Section II: How to Find a Surgical Residency

First, the good news. Each year there are more surgical residency positions offered than there are students waiting to apply. In evaluating programs, you will find helpful information in the "Program Requirements" section for each specialty, posted on the Web site of the Accreditation Council for Graduate Medical Education (ACGME). The ACGME is the home of the Residency Review Committees (RRCs) for each specialty; the RRCs set the rules by which programs must abide, and serve to maintain quality in every accredited program. You will find additional links to this site as we get into specific specialties and programs. In addition, the section for medical students on the American College of Surgeons Web site has good basic information on selection of programs and the application and interview processes: http://www.facs.org/medicalstudents/information.html.

You can begin to narrow your selection process and pick the programs to which you will apply, by answering the following questions:

1. Academic vs. Community-based Private Program?

There are a number of fine nonacademic programs that will adequately prepare you for community practice. In fact, a substantial proportion of practicing surgeons in all specialties today did not train in an academic program. The academic programs will often require a year or more in research. This requirement, while valuable to most residents in instilling important critical reading skills, may not be suitable for those planning on community practice. The advantages of academic programs include the emphasis on teaching that is found when medical students and full-time faculty are involved, and often the affiliations with public hospitals such as the VA, which provide an added measure of supervised independence. (To say nothing of the security of cross pollinization with nearby residents and students in other disciplines.)

2. Do you plan on added training (a fellowship) once the core residency is completed?

For those of us who are perennial students, additional fellowship training is available in most of the surgical specialties. The competition for positions in these fellowship programs is at least as tough as the competition for positions in the core residencies. Therefore, the more "prestigious" the institution where you do your basic residency, the higher the likelihood your application for a fellowship will go to the top of the pile. In general, doors are never closed to you if you've had training in a good academic setting; however, those who choose less well-known community or nonacademic programs may encounter some barriers and biases when applying for a fellowship.

3. Urban or Rural?

Most surgeons find themselves practicing in an urban environment. However, if you are planning on practicing in a rural environment, you may be required to care for a broad range of patients with surgical illnesses, and will be best served by a residency program that offers experience in all aspects of your specialty. For those who intend to practice in a third world setting, such as serving as a missionary, you may want to seek a residency in which you have the opportunity for extensive exposure to all aspects of surgery.

4. Are you locked into a specific area of the country?

If you already know that you are going to practice surgery with a family member at the Medical Arts Building in Billings, MT, you might wish to consider training programs that are well-known to the other people who practice in that same geographic area. This training decision will give you a head start over people trained in far-away places unknown go the community or to the referring physicians. This suggestion is probably a trivial point, as within three of four months of starting practice, you will be judged primarily on your affability, availability, and ability (and in that order). If your practice horizons are not limited, the world is your oyster, for no part of the country is educationally or medically superior to any other part. An important corollary, by the way, is this: statistically, the leading predictive factor for where you will ultimately practice is where you do your residency. So be relatively sure that you, and especially your spouse, find the location of your proposed residency program at least acceptable.

5. What is your energy level and your level of personal and family commitment?

Are you the type of person who thinks that the only thing wrong with being on a night float team is that you miss half the good cases? Or do you find every-fourth-night call unacceptable because it interferes with your weekend plans? Your own, and your family's requirements, should seriously be considered when choosing a residency. You should remember that—especially in the junior years and the chief year of residency—you will be working approximately 80 hours per week and you will spend a large portion of your time at home crashed out. We cannot overemphasize the importance of these considerations. Perhaps the most important of all of our recommendations is to carefully discuss these issues with your spouse ahead of time, and to ponder by yourself, before embarking on a time schedule that might make you, and your family, chronically unhappy.

