly.
  • Depending on your expectations and preferences regarding a research project, you can initiate the conversation in different ways:
    • If you consider a certain attending a good mentor or you are interested in any kind of research project, you could say: “I’m interested in [clerkship field] and would like to get involved with research; are you working on any projects that would benefit from the assistance of a medical student?”
    • If you already have an idea for your own project and are hoping for guidance and supervision, you can be more straightforward: “I think this case would be great for a case report. Would you be willing to advise me?”
  • Another method is emailing an attending to express your interest with your CV (with potentially a picture of you if you have worked with the attending before and want to help them remember you).
  • Working with an attending increases your chances because they have seen your commitment, attitude, and dedication to their service.
  • Working with attendings on research projects is a great opportunity to develop a mentor-mentee relationship, which will be extremely helpful as you advance in your medical career.
    • They will be able to write you LORs and advocate on your behalf during the residency interviewing process.
    • They can also help guide you regarding which residency programs to apply to and which to avoid.

Types of research work

Case reports

If you have no prior research experience, case reports are an easy and excellent way to get started.

• Selection of a topic
  • Pick an interesting case that you have encountered during your rotation and search the literature to see if any similar cases have been published.
  • Case reports can be about a new disease, a rare presentation of a common disease, unique side effects to medications, or a rare disease that you read in textbooks but don’t encounter frequently in real life.
• Before you start writing
  • Search the literature for case reports (ideally of similar cases) and look at how they are formatted.
  • Note that informed patient consent is required to include patient's data in any publication even if their data is anonymized. Ask your preceptor about obtaining it from the patient you are intending to write about.
• Writing a case report: Start with a rough draft and include everything you think is relevant about your patient case.
  • Abstract: Summarize the entire case (word limit varies by each journal).
  • Introduction (or background): Give a general overview of the disease you are going to talk about, including etiology, pathophysiology, epidemiology, presentation, diagnosis, and treatment.
  • Case description
    • Describe the presenting symptoms, history, examination findings, laboratory and imaging findings, the reasoning behind the diagnosis and the treatment plan.
    • Include only pertinent information.
    • Illustrate your case with tables and images if feasible.
  • Discussion: Write about the implications of this case by answering questions such as:
    • Why is this case important for other clinicians to be aware of?
    • Are there any other similar cases in the literature?
    • How is your case different from the other cases in the literature?
    • What lessons did your team learn from this case?
  • Conclusion: Summarize the case briefly and emphasize the main findings of your report.

Other research formats

• Retrospective studies
  • A retrospective study answers a clinical question using retrospective data.
  • The process will usually include institutional review board approval, patients' chart reviewing to gather data, analyzing the data (e.g., with a statistician), and writing a manuscript based on the data you gathered.
  • Student can easily get involved and start working in during rotations as the data already exist.
• Prospective cohort studies
  • Usually take a long time to plan and periods of data collection may extend beyond your time in medical school
  • Students might benefit from joining at a later point in time after data collection has been completed.
• Others: See “Epidemiological studies” in the epidemiology AMBOSS article for more information on different types of study designs.

Supervision and publishing

• Your attending or resident will guide you on various aspects of your project, including tasks like working on institutional review board protocols, data gathering, data analysis, and manuscript writing.
• After you finish your research work, prepare a research manuscript draft that you can send to your preceptor for review.
• Discuss with your attending and/or resident if you should submit your abstract for publication in a journal or a presentation at a conference.
• Once you and your preceptor have decided where to submit the results of your research work, look up specific requirements such as a maximum amount of words, layout specifications, and submission deadlines.