In evaluating programs, you will find helpful information in the "Program Requirements" section for each specialty, posted on the website 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 this website has good basic information on selection of programs and the application and interview processes.
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 those that may be interested in you. It is important to 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 well. Review your list with your advisor or another knowledgeable faculty member.
Plan your fourth year elective schedule. Apply for away rotations through the Visiting Student Application Service of the Association of American Medical Colleges (AAMC). Familiarize yourself with the Electronic Residency Application Service (ERAS) and National Resident Matching Program (NRMP) sites. Develop your personal statement. Provide your application list to your dean's office so the dean's letter can be mailed on November 1 to those programs.
Approach the faculty you have selected for strong letters of recommendation (LOR). Provide the faculty members who are writing your letters a copy of your curriculum vitae, LOR cover sheet (available in your Student Affairs office) and personal statement. Refine your list and complete your ERAS applications by early September. Applications are made to all accredited programs using the ERAS forms. Please consult the ERAS for detailed instructions.
Register for ERAS.
Acquire your ERAS tokens from your designated dean’s office. For U.S. applicants, tokens can be obtained from your medical school of graduation. International applicants receive their tokens from the Educational Commission for Foreign Medical Graduates (ECFMG), and Canadian applicants receive their tokens from the Canadian Resident Matching Service (CaRMS).
Take required examinations, such as Step II of the United States Medical Licensing Examination (USMLE) and/or Comprehensive Osteopathic Medical Licensing Examination (COMLEX), and authorize sponsoring institutions to release your results to ERAS.
Register for the NRMP.
Schedule and complete interviews. Take “audition” electives, if planned. Make sure your letters of support have been sent. (Showing your appreciation to the faculty member's assistant who types the letter is a very good idea).
Complete interviews. Notify the programs if you have been elected to Alpha Omega Alpha (AOA) or the Gold Humanism Honor Society if you received honors, grades, or other awards. Work with your dean's office and/or advisor to develop your rank order list (ROL). List at least eight residency programs.
The applicants and programs must submit their final rankings by mid-February.
On Match Day, a Friday in mid-March, you and your classmates will open your envelopes and learn the good news! Most students get one of their top choices, but if by some chance you did not match, you will be notified by your dean's office on the Monday of Match week.
A supplemental match process, the Supplemental Offer and Acceptance Program (SOAP), has been developed to assist unmatched students. Your dean’s office will work with you to submit applications to unfilled programs through ERAS. The SOAP match then begins at noon EST on Wednesday. If you are matched, you have two hours to electronically accept the position. There are multiple rounds of this process scheduled on Wednesday, Thursday, and Friday. The SOAP process is binding once an applicant agrees to the position. Match day is on Friday of Match week for all matched applicants, and results are posted online at 1 PM EST.
Not all programs are looking for similar characteristics, and therefore gauging your competiveness for a program varies markedly depending on what you are looking for and what the program is looking for. Many of the more competitive, strongly academic university programs stress election to AOA, class rank in the top 10%, with research publications or graduate degrees to train the next generation of research-oriented academic surgeons. USMLE scores above 220 are felt by many program directors to be a predictor of success in passing boards, while others use class rank in the upper 25% as a better predictor of success. Recently, election to the Gold Humanism Honor Society is playing a role in some program directors decision making. The middle tier of institutions, either university or independent medical center programs may prefer election to AOA and ranking in the top 25% as well as higher USMLE scores. There are a significant number of institutions who do not place as much value on election to AOA, research, or class rank as other parameters. These may be programs where USMLE scores below 220 are accepted.
If you have all the credentials—election to AOA, USMLE scores in the upper 10%, ranked in the upper 10% of your class, research publications, and excellent letters of recommendation from attending surgeons—you should be able to qualify for any program in the country. Since USMLE is an objective screening device, you need to make sure your USMLE part II score is in your file when you apply. A high USMLE score gives you a better chance of getting an interview at a program of your choice.
If you know roughly where you rank in your own medical school class and have excellent USMLE scores, you can quickly determine whether you might be competitive for a given program. Although “reaching” is encouraged, using these guidelines for institutions can help you determine whether you should go to the not-inconsiderable expense in time, effort, and money required for an application and interview. A knowledgeable dean or surgical mentor should be able to help guide you in your application process and have some feel for what many programs desire and require from their applicants.
In the Residency Program Profile of the searchable database, the category "Operations performed by residents" represents cases in which the resident and attending surgeons 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.
The Division of Education at the American College of Surgeons would like to sincerely thank the following surgeons for their invaluable help revising Sections I and II of this website:
Questions to Ask Yourself
You can begin to narrow your selection process and pick the programs to which you will apply by answering the following questions:
There are a number of fine independent medical center-based programs that will prepare you very well for surgical practice. In fact, a substantial proportion of practicing surgeons in all specialties today trained in these types of programs. The university-based programs will often require a year or more in research. University-based and medical school-affiliated programs will include medical students, more full-time faculty, and affiliations with public hospitals such as the Veterans Affairs (VA).
