As you begin narrowing your options and deciding which programs to apply to, consider the following questions to help guide your selection process:
University-Based or Independent Medical Center Program?
There are two main types of residency programs that will prepare you well for surgical practice: independent medical center-based programs and university-based programs. Independent programs are typically independent of any medical school, hence the name. However, they may still have medical students who will rotate at the institution. These programs tend to have fewer residents and fellows, less emphasis on research and more clinical opportunities. Alternatively, the university-based and medical school-affiliated programs will most certainly include rotating medical students, more full-time faculty, and more residents/fellows. They often have close affiliations with public hospitals such as the Veterans Affairs (VA) or trauma hospitals University-based programs will often require a year or more in research, and have more research emphasis during training. Both types of programs offer excellent training environments.
Do You Plan on Applying for Additional Specialty Fellowship Training Once the Core Residency Is Completed?
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 specialty fellowship programs 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.
Will You Practice in an Urban or Rural Location?
Most surgeons find themselves practicing in an urban environment, but certainly the need for surgeons exists in our rural communities. If you are planning on practicing in a more rural environment, you may be required to care for a broad range of patient conditions and may be best served by a residency program that offers a broad and comprehensive experience in all aspects of your specialty. Some programs offer a rural track in which rotations are designed for surgeons who may need a broad skill set. For those who intend to practice in a developing nation or under resourced environment, you may want to seek a residency in which you have exposure to international opportunities available in the program.
Are You Locked into a Specific Area of the Country?
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. Statistically, the leading predictive factor for where you will ultimately practice is where you do your residency or fellowship. As such, location may be an important factor for you to consider.
With My Academic Track Record, How Many Interviews Will I Get?
All programs try to attract the best applicants they can, and your academic credentials dictate your chances. Some institutions may require that you have an advanced degree, several publications, or be elected to Alpha Omega Alpha (AOA). Others will review your record more broadly and value your other accomplishments as well, such as leadership experience, volunteer work, and personal endeavors. Evaluations from your clerkships and letters may also give the programs a feel for whether you are the sort of person they seek.
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 many programs in the country. Your medical school advisor should be able to guide you on the competitiveness of your application and provide advice on how to increase your number of interviews by applying to target programs and considering other specialties if you do not get enough interviews in your desired specialty.
Remember, you are obligated to go to the program to which you have matched. Switching programs later in residency is 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. 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.
Should I Do a Sub-Internship (“Audition” Elective) at an Institution that I Am Seriously Considering?
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 completing a surgery sub-internship and putting in a stellar performance. The more the surgical faculty get to know you, the better your chance of being selected, but your performance must be exceptional. A mediocre performance can actually hurt you more than it can help you. 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, sub-internships 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.
What About My Interview?
You will not be considered for any program without an interview of some sort, and you should be wary of a program that does not require an interview. This is a time for you to obtain answers to questions that will guide your rank list. 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 is appropriate 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. Canceling 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.
What Specific Factors Should I Consider 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? Programs should have an excellent mix of common and unusual or complex patients. Are the complex cases distributed equitably among the residents?
- 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?
- Do residents complete rotations at geographically distant hospitals? Does the program offer appropriate resident support, including housing for outside rotations?
- Are the residents happy? Is the morale good? Is there a big turnover? These are very important issues. Remember, you're thinking about spending five years or more in this environment.
- Do I fit in with these residents? Can I see myself spending time with the residents and faculty—inside and outside of the hospital? Can I envision myself working well as a team with these people?
- Can current residents speak to the quantity and quality of faculty involvement, the opportunities for residents to make treatment decisions, collegiality between residents, and faculty and case variety?
- Are there high-quality educational conferences and technical skills labs? Do the residents have protected time away from their duties to attend conferences and work in the lab?
- 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.
- Is there a dedicated research year or the opportunity to do one to two years of research? What resources are available for resident research? Is resident research primarily clinical or a mixture of clinical and basic science? Do surgical faculty have ongoing research, and are they willing to mentor residents on their projects? Are there local venues for research presentation?
- Are 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 important questions to pose to the residents in the program when you meet them.
- What are the possibilities for living arrangements for you? Is the area near the hospital suitable, or must you commute?
- 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? Is attendance at yearly national conferences and/or review courses supported? If resident research is accepted for presentation locally or nationally, is additional time-off and funding available? Ask these questions of the residents you meet.
- What is the diversity like in this program? If you are in an underrepresented group, consider inquiring about the inclusivity of that group.
Letters of Recommendation
Three or four letters in addition to your dean's letter are optimal. More than this recommended number of letters is unnecessary. 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.
Most of the letters should come from surgeons. If you can get a strong supporting letter from a non-surgical attending or basic scientist who knows not only your clinical skills but also your human side, this type of support would be a great addition. 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. If you have done several rotations during your clerkship, a letter from the clerkship director synthesizing your overall performance could be helpful.
An Untapped Resource
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.
Ranking Programs on Your Match List
You've completed all of your interviews, 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:
- DON'T rank any program where you know you would be unhappy; if you match there, you're required to go there.
- DO include 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. Telling you that you have a guaranteed spot is a violation of the rules.
- 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. Alternatively, you should also consider other specialties that are less competitive.
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!
Content Contributor:
Lily Chang, MD, FACS
Seattle, WA
August, 2026