6. Public or Private Institution?

Quality varies tremendously between both types of institutions. Although generalizations are not always accurate, some need to be made. Community-based, nonuniversity programs are generally staffed by private attendings who usually initiate contact with their elective patients in their offices. The attending staff at such hospitals is not chosen on the basis of their ability or willingness to teach. By the time the patient is admitted to the hospital, the workup is frequently complete and important surgical decisions are already made. The residents risk gaining only spotty experience in actual surgical decision-making situations, because the nature of the private patient/physician relationship demands "one-on-one," that is, the attending physician must be contacted prior to any involvement by the resident.

On the other hand, a purely public institution may suffer from a relative or total lack of highly experienced attending staff involvement. When residents learn primarily from other residents, shortcomings may literally be passed on through generations of residents. Continuity of patient care may be lacking, and the residents may never see the long-term results of their work.

When you visit hospitals during your interview trips, you should carefully query the current residents about attending surgeon involvement, the opportunities for residents to make decisions in workup and treatment situations, and case variety. A logical solution to the dilemma of public or private institution, in our view, might be a program in which a resident spends time at several different types of hospitals - county, private, VA, and children's. Programs with this type of configuration are very common.

Remember, you are required to go to the program to which you have matched. Switching programs later on is very, very difficult. So, be sure that the programs you select as part of the National Resident Matching Program in your rank order list, will all be satisfactory to you and your family. Never list a program that you do not want to go to—you might, to your dismay, find that this is the program to which you have matched.

7. With my academic track record, where should I apply?

All programs try to take the best applicants they can, and your academic credentials dictate your chances. Some institutions require that you have an advanced degree, several publications, and be elected to Alpha Omega Alpha, while another institution may be willing to review your record more broadly and value your other accomplishments, as well, such as the fact that you worked your way through school, and are involved in community activities. Students coming from schools that lack a grading system and have abolished Alpha Omega Alpha, or students from foreign medical schools, are extremely difficult to evaluate.

If your record places you in the lower half of your class or if you scored below the mean on the United States Medical Licensing Examination™ (USMLE), it is unlikely that you will be competitive for any of the better-known programs throughout the country. Placement in the second quarter of your class or at least a mean score on USMLE tests will make you competitive for many good community-based programs and some university programs. If you are in the top quarter of your class and have scores well above the mean on the USMLE examinations, and have some honors on your clinical clerkships, there are quite a few university programs you can consider. If you have been elected to Alpha Omega Alpha and have many major clinical honors, you should be competitive for any program in the country. We discuss this scenario further in Section III.

8. Should I do a subinternship (audition elective) at an institution that I am seriously considering?

Our general advice to students is to take just enough courses within your specialty choice to make sure that you really want to spend your life in that specialty. You should then spend as much time as possible in areas to which you will not have further exposure—such as nephrology, cardiology, and radiology. You will find the American College of Surgeons' handbook, Successfully Navigating the First Year of Surgical Residency: Essentials for Medical Students and PGY-1 Residents, to be quite useful in determining where your deficiencies lie. Arrange your electives accordingly. You can download a copy of the "Essentials" in PDF and Microsoft Word formats at http://www.facs.org/education/navigatefirstyear.html, or order a printed copy by sending a request by e-mail to csherman@facs.org.

You might be able to improve your letters of reference by taking a surgery sub-internship and putting in a stellar performance, but this strategy could be a little risky. Institutions try to get as much information as possible about each applicant; therefore, to separate you from the "herd," they might want to know you better. The more they like you, the better your chance of being selected. When two candidates with similar credentials are being compared, the nod will likely go to the one who performed well on-site during a senior elective. However, we certainly do not recommend more than a total of two audition electives.

9. What about my interview?

You will not be considered for any good program without an interview, and you should not consider a program that does not require an interview. This is a time for you to obtain answers to questions that will guide your choice. Do not ask the faculty who interview you about the call schedule—get those answers from the house staff with whom you meet. The faculty expect you to be concerned about the educational aspects of the program. It's fine to ask about case variety and complexity, research opportunities, faculty and resident stability and morale, and what has become of the program's graduates, so include queries such as what is the "pass rate" on certifying board exams, and how many graduates go on into subspecialty fellowships.

Many suggestions about the interview process are found in the excellent section for medical students on the American College of Surgeons Web site: http://www.facs.org/medicalstudents/answer4.html.

10. What specific things should I look for at each program?

• How many cases has the average program graduate performed during residency? Each certifying board sets minimum requirements and these must be met for the program to keep its accreditation by the RRC. Make sure the program provides at least that number of cases.
• Is the case load sufficiently varied and complex? The good programs have an excellent mix of common and unusual or complex patients.
• What are the outside rotations at affiliated institutions like? Do the residents in the program like these rotations and find them valuable? Is the level of supervision satisfactory?
• Is the house staff happy? Is the morale good? Is there a big turnover? These are very important issues. Remember, you're thinking about spending four to five years or more in this environment.
• Are there good educational conferences? Do the residents attend them regularly, or do they have problems "getting away" from their duties to go to the conferences?
• Are the department and the institution stable? Many teaching hospitals have merged or even closed in recent years, and the "life expectancy" of a department chair may be less than the duration of your residency. Turnover of junior faculty may be a barometer of the department's stability, as well.
• Are the subspecialty fellowships available? What is their impact on the residency program? The presence of subspecialty fellowships is an indication of a substantial educational commitment of the department and the depth of its faculty and research, but do the fellows take "all the good cases?" These are good questions to pose to the residents in the program when you meet them.
• What are the possibilities for living arrangements for you and your family? Is the area near the hospital suitable or must you commute? Long distance commuting is incompatible with a surgery residency at any stage!
• Are the institution's fringe benefits satisfactory? Do you have access to important benefits such as day care, extended medical coverage such as long-term disability insurance, active mentoring opportunities, a social support network, and counseling services? Ask these questions of the residents you meet with.
• Are women and minorities welcome in this program? The answer to this question can be found in the number of these groups enrolled in the program and their reaction to the climate provided by the program.

11. Letters of recommendation

Three or four letters in addition to your dean's letter (sent routinely to your application list on November 1 but not before) are optimal. More letters than this recommended amount is overkill. The most effective letters come from persons who have worked directly with you and know your abilities, especially if this faculty member personally knows the program director where you are applying.

• Most of the letters should come from surgeons. If you can get a strong supporting letter from an attending who knows not only your clinical skills but also your human side, this type of support would be a great addition.
• Letters from basic scientists, unless you are deeply involved in research and intend to continue a laboratory presence during residency, are not valued by program directors.
• If you did a spectacular job on a clerkship, a letter from your chief resident, who knows you best, may help. However, a letter from a resident should not be one of your primary letters.
• A letter from the department chair is potent, but only if the chair knows you personally or takes the trouble to speak with the faculty who know you well. Letters resulting from a cursory review of your file are worthless.
• If you have done several rotations during your clerkship, a letter from the clerkship director synthesizing your overall performance would be helpful.

12. An untapped resource

By now, you have all been in contact with surgical residents at your own medical school. All of these residents know a lot about other programs; ask them about resident morale, who really does the cases, if the attending and resident staff are supportive or abusive, and so on. In fact, the PGY 1 residents at your school were going through the same decision-making process that you are doing now, as recently as 12 months ago. Informal input from these residents, whose residency interviews and application process are still freshly in mind, can be very useful to you. Keep in mind, though, that rumors abound and may or may not be accurate—so use your best judgement.

13. Ranking programs on your match list

You've made all your interviewing trips, met all the right people, asked all the appropriate questions. Now it's time to rank those programs. Here are some general principles:

• DON'T rank any programs where you know you or your spouse would be unhappy; if you match there, you're required to go there.
• DO put a couple of "dream" programs, where you're probably not competitive but "wouldn't it be great if..." at the top of your list. The matching plan favors your ranking, so it doesn't hurt to list those programs first. It won't hurt you in the long run and the first program you list that also lists you highly, will be the one to which you will be matched.
• DO put a couple of "sure thing," programs where you're slightly overqualified, at the bottom of your list. You DO NOT want to go unmatched.
• DON'T pay any attention to programs that say they have "guaranteed" you a spot. The way the match works, unless you and your significant other are in the couples match, telling you that you have a guaranteed spot is breaking the rules.
• DO apply only for categorical positions because these are the only assurances you will have that you will finish the program, assuming that your performance is up to the program's standards.

We hope that we have answered some of your questions. Cheer up. You're probably really going to love your surgical residency and remember those years as some of the best of your life!

An Application Chronology

Winter and spring of your third year in medical school:

Conduct informal or formal conversations or interviews with surgery residents, faculty, and/or community surgeons. Firm up your personal career resolve. Make a list of programs you are interested in after reviewing the information in this site, and which may be interested in you. IMPORTANT: select a surgery faculty member to act as your advisor, preferably someone who knows you, can write a letter for you, and understands the application and match process. Go over your list with your advisor or another knowledgeable faculty member.

Late spring, early summer of the third year:

Send away for application forms. Approach the faculty you have selected for letters of recommendation. Provide your application list to your dean's office so the dean's letter can be mailed on November 1 to those programs.

Summer of your fourth year:

Refine your list and complete and return the applications. Applications are now made to all accredited programs using the Electronic Residency Application Service (ERAS) forms: http://www.aamc.org/students/eras/start.htm. Please consult the ERAS for detailed instructions.

November through January, fourth year:

Complete interviews. Take audition electives, if planned. Gather your letters of support and be sure they have been sent (showing your appreciation to the faculty member's assistant who types the letter is a very good idea). Notify the programs if you have been notified that you were elected to Alpha Omega Alpha and other honors grades or awards. Work with your dean's office to develop your rank order list (ROL). List at least six residency programs.

February - mid March, fourth year:

The programs must submit their final ranking by mid-February. Chew fingernails until Match Day, sometime around the 15th of March.

Match Day

On Match Day, a Thursday, you and your classmates will open the envelopes and learn the good news! Most students get their first or second choices, but if by some chance you did not match, you will be notified by your dean's office on Tuesday of match week, and will be given a list of all of the programs in your specialty that did not match all of their positions. The time between then and the announcements on Match Day is called "the scramble," and you and your advisor and the dean's office will need to work hard and fast to get a position; most students are successful in this endeavor, so don't despair.

Program Grading Scale

For each program that responded to our survey, we have included the information the program director provided about the academic records of their average residents: how many of the residents have been elected to Alpha Omega Alpha, and what percent of their residents were in the top 15 percent of their medical school graduating classes. You can roughly gauge your competitiveness for the program by comparing your record with the program's average resident.

If you are one group better (see above descriptions), you should have a good shot at matching with that particular program. The Alpha Omega Alpha number may also help your analysis. You should also know that many programs base their decision on offering you an interview on your file—so your file should be complete when you apply—and on your USMLE I score. If you did well on USMLE II and it is not already included in your file, be sure to notify the program director's office of your score (a copy of your notification from the USMLE should be sent).

If you know roughly where you rank in your own medical school class, you can quickly determine whether you are competitive for a given program, and whether you should go to the not-inconsiderable expense in time, effort, and money required for application and interview.

Note that our program grading scale depends entirely upon the candor of the program director in accurately representing the credentials of the program's residents. Our impression is that most program directors have been truthful.

Important Note:

The assumption is that the category, "Operations performed by residents" represents cases in which the resident and attending surgeon work closely together, as a team, under the direction of the attending surgeon. It is not ethically or educationally acceptable to have residents caring for surgical patients without attending staff supervision, and there is no implication that the resident has independent or unsupervised responsibility for any surgical procedure at any institution.

 Surgical Specialties