Your surgery residency will prepare you to be a competent and capable surgeon in your specialty. That being said, additional fellowship training is available in most specialties. The competition for positions in some fellowship programs such as pediatric surgery can be tougher than the competition for positions in the core residencies. The number of subspecialty fellowships is increasing, and the majority of graduates from both university-based and independent medical center-based general surgery programs are continuing their training with fellowships. If you know you want to go directly into practice, the five-year clinical experience in most residencies will allow you to do so without feeling the pressure to do an additional fellowship. In fact, there is an increased need for broad-based surgeons in this country, and that may make a career choice in general surgery even more appealing. When you visit any surgery training program, it is wise to inquire what graduates from the past five years have done after residency and, if they chose to go directly into practice, whether they felt comfortable and prepared to do so.
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 developing nation or do missionary work, you may want to seek a residency in which you have the opportunity for extensive exposure to all aspects of surgery and/or consider an Acute Care Surgery fellowship.
If you already know that you are going to practice surgery in a specific community or area, you should 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 to the community or to the referring physicians. This suggestion is probably a trivial point, as within three or four months of starting practice you will be judged primarily on your affability, availability, and ability. An important corollary is the fact that, 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 significant other, find the location of your proposed residency program at least acceptable.
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? You should seriously consider your own and your family's requirements when choosing a residency. 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 sleeping. We cannot overemphasize the importance of these considerations. Perhaps the most important of all of our recommendations is to carefully consider these issues before embarking on a time schedule that might make you, and your family, chronically unhappy.
All programs try to attract 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 (AOA). Others 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. Evaluations from your clerkships and letters may also give the programs a feel for whether you are the sort of person they seek. They are looking for someone who treats everyone well and will remain calm and effective in the face of all the challenges a surgery resident may encounter during a hectic clinic or in the middle of the night.
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), you may not get many invitations to interview relative to the number of places you apply. Placement in the second quartile of your class or scoring at least a mean score on USMLE tests will make you competitive for many good programs. If you are in the top quartile of your class, have scores well above the mean on the USMLE examinations, and have some honors on your clinical clerkships, you will be considered at most programs. If you have been elected to Alpha Omega Alpha or the Gold Humanism Honor Society and have many major clinical honors, you should be competitive for any program in the country. We discuss this scenario further in the section below on our program grading guidelines.
Remember, you are obligated to go to the program to which you have matched. Switching programs later on is very, very difficult. Make sure that every program you select as part of your rank order list in the National Residency Matching Program (NRMP) will 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.
Our general advice to students is to take just enough courses within your specialty choice to make sure that you really want your career to be in that discipline. You should then spend as much time as possible in areas that 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 format online, or order a printed copy by sending a request by e-mail to Brad DeFabo Akin.
You might be able to improve your chances of matching at an institution, particularly one that is geographically or philosophically remote from your medical school, by taking a surgery subinternship and putting in a stellar performance. The more the surgical faculty get to know you, the better your chance of being selected. It also provides the opportunity for you to gain a deeper knowledge of the program and determine if it is a good fit for you. However, subinternships should be chosen carefully, generally no more than two programs. Consider utilizing time away from your home institutions to become familiar with programs where you have a reasonable chance of matching based upon your academic track record.
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 member who interviews you about the call schedule or benefits—get those answers from the program’s website or residents with whom you meet. The faculty expects 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 to subspecialty fellowships. While you are being interviewed for a residency position, you are also interviewing the residency to see if the training offered will meet your professional needs. The goal of the interview for both you and the program is to assess how you would “fit” into the program.
Should a conflict arise and you need to cancel a scheduled interview, it is essential that you notify the residency coordinator of the program with as much notice as possible. Cancelling an interview at the last minute inhibits other people’s opportunities for interviews, throws off complicated interviewing schedules, and can damage your medical school’s credibility.
Many suggestions about the interview process are found in the excellent section for medical students on this website.
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 than this recommended number of letters is overkill. The most effective letters come from people who have worked directly with you and know your abilities, especially if the faculty member personally knows the program director where you are applying.
By now, you have become acquainted with surgery residents at your medical school-affiliated hospitals. 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. The postgraduate year 1 residents at your hospital were going through the same decision-making process that you are going through now, as recently as 12 months ago. Informal input from these residents, whose residency interviews and application processes are still fresh in their minds, can be very useful to you. Remember, though, that rumors abound and may or may not be accurate—so use your best judgment.
Another source of information is the Alumni registry at your medical school, which contains the current location of all graduates and their medical specialty. Alumni are usually very open to inquiries about their current residency and others that they considered. They also may provide an entrée, paving the way for future medical students from your medical school to become residents in their program.
You've made all your interviewing trips, met all the right people, and asked all the appropriate questions. Now it's time to rank those programs. Here are some general principles to follow when doing so:
The number of categorical general surgery year 1 positions has been relatively stable at about 1,100 for several years. Other surgical specialties are also not adding significant numbers of residency positions. United States medical schools are preparing to increase enrollment by 30 percent in 2015. The ratio of US graduates applying to categorical positions approaches 1:1, while almost 100 percent of categorical positions are filled. As more students graduate from US schools, the competition for categorical positions will increase.
Students who feel they are not as competitive should apply for preliminary surgery positions as well as straight categorical slots. When resident attrition from categorical positions occurs, the openings are often filled by preliminary surgery residents. It behooves you to take a preliminary position in a program you like rather than to go unmatched.
Despite the challenges and long hours, rest assured that, like us, you're probably going to love your surgery residency and remember those years as some of the best of your life